Family doctor

What is breast reduction surgery?

Excessive breast enlargement (mammary hypertrophy) causes a number of medical problems:

• back and neck pain
• strap marks and shoulder strain
• poor posture
• skin irritation and infections (intertrigo)
• shortness of breath
• difficulty participating in recreational activities
• difficulty fitting bras, swimming costumes and clothes
• social/sexual embarrassment/harassment

Women with extremely large breasts may become very self-conscious about their appearance and will go to the extent of camouflaging their body shape by wearing baggy clothing, and avoiding social and recreational activities. In some severe cases, women become introverted, reclusive and depressed.

Breast reduction surgery, also known as reduction mammaplasty, is a commonly performed operation, designed to make large breasts smaller, lighter, symmetrical and more proportionate to the rest of the woman's body. In most cases the darker skin around the nipple is reduced in size and the nipples are elevated to a normal position at or just above the level of the fold where the breast meets the chest.

Breast tissue is a mixture of glandular tissue and fatty tissue. There is more glandular tissue and less fat in young women's breasts and less glandular tissue and more fat as women get older. Liposuction can be used to remove some of the excess fat but it is invariably necessary to cut out the excess glandular tissue and skin. The breast tissue is carefully examined afterwards to make sure it is healthy.

As a result of surgery there will be scars on the breasts but these are carefully placed so that they are relatively inconspicuous once they fade and are hidden by a bra or swimwear.

The vast majority of breast reductions are done for legitimate medical reasons rather than for cosmetic improvement. There is a dramatic improvement in musculoskeletal symptoms following the operation and women find they can exercise more easily.

It is one of the most gratifying plastic surgical procedures. Many patients after breast reduction say "It is the best thing I have ever done".

Who are the best candidates for breast reduction?

Breast reduction is usually performed for physical relief rather than simply cosmetic improvement. Most women who have the surgery are troubled by very large, sagging breasts that restrict their activities and cause them physical discomfort.

In most cases, breast reduction isn't performed until a woman's breasts are fully developed; however, it can be done earlier in the teenage years if large breasts are causing serious physical discomfort. The best candidates are those who are mature enough to fully understand the procedure and have realistic expectations about the results.

What are the risks?

All surgery contains some uncertainties and risks

Breast reduction is not a simple operation, but it's normally safe when performed by a qualified plastic surgeon. Nevertheless, as with any surgery, there is always a possibility of complications, including bleeding, infection, or reaction to the anaesthesia.

An "invisible mending technique" using dissolving stitches is used to close the breast skin - occasionally one or two of the buried knots may irritate or inflame the overlying skin but can be easily trimmed by a nurse or treated with antibiotic cream. The great advantage of this stitching technique is that you do not have to suffer the pain and discomfort of suture removal. The scars that result are of very high quality. You can reduce your risks of developing complications by closely following your surgeon's advice both before and after surgery.

The procedure does leave permanent scars, although they'll be covered by your bra or bathing suit. (Poor healing and wider scars are more common in smokers). The procedure can also leave you with slightly mismatched breasts or unevenly positioned nipples. Future breastfeeding may be possible and is encouraged. Surgery removes some of the milk ducts leading to the nipples so milk production may be reduced and supplementation with formula milk may be necessary.

Some patients may experience a permanent loss of feeling in their nipples or breasts. Rarely, the nipple and areola may lose their blood supply and the tissue will die. (The nipple and areola can usually be rebuilt, however, using skin grafts from elsewhere on the body).

Planning your surgery

In your initial consultation, it's important to discuss your expectations frankly with your surgeon, and to listen to his or her opinion. Every patient - and every surgeon, as well - has a different view of what is a desirable size and shape for breasts. The aim of surgery is to make your breasts proportionate in size but it is difficult to guarantee what cup size will result.

Your breasts will be examined and measured by the surgeon and photographs taken for reference during surgery and afterwards. He or she will discuss the variables that may affect the procedure - such as your age, the size and shape of your breasts, and the condition of your skin. You should also discuss where the nipple and areola will be positioned; they'll be moved higher during the procedure, and should be approximately level with the crease beneath your breasts.

Your surgeon should describe the procedure in detail, explaining its risks and limitations and making sure you understand the scarring that will result. The surgeon should also explain the anaesthesia he or she will use, the facility where the surgery will be performed, and the costs.

Some insurance companies will pay some of the costs towards breast reduction if it's medically necessary; however, they will require a supporting letter from your surgeon beforehand. Check beforehand with your insurance company what they will cover, as different companies may have different policies for this operation.

Preparing for your surgery

If you are over the age of 30 your surgeon may recommend that you have a mammogram (breast x-ray) before surgery. You'll also get specific instructions on how to prepare for surgery, including guidelines on eating and drinking, stopping smoking and taking or avoiding certain vitamins and medications. Some surgeons suggest that their patients lose a certain amount of weight before the operation.

Breast reduction rarely requires a blood transfusion. If your blood count is low you should take iron supplements before and after surgery.

While you're making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days if needed.

Where your surgery will be performed

Breast reduction is generally done in a hospital, as an inpatient procedure. The surgery itself usually takes two to four hours. You can expect to remain in the hospital one to two days.

Breast reduction is nearly always performed under general anaesthesia. You'll be asleep through the entire operation.

The surgery

The techniques for breast reduction vary, but the most common procedure involves an anchor-shaped incision that circles the areola, extends downward, and follows the natural curve of the crease beneath the breast. The surgeon removes excess glandular tissue, fat, and skin, and moves the nipple and areola into their new position. He or she then brings the skin from both sides of the breast down and around the areola, shaping the new contour of the breast. Liposuction may be used to remove excess fat from the armpit area.

In most cases, the nipples remain attached to their blood vessels and nerves. However, if the breasts are extremely large or pendulous, the nipples and areolas may have to be completely removed and grafted in a higher position. (This will result in a loss of sensation in the nipple and areola tissue).

Stitches are usually located around the areola, in a vertical line extending downward, and along the lower crease of the breast. In some cases, techniques can be used that eliminate the vertical part of the scar. And occasionally, when only fat needs to be removed, liposuction alone can be used to reduce breast size, leaving minimal scars.

After surgery care

After surgery, your breasts will be wrapped in an elastic bandage or a surgical bra over gauze dressings. A small suction drain may be placed in each breast to drain off blood and fluids for the first day or two.

You may feel some pain for the first couple of days - especially when you move around or cough - and some discomfort for a week or more. Your surgeon will prescribe medication to lessen the pain.

The bandages will be removed a day or two after surgery, though you'll continue wearing the surgical bra day and night for two weeks, until the swelling and bruising subside. Your stitches will dissolve and the skin incisions will be covered with steristrips (adhesive paper tapes).

If your breast skin is very dry following surgery, you can apply a moisturiser several times a day, but be sure to keep the incision lines dry.

Your first menstruation following surgery may cause your breasts to swell and hurt. You may also experience random, shooting pains for a few months. You can expect some loss of feeling in your nipples and breast skin, caused by the swelling after surgery. This usually improves over the next six weeks or so. In some patients, however, it may last a year or more, and occasionally it may be permanent.

Getting back to normal

Although you may be up and about in a day or two, your breasts may still ache occasionally for a couple of weeks. You should avoid lifting or pushing anything heavy for three or four weeks.

Your surgeon will give you detailed instructions for resuming your normal activities. Most women can return to work (if it's not too strenuous) and social activities in about two weeks. But you'll have much less stamina for several weeks, and should limit your exercises to stretching, bending, and swimming until your energy level returns. You'll also need a good sports bra for support. Do not wear an underwire bra for at least 4 - 6 weeks.

You may be instructed to avoid sex for a week or more, since sexual arousal can cause your incisions to swell, and to avoid anything but gentle contact with your breasts for about six weeks.

A small amount of blood or clear yellow fluid draining from your surgical wound, or some crusting, is normal. If you have any unusual symptoms, such as bleeding, redness of the skin or severe pain, don't hesitate to call your surgeon.

Your new look

Although much of the swelling and bruising will disappear in the first few weeks, it may be six months to a year before your breasts settle into their new shape. Even then, their shape may fluctuate in response to your hormonal shifts, weight changes, and pregnancy.

Your surgeon will make every effort to make your scars as inconspicuous as possible. Still, it's important to remember that breast reduction scars can be extensive and permanent. They often remain lumpy and red for months, then gradually become less obvious, sometimes eventually fading to thin white lines. Fortunately, the scars can usually be placed so that you can wear even low-cut tops.

Of all plastic surgery procedures, breast reduction results in the quickest body-image changes. You'll be rid of the physical discomfort of large breasts, your body will look better proportioned, and clothes will fit you better.

However, as much as you may have desired these changes, you'll need time to adjust to your new image - as will your family and friends. Be patient with yourself, and with them. Keep in mind why you had this surgery, and chances are that, like most women, you'll be pleased with the results.

Getting help

This information has been written to give you the basic facts about breast reduction. If you decide you would like to know more about breast reduction make an appointment to see a plastic surgeon. Please write down any questions you wish to ask the surgeon.