7th January 2013 Breast reduction
Breast reduction is one of the most successful operations in plastic surgery and is associated with a very high degree of patient satisfaction. It may count as a cosmetic operation in that its purpose is to create a beautiful shapely bust in proportion to the rest of the body, but it also has the functional benefit of relieving the pain and discomfort caused by heavy breasts. It may reduce breast tenderness, back pain, shoulder grooving from bra straps, intertrigo (inflamed, moist skin below the breast) and breast discomfort – but only if these symptoms are actually caused by large breasts. Back pain for instance, if due to other causes, will be not helped by a breast reduction.
The operation is also useful to correct breast asymmetry, so that the breasts can be equalised and lifted at the same time.
With large breasts, the nipple often lies quite low on the breast, and the areola around the nipple may be stretched. This can all be corrected as part of the breast reduction. The nipple usually does not need to be detached from the breast, but just moved upwards into position with its blood supply still connected.
It is important not to underestimate the magnitude of a breast reduction operation. It takes about three hours under general anaesthetic, and a stay in hospital of one to two nights is usually recommended. After this, a good month is needed to regain one’s energy, and up to two months for a full recovery.
A MASTOPEXY is a similar operation, but little or any breast tissue is removed, the purpose being to change the appearance of the breast to give a more lifted look by removing just the excess skin and areolar tissue.
Preparation for surgery
For a breast reduction or mastopexy as for any other operation, it is important to prepare yourself for surgery, making yourself as fit as possible in order to facilitate your recovery and reduce the chance of complications. This means ensuring that you are not anaemic, eat sensibly and stop smoking if you are a smoker, but also look after your stress and mental well being.
Why stop smoking? Apart from the general increased risk of chest infection, the nicotine in smoking/vaping/nicotine patches causes a temporary narrowing or constriction of blood vessels, so that you carry less oxygen to the breast so you heal less quickly and may be more likely to heal with an infection or more scar tissue.
You may need to lose weight, as overweight people have a higher risk of deep vein thrombosis, chest infection, and wound infection as well as possibly not getting as nice a cosmetic result. You need to check your list of supplements and medication with your general practitioner, and myself, in order to ensure that you are not more susceptible to bleeding or other complications.
You should also avoid a flight of more than two hours 4 weeks either side of the operation, because of the increased risk of deep vein thrombosis associated with travel and surgery.
What does a breast reduction, or mastoplexy, entail?
The operation itself is performed under general anaesthetic. The anaesthetist will see you before your operation. Discuss any queries you have about the anaesthetic with your anaesthetist. If you have had any difficulties during a general anaesthetic in the past make sure that the anaesthetist and I know about it. On the evening after your general anaesthetic you will feel rather tired and sleepy and should warn your visitors not to visit you for too long.
During the operation a large quantity of tissue is removed from within the breast. It is not possible to do this without creating scars. Your scar will run around the nipple, and possibly down the centre of the breast below the nipple and along the crease below the breast. I try to limit the scars as much as possible, so that they don’t show with revealing clothes. The scars will never completely disappear and may even stretch (widen) as the year goes by. The scars start off red and noticeable. Over a period of time they will fade – it will take about 12 to 18 months for this process to occur. Some people’s scars fade better and faster than others. If you scar badly there will be only slight fading and you may be left with red, thickened scars that remain noticeable (keloid or hypertrophic scars). I do my best to advise how to reduce this. Hypertrophic scars generally mature with or without treatment; keloid scars require treatment.
Most if not all the sutures used are buried and dissolvable. The sutures can make their way out through the skin instead of dissolving,or can cause small areas of inflammation or suture abscesses. This is a temporary nuisance but is not serious.
Removing tissue from the breast interferes with the blood and nerve supply of the nipple. This can result in an alteration in the nipple sensation. Some ladies find a decrease in sensation with a degree of numbness and others an increase in sensation with a degree of tenderness. Most experience no change in sensation.
Interfering with the blood supply to the nipple may occasionally result in small areas of breakdown of the nipple or areola. These areas will be slow to heal but will heal leaving an area of scarring on the nipple or areola. It is possible to lose all or nearly all of the nipple and areola on one or both sides. This is a more serious complication and would require further surgery to reconstruct the nipple. Fortunately this more serious complication rarely occurs.
Removing breast tissue and moving the nipple/areolar complex damages the milk ducts of the breast. More often than not breast-feeding is no longer possible after a breast reduction operation. You must be satisfied in your own mind that you will not want to breast feed in the future. If you are unsure about this it is perhaps best to delay your breast reduction operation until you have completed your family. In the case of small breast reductions or mastopexies I am sometimes able to preserve the ducts.
The fat tissue in the breast occasionally forms hard tender lumps after surgery. This is called fat necrosis. These lumps usually settle on their own over a period of time (which may be several months). Rarely surgery is required to remove particularly troublesome areas.
Any operation can result in infection or bleeding, and breast operations are no exception. Simple infections will settle with dressings or a course of antibiotics. Some infections will require further treatment.
If you notice increasing redness of your wound and it is painful make sure to get it checked as soon as possible – infections caught early are easier to cure. Bleeding after your operation can result in a collection of blood called a haematoma. Haematomas must be drained in theatre otherwise they can cause wound problems later on. If you know that you have a history of bleeding please let me know as we can then be prepared for the increased risk of it happening.
I try to size your breasts in proportion to your general shape but will take into account whether you prefer to be ‘bigger’ or ‘smaller’. If you look carefully at your breasts before your operation you will notice there is some asymmetry. This is normal. After your operation it is inevitable that you will have some asymmetry but I will reduce the difference. I try to reduce any obvious preoperative asymmetry.
Sometimes there are little folds at the ends of the scars. These are called ‘ dog ears ’. If they do not settle over a period of about 6 months they can be removed as a small operation under local anaesthetic. In large reductions I plan the dog ears, as I try to minimize the scar length.
Internal flaps. Sometimes, particularly after weight loss, or with soft pendulous breasts, the breasts look very empty at the top. This traditionally has been corrected by inserting breast implants to provide fullness. I prefer to use internal flaps, taking tissue from the lower part of the breast to move it into the empty upper part of the breast, thereby keeping the breast natural. This takes a little longer but means that you don’t have to worry about having implants and needing to change them in the future.
What to expect when you return from theatre
- A drip – this stays in until you are eating and drinking normally – usually just overnight
- Drains – one to each breast. These stay in until they stop draining – usually about 24 hours, but may be longer – sometimes you do not require drains. They come out before your discharge from hospital.
- Dressings – a firm dressing will be applied to support the breasts after the operation. This usually stays on until after you go home and will be removed in due course at the first follow up appointment. I will provide you with comfortable soft (not underwired) but supportive bras once you are up and about.
- Heparin – lying in bed increases the chance of the veins in your legs clotting. To counteract this you will have tiny heparin injections under your skin until you are mobile. You will also be given firm TED stockings to wear until you go home.
- Home – once your drains are out and you are up and about and feeling well enough you will be able to go home.
What to expect after you go home
At first you will feel rather tired and should spend the first week or so taking it very easy, although not staying in bed. Thereafter you will be able to build up slowly to doing your usual activities. A breast reduction is a big operation, which does take time to get over. Expect to feel more tired than usual for up to 3 months.
You will be able to start driving once you feel up to it. For most people this will take two to three weeks. Do not drive if you are not well, alert and able to take emergency action safely. It is advisable to check with your insurance company before you start driving. You will, likewise, be able to start work again once you feel up to it,. If your job involves a lot of lifting or heavy work this will take longer. Most people get back to work after about a month.
Breast reduction is an excellent operation when done under the right conditions. Not only does it enable you to finally go shopping for clothes without spending hours trying to minimize a chest, which is out of proportion to the rest of your body, it can also give you a lovely looking breast once the scars have matured. It may relieve back and neck ache, and the loss of the extra weight may facilitate running and playing sports and other activities.
One should not, however, underestimate the size of the operation, potential for complication and the length of the recovery time.
Further information is available on the British Association of Plastic Surgeons website