Breast reduction, or reduction mammoplasty (RM), is one of the most commonly performed plastic surgery procedures. Macromastia, or large breasts, can cause a host of signs and symptoms, including back and neck pain, breast pain, decreased sensitivity of the breast and nipple areola complex, shoulder, arm and hand pain, painful bra grooves, as well as unpleasant rashes and itching between skin folds. Furthermore, patients with very large breasts can find simple activities such as running and playing sports challenging, and finding properly fitting clothes equally daunting.
Along with the relief afforded by reducing the volume and mass of the breast, RM can also significantly lift sagging breasts, resulting in much more attractive breasts. Large nipples may be reduced at the same time, further improving the overall appearance of the breasts. Given that this surgery usually results in significant relief of symptoms and the fact that RM may also enhance the appearance of a patient’s breasts it is not surprising that multiple scientific studies have documented significant improvement in a woman’s quality of life as a result of RM.
Determining the indications for breast reduction is one of the most complex issues facing the plastic surgeon and their patients. In theory, the indications are quite simple, as anyone who wants their breast reduced and lifted is a candidate for breast reduction. Any patient who wants a lift but does not desire to be smaller is a candidate for breast lift. The complexity arises in attempting to justify such surgery for insurance companies. Each insurance company defines who is a candidate based on their own, often different, criteria. Some insurance companies have gone so far as to exclude all breast reductions from coverage. Therefore, in many cases 3rd party payers actually have a significant impact on the indications of the procedure that go beyond the doctor/patient relationship.
Any patient whose breast size is out of proportion to their body shape and size, especially with associated pain and discomfort, are candidates for breast reduction. However, the determination of whether the breast size is out of proportion to the body size can be controversial. Many people agree that at some point large breasts produce predictable symptoms: neck and shoulder strain, headaches, persistent rashes in the crease under the breasts, heaviness in the chest, and numbness and tingling in the arm extending down into the pinkie and ring fingers. On physical examination, these women tend to have bra strap grooving in their shoulders, poor posture, stretch marks on the breasts, and skin rashes and irritation in the breast crease.
There are many studies that show significant improvement in physical and psychosocial characteristics in such patients after breast reduction surgery. Psychological improvement in a woman is hard to quantify, but most patients undergoing the procedure, as well as the physicians who treat them, feel that a woman’s self esteem and overall happiness are significantly improved with this procedure. Interestingly, studies have shown that the breast volume and the patient’s age and weight before surgery are not predictable factors in determining the benefits from surgery. Studies also suggest that the symptoms alone are enough to justify performing the procedure. Some studies have shown also that non-surgical physical therapy and weight loss do not result in long-term resolution of symptoms.
The indications for a breast lift without reduction focus purely on excess breast skin, which produces droopiness (ptosis) of the breast. Breast ptosis is measured by 2 different scales. The Baker classification system involves comparing the nipple position in the upright position compared to the breast fold. An imaginary line at the lower portion of the breast fold is compared it to the nipple location producing 4 grades of ptosis. Pseudoptosis or false ptosis describes a breast that looks somewhat droopy, with some hollowness in the upper pole yet the nipple remains above the inframammary fold line.
The goals of breast reduction include improving physical symptoms while also achieving an improvement in the aesthetic appearance. For breast lifting alone, the goals are solely cosmetic. One goal for both procedures is to minimize scarring. Though some amount of scarring is unavoidable with breast lifts or breast reductions, patients should review a number of example postoperative photographs to be sure these scars are acceptable.
Importantly, there is no strictly objective definition of macromastia; it is more appropriate to apply the term subjectively; that is when a patient feels that her breasts are large enough to cause symptoms that interfere with her quality of life. However, some insurance companies will refrain from approving breast reduction procedures unless a minimum of 500g (about 1lb) per breast is removed, despite scientific evidence that proves that reductions even smaller than that can result in significant improvement for appropriately selected patients. Patients should know that nipple sensation is often decreased in the early post-operative period but usually returns to baseline in the ensuing weeks to months. Studies have shown that women who have breast reduction have the same rate of successful breast feeding (between 60-70%) as those women who have never had surgery. Finally, all women who are planning to have breast reduction should have a mammogram before their surgery if they are 40 years old (although some plastic surgeons will get one in women as young as 35).
Smokers are at risk for delayed healing or skin loss as both nicotine and carbon monoxide diminish oxygen carrying capacity of red blood cells and therefore put all of the tissue at risk for viability. In addition, patients with uncontrolled systemic medical problems (hypertension, heart disease, diabetes, chronic lung disease) are poor candidates for operative procedures.
Your surgeon will plan (“mark”) your incisions while you are in the standing position so that the greatest effects of gravity can be seen. In general there are two approaches to removal of excess skin: the “short scar” approach in which incisions are made around the areola and down the front of the breast only (“lollipop incision”), and the more traditional “wise pattern” in which in addition to the lollipop, the incision extends under the entire length of the breast (“inverted T” incision). Nearly all patients who are candidates for breast reduction also have breast ptosis, or sagging of the nipple/areola below an aesthetically pleasing position. In a breast reduction, the nipple/areola is moved to a higher and more aesthetically pleasing location. In most cases the nipple and areola are not detached from the underlying breast tissue but are moved along with it. Only in the very largest reductions (usually more than 3 lbs per breast) will the surgeon detach the nipple and areola completely then replace it in its new higher location. In select patients, liposuction alone can be used to reduce the breast, although it is more commonly used in association with an incisional procedure in order to provide better contour on the outside of the breast.
Breast reduction is usually performed under general anesthesia. Since patients will be placed in the sitting position during surgery so that the surgeon can best assess the size and symmetry of the reduced breasts, the ability to breathe must be maintained with the use of a breathing tube. Studies have shown that placing long acting local anesthetic in the breast at the end of the surgery will reduce the need for post-operative pain medications.
The smaller the patient’s breast size is postoperatively, the longer the results will last. Since heavier parts of the body tend to droop more quickly, larger breasts droop more rapidly smaller ones. This results also in a loss of skin elasticity. Therefore the skin of the breast cannot be expected to maintain a perfect youthful shape over time. That being said, the breast shape after such surgery should be much improved over the pre-operative condition for the remainder of the patient’s life, providing conditions that would cause further enlargement of the breasts (pregnancy, significant weight fluctuations) do not occur.
Postoperative bruising after breast surgery can be expected to resolve over a 2-3 week period. Discomfort is greatest in the first 3 days, with a diminution over the first week and near complete resolution through the third week. In most cases, one can expect to return to work with a breast lift or breast reduction in 7-14 days. However, a full recovery with return of energy can be expected at 6 weeks. Return to light physical activity is permitted at 2 weeks, with a slow, steady increase to normal activity by 4-6 weeks.
Breast reduction is now performed routinely as an outpatient procedure, although some surgeons will suggest an overnight stay for very large reductions. The surgery will usually take between 2-4 hours. You may be put into a post operative bra after surgery, although different surgeons have different post-operative practices. You will be able to eat and drink normally, likely starting the day after surgery. Finally, you may be discharged with a drain in each breast, which would be removed at your first post-op visit. Breast reduction patients usually notice an improvement in their macromastia related symptoms as soon as they wake up from general anesthesia. Decreased sensation or even numbness of the nipple/areola is common in the early post-op period, although this usually returns to pre-operative levels within weeks to months.
Side effects of breast reduction or breast lift surgery include those of all surgery, including infection and bleeding. These typically occur at a rate of 1-2% or less. Complications unique to this surgery include skin loss, loss of sensation of the nipple/areola complex, asymmetry of the breasts, poor cosmetic outcome, and unsightly scarring. The scarring location is predictable, but the quality of the scar is unpredictable, even in the best of hands. Despite this, scars in most patients are very acceptable, and the trade off for shape and improvement in symptoms are well accepted by the overwhelming majority of patients.
There are no good non-surgical alternatives for significant breast droopiness or hypermastia. There are ways to reduce breast volume with liposuction, cryolipolysis (cool sculpting/Zeltiq), or high frequency ultrasound techniques, but these remain unproven. Any procedure that involves reducing breast volume without skin tightening will result in more breast droopiness because skin laxity remains. Quite simply the amount of skin that needs to be removed and tightened cannot be addressed with current non-invasive technology.
With any surgery, the major risks are infection and bleeding. Breast reduction is a clean procedure done under sterile conditions and therefore the risk of infection is very low. The incisions tend to heal well, but may widen or hypertrophy. In the traditional or “Wise Pattern” reduction, the inner and outer extent of the scars may be visible outside of the bra/bikini line. Necrosis (death) of the areola or nipple is a rare but feared complication of breast reduction that is more likely to occur in patients who smoke or who have very large reductions. Other less devastating but problematic complications involve uneven size and shape, improper position of the nipple/areola, and excess skin at the outer aspect of the incision (“dog-ears”).
Breast reduction is a commonly performed reconstructive procedure that has been shown to result in significant improvement in patients’ macromastia related symptoms and overall quality of life. As an additional bonus, most breast reductions result in an improved appearance of the breasts as a result of returning the nipple areola complex to an aesthetically pleasing position and the removal of excess skin.
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