BREAST REDUCTION (Reduction Mammaplasty)

 Background
 Patient Groups
 Patient Concerns and Planning
 Preparing for Surgery
 The Operation
 Recovery
 At Home
 Office Visits and Follow-up
 Outcome and Complications
 Case Histories (Before and After)

PATIENT CONCERNS AND PLANNING
1. The typical patient who seeks breast reduction surgery is concerned that the breasts are made sufficiently smaller to make the effort worthwhile. Thus, a smaller more comfortable cup size is the primary goal for the patient. Many patients may comment that they are done with large breasts of DD cup size and beyond, and may prefer something in a C range. Often the body habitus or frame size and body fat distribution will not permit reduction into a small C range, as the operated breasts may look widely under-proportion to the remainder of the body. This is where a review of case result photographs can help the prospective patient understand what is possible with minimal to more significant breast reductions. The patient can decide what is most appealing and if is both possible and practical for their particular body type. A discussion of the patient's skin quality and breast consistency is critical in predicting the overall quality and duration of the lifting component of the reduction operation.

Patients who are overweight and have not done much to seek weight loss are strongly recommended to lose weight both to improve anesthesia safety and facilitate a smoother operation for the surgeon. Women with dense heavy breasts and a lesser fatty component will often state that no matter what their weight has been, the breasts seem to stay about the same size. These patients can ordinarily lose weight after breast reduction and not fear major loss of breast volume thereafter. Women with high body fat may experience a reduction in breast volume if they lose considerable weight following operation.

2. BREAST SHAPE is an important issue for patients. Some women want a dramatic reduction in volume such that projection and particular remaining fullness in specific areas is not so important. Most patients, on the other hand, as with the women seeking a breast lift are hoping they can have the maximum amount of fullness in the upper chest and cleavage area, and that their small to large breast reduction can accomplish this. A discussion of whether implants may be necessary in achieving more lasting fullness in the upper chest is made. With the wide array of presenting shapes and sizes, it is important to convey to the prospective patient what may be expected but that the surgery cannot be perfectly planned to deliver one shape or another. In patients who desire the least scar possible and are candidates for minimal to moderate breast reduction, a periareolar purse string approach can be offered. There is some rounding of the breast cone such that a pointed highly projecting breast shape may not be possible unless the patient has exceptionally dense breasts and thick elastic skin. For those patients with heavy pendulous breasts and marked stretch lines plus loose skin, they must be cautioned that some stretch will occur over time. A secondary lift or adjustment may be necessary in patients with this type of breast quality.

The breast taping test is performed at consultation to help gather and assemble the long pendulous breasts into a more reasonable shape. It is at this time that the patient comments about shape and volume. If the breasts are fatty with thin elastic skin, often the tape test alone will compress the breasts 1-2 cup sizes smaller which reflects more of an indication for lifting with minimal reduction. In the patients with dense full breasts, the tape test will demonstrate a more pleasing nipple position higher on the breasts but the patient will reflect that the breasts are still too large. This person will therefore require a minimal to large reduction. If the overall shape and weight is considerable and the surgeon anticipates that over 600 grams of breast tissue is to be removed from each breast, the choice of operations can change. The minimal scar purse string method is not suitable for the largest reduction cases. In this situation, either a Vertical (lollipop scar) or Wise pattern or free hand (T scar) reduction approach is suggested. For the massive breast hypertrophies, one of those methods or even a free nipple transfer is discussed with the patient. A review of the changes that can evolve after operation is further highlighted. Sometimes a certain method may cause an initial squaring of the breasts, compression of the central cone, or shifting of the direction of the breasts. Widely spaced breasts may have the same general condition but with a smaller overall volume. Proper informed discussion of shape is best done at the first office visit.

3. SCARS are important to all patients, although women seeking breast reduction for relief of embarrassment over large breasts with symptoms will find that scarring is not so critical. A history of abnormal, large, wide, and even keloid scars must be elicited in order to made proper preparations for breast reduction surgery. Anticipation of poorly healing scars can even be a reason to defer surgery. With the increasing popularity of minimally invasive Plastic Surgery and the search for scar-less operations, the benefits of a periareolar purse string skin repair for minimal to moderate states of breast hypertrophy and sagging are clear. The scars from a purse string circular skin closure may be a starburst pattern which fades considerably over time. Patients with thick elastic skin may experience some pleating and thick scars for a few months only to rapidly resolve over 6 to 12 months. Those with thin elastic skin may experience some scar widening and stretch of the areolar diameter. Fair skinned patients as a rule will recover from normal scarring at 6 months while those individuals of color can expect some delay in scar fading up to a year or so. The scars will be pleated in all patients for a few weeks or more and resolve considerably in time. In patients having thick dense breast tissue, or who have small implants inserted at the time of breast reduction, the duration of scarring as well as tiny pleats around the purse string repair will be more short term.

4. BREAST FEEDING IN THE CHILD-BEARING YEARS IS AN IMPORTANT ISSUE. Since breast reduction removes breast tissue that is involved in milk production and release through the nipples, there is a chance that this function may be reduced or eliminated by the operation. Many current methods attempt to preserve valuable breast tissue in the center of the gland. Larger reductions may result in more loss of function. Adolescents may not be as concerned about breast feeding, but later may consider this much later into womanhood, and for that reason, a careful discussion of breast feeding issues must be held with all young women. Choice of standard scar or minimal scar breast reduction has no bearing on breast feeding potential. It is the degree of breast removal and location of resection that can be critical in the preservation of this function.

5. BREAST SENSATION may be reduced in some patients with very large breasts prior to operation. Often due to the length of the nipple column from the base of the breast the nerves are stretched and patients may report lack of full sensation. For others, the presence of normally functioning nerves and erectile quality of the nipples is important. A perception of breast sensation is discussed with the patient before surgery. After the operation it is customary for some diminished sensation to result in all patients, only to gradually return in weeks to months. A small percentage of patients with small to large reductions can experience diminished feeling.

6. SYMMETRY is very important to all patients but many women present with various forms of asymmetry. There can be as much as one or more cup size differences in the breasts. Often patients are unaware of the elements of asymmetry to their breasts. Even with superb planning and precision markings made before operation, the various tensions imposed on the reduction, repair, and skin closure can yield minor flaws in symmetry. Since some form of suspension is performed to create an internal bra with the periareolar purse string method of breast reduction and breast lift, the influence of healing, activity, and tissue integrity can affect remodeling and settling in the final result. Minor asymmetries as well as subtle differences in areolar size and height are usually well tolerated by patients. Marked differences in shape may require revisionary surgery, but this is a rare occurrence.

7. BREAST SURVELLANCE is always important when operating to alter shape and structure. The ability to detect lumps is not impaired with breast reduction or lifting surgery. A mammogram is recommended in most all patients who undergo breast reduction, and particularly if they have a family history of breast pathology, or are over 40 years of age. At operation, the breast tissue that is removed is sent to a Board Certified Pathologist for careful review. Adolescent patients and some young women may not gain benefit from a mammogram since the breast tissue is ordinarily quite dense and impenetrable by standard x-rays. History and physical examination are more important screening tools in the youngest patients who seek breast reduction surgery.