Breast Reduction Procedures

Indications

Macromastia or very large breasts is a common problem for women. It usually results from the exuberant growth of overly sensitive breast tissue in response to circulating female hormones. It often occurs during adolescence but can plague woman of any age. Breast reduction surgery provides a nice solution for those patients with very large breasts and out of proportion for the size of their body. It is a common and generally safe surgical procedure which provides a wonderful change of life for women with this problem. Often, they are some of the happiest patients plastic surgeons have.

(Fig 18 a,b,c) These are before and after photos of a patient who had a breast reduction. She decreased her bra size from a size EE down to a full C, small D. She also had quite a bit of asymmetry which was improved.

Fig-18a

Fig-18b

Fig-18c

(Fig 19 a,b,c) This is another patient who has had a breast reduction surgery. Again a better shape, size, position, and symmetry have been accomplished. The scar and its location is an excellent trade off. The patient also has had a significant improvement in her symptoms of pain and heaviness.

Fig-19a

Fig-19b

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Functional problems: There are many symptoms and physical signs commonly associated with large breasts. Frequently, woman with very large breasts complain of excessive weight on their chest, as well as headaches, neck, shoulder, breast and back pain. Because of the excessive weight of the breasts, their bra straps dig into their shoulders causing grooving and shoulder discomfort as well as bad posture. Frequently there is excessive wetness and subsequent rashes underneath the breast tissue from constant warmth and perspiration. Adequate self examination for cancer surveillance is extremely difficult if not impossible. Often, it is also impossible for all the breast tissue to be viewed with mammography for cancer screening. The enormous size prevents them from wearing many clothes and makes participation in normal daily activities such as exercising very difficult. This diminished ability to be active and exercise can obviously contribute to an unhealthy lifestyle and associated poor health. Aesthetically, these breasts are usually very pendulous and unattractive. The nipple areola complex is typically large and malpositioned. It is common for many of these patients to have an altered and negative self-image because of their large breasts. It is because of the chance for significant improvement in these functional, cosmetic, and associated psychological issues, breast reduction patients are often some of the happiest plastic surgery patients.

Goals

The goal of breast reduction surgery is to reduce the size of the breasts and thus improve those associated functional and cosmetic problems. Ideally, the breasts after reduction should be more symmetrical and have a much improved and beautiful shape. Obviously, the procedure should be performed safely, and the recovery period smooth, fast, and without complications.

There are a variety of surgical techniques to remove breast tissue in order to accomplish those functional and cosmetic goals safely. You should carefully discuss these with your surgeon. Excellent and poor results can occur with every technique. It is very important that your surgeon is comfortable and experienced with the technique he commonly uses.

(Fig 20) In every technique, tissue is removed from the breast in a geometric design unique to that particular technique, resulting in smaller breasts and a variety of patterns of resultant scars. Here is an example of a very common breast reduction technique called the inferior pedicle technique. Usually, the nipple-areola complex is not completely taken off, but rather remains connected to underlying breast tissue called a pedicle as shown in this graphic. It thus is able to maintain a blood supply as it is moved higher on the final breast mound. These incisions on the breast skin and removal of underlying tissue place limitations on the blood supply, which is necessary for skin and tissue to live. Thus, all attempts are made in the design and execution of the breast reduction surgery to maintain the crucial blood supply necessary to avoid postoperative complications. As discussed later, sometimes the blood supply becomes compromised resulting in difficulty in healing, necrosis or death of tissue and skin, which may require revisional surgery.

Fig-20

(Fig 21) The final scars with this technique are in the shape of an anchor, as they go completely around the nipple areola, down the front of the breast as well as under the breast in the fold. Because of the scar around the nipple areola, it appears that the nipple has been completely removed when it has not. Occasionally however, the nipple areola complex indeed has to be removed, and replaced during the operation as a skin graft. Your surgeon may feel this is a necessary step in his judgment and will typically discuss that with you. Generally, this is done with extremely large breasts. Sensation in the nipple is almost always lost permanently in these grafting cases and some or all of the graft may not take or live. This might require revisional surgery.

Fig-21

(Fig 22) This is a photograph of a sample patient in the operating room, after one breast has been reduced, but not the other yet. Breast tissue is removed from each breast to provide an ideal shape, maintain essential blood supply to allow optimal tissue healing and provide symmetry. The nipple location is generally chosen at the level of or slightly above the inframammary fold under the breasts. One of the hardest problems to correct is a nipple that is too high. Unfortunately, many patients try to pressure their surgeons into placing the nipple to high. One nice additional benefit of this surgery is to make the nipple areola smaller and more defined, more proportional, and more pleasing aesthetically. Following the removal of tissue and reshaping of the breast tissue in the operating room the skin edges are sutured together. Dressings and a supportive garment are then placed on the breasts and maintained during the healing process.

Fig-22

Liposuction: In the appropriate patient, liposuction can certainly be considered to reduce the size of the breast. Patients often desire this technique to limit the extent of scarring associated with a reduction. Liposuction has definite limitations and is generally not effective for very large breasts, very dense breasts, very droopy or saggy breasts, or with breasts where the nipples are low. Liposuction is not effective for treating sagging or excessive skin. In the majority of breast reduction cases, skin excision is required (scars) to elevate the nipple and form a more pleasing and perky breast shape. In addition, it is more difficult to examine the removed breast tissue in pathology (for possible cancer) in the liposuction assisted cases.

Possible Complications of Breast Reduction

The rate of complications vary greatly depending on many variables including the particular surgeon, type of technique, extent of the reduction, and general health and risk factors of the patient. Common complications occur approximately 20% of the time in some clinical studies.

Alternatives

You should always consider the non surgical options to breast reduction surgery. These may include changing your present diet or beginning a new diet program, changing your exercise routines, or possibly addressing a current medical problem if applicable. Different supportive bras can be worn to decrease the symptoms of heaviness. Different clothes can be worn as well to possibly conceal larger breasts. Breast reduction is often an elective surgery and if you choose not to have it, you will avoid the risks associated with the procedure. You should consult with your doctor about available alternatives other than breast reduction.

Asymmetry: Asymmetry is really not a complication. Your surgeon cannot make your breasts look exactly the same. Good results are anticipated but perfect symmetry is not obtainable.

Undesired Bra Sizing: A bra size cannot be guaranteed either since bra sizing itself is an inconsistent communication tool. You should communicate as clear as possible with your surgeon the size breasts you want. Many intraoperative factors however play a role in ultimate size of your breasts. Your surgeon has to place a priority on safety of the procedure and other concerns ultimately over your choice in size. Sometimes patients will feel postoperatively that their breasts are too big, or too small.

Scarring: Incisions heal unpredictably depending on many factors. Some of these include the location of the incision, surgical technique utilized, unique healing characteristics of the patient and their genetics, and how compliant they are with postoperative orders, among others. All scars are permanent and can be seen when examined, however some heal better than others. The degree of scarring ranges from excellent scarring to very poor, with most scarring somewhere in between. Revisions are sometimes needed to improve the appearance. If poor scarring occurs, usually it is under the fold of the breast instead of around the nipple or down the front of the breast.

For some cases of keloid scar formation, post operative x-ray treatment during healing improves the chances of scars healing better in many cases. Sometimes these scars and other deformities are permanent however, and cannot be corrected. It is wise to see a representative patient with good scars and poor scars to decide if you are willing to accept these risks.

Retained Pigment: One type of unique scarring issue which is noticeable and might require revisional surgery is called “retained pigment”. The location of skin excised and the method of closure in some techniques will sometimes result in the incorporation of the pigmented areola skin along a scar. (Fig 23) If this occurs, the pigment is usually along the vertical scar from the nipple to the inframammary fold as shown here. This pigment can usually be excised in one or multiple very small procedures at a later date. This problem is most often seen in those patients with remarkably large areolas, especially when the nipple is not raised much higher than its present position.

Fig-23

Pain: It is possible after your surgery that your symptoms of neck, back or breast pain are not improved as much as you had wanted. Even more unlikely but possible is that you may have pain in your breasts or along your scars following the surgery.

Healing Problems: Sometimes there are areas along the incision that may not heal well from infection, tension, poor blood flow or other reasons. The inverted “T” intersection at the bottom of the breast is a common site for this to happen because of the tension in this area. When this happens, delayed healing or separation of the wound may occur, requiring prolonged medical attention to the area with dressing changes and sometimes antibiotics.

Necrosis of tissue: The worst-case scenario may be if tissue actually dies from compromise of the circulation. Although infrequent, the patients at highest risk for this problem include smokers and patients with tremendously large breasts seeking reduction. (Fig 24) The area most frequently involved is the nipple areola complex as seen in this photograph. Some skin might die requiring placement of a skin graft at a later time or other surgical revisions. These areas may heal a different color than the surrounding areola and may require medical tattooing to blend in. If the breasts are uniquely large as described, sometimes the surgeon will decide to take the nipple off during surgery and apply it in a controlled fashion as a skin graft. These points should be discussed with your surgeon.

Fig-24

Bottoming Out: A common occurrence after breast reduction or breast lifting surgery is bottoming out or further drooping. These surgical procedures will not arrest the process of aging, and your breasts will continue to droop over time. In some patients this can be accelerated within the first two years. Although it is unlikely that significant breast tissue enlargement will reoccur, patients often see a bottoming out of the lower pole of the breast. (Fig 25) This can be treated and improved with an additional much smaller excision of skin on the bottom of the breasts at a later date if needed.

Fig-25

(Fig 26) These are pictures of a patient which demonstrate bottoming out which can occur with breast reductions, lifts, or augmentation. This particular patient had an anchor type breast lift along with placement of implants and the after pictures were taken a year after her surgery. You can see in the before photo that the patients breasts are obviously droopy and the nipple is below the level of the inframammary fold or fold under the breast. Although she has had substantial improvement from this surgery, her breasts have settled and dropped more since that surgery. (Fig 27) This is a picture taken in the operating room at the time of the surgery. You can see that the lifted breast is very high, and in fact the bottom part of the breast (arrow) is not laying on or touching the chest wall. This area of the breast will almost always relax after surgery with the effects of gravity. You cannot expect the breast tissue to stay as tight and high as the day of surgery.

Fig-26a	Fig-26b
Fig-26c

(Fig 28) This picture was taken one year after her lift surgery. The pen is inserted at the level of the inframammary fold and shows how the bottom part of the breast has bottomed out or stretched over time and is now in fact touching the chest wall. Although clearly improved from preoperatively, this is something that can commonly occur after this type of surgery. The degree is variable.

Fig-28

Breast Regrowth: In the unlikely event that breast tissue regrowth recurs, it happens most frequently in those patients with very large breasts during adolescence whom have a reduction procedure during adolescence prior to stabilization of breast size. It obviously can also happen if patients gain weight after the procedure.

Hematoma: Sometimes the breast can develop a collection of fluid or blood within the dissection area from continued postoperative oozing. Most studies show this occurring approximately 5% of the time. Another smaller surgery to drain this excess fluid from the surgical area may be required. The placement of drains often helps prevent these complications.

Loss of Sensation: Although there is a reasonable chance to maintain nipple sensation following breast reduction or breast lift surgery, a patient must be prepared to lose sensation in their nipple or other areas of the breast.. Usually, the larger the amount of reduction, the higher the risk of losing sensation. Unfortunately, this change in or loss of sensation may be permanent.

reast Feeding: Likewise, a patient may not be able to breast feed after breast reduction or breast lift surgery. Although the chance remains that breast feeding is possible, it is best to prepare for this possible permanent loss as the result of surgery. Because of the growth and distortion of the breasts during pregnancy, it is probably wise to delay this surgery if pregnancy is planned or desired in the near future.

Calcium Deposits: Breast surgery does NOT increase your risk of breast cancer. The surgical dissection of the breasts however, leads to scarring inside the breasts. Occasionally calcium deposits can form within this scar tissue which can mimic the appearance of breast cancer on future mammograms. This can lead to confusion when later trying to evaluate the presence of breast cancer. Mammograms before and after surgery can help to resolve some of this confusion and establish a baseline for other mammograms to be compared to. It is important to have the breast tissue, which was discarded from your breasts sent to pathology for postoperative evaluation. Often, breast reduction patients have breasts so large; they can not be effectively examined with mammography. Reducing their size often is helpful in evaluating the breasts for cancer with these tests.

Other: Other complications can result from any surgery including permanent deformities, need for expensive revisional surgery, hospitalization, and even death. There are certainly other risks that could occur, and the rate and severity vary with different surgeons and their experience. A more accurate and detailed list can be provided by your surgeon based on the uniqueness of your exam and medical history. Related financial obligations should also be discussed prior to surgery with your doctor.

Anesthesia, Operating Time, Postoperative Instructions

The overwhelming majority of surgeons utilize a general anesthetic, and most surgeons feel that this is the safest approach. The time it takes to perform the procedure varies among surgeons and with the extensiveness of the procedure.

Postoperative instructions also vary with surgeons and should be carefully followed to increase the likelihood of a favorable result. Generally, sutures need to be removed, and your surgeon will need to carefully monitor the healing process and evaluate for the development of any potential complications. Make sure you keep all your scheduled follow-up appointments so your doctor can evaluate your healing process.

Drains: Often, surgeons will place small drainage tubes in each breast. These thin little tubes evacuate small amounts of postoperative oozing within the breasts into small collection containers outside of the body. This will help speed up your recovery process and the tubes will be easily removed on one of your post-operative visits.

Recovery Period:

It is common for patients to go home after breast reduction surgery although a short stay in a hospital or aftercare facility is sometimes preferred. The amount of discomfort varies greatly depending on technique, surgeon, and patient. One of the most important variables is the individual patient’s unique tolerance to pain. Some people have more pain than others. The average patient however is usually able to get back to a desk job in one to two weeks and the gym in 6 to 8 weeks.