Breast Reduction can be immensely rewarding, easing the physical discomfort and embarrassment of large or unwieldy breasts, or when used to reduce disproportion between the two breasts. It is a very satisfying procedure in the correct patient and can produce a very pleasing improvement in a patients appearance and sense of well being. It is however a complex and delicate operation, and like all operations has the potential for complications that can be minor or not so minor. I believe that all potential patients should be aware of these problems before they can make a sensible and informed decision about surgery. It should be stressed that in the vast majority of patients no significant complication occurs, but in any surgeon’s practice problems can arise, and before embarking on surgery you should ask yourself whether you feel you could cope with that eventuality.
Large breasts may be inherited and commonly produce a number of symptoms. Firstly, by their sheer size they may be painful and ungainly, and prevent the woman from participating in sports satisfactorily, or greatly restrict her choice of clothing. Further, they may produce symptoms of back or neck and arm ache, and bra straps may dig deeply into the shoulders. Finally, the size (and perhaps the accompanying drooping) alone may be the source of understandable embarrassment.
Surgical correction is the only serious option (although of course in obese patients dieting and weight loss will ease the situation proportionately). Such correction can be achieved by several means, and here I outline the most common techniques. In most cases it is necessary not just to reduce the volume of the breast but to lift the breast so that the nipple and areolar (the brown area around the nipple) are in a more ideal position, and the skin area of the breast is reduced to match the size reduction. This in turn means that skin must be removed, and an ingenious design of incision avoids placing scars on the cleavage area of the breast. In fact the commonest scar runs in a complete circle around the areolar before passing vertically down to the level of the skin crease underneath the breast. From there it passes horizontally within the crease both toward the breast bone, and out toward the armpit. No surgeon can guarantee the quality of a scar, since much depends on healing that can vary enormously from part of the body to part of the body, and from age to age in the same patient. In general however the scars on the breast are acceptable, and fade to a pale soft nature with time. They are however always present to some degree and it is never possible to produce a breast that shows no signs of surgery. In addition there are occasions when the scars remain lumpy or livid for a long time or even, very rarely, for ever. This however is very unusual. I try hard to limit the extent of scars and in order to do this I sometimes prefer to leave a small pleat of skin at either end of the horizontal scar, instead of allowing it to extend into a visible zone. This small pleat of excess skin usually disappears with time but may require a minor adjustment after six to twelve months.
A common problem is some slight delay in wound healing either below the nipple or at the point in the fold beneath the breast where the vertical and horizontal scars meet. This problem is exacerbated by smoking and it is therefore imperative that patients do not smoke for 2 weeks either side of surgery. Very rarely the problem is severe enough to need further surgery or to threaten the health and survival of the nipple itself.
The surgical technique most commonly used aims to preserve sensation in the nipple together with the erotic sensibility and the ability to become engorged and to breast feed. Any or all of these functions can suffer as result of surgery however and the likelihood in individual cases will be discussed.
Breast reduction and mastopexy principles
In both reduction and lifting of the breast skin must be removed. New techniques for doing this are beginning to appear for mild deformity (or droop) but the commonest pattern of removal of skin is shown here (and removal of tissue if reducing the breast) and the resulting scar pattern is also shown.
The shape of the reduced breast is different from the shape of the original, and the aim is to create as natural a form as possible. However the shape you first see after surgery will not be the final shape since in the first six months a lot of settling and natural adjusting of the contour occurs. It is impossible to predict this process (which is highly individual) precisely, and so it is equally impossible to guarantee a particular shape. Similarly, just as nature often allows minor differences between breast of the same individual, so it is possible that there will be some small difference in final volume between your breasts after surgery although this is rarely appreciable.
Like all operations minor problems with bleeding or infection may occur but it very rare for these to be troublesome. Occasionally small areas of blood beneath the skin (or small areas of damaged fat (fat necrosis)) may leave lumps that can be felt rather than seen, but on the rare occasions these are present they usually clear up spontaneously. There is no reason to believe that breast reduction surgery leaves you any more or less at risk from cancer of the breast, nor does it preclude accurate mammography after surgery..
General health problems following aesthetic (cosmetic) surgery are uncommon. The most serious of these is venous thromboembolism. Here clots of blood form in the legs and break loose to travel through the blood stream to lodge in the lungs where they can do serious, even fatal, damage. The risk of such a complication is increased in smokers, those on the pill, those in whom pelvic surgery is undertaken, or in whom post operative immobility increases the risk. Preventative measures can be taken and these include special pneumatic calf compressor devices during and after surgery, specialised supporting stockings during periods of enforced rest, and some pharmacological treatments to reduce the tendency of blood to clot. The latter treatments will be discussed with you prior to surgery but have the potential side effect of slightly increasing bleeding during and immediately after surgery.
The operation is usually scheduled for the same day as admission, and after surgery your new breasts will be lightly bandaged or dressed. Pain of any severity is unusual, but adequate pain relief is always available. Sometimes it is necessary to place drains to take away excess blood, and these are then removed at 24 or 48 hours. Stopping smoking is essential prior to surgery, and usually patients will be advised to stop the oral contraceptive. Usually patients are fit for discharge to home after 48 hours, and return at one week for wound inspection. In my own practice I generally use absorbable sutures that need not be removed, but some surgeons may prefer to remove sutures and will make appropriate arrangements.
The benefits of surgery begin to be felt almost immediately, and whilst it is clearly advisable to refrain from heavy work or arduous lifting, patients often report an early feeling of relief that the weight and discomfort has gone. Return to work is sometimes feasible within one or two weeks, but I usually recommend that a month is a more realistic time-frame for anyone with a physical element to their job. This gives you a chance to overcome the tiredness and lethargy that follow almost all types of surgery.
Scarring following breast reduction or mastopexy (breast lift).
The illustrations show the disposition of scars following breast reduction or the “Wise” pattern of mostopexy (breast lift).
Other techniques of reduction or lift may leave less scarring but are not suitable for all cases
As I said earlier, breast reduction is a very rewarding operation in the appropriate patient, regardless of age, but no one should proceed without being fully informed. This outline of the process is not meant to replace proper consultation with your surgeon but may serve as an additional soiurce of material to discuss with your primary care physician (G.P.) or surgeon at the next consultation. It is always a good idea to write the questions you may have so that they do not slip your mind during that consultation.
Simon Kay, Consultant Plastic Surgeon