REDUCTION MAMMOPLASTY Oversized breasts have been seen to cause far more discomfort and loss of confidence than having smaller breasts in women. Apart from the large size, it is also associated with a host of medical problems like pain in the back, neck, and shoulders; shoulder notching due to constant digging in by bra straps; the unpleasant smell of sweating under the breasts, sometimes may be accompanied by infection, rashes and dark pigmentation in the folds. This condition may present itself at puberty, after childbirth, after considerable weight gain or later in life following the menopause or because of the use of hormone replacement therapy (HRT). Breast reduction surgery has today evolved to a much safer procedure with predictable and better cosmetic results, as well as fewer complications making it one of the most frequently requested procedures.
While some patients seek ‘reduction mammoplasty’ to address medical issues, others do it for cosmetic reasons, wanting to achieve smaller, lighter and firmer breasts that are more proportionate to the rest of their body. Excessively large breasts usually lead to a much lower self-esteem in women than having smaller breasts, as they need to wear clothes that are a size too large. Moreover with age further sagging of skin or drooping of the breasts exaggerates the problem, but the good news is that reduction mammoplasty not only reduces the excessive tissue but treats the drooping, sagging by providing a lift along with treating any breast asymmetry if present.
As we can see that this surgery is not just about cutting away of excessive tissue and is about a lot more. An experienced plastic surgeon with a keen aesthetic sense should be able to address all these issues while minimizing all possible risks. Hence one should spend enough time researching the clinic and the surgeon. After all well-proportioned breasts and a balanced silhouette go a long way in an instilling a renewed sense of confidence and also enhance the quality of life.
Q: Who are the ideal candidates for breast reduction surgery?
A: Following are the good candidates for reduction mammoplasty:
Those who feel that their physical activity is being restricted because of the heavy breasts
Those who are bothered by their large and pendulous breasts, usually more than cup size “D”
Those who experience symptoms of a chronic headache, neck or upper back pain
Those who are distressed by their bra straps digging into their shoulders, because their bras supporting the excess weight of breasts
Those who have chronic skin irritation or rashes in the crease under the breasts
Those who have body image issues because of the large size of their breasts.
Q: Is there a right age for reduction mammoplasty?
A: Excessively large breasts may present any time after puberty and a reduction mammoplasty can be done anytime after that, but it is advisable the patient undergoes the surgery after the breasts have fully developed. However, parent or guardian consent is required for all cosmetic or plastic surgery procedures performed on patients 18 years old or younger.
Q: In what instances should you avoid this surgery?
A:If you are planning to lose a significant amount of weight or plan to get pregnant in the future, you should inform your doctor before your breast reduction surgery. It is prudent to wait until you have achieved your desired weight goals and have completed your family.
Q: What is the average expected reduction in cup size after the surgery?
A: This varies from patient to patient and depends on the desired aesthetic and physical goals. After breast reduction surgery, one can usually see a reduction by one or two cup sizes.
Q: Will breast reduction surgery correct saggy breasts?
A: All breast reductions include a lift as well. Reductions will not provide upper breast fullness but will move the nipple to its original position and remove the hanging breast tissue.
Q: What is the preoperative preparation required?
A: Before the surgery, we usually recommend a preoperative mammogram screening to rule out any preexisting growth or malignancy. However, if you have a mammogram within the past year, then a repeat test is usually not required.
Since smoking interferes with tissue healing, patients need to quit smoking 6 weeks prior to surgery and abstain from it until full recovery has occurred. One also needs to avoid certain vitamins and drugs that can cause bleeding, such as aspirin, ibuprofen and vitamin E.
Additionally, preoperative instructions given by the anesthesiologist during the pre-anesthesia checkup also need to be followed.
Q: What type of anaesthesia is used in the surgery?
A: Breast reduction surgery is usually performed under general anesthesia. However, if the only liposuction is required, it can be performed under local anesthesia with sedation.
Q: How much time does surgery take and how long does one need to stay in a hospital?
A: Breast reduction surgery itself takes about two to five hours and generally, an overnight stay at hospital suffices. However, if the patient is undergoing multiple procedures or has a coexisting medical illness that requires care, she might need extra stay in the hospital.
Q: What does the Breast Reduction surgery involve?
A: Breast reduction can be achieved by either Liposuction or Mammoplasty.
- Liposuction: It offers a minimally invasive alternative when the breast tissue has more fat than the glandular part especially where the patient is unmarried and wants to preserve breastfeeding function. Liposuction, which involves removal of excess fat, is a shorter, less invasive, less expensive procedure that causes lesser trauma to the glandular part of the breast, can be done under local anesthesia with sedation and leaves virtually undetectable scars. However, this technique is suitable for younger patients, who need little to moderate reduction in breast size, have good skin elasticity without any sagging and whose excess breast size is mostly due to excess fatty tissue.
- Mammoplasty: This more invasive procedure is preferred when there is noticeable sagging, asymmetry, stretched skin of the breast; those who require removal of a more significant amount of tissue and those in whom the glandular part is of greater proportion than the fat esp in women who have borne children. It is preferably done in women who have completed the family and don’t need to breastfeeding anymore. Mammoplasty, however, needs to be done under general anesthesia and involves removal of excess fat as well as the glandular tissue and skin, making the breasts firmer, less wobbly and lighter than before. In most cases of breast reduction surgeries, the nipple and areola remain attached to the blood and nerve supply, while the excess breast tissues are removed. The areola is also reduced in size. The nipple and areola are then repositioned at a higher level and the incisions are closed. Since this procedure is usually combined with breast lift (Mastopexy) in older women, the breasts also get lifted, with the nipples pointing forwards instead of downwards making them aesthetically more appealing. Any asymmetry if present is also corrected and sometimes if areola is too big, that too is reduced.
Traditionally, two main types of incisions are used: anchor incisions and lollipop incisions. Anchor incisions are made around the areola, extended vertically down the breast and horizontally along the breast crease. Lollipop incisions are the same but without the horizontal cut and are usually used when less amount of tissue needs to be removed. After removing the required amount of fat, glandular tissue and skin, the nipple and areola that are still attached to breast tissue are repositioned and sutured into place. This preserves nipple sensation and the ability to breastfeed.
In cases of extremely large and pendulous breasts, however, the nipple and areola are sometimes removed from the breast tissue and grafted into a new position. This usually results in a reduction in sensation in the nipple area and the inability to breastfeed later on.
Q: What is the postoperative care after surgery?
A: Although the recovery varies depending on individual healing rate and extent of surgery, most of our patients are able to get up and walk around the same day of surgery. After a night’s stay in the hospital, the patient is usually discharged with advice to rest for another 48 hours at home. Sometimes a surgical drain is placed under the armpits to prevent any fluid collection. In that case, you might be advised to stay in the hospital for one more day so that the drains are removed before we send you home. If everything goes well, a follow-up visit is usually planned on the 8th day for suture removal.
You would be required to wear a pressure garment or an elastic compression bra is for 4 weeks. Help is required for the first few days to get dressed and in other activities as a range of motion in the upper chest and shoulder region is restricted.
You can expect your breasts to be sore for a few days. This can be taken care of with painkillers in the initial few days after which they are tapered off as the bruising and swelling resolve over the next 4-6 weeks. Depending on the extent of surgery, some patients also experience decreased nipple sensation, and this too gradually improves over a few months.
Following pointers would help you know what is expected of you postoperatively:
Shower: While you may sponge yourselves clean in the first few days, a full shower is permitted only after one week.
Exercise: Minor activity like walking can be resumed in 4 to 5 days but you would have to wait for a minimum of 4 to 6weeks before resuming gym exercise.
Driving: Although you may feel ready to drive after a few days, we recommend you to wait at least for 3-4 weeks since wearing a seat belt might exert undue pressure sometimes.
Work: There is no harm in resuming a job that doesn’t require physical activity after 7-10 days. However,
Sexual activity: Although you may resume sexual activity after two weeks you need to be very gentle with your breasts for up to six weeks after the surgery.
Clothing: You must wear loose clothing for the initial few days and avoid underwired bra for a few months.
Sun Exposure: To ensure lighter scars, you should avoid sun exposure in the breast area for a few months.
Scar care: Scar management begins after suture removal and you should follow the surgeon’s instructions on the application of scar reducing creams or silicone gel sheet in the postoperative period. You need not worry if the scars are reddish or pink in the initial few months. It usually improves with time.
It is very important to follow these instructions in order to have an uneventful recovery.
Q: When do I get to see the results? Are the results permanent?
A: While most patients experience an immediate relief from back and shoulder pain after breast reduction, you will have wait for about 2-3 months for swelling to completely subside and for the final result to settle in. The scar, however, keeps softening over the first 6 to 12 months.
The effects of the surgery are more or less permanent since excess tissue has been removed from the body. However, you must understand that nothing can stop the normal aging process. Eventually, your breasts will begin to sag once again, although the effect would be much less than what you would see without undergoing a breast reduction. Moreover further weight gain, weight loss or might also lead to a change in the shape and size of the breast. If that happens, you might want to consider a revision surgery.
Also, future pregnancies might reverse some of the effects of breast reduction surgery. Therefore we generally advise our clients to postpone the surgery until they have completed their family.
Q: Are there any changes in the areola after the surgery?
A: The areola is the area of darker skin surrounding the nipple. In women with large breasts, sometimes the areola too becomes large and if this is not corrected during reduction mammoplasty, it might look disproportionately large relative to the newer and smaller breasts. Since the incision occurs around the areola, it is easy to trim away the excess amount of areola during the surgery without giving any additional scar. However, only a surgeon with a keen sense of aesthetics, surgical finesse and experience would be able to give a perfect result.
Q: How bad is the scar after breast reduction surgery?
A: Like any other invasive surgery, breast reduction surgery does leave some scarring on the breast, but it is mostly hidden beneath a bra or a bikini top. Depending on the technique used, there can be up to three scars:
One around the nipple – that is mostly concealed due to the color difference between the darker areola and lighter breast skin
Another that runs vertically from the nipple to the crease below the breast – this is usually hidden well within the bra cup. As it is on the underside of the breast, it is also well concealed from a frontal view.
Sometimes there is an additional scar along the crease below the breast – this happens when a traditional anchor incision is chosen. Most surgeons try to avoid this technique these days, unless and until it is absolutely necessary.
While the scars are usually reddish for the first six weeks, with proper care and use of scar softening creams, they typically fade considerably over the first year after surgery. Moreover, they are easily concealed while wearing a bra or a bikini top.
Q: What are the risks or complications from this surgery?
A: After the breast reduction surgery, our clients are generally very satisfied with relief of symptoms and a well-proportioned upper body. However, as with any other surgery, occasionally one may encounter complications but these are infrequent in the hands of an experienced surgeon and a good facility.
The following are the potential risks that one should be aware of:
Bruising, swelling and pain – these usually subside in 2 – 3 weeks time. During the first menstrual period after surgery, there may be a slight increase in swelling and pain but this is self-limiting. You may also experience random, shooting pains for a few months.
Sometimes, there is a loss of sensations in the nipples and breast skin and is usually caused by swelling after surgery. Sensations usually reappear over the next six weeks or so. In some patients, however, it may last a little longer, and very rarely it may be permanent.
In most breast reduction procedures, the nipple remains attached to the milk-producing breast tissue and hence breast-feeding ability is usually preserved. However, it may be limited in certain cases especially when a large amount of breast tissue is removed.
While we aim to achieve nearly perfect size, shape, and symmetry of results on both sides. Occasionally, this may not be possible and you may notice slight asymmetry. In cases when this asymmetry is significant, a revision surgery is always an option to consider.
Nipple death is another very uncommon complication that occurs if the blood supply to the nipple is compromised. This can occur in extensive breast reductions when the nipple has to be excised and grafted back. However, in routine breast reductions, this is an extremely rare complication.
Occasionally, the scars can be hypertrophic and painful. Sometimes there is a tendency of keloid formation and if you have a past history of this occurring, you must inform the surgeon. However, there are several ways to soften the scars and promote healing.
Other general complications are those that are associated with complications of anesthesia, bleeding inside the breast tissue (haematoma) or infection. These complications, if they occur, usually present themselves in the early postoperative period and can be managed with good post-op care.
Some of these complications, however, can be avoided by following surgeon instructions during the recovery phase.
Q: What if I choose to become pregnant after the surgery? Does it cause problems in lactation if I plan to have a baby later on?
A: If you plan to have breast reduction surgery before having children, you must understand that breasts can get larger again during pregnancy and this may reverse some of the results of the surgery. Also, there's a chance you wouldn't be able to breastfeed comfortably after the operation. Therefore it is prudent to wait until the family is complete unless the physical side effects of heavy breasts are decreasing your quality of life. However, there is no problem in being able to continue the pregnancy to term and deliver a baby. In case the breasts enlarge again, you might opt for a revision surgery at a later date.
At our practice, we use the latest techniques that help us preserve a significant amount of the milk ducts and their attachment to the nipple. Thus most women are able to breastfeed after breast reduction surgery. But one must remember that many women (who have not undergone any surgery) inherently, are unable to breastfeed due to immature development of the duct or milk producing system.