BREAST REDUCTION
Introduction
Have you experienced any of the following and believe these symptoms may be correlated with large breasts?
Back or Neck pain
Suboptimal posture and/or shoulder grooving
Difficulty with your wardrobe
Tension headaches
Paresthesias (numbness) in hands or along the arms
Rashes in skin folds, infections, maceration of skin
Cervical or thoracic degenerative joint disease
Body
1. Overview of the Topic
While many view plastic surgery on the breasts through a purely aesthetic lens, breast reduction surgery allows for a reframing of goals to include both aesthetic and functional objectives to address many of the often debilitating symptoms above.
There are a few classic measurements associated with desired breast aesthetics – these include sternal notch (SN) to nipple distance of 21-24cm, nipple to inframammary fold (IMF) distance of 7-9cm and areolar diameter of 38-45mm. See Figure 1 below:
2. Ideal Candidates/Evidence
Several influential peer reviewed studies in the plastic surgery literature suggest that presence, duration and severity of symptoms are the most important factors when assessing the medical need for breast reduction surgery. Often, there is little if any correlation between the patient’s weight or breast size than purely volumetric reductions.
Other studies have demonstrated the quality of life benefits of breast reduction surgery are on par with alleviating certain other significant chronic health conditions such as renal failure with a kidney transplant.
It is also important to note that insurance companies often require ‘prior authorization’ for breast reduction surgery. This involves multiple documented reports from certain specialists such as physical therapists, chiropractors, dermatologists or orthopedic surgeons documenting the range, duration and scope of conservative therapies attempted for the macromastia induced symptoms prior to approving coverage for the operation; it is not uncommon, depending on the insurer, to require 6-12 months of such therapies based on individual policies.
As a plastic surgeon, I will work on your behalf to advocate for the operation by sending relevant clinical photographs, measurements, and anticipated reduction volume to facilitate timely and appropriate coverage.
Our goals are manifold:
First and foremost, improve the debilitating symptoms arising from macromastia
Second, reposition the nipple areolar complex to a more anatomically correct position while preserving blood supply/sensation
Third, maintain parenchymal support for anatomic longevity
Fourth, design and execute a limited tension closure that minimizes scarring; I often counsel patients that one of the biggest tradeoffs in plastic surgery is scarring for contour/functional improvement. From this vantage point, patients almost always tolerate the resultant scarring once the functional and aesthetic benefits are realized!
Contraindications include: smoking, active weight loss, wound healing issues/connective tissue disorders, comorbidities making general anesthesia difficult, unrealistic expectations (we work together on this one!)
3. The Procedure
Preoperatively, Dr. Iyengar will call you to the office for markings in order to streamline your experience on the day of surgery.
The anesthesia team will perform a comprehensive clearance prior to proceeding to the OR.
Broadly speaking, breast reduction surgery involves a few techniques to preserve blood and nerve supply to the nipple (‘pedicle’ design). This means that the blood supply comes to the nipple either laterally, medially, inferiorly or centrally; once we have decided how to keep the nipple alive, we will then proceed with removal of the excess breast tissue.
I then choose the appropriate skin reduction pattern based on your breasts to achieve the most optimal results. Typically, this is either a Wise Pattern (anchor, inverted T) or vertical (lollipop/linear) scar configuration. See Figure 2.
This is outpatient or day surgery, meaning you will typically go home the same day. Please coordinate with friends or family for a ride to and from the surgical facility.
4. Recovery and Results
EARLY POSTOPERATIVE PHASE
The initial postoperative phase involves bulky dressings with xeroform, gauze, ABD pads, and Ace wraps. These dressings should stay on for 72 hours.
Showering is allowed after 72 hours. No submerging the incisions for at least 6 weeks.
Patients often experience some drainage from the incisions; clear or yellow drainage is fine – purulent or foul-smelling drainage is not.
No strenuous activities or exercise for 3 weeks; this includes sexual activity, which we typically advise can be resumed at the 3 week mark.
When resuming exercise, start slowly – incline walking, then light jogging, progressing to running/weightlifting gradually if desired.
Please also lie on your back for the initial 3 weeks as the breast tissue and incisions continue to heal. The best option for stomach or side sleepers may be to sleep in a recliner.
It is normal to experience bruising and swelling for 4-6 weeks following the operation, with the final contour apparent at 3+ months.
LATER POSTOPERATIVE PHASE
Swelling continues to subside over 4 months
The breasts may feel numb for weeks to months, and only later ‘wake up’ with tingling and zinging sensations over time. This is normal, and takes time (additional weeks to months) to subside.
Scars often take over 1 year to fully mature and soften. We start silicone sheeting at about the 4 week mark to help optimize scar profile; this continues over a period of several months post-procedure.
5. Risks and Considerations
Risks include decreased nipple sensitivity, decreased breastfeeding ability (depending on the type of planned resection pattern), infection, pain, need for further procedures, seroma, hematoma, fat necrosis, aesthetic concerns, scarring.
6. Choosing the Right Surgeon
Look for a qualified surgeon, with credentials in the field of plastic and reconstructive surgery prior to proceeding.
Conclusion
Breast reduction surgery prioritizes functional and aesthetic goals
Insurance coverage typically requires documented evidence of symptom severity and conservative modalities attempted for at least 6-12 months. At Iyengar Plastic Surgery, we are your biggest advocates! We will work with you to help facilitate however we can.
Breast reduction surgery involves at least a week-long initial recovery with gradual return to normal activities over the course of several weeks.
Final contour is usually assessed at 3-4 months as the swelling subsides; scars mature over the course of 1 year.
"Ready to learn more? Schedule a consultation with Dr. Raj Iyengar to discuss your goals and create a personalized treatment plan."
