Breast Procedures

Breast Reduction

Also known as reduction mammaplasty

The goal of breast reduction surgery is to reduce the size of your breasts and reshape them so that they are proportionate to the rest of your body and are no longer a source of physical discomfort. This commonly requested, predictable procedure has the dual benefits of improving your appearance while relieving the physical and emotional burden of overly large breasts.

When to Consider Breast Reduction

• If your breasts are too large for your body frame and create neck, back, or shoulder pain
• If you have heavy breasts with nipples and areolas (pigmented skin surrounding the nipples) that point downward
• If one breast is much larger than the other
• If you are unhappy and self-conscious about the large appearance of your breasts

Considerations

Pros

• Your breasts will be in better proportion with your body and will feel firmer.
• Surgery will alleviate neck, back, and shoulder pain and make it easier to breathe and exercise.
• Your clothes will fit better and you will feel more confident about your appearance.

Cons

• You may have decreased sensation in some areas, including the nipples and areolas.
• Some women complain that their breasts and nipples look slightly uneven.
• Breast-feeding may be a problem.

These are the top three pros and cons to weigh when considering breast reduction. If you want to focus on those specifically unique to you, please consult with your aesthetic plastic surgeon.

Are you a good candidate for a breast reduction?

Women who seek breast reduction often have had children, are overweight, have a predisposition for large, disproportionate breasts, or are sensitive to estrogen. Big breasts often run in a family, inherited from mothers and grandmothers.

Following are some common reasons why you may want to consider breast reduction:

• You have backaches, neck aches, or skin irritation under your breasts.
• You have difficulty breathing and notice grooves in your shoulders from your bra straps.
• You have poor posture or numbness in parts of your breasts and upper chest from excessive breast weight.
• You find it nearly impossible to buy dresses and blouses and difficult to find tops that fit.
• You are very unhappy with your appearance because of your breast size.
• You are in good health with no active diseases or pre-existing medical conditions.
• You have realistic expectations of the outcome of your surgery. You must be able to discuss what you want with your plastic surgeon so that you can reach an understanding of what can realistically be achieved.
• Your skin has adequate elasticity, so it can resume its former tightness following surgery.
• You are mentally and emotionally stable. Breast reduction requires patience and stability to deal with the healing period.
• You are old enough so that your breast development has stopped.
• You have finished having children and breast-feeding, because this can have significant and unpredictable effects on the size and shape of your breasts. Nevertheless, many women decide to undergo breast reduction before having children and feel that they can address any subsequent changes later. If you plan to breast-feed in the future, you should discuss this with your plastic surgeon

A history of irregular mammograms, undiagnosed lumps or other types of masses, severe obesity, diabetes, wound healing disorders, current breast-feeding, smoking, clotting disorders or a family history of them, and heart or circulatory disorders are all contraindications for breast reduction.

If you are in good general health and have a positive attitude and realistic expectations, you are most likely a good candidate for this procedure.

Detailed Procedural Info

How is a breast reduction procedure performed?

Breast reduction surgery, which usually takes from three to five hours, is performed in a hospital or surgical center. An overnight stay is not usually required. The surgery commonly involves three incisions. After the surgeon removes excess breast tissue, fat and skin, the nipple and areola are shifted to a higher position. The areolas may be reduced in size. Skin that was located above the nipple is brought down and together to reshape the breast. Liposuction may be used to improve the contour under the arm.

• Your surgeon will use a surgical marker on your skin to indicate where the incisions will be. These markings are especially important, because your breasts change shape once you are lying on your back on the operating table.
• Most surgeons prefer general anesthesia for this procedure. A few may perform breast reduction with intravenous sedation, also known as “twilight sedation.”
• Your incision pattern will depend on the size of your breasts, how much your breasts sag and where your nipple-areola complex is positioned. With each technique the areolas can be made smaller if they’re too large. An areolatome, more commonly known as a “cookie cutter,” is used as a circular template to make the new areola size. The cookie cutter diameter ranges from thirty-eight to forty-five millimeters. Here are some commonly used incision patterns:
  • Microincisions are used for breasts that are fatty (not fibrous) and not sagging. Liposuction is used to decrease breast size. Small incisions allow the liposuction cannula (tube) to enter the breast.
  • A donut incision, or periareolar incision, is made solely around the border of the areolas.
  • A keyhole incision, also known as a lollipop incision, is made around the border of the areolas and vertically down from the areolas to the breast crease.
  • An anchor incision, the most common technique used by plastic surgeons, involves three distinct cuts. One incision is made around the border of the areolas; the second extends down vertically from the areolas to the breast crease and merges with a third incision along the breast crease.
• Your surgeon will remove excess breast skin and fat with a scalpel and/or cautery instrument based on the size breast you desire. If your breasts are asymmetrical (or uneven), the surgeon may remove more tissue from one breast than the other. He or she will then reshape the remaining skin and fat to create a more youthful breast shape and move the nipple-areola complex to a higher position.
• In most cases, drains will be placed in the breasts to collect excess fluid.
• Breast incisions are then closed with sutures that go from the deep tissue layers to the more superficial layers (the skin).

The goal of your aesthetic plastic surgeon and the entire staff is to help you achieve the most beautiful and natural-looking results, as well as to make your surgical experience as easy and comfortable as possible.

What are my options?

The size and shape of your breasts and how much reduction you desire are factors that will help your plastic surgeon determine the best technique for you. In some cases, it will be possible to avoid the vertical incision that runs from the bottom edge of the areolas to the breast crease or the horizontal incision underneath the breast (typical components of the anchor incision). Rarely, if your breasts are extremely large, the nipples and areolas may have to be completely detached before they are shifted to a higher level. In such a case, you will have made the decision to sacrifice sensation and the possibility of breast-feeding to achieve your desired breast size. Another breast reduction option, which is appropriate only in a select group of women, is liposuction alone.

Liposuction for breast reduction
Breast liposuction may be right for you if you have fatty breasts, need a minor-to-moderate reduction, and do not need to correct sagging. Here are some considerations:

• Results may be acceptable for women who need significant reduction but do not want the scars and loss of sensation and are willing to accept some sagging.
• With the onset of menopause, breast tissue is gradually replaced by fat, so postmenopausal women are among the best candidates for liposuction-only breast reduction.
• Patients with fibrous tissue and minimal fat in their breasts are not good candidates.
• Ptosis (sagging), poor skin condition with little tissue elasticity, and low nipple position are also contraindications.
• Liposuction alone may be used to treat asymmetry up to one cup size.
• Following liposuction of the breast, the elastic qualities of the skin cause it to contract, and subsequent uplifting of the breast contour should occur to some extent.

What will my breast reduction incisions and scars be like?

These vary according to type of incision your aesthetic surgeon suggests for you. Your surgeon can conceal some incision lines in natural breast contours, but others will be visible on the breast surface. Although incision lines are permanent, in most cases they will fade and significantly improve over time. Aesthetic plastic surgeons make every effort to hide and minimize scars, with the goal of achieving the desired results with the shortest possible scar. Special tissue handling and suture techniques further minimize scars.

1. This common anchor incision follows the breast’s natural contours and defines the new location for the nipple.
2. Once breast tissue, fat and skin are removed, the skin is brought down and together to reshape the breast.
3. Large breasts that sag can cause back pain and other physical and emotional discomfort.
4. After surgery, breasts will be in proportion to your body and scars will fade over time.

Selecting a Surgeon

Select a surgeon you can trust

It’s important to choose your surgeon based on:

• Education, training and certification
• Experience with breast reduction surgery
• Your comfort level with him or her

After finding a board-certified plastic surgeon in your area who is experienced in performing breast reduction, you will need to make an office appointment for your consultation. Generally, because of the in-depth nature of the consultation, there is a cost associated with the initial visit.

Your initial consultation appointment

During your initial consultation, you will have the opportunity to discuss your cosmetic goals. Your surgeon will evaluate you as a candidate for breast reduction and clarify what a breast reduction surgery can do for you. Once your surgeon understands your goals, he or she may suggest additional or related procedures such as breast lift, liposuction, or an upper body lift.

Your plastic surgeon will examine, measure, and photograph your breasts for your medical record. Your surgeon will consider:

• The current size and shape of your breasts
• The breast size and shape that you desire
• The quality and quantity of your breast tissue
• The quality of your skin
• The placement of your nipples and areolas

You should come to the consultation prepared to discuss your complete medical history. This will include information about:

• Past and present medical conditions
• Drug allergies and current medications
• Medical treatments you have received
• Previous surgeries, including breast biopsies
• Family history of breast cancer
• Current mammogram results

If you are planning to lose a significant amount of weight, be sure to tell your plastic surgeon. The surgeon may recommend that you stabilize your weight before undergoing surgery.

If you think that you may want to become pregnant in the future, discuss this with your surgeon. Pregnancy can alter breast size in an unpredictable way and could affect the long-term results of your breast reduction.

Your treatment plan

Based on your goals, physical characteristics, and the surgeon’s training and experience, your surgeon will share recommendations and information with you, including:

• An approach to your surgery, including the type of procedure or combination of procedures
• The outcomes that you can anticipate
• Your financial investment for the procedure
• Associated risks and complications
• Options for anesthesia and surgery location
• What you need to do to prepare for the surgery
• What you can expect to experience after surgery
• Show before-and-after photos of cases similar to yours and answer any questions

Questions to ask your aesthetic plastic surgeon

For a general list of questions to ask your surgeon about his or her background, to find out about plastic surgery safety, and to plan your procedure. We developed these questions to help you:

• Make the most informed and intelligent decisions about your procedure.
• Confirm that you have the right surgeon for your procedure.
• Make your initial consultation as rewarding and productive as possible.
• Understand your options, potential outcomes and risks.

It is important for you to take an active role in your surgery, so please use this list of questions as a starting point for your initial consultation.

• Am I a good candidate for a breast reduction?
• Are the results I am seeking reasonable and realistic?
• Do you have before-and-after photos I can look at for the procedure I am undergoing?
• Will my scars be visible? Where will my scars be located?
• What kind of anesthesia do you recommend for me?
• What will be the costs associated with my surgery?
• What will you expect of me to get the best results?
• What kind of recovery period can I expect and when can I resume normal activities?
• What are the risks and complications associated with my procedure?
• How are complications handled?
• What are my options if the cosmetic outcome of my surgery does not meet the goals we agreed on?

Preparing for Your Procedure

How do I prepare for a breast reduction procedure?

Your surgeon will provide thorough preoperative instructions, answer any questions you may have, take a detailed medical history and perform a physical exam to determine your fitness for surgery.

You may be asked to have a mammogram (if you’re over forty years of age), electrocardiogram (ECG) or chest x-ray. If your surgeon recommends weight benchmarks or lifestyle changes, do your best to achieve them to ensure the best results and minimize the chance of complications.

In advance of your procedure, your surgeon will ask you to:

• Avoid taking aspirin, certain anti-inflammatory drugs and some herbal medications that can cause increased bleeding.
• Stop smoking at least six weeks before undergoing surgery to promote better healing.
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery and critical outcomes.
• Keep alcohol consumption at less than two to three drinks per week.
• Before surgery, stock your refrigerator with high-protein, low-sodium foods, including premade meals, fresh fruits and vegetables and lots of caffeine-free beverages and water. Avoid food and drink containing salt during your recovery.
• As you heal, your arms will have a limited range of motion, so store all the supplies you’ll need during recovery where they’re easily accessible (at counter level, not in overhead or very low cabinets).
• Stockpile movies or prerecorded programs and novels and magazines. If possible, have a speaker phone by your bed and a remote control for the TV.
• Establish a no-fail support system for the full recovery period indicated by your surgeon. This is most critical to your recovery. If you have children less than five years of age, you must have someone to take care of them for a week or two. You must not lift, drive or do laundry and cleaning for the first two weeks.
• Rest and sleep on your back continuously in an inclined position (25 to 45 degree angle) for the initial postoperative days or while significant swelling remains. You can achieve elevation with wedge pillows with an incline design or by sleeping in a recliner chair.
• Avoid hot showers, hot tubs and saunas for two to three weeks.
• Decide what you will wear for the first few days; pick items that open in front. Wear slip-on shoes so you don’t have to bend.

Breast reduction surgery is usually performed on an outpatient basis. Be sure to arrange for someone to drive you home after surgery and to stay with you at least the first night following surgery.

What can I expect on the day of my procedure?

Your breast reduction surgery may be performed in an accredited hospital, free-standing ambulatory facility or office-based surgical suite. Your surgeon will give you an estimate of how long your surgery will last based on the details of your surgical plan.

• You may be asked to wash your body with antibacterial soap prior to surgery.
• Make sure not to wear cosmetics (including nail polish), lotions, perfumes or other substances.
• Dress in or bring soft, comfortable clothes that you’ll be able to wear after the surgery, including a top that opens in the front and shoes that slip on.
• Bring only the essentials (ID, insurance card, cell phone, etc.) and leave other personal belongings such as jewelry at home.
• Medications are administered for your comfort during the surgical procedure.
• General anesthesia is commonly used during your breast reduction procedure, although local anesthesia or intravenous sedation may be desirable in some instances.
• For your safety during the surgery, various monitors will be used to check your heart, blood pressure, pulse and the amount of oxygen circulating in your blood.
• Your plastic surgeon will follow the surgical plan discussed with you before surgery. Once the operation has begun, the surgeon may decide to combine various techniques or change a technique to ensure the best result. It is important that you feel comfortable and trust your doctor to make these decisions.
• After your procedure is completed, you will be taken into a recovery area where you will continue to be closely monitored.
• Following the surgery a bulky gauze dressing (bandage) will be wrapped around your breasts and chest or you might wear a surgical bra. Drainage tubes may be attached to your breasts.
• Before leaving for home, you (or someone looking after you) should feel capable of emptying and resetting the drains.

You will probably be permitted to go home after a short observation period unless you and your plastic surgeon have made other plans for your immediate postoperative recovery.

Aftercare and Recovery

Your surgeon will discuss how long it will be before you can return to your normal level of activity and work. After surgery, you and your caregiver will receive detailed instructions about your postsurgical care, including information about:

• Drains, if they have been placed
• Normal symptoms you will experience
• Potential signs of complication

Immediately after your breast reduction surgery

• If you’ve had general anesthesia, you might wake up feeling disoriented.
• You will have a surgical dressing over your upper chest and will probably have drains coming from each breast.
• You may have compression sleeves on your legs to help with circulation
• You will feel discomfort, but your medication will keep you from feeling pain.
• After the hospital staff observes you for a few hours it is likely that you will be allowed to go home, where you will need someone to care for you for the next few days.
• Before the hospital or surgical center releases you, they will show you how to care for your incisions, instructing you on how frequently to change the bandages and how to empty your drainage tubes.
• When the anesthesia wears off, you may have some pain. Any discomfort can be controlled with pain medication. If the pain is extreme or lasts long, contact your physician.
• You might notice a change in breast size, but at this point you will have significant swelling. In most cases, this swelling will remain for weeks or even months.

When the anesthesia wears off, you may have some pain. If the pain is extreme or long-lasting, contact your physician. You will also have some redness and swelling after the surgery. Contact your surgeon to find out if your pain, redness and swelling are normal or are signs of a problem.

Recovery time frame after breast reduction
It is vitally important that you follow all patient care instructions provided by your surgeon. This will include information about wearing compression garments, care of your drains, taking an antibiotic if prescribed and the level and type of activity that is safe. Your surgeon will also provide detailed instructions about the normal symptoms you will experience and any potential signs of complications. It is important to realize that the amount of time it takes for recovery varies greatly among individuals.

Here is a general idea of what you can anticipate:

• Your drains will more than likely be removed at your first follow-up appointment, which is usually within the first week after surgery.
• Incision care. Keep your incisions/suture line dry. Your surgeon may have placed Steri-Strips on top of your incision line and sutures, or you may have sutures internally and tissue glue externally to bind your incision edges. Either way, your surgeon will give you specific care instructions at your preoperative appointment or send them home with you the day of your surgery. It is best to understand it all beforehand so that your spouse, friend or caretaker will understand and assist you instead of having to learn the routine at the last minute. Be careful not to get creams, lotions or topical Arnica into the incision, because these can cause inflammation.
• Suture removal. Your incision sites will be checked and your stitches removed in approximately ten days.
• Monitoring your temperature. While you are healing from breast reduction, take your temperature regularly. An elevated temperature could mean an infection.
• Soreness and pain. You will feel tender, stiff and sore for a few days and will more than likely not want to move too much. This will subside. Be sure to take your required medications and follow the precise instructions provided by your surgeon. You may be given a pain pump; pain pumps deliver pain medications directly to the area of treatment and effectively relieve discomfort without making you groggy. Not all surgeons offer this option, so be sure to ask about it.
• As with all surgeries, swelling will be an issue. You may be swollen for up to three to four months, although this could be very slight and only noticed by you. Your breasts, of course, will be smaller than they were before and higher, so you may not notice swelling too much. Treatment for prolonged swelling includes increasing your fluid intake (preferably water), having normal to low sodium intake, and movement, such as light walking.
• Bruises may or may not be present after your surgery. This depends entirely on the patient, the technique used, and the effectiveness of the epinephrine that was administered during surgery. Other common side effects during recovery include numbness or changes in nipple sensitivity, itching around incision sites, and increased firmness or fullness in the breast tissue. These side effects should subside over the next few weeks, with some residual effects lasting up to three months after surgery.
• It is important to sleep with at least two or three fluffy pillows under your upper back and head, or on a wedge pillow or a recliner chair, to keep your torso elevated. This helps relieve pressure on your treatment area, reducing swelling and pain. Many patients place a pillow under their knees to prevent rolling over during the night. They also place pillows alongside them to create a sort of recovery nest.
• You may be asked to take sponge baths until your incisions are completely closed and your sutures are no longer in place. You may not be able to wash your hair for a while, because you will not be allowed to raise your hands over your head. If you must wash your hair, have a friend assist you in the sink or basin or with a handheld showerhead.
• Even though you may not feel like it, your surgeon will probably advise you to walk and move around as soon as you can to prevent blood clots and swelling. You will be instructed not to exercise or engage in strenuous activities for at least three to four weeks. Don’t lift anything over five pounds and try not to raise anything over your head until your surgeon releases you for activity. Take your time in healing so that you give yourself the best healing environment possible. Your full range of motion should return between six to ten weeks, depending on how well you have healed. Within six months, you should be able to do all those things you wanted to do but couldn’t because of your oversized chest.

How Long Will the Results Last?

Unless you gain or lose a significant amount of weight or become pregnant, your breasts will remain a consistent size. However, gravity and the effects of aging will eventually cause your breasts to loosen and sag over time.

Maintain a relationship with your aesthetic plastic surgeon
For safety, as well as the most beautiful and healthy outcome, it’s important to return to your plastic surgeon’s office for follow-up evaluation at prescribed times and whenever you notice any. Do not hesitate to contact your surgeon when you have any questions or concerns.

Associated Costs

The cost of a breast reduction varies from doctor to doctor, from one geographic area to another.

Your health insurance may cover your breast reduction based on their assessment of your medical necessity for the procedure. Your board-certified plastic surgeon will be able to provide the necessary documentation. Each insurance company has their own criteria and these criteria change based on the specific plan you have with them. All insurance companies, however, evaluate you for breast reduction surgery based on set criteria for height, weight, body surface area and body mass index (BMI).

Choose your surgeon based on quality, training and experience—not cost

Limitations and Risks

Fortunately, serious risks of breast reduction surgeries are rare and the satisfaction rate with these procedures is high. The overall complication rate is small if the operation is done by an experienced plastic surgeon operating in an accredited facility.

All surgical procedures have some degree of risk. Some of the potential complications of all surgeries are:

• Adverse reaction to anesthesia
• Hematoma or seroma (an accumulation of blood or fluid under the skin that may require removal)
• Infection and bleeding
• Changes in skin sensation
• Scarring
• Allergic reactions
• Damage to underlying structures
• Unsatisfactory results that may necessitate additional procedures
• Blood clots in the legs or lungs

You can help minimize certain risks by following the advice and instructions of your board-certified plastic surgeon, both before and after your breast reduction.

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