Women who have undergone breast reduction surgery are amongst the happiest of patients for they have literally had a “weight lifted off their chests.” Large, pendulous, painful, heavy breasts are a burden for many women and surgery to reduce the size of the breasts, though lengthy and complicated, is frequently sought for the physical and emotional relief it can bring.
Enlarged breasts frequently result in chronic neck, back and shoulder pain, deep groove marks in the shoulders, pain within the breasts themselves and frequent skin rashes and infections on the moist skin where the droopy breasts overlap the upper abdomen. Over time, this added weight can lead to chronic pain due to eventual deformities of the spinal skeleton. In younger women, very large breasts can hinder participation in sports. Finding appropriate and comfortable clothing, bras and bathing suits is also a continuing problem. And in all women, large breasts can invite undesired whistles, taunts and comments from men who unfortunately do not understand the reality of the situation.
Breast reduction surgery always involves removal of excessive breast tissue and skin, elevation of the nipples to a higher more youthful position and a lifting of the entire breast as well. The goal is breasts which are smaller, lighter, firmer, symmetric and lifted. It is a complex, demanding operation and should always be performed by an experienced, board certified plastic surgeon.
In the past, breast reduction surgery was unquestionably covered by insurance companies. At present, these companies are seeking to limit coverage by requiring a minimal amount of tissue to be removed at surgery (usually about one pound from each breast), requiring the patient to be on painkillers for a period of time prior to surgery (as though treating the pain would actually negate the need for surgery), requiring pre-operative photos to be submitted for surgical approval, requiring physical therapy to help back pain and thereby avoid surgery, etc. In sum, each policy is different and insurance coverage for this necessary surgery cannot be guaranteed.
At your initial consultation, an extensive discussion will cover every aspect of the proposed procedure. An examination will determine the health, size, shape and density of the breasts. Measurements of the breasts and nipple locations will be taken and recorded. Varying degrees of breast asymmetry will be addressed – surgery provides an excellent opportunity to make the breasts more symmetric Notation will be made of any additional fat deposits which should be treated, such as in front of the armpit or extending along the sides of the chest beneath the arms. Most important, there will be a thorough discussion as regards the desired final size of the breasts, for this must be in proportion to the remainder of your body.
Classic (“inverted T”) breast reduction: The gold standard for this surgery and proven for many years. There will be scars around the areola, then vertically downward from the areola to the fold under the breast and then continuing in both directions in the fold under the breast. It is used for larger breasts. A variation of this procedure, used for extremely large breasts, involves the use of a free nipple graft.
Next, there will be a description of the various surgical methods for the operation and the scars to be anticipated with each technique. Although there are a number of distinct surgical techniques, not every technique will be applicable for every patient. However, every procedure will leave permanent scars – and some techniques leave more scars than others. These scars will fade in time but will always be there. Therefore, the patient must be willing to accept the scars in trade for a more comfortable lifestyle.
The various surgical techniques will be diagrammed and each, together with its pros and cons, will be discussed in detail.
Vertical breast reduction: There will be scars around the areola and then extending vertically downward from the areola to the fold under the breast and perhaps continuing slightly further downwards beyond the fold. It is sometimes called a “lollipop” incision.
Peri-areolar breast reduction: There will be scars only around the edge of the areola.
One breast is noticeably smaller than the other.
Liposuction breast reduction (minimal scar) Best used for older women with soft, fatty breasts. Only a nick in the skin in the fold under the breasts is used. The downside is that there is only minimal lifting of the breast and nipple – the breast simply shrinks.
Combination liposuction and peri-areolar breast reduction: Liposuction, through a nick in the skin, is performed to shrink the breast. Then the breast is lifted and re-shaped through the peri-areolar technique.
Finally, there will be discussion about where and how the surgery will be performed. Many factors, such as age, general health, anticipated length of surgery, patient preferences, etc, will determine whether the surgery should be done in a hospital under general anesthesia or in the office surgical suite under sedation anesthesia. For most cases, this will be a 3 – 4 hour operation.
WHAT TYPE OF ANESTHESIA IS USED?
All operations in the office surgical suite are performed under sedation or “twilight sleep” anesthesia. The anesthesiologist will monitor your vital signs for your safety and administer small, frequent doses of a variety of medications through a vein. The result is a gentle, relaxed sleep while your operation is performed. There is no pain and no awareness and you will awaken quickly and comfortably in the operating room just minutes after the completion of surgery. There is usually no hangover or nausea afterwards.
Operations performed in the hospital are done under general anesthesia, which is administered by an anesthesiologist or nurse anesthetist. This is deeper anesthesia and recovery will be somewhat longer.
HOW IS THE OPERATION PERFORMED?
Photographs are taken prior to surgery. There will be extensive drawings on your breasts to guide the surgeon during the operation. You will be taken to the operating room and prepared for surgery. The surgery will be performed according to the chosen technique. If there are fat deposits in front of the armpit or extending around the sides of the chest, then additional liposuction will be performed on these areas. All wounds are closed with multiple layers of dissolving sutures on the inside so that there are no stitches to be removed afterwards – only some tapes on the skin. Drains may be utilized to remove any fluids that might collect inside the breasts. The procedure takes about 3-4 hours to perform. At the end of the operation, you will be placed in a post-operative bra and brought to the recovery room.
WHAT CAN I EXPECT AFTER SURGERY?
You will have some soreness and tenderness of the breasts, which will last for several days. Appropriate pain medication will be provided. There will also be some bruising and swelling of the breasts which will disappear within 1-2 weeks. Recovery takes about 7-10 days although there is considerable healing during the ensuing months as well. You may drive a car within one week and perform only sedentary activities for two weeks. Strenuous exercise training can be resumed in one month.
Dr Jacobs will schedule several post-operative examinations after your procedure.
WHAT CAN I EXPECT IN THE LONG TERM?
Amazingly, within a week after surgery, your body image in your brain will change and you will accept your new breast size as if you had always been that size!
Your breasts will still be swollen for a while, so please defer shopping for new bras and bathing suits for a few weeks. The final shape of your breasts will take at least three months to be seen and there will always be some relaxation of the tissues – and perhaps even some slight droop – when everything is healed. You should wear a bra at all times and in particular, a strong support bra when participating in sports or exercise.
The scars will be red initially and then fade to pink and eventually to white – this may take anywhere from 6 to 24 months. Sometimes the scars may thicken and Dr Jacobs may treat this with injections or prescribed skin creams. Strong sunblock should be applied to the scars for a year – even if you are wearing a bathing suit.
You are encouraged to have a post-operative mammogram anytime between six months and a year after your surgery. This will establish a baseline “normal” mammogram so that any future mammograms can be compared to it.
You should return for routine follow-up examination on an annual basis. Any changes in your breasts in-between scheduled appointments should prompt a call to our office.
FREQUENTLY ASKED QUESTIONS
Is there an added risk of cancer if I have had breast reduction surgery? Absolutely not!!! There is no added risk of breast cancer if you have breast surgery – but you must be aware that breast cancer remains a risk for all women and that periodic self-examination, physician examination and mammograms are essential.
Can I become pregnant if I have had a breast reduction? Yes! Having had breast surgery does not affect your ability to become pregnant. Bear in mind, though, that women sometimes have trouble becoming pregnant, regardless of whether they have had breast surgery. Remember, too, that your reduced breasts will naturally become larger during the course of your pregnancy and you should wear a good support bra – otherwise the breasts may stretch out and droop again.
Can I nurse a child if I have had a breast reduction? During the course of breast reduction surgery, some of the milk ducts may be interrupted and may adversely affect your ability to nurse. Some breast reduction techniques, such as the peri-areolar technique, do preserve breast tissue continuity more than others. Remember, some women may have an inability to nurse regardless of whether or not they have had breast surgery.
Will I still maintain sensation in my nipples? During the course of breast reduction surgery, some of the nerves providing sensation to the nipples may be interrupted. Fortunately, there are a great many small nerve fibers which provide nipple sensation so if some are lost, the others will “take over.” Immediately after surgery, sensation may be diminished but it usually returns, to some extent, in the majority of patients. In some cases there may be permanent diminished sensation.
I have had a breast reduction already and am unhappy with the scars. Can anything be done about this? Once there are scars on the breasts, they are permanent and no-one can remove them. However, sometimes improvement of the scars can be obtained through scar revision surgery.
I had a pregnancy after breast reduction surgery and my breasts have drooped again. Can something be done about this? Yes, a second breast reduction or just a breast uplift can be performed. It would be more difficult to perform due to the natural scarring that occurs after any prior surgery. It would also be very helpful for you to bring a copy of the original surgeon’s operative report to our initial consultation.
Must I stop smoking prior to breast reduction surgery? Absolutely!!! You must stop smoking at least two weeks prior to and two weeks after the operation. Failure to do so will substantially increase your risk of complications. No nicotine patches or gum either – they contain nicotine which is the main cause of the problem.