Breast Reduction

Breast reduction can bring significant relief to women with large, heavy breasts, which can be uncomfortable both physically and psychologically. The excess weight of large breasts may cause back and neck pain, skin irritation and in extreme conditions, skeletal deformities and even breathing difficulties. Many teenage girls and women are also extremely self conscious about the size of their breasts.

Breast reduction surgery (reduction mammoplasty) removes fat, glandular tissue and skin from the breasts and should leave them smaller, lighter, more lifted and firmer. The size of the areola (the darker skin surrounding the nipple) can also be reduced to bring it into proportion with the new, smaller breasts.

Your goal should be attractive breasts that are in proportion to the rest of your body.

Your consultation

During your consultation, your surgeon should take a medical history and ask for details of any previous breast surgery you may have had. He should examine you and show you what your after surgery effect may be, by defining the area of breast to be removed and the new position of the nipple.

Your surgeon should also explain the procedure itself and ask what sort of results you would like to achieve. If you are suffering from significant neck and shoulder pain you may think that very much smaller breasts are desirable, but your aim should be for attractive breasts that are in proportion to the rest of your body. In addition, your surgeon should:-

• Explain that it is normal for most women to have breasts that are slightly uneven (asymmetric). Whilst he may attempt to make your breasts as symmetrical as possible they will never be truly identical.
• Explain that scarring will take place and although in time these will return to skin colour, they will remain visible.
• Tell you that after breast reduction surgery, breast-feeding can be unpredictable. If this is of concern to you, you may wish to delay surgery until you have completed your family.

What to expect from your operation

Breast reduction surgery should be carried out under general anaesthesia and will require 1 or 2 nights' stay in hospital. The procedure will normally take around 2 hours.

• Having marked the incision site pre-operatively, the surgeon will remove excess skin and glandular tissue from the breast, leaving the nipple on a stalk (pedicle). The nipple is then repositioned in a lifted position.
• The suture line is anchor-shaped and extends around the new position of the nipple, downwards to the crease under your breast (intramammary fold) and outward toward the underarm area. In some cases, depending on the amount of tissue removed, it is possible that you would have only a single vertical scar.
• Dissolvable sutures, which do not need removing, are used. Dressings should be applied and you should receive intravenous fluids for several hours.

Drainage tubes should be inserted at the end of the operation to remove fluid or blood after surgery, which are removed once any oozing has stopped. New dressings should be applied before you go home.

Blood clotting can sometimes be a problem with this procedure, so you should be told to wear anti-embolism stockings (TEDs) as a precautionary measure. These should not be removed until you are advised to do so. Expect to get out of bed and move around as soon as possible.

After surgery

Immediately after surgery your new breast size will be apparent. It will take up to 6 months for your breasts to settle into their final shape.

During your recovery there are several things you should expect.

• Following surgery your breasts will probably be uncomfortable, possibly painful. Your surgeon should provide you with sufficient pain relief. After returning home mild painkillers can be taken, such as paracetamol. Aspirin must be avoided as it can promote bleeding.
• Your dressings should be kept clean and dry for 1 to 2 weeks following surgery to allow healing to occur. You should wear a soft, well-fitted bra for 6 weeks after surgery.
• You may experience bruising and swelling and this will cause your new breasts to appear larger than anticipated. This should improve markedly in 2 or 3 weeks and settle within 2 to 3 months. To help decrease swelling and bruising, you may be advised to take arnica for 1 week prior to surgery and 2 weeks afterwards.
• Bleeding. If you are a smoker your healing may be delayed. Likewise drinking alcohol to excess after surgery could increase your risk of bruising.
• Your scars may initially be hard, red, raised and lumpy and can take up to 18 months to become pale and flat. This will depend on your individual healing qualities. Moisturising and massaging the scars can help them to soften more quickly.
• You may experience numbness of your nipples and the surrounding skin in the early stages after surgery. This is not uncommon and sensation should return.
• The blood supply to the nipple stalk may be inadequate and part or even all of the nipple may die. In this case you may wish to consider reconstruction of your nipple in a secondary procedure.
• Although your surgeon is careful to stop any bleeding points, occasionally a blood vessel may leak, causing a significant collection of blood (haematoma) and may necessitate a return to theatre. If a haematoma is very minor, natural re-absorption takes place.
• As with any surgery, there is a possibility of infection, which can be treated with antibiotics and/or dressings as required.
• You may feel tired for up to 2 weeks after surgery. If you tend to be anaemic or have heavy periods consider taking some iron and folic acid supplements.
• You can commence driving after the first week, but avoid vigorous exercise for at least 3 to 4 weeks. If you wish to fly within 4 weeks after surgery, consult your surgeon.

List of possible complications

Bleeding, infection, asymmetry, haematoma (3-4% risk), seroma (collection of tissue fluid), heavy scarring, nerve damage-may result in permanent numbness to the nipple, sensory change to the breast as a whole, nipple loss (1% risk), dissatisfaction with breast size/position, adverse reaction to medications, slow healing, skin loss, fat necrosis (breakdown) skin irregularities, visible scars, and interference with future lactation.

Asymmetry

Some minor discrepancy in breast size is not uncommon following a mastopexy or breast reduction, although major discrepancy is very rare. One should remember that breasts naturally exhibit minor variations in size and shape.

Fat necrosis

Fat necrosis, or fat breakdown, can be seen following a mastopexy and breast reduction. It is usually a minor problem that does not require intervention, but larger areas of necrosis may require corrective surgery. The risk of fat necrosis occurring increases with the size of the surgical resection. The overall risk of fat necrosis has been reported as 0.8% in a study including over 370 patients.

Nipple sensation

Most patients will experience some initial temporary alteration in nipple sensation following a mastopexy or breast reduction. The altered sensation usually spontaneously resolves in a number of weeks but for a small number of women may be permanent.

Wound problems

Occasionally there are problems with wound breakdown that require further dressings, or sometimes, further surgery.

Breast reduction by liposuction

Liposuction removes excess fat and if there is enough elasticity in the skin it will retract producing a lift of the breast. Liposuction may be advantageous as is produces less trauma, has a faster recovery, has smaller scars, and has fewer post-operative complications. Not everyone is suitable for breast reduction by liposuction; suitable candidates are those with firm, elastic skin with an underlying breast that has a large proportion of fat. Your surgeon will be able to advise you if you are suitable for this kind of surgery. Groups of women that may be more likely to be suitable include:

• Women that do not have very large or pendulous breasts
• Women that are not very thin (very thin individuals have less fatty breasts)

Women past the menopause

Breast liposuction will reduce the size of the breast but will retain a very similar shape to the breasts before surgery. There will be swelling that will subside fully over a period of a few months to reveal the final size of the breasts. Occasionally there may be some "lumpiness" to the breasts following liposuction, this is normal and part of the healing process, it typically resolves after a couple of weeks following surgery.