Breast Reduction

These patients often report that the large breast size does interfere with their activities of daily living.

Like most plastic surgical procedures performed a trade-off exists between the improvement in size and positioning of the breasts (and the resulting improvement up next, back, and shoulder symptoms) versus the resulting scars, potential loss of sensation in other complications associated with breast surgery in general. Most patients who undergo this procedure are very happy to accept the trade-off with a common regret afterwards being " I wish I had the breast reduction procedure done earlier in life”.

One of the inevitable questions that arises when discussing any type of breast surgery is the issue of resulting breast size. Every patient will have different goals; some women wish to be “as small as possible”, some women wish to achieve breast size proportionate to the remainder of their body.

In order to achieve the patient's goals, it is critical that the plastic surgeon be able to communicate clearly with the patient. I have found that the use of words such as “natural” or “C cup” or "fake looking" or "top heavy" means different things to different people and therefore these terms prove unhelpful. Also cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate. Furthermore, every patient's chest width varies;  if the patient has a wide chest wall it may not be possible to achieve a smaller width  or cup size.

In my practice I use goal pictures to communicate with patients.  With this technique patients are able to demonstrate what they are trying to achieve and what type of looks they do not like as well.   The patient's goal pictures are hanging on the wall in the operating, and allow for direct comparison. I have found that this system is very helpful in improving the chances of achieving the patient's goals as consistently as possible. 

Unfortunately,despite the best efforts at communication, no plastic surgeon is able to predict exactly what cup size patient's will be after breast reduction surgery.  Unfortunately, there is also no direct correlation between the amount of tissue removed and the ultimate cup size that a patient will wear after breast reduction surgery.

For the patient who presents with the desire to achieve as small as possible breast size after surgery some words of advice may be helpful. First off, it is possible to reduce the breasts size very significantly.   Sometimes  when this is the goal the breast reduction should be done in two stages.  The concern with the amount of tissue removed is related to blood flow to the remaining tissue;  if too much tissue is removed in one operation the blood flow to the remaining tissue (including nipple/areola)  may be compromised.   Part of the tissue that is left in place is called the “pedicle"; this segment of tissue is responsible for delivering the blood supply to the nipple/areola tissue. If the pedicle is made too small (in the effort to reduce the breasts as much as possible)  then patient will likely have problems with tissue survival.  Doing the procedure in more than one stage allows the tissues to  acclimate to the surgically decreased blood flow before  further tissue removal (and potentially further decreased blood flow)  occurs ( with the second stage operation).

The other concern with overly aggressive breast reduction surgery is patient dissatisfaction  afterwards.  It is not unusual for patients who have lived with very large breasts to want to have as much as possible removed. Care must be taken to be judicious in this removal to avoid an outcome where the breasts  are too small in relation (proportionately) to the patient's other body parts.  Again, it is not uncommon, for patients'  breasts to become smaller ( after the breast reduction procedure) with time and/or weight loss-  breast augmentation may become necessary to achieve the patient size.

Breast augmentation (with breast implants) is certainly possible after previous breast reduction surgery. Typically patients requesting breast implants after breast reduction surgery wish to increase the size, fullness and projection of the breasts. This situation may be brought about by over reduction during breast reduction surgery or by weight loss that occurred after the breast reduction surgery was performed.

Another commonly asked question involves insurance coverage for the breast reduction procedure. This is a possibility given that some insurance companies consider the operation “medically necessary” for patients meeting their requirements.The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure. The documentation and letter/pictures from the consultant plastic surgeon will also help obtain authorization. Make sure you're  working with a well-trained/experienced board-certified plastic surgeon.
Another commonly encountered a situation involves a teenager who presents with “juvenile breast hypertrophy”. This describes the young who presents with breast hypertrophy along with the physical and psychosocial consequences of this diagnosis. In other words, the breasts are too large for her frame causing  both physical and psychological distress.  For the right teenager (enough symptoms) the breast reduction procedure maybe an excellent option. However, it is very important that the young lady contemplating breast reduction surgery does her homework and understands the potential risks and complications associated with  the procedure.  She should also understand that further surgery may be necessary in the future (for example if the breasts were to grow in size again).

All in all, breast reduction surgery remains one of the most patient pleasing operations we perform. Critical in the decision-making will always be selection of a well experienced board-certified plastic surgeon, clear communication of patient goals as well as the potential risks and complications associated with the procedure.

Tom Pousti MD

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