Breast Reduction

Breast reduction (or reduction mammaplasty) is an enhancement procedure that reshapes the breasts in order to make them smaller, lighter, and firmer.  Reduction is accomplished by removing excess fat, glandular tissue, and skin.  Large breasts can cause physical pain as well as emotional and social anxiety.  Women who take advantage of the breast reduction procedure find that they are able to lead a healthier, more comfortable life, in addition to enjoying a beautiful, more proportionate appearance.

Reasons for Considering a Breast Reduction:

  • Back, neck or shoulder pain caused by heavy breasts.
  • Sagging breasts produced by their large size.
  • Disproportionate body frame attributed to oversized breasts.
  • Restriction of physical activity due to the size and weight of the breasts.
  • Painful bra strap marks and/or rashes as a result of large breasts.

Breast Reduction surgery is one of the most commonly requested operations in Plastic Surgery. It is a very similar operation to breast lifts (mastoplexy) but is typically a much more extensive procedure.

Q & A

With so many women wanting their breast enlarged, why would they want to have them reduced? Excessively large breasts (macromastia) can lead to, or aggravate, a variety of symptoms. The symptoms are related to the weight of the breasts and skin conditions caused by chronic moisture exposure. Simply put, having large heavy breasts is the same a strapping large water balloons to you chest using a bra. The weight leads to deep grooves in your shoulders from the tension on the bra strap. This tension is transmitted to your shoulders, upper back, and neck leading to muscle strain, and chronic discomfort or pain in these areas. The weight also “pulls” on the attachments of the breast to the chest leading to additional discomfort. The physical size of the breasts interferes significantly with many activities. The momentum transferred to the breast tissue results in bouncing and swaying that can amplify the discomfort associated with the weight of the tissue. Picture yourself trying to jog with large breasts and you can easily imagine how they might be functionally limiting. Limitations may be severe enough to interfere with activity that is an essential part of a weight loss program.
As if the weight were not enough of an issue, skin-on-skin contact at the border of the breast and the chest wall creates a chronically moist area. Most large-breasted women are forced to apply liberal amounts of powder to the area to help combat the moisture. Despite these precautions, fungal infections and chronic irritation of the skin are common. It is important to medically document any rashes or infections that require treatment in order to build a strong case for insurance reimbursement for the operation.
In addition to physical problems associated with macromastia, there are also significant emotional and psychological issues. Psychological problems can range from excessive self-consciousness and shyness, to an inability to form normal relationships. More severe emotional disturbances are typically associated with the onset of macromastia at an early age. In these crucial formative years, a patient’s interactions with the world can become defined by her breasts. Surgery can offer a new opportunity for socialization free from a long-standing stigma.

What needs to be changed in order to reduce the size of the breasts? If you look at a large pendulous breast from the side, it has a shape like “Snoopy’s nose”. The bulk of the breast volume collects in a round mass at the lower portion of the breast, and the nipple points down. For the breast to be re-shaped and reduced in size, three things must be changed: 1. The amount of excess skin; 2. The breast volume or weight; 3. The nipple position. Operations properly designed to reduce the breast must address all three variables.

The fact that skin needs to be removed from most large breasts is not immediately obvious to many people. The weight and size of the breasts gradually stretches the skin over time. Stretched skin will not shrink to fit a smaller volume as does the rubber on a balloon after air is let out. Instead, the excess skin sags even more and takes on the appearance of an “empty sack” – similar to photos in the National Geographic. In order to create a more normal breast shape, skin typically needs to be removed to fit the new, smaller, volume. Removing skin unfortunately leaves significant scars on the breast regardless of the technique used to perform the reduction. The pattern of the scars is one of the principle differences between techniques.
Decreasing the breast volume or weight is usually done by surgically excising it using the incisions in the skin to gain access. If the attachments of the ducts to the nipple are preserved, breast feeding can still be possible after the operation. In some patients who have a preponderance of fatty tissue in the breast, liposuction can adequately reduce the volume. Liposuction will not, however, reliably remove excess skin or change the nipple position.

In order to move the nipple to a higher position on the breast, an incision around the areola is used to detach it from the surrounding skin. Most women with large breasts also need reduction of the diameter of the areola at the same time. The nipple remains attached to the underlying breast tissue to preserve blood supply and to retain attachment of the nipple to the underlying milk ducts and sensory nerves. Less commonly the nipple needs to be completely removed from the breast and re-applied as a skin graft. This is known as a “free nipple graft” and is needed in patients having a long distance from the nipple to the natural crease between the breast and the chest wall.

There are many techniques used to accomplish all three of the above changes to reduce the size of the breast and reconstruct a more normal shape. Each technique differs principally in the location and size of the scars, and no single procedure is appropriate for every patient. Similarly, results using a given technique can differ significantly when performed by various surgeons.

How is the surgery done? This depends on the technique used. If the nipple position needs to be moved, a scar around the areola will be created regardless of the procedure. The principle difference in the more commonly applied techniques is in the pattern of the scars created by removing excess skin from the breast. Commonly used techniques include:

Liposuction: This is a procedure most appropriate for breast having a higher percentage of fatty tissue. It can reduce the weight of the breast, but relies on the reduced weight and unpredictable skin shrinkage to reduce the amount of skin and the position of the nipple. It is somewhat controversial as the sole means of accomplishing reduction of breast size, and is not appropriately applied to all patients.

Modified Wise Pattern: This is the most commonly used method of reducing breast size, and is considered the “gold standard” by which other procedures are compared. It has the longest track record of any operation, and reliably addresses all three of the “issues” involved in large breasts. The disadvantage of the technique is the significant scarring caused by removal of excess skin. Typically, there is a scar around the areola, a scar in the midline of the breast extending from the bottom of the areola to the infra-mammary fold (the natural crease between the bottom of the breast and the chest wall), and a scar along the infra-mammary fold itself.
Vertical or “short scar”

Mammaplasty: This technique differs from the Modified Wise Pattern by eliminating the scar in the infra-mammary fold. It is most suitable for smaller reductions and “gathers” skin in a “pucker” at the inferior limit of the midline scar on the lower portion of the breast. Results can be highly dependant on the level of experience of the surgeon performing it. Even in the most experienced hands, the breast initially has a highly abnormal shape which settles during subsequent months.

Peri-areolar Reduction: Small reductions can be done through an incision around the areola. A small amount of excess skin can also be removed with this approach, and the nipple position elevated. It is a technique most commonly used for mastopexy or “breast lifts”.

Is Breast Reduction covered by insurance? This depends on your insurer. Most insurers (including Medicare) will cover Breast Reduction as a reconstructive or medically indicated procedure. Other government-sponsored coverage such as the military’s TRICARE program also cover breast reduction. In the current insurance climate, most plans put great effort in avoiding coverage of as many procedures as possible. The only reliable means of determining if your carrier includes Breast Reduction as a benefit is to call them and ask.

Can I breast feed after a breast reduction? In approximately 40% of patients, the answer is yes. There is a chance that breast feeding may not be successful as with patients that have never had a reduction.

Will Breast Reduction change my mammogram? Yes, however this does not represent a problem. This issue has undergone extensive study and the changes in the mammogram do not create confusion in the detection of cancer. In patients old enough to need annual mammograms, they should be done prior to surgery to insure that no “surprises” occur during or after the operation. Abnormalities on a mammogram should be thoroughly evaluated prior to undergoing reduction mammaplasty. A new baseline mammogram should be done approximately six months after the surgery.

What are the risks of surgery? Most risks are the same as any operation and include bleeding, infection, wound separation, and fluid collections. Potential problems specific to Breast Reduction are: Loss of nipple sensation; necrosis and loss of part or all the nipple; asymmetry of the breasts; scar hypertrophy; and necrosis of fat within the breast. Serious complications are most common in patients who smoke due to poor wound healing and impaired blood supply to the tissues. The overall rate of significant complications is low and breast reduction patients are among the happiest in Plastic Surgery.

Can the breasts grow and require another operation? In patients who gain significant weight after surgery, the breast can increase in size due to increased fatty tissue volume. Similarly, if pregnancy occurs after Breast Reduction, the breasts can increase in volume as do breasts that have never been surgically altered. For this reason, Breast Reduction is ideally done on patients who have completed child-bearing. Younger patients who have not yet started a family are still good candidates for Breast Reduction depending on their degree of symptoms and motivation.

Can I have a Breast Reduction at the same time as a Gynecologic operation such as a hysterectomy, tubal ligation, or laparoscopy? The answer is yes for many types of gynecological surgery. Ask you GYN doctor if combined procedures are right for you.

Why would I want to combine these types of operations? Cost savings are realized by reducing the total operating time. If you are having gynecologic surgery for medically indicated reasons, there is usually a recovery time involved that includes time off of work. By having your breast operation at the same time as your gynecologic procedure, you can recover from both at the same time!


Additional information can be found on the following web sites:
plasticsurgery.org
surgery.org

To arrange a consultation, please call Aesthetic Surgery Associates at (254) 526-5106 or toll-free 1-866-232-0469