There are many women now opting for breast surgery – what exactly is a Breast Reduction?

The correct medical term is reduction mammoplasty but most surgeons and patients refer to it as breast reduction surgery. A breast reduction is an operation where a variable amount of excess breast tissue is removed, in combination with a reshaping of the remaining tissue. With almost every breast reduction, the technique also involves a breast lift.  The nipple is lifted to a new position because large breasts inevitably tend to sag, so every reduction will involve some degree of lift. Although conceptually the same operation major difference between a breast lift and a breast reduction is in a breast lift a small to moderate amount of tissue is removed and in a breast reduction a much larger amount is removed. This could be anything from 300g per breast, up to several kilograms per breast.

Tell us about some of these techniques, their advantages and their disadvantages and even the type of scarring with each technique?

The most common technique is the Wise-pattern. The Wise-pattern is an inverted ‘T’ scar, meaning the scar is placed circumferentially around the nipple, vertically over the breast and then into the fold where the breast meets the chest wall (infra-mammary fold) to a variable distance. In large reductions, or where there is a lot of excess skin this pattern is employed.

The Short scar technique is gaining popularity as it limits the length of the scar in the infra-mammary fold. The short scar entails the same 360 degree scar around the nipple and a vertical to the fold but no scar in the fold. Occasionally, a short horizontal scar may be necessary.

Thus, every technique will have a scar around the nipple and apart from the very rarely performed Schwarzman technique; all other techniques have the vertical scar. The Schwarzman technique may be appealing conceptually, but the inability to “cone” the breast tissue results in a flattened breast with limited projection. The most objectionable scar really, is the vertical scar that goes over the breast. There is no border, or natural junction in which to conceal the scar and it is over a convex path, so the light will always make that scar visible. The scar around the areola tends to blend well as it is a natural junction of texture and colour. The scar in the infra mammory fold also tends to hide well because it’s in a groove

What does the actual operation entail?

This is major surgical procedure and I always perform it under general anaesthetic. The procedure takes around 2 – 4 hours. Patients generally will spend a night in hospital for postoperative monitoring and also for pain and nausea control. Some medical aids will cover the operation, based on medical motivation, while others will not cover the operation at all.

What would qualify a woman as being a suitable candidate for this procedure?

Many patients come with both cosmetic and physical symptoms. The physical symptoms are often heaviness of their breasts that cause neck ache, backache, or a rash where the bra strap rides over the top of the shoulders. Some patients may get a rash on the underside of the breasts where the breasts meet the chest wall.  The medical term for this is intertrigo. There are also patients who just want to have smaller breasts as they believe it would be cosmetically better to have their breasts smaller and lifted.

Are there situations where you would advise against the surgery?

Breast reduction or lift is major surgery, so everyone who is going to have this surgery needs to be in good health. Any major medical conditions, especially if they are untreated, or if they are not being optimally managed, disqualifies such a patient for the surgery, especially considering that breast reduction surgery is elective. Obesity is a relative contra-indication.

Medical reasons excluded, the American Society of Plastic Surgeons (ASPS) recommends that cosmetic surgery for children under the age of 18 be really well motivated. For instance, breast reduction surgery in young girls, who have really large, symptomatic breasts and possibly psychological distress, are considered on a case-by-case basis. Generally, I don’t perform breast reduction surgery on patients under the age of 18 especially if their breasts are still growing.

I also always ask the patients whether they are planning a pregnancy.  If they plan to fall pregnant within a year of the surgery, I ask them to wait till after the pregnancy and then come for the procedure. It doesn’t make sense to do a breast reduction before then, because you don’t know how large the breasts will grow. They may grow asymmetrically, or they may not involute symmetrically thereby losing the cosmetic result of a breast reduction and the patient may require a second breast reduction.

Smoking is associated with an increased risk of all complications. Although smoking is not an absolute contra-indication to surgery, patients should be aware of the increased risk of complication and possibly adversely affected aesthetic outcome. It is preferable to refrain or reduce nicotine intake for the 6 weeks prior to and after the surgery.

Does the surgery affect breast milk production?

It definitely does. The structure of the breast consists of connective tissue, fat cells, actual breast glands and breast duct tissue. All the ducts lead to the nipple. By removing breast tissue you are removing some of the ducts which will decrease the milk production. This is not to say that patients who have had a breast reduction absolutely can’t breastfeed; there are patients who have had extensive surgery and are able to breastfeed, and then there are patients who have had no breast surgery whatsoever and can’t breastfeed. Obviously breastfeeding is best but these days the formula feeds are also good.

What are the things you would advise women to consider before having breast reduction?

It would depend on what the patient’s real desire is.  If a patient has physical symptoms because of the size of their breasts, they are usually undeterred by the scarring or the length of recovery time. For these patients it is about relief from the physical symptoms. For the patients who want it more for cosmetic reasons, the scarring is probably the biggest thing I feel the patient must consider. Many do not really know what the procedure entails. Some may actually require a breast lift and not a breast reduction. Generally, most patients don’t anticipate how long the scars are. Once the skin has been incised, there will be a scar and although it usually heals well, you can never completely hide the scarring.

The breastfeeding issue is one I make sure they understand and finally, patients must know it is a major operation and like any other surgery there can be possible complications. If the patient understands all these risks then we can proceed with the operation.

What are the potential risks and complications?

As a breast reduction is major surgery, there are surgical risks as well as anaesthesia risks. There could be major complications that may require revision surgery and longer hospitalisation. There might also be minor complications. Prior to the surgery patients are given a list of potential complications and what the treatment of those complications may involve.

What about loss of sensation in the breast following a breast reduction?

The most important sensation would be that in the nipple, especially the erogenous sensation.  Women with gigantomastia (very large breasts) have such stretched nipples that they tend to have decreased sensation in the nipples anyway. The main sensation comes from 3 branches (two lateral and one medial) of the 4th intercostal nerve. You cannot see these nerves as they are tiny and mingled with the breast tissue and thus it is not easy to definitively identify and preserve it during the surgery. Surgeons tend to adopt a design that will preserve at least one of the branches so the patient can generally retain sensation in the nipple. I always warn the patients that they may lose sensation if the nerve gets slightly bruised and stretched, but this is often a temporary phenomenon. Sensation usually returns between a period of 6 weeks to 6 months, but sometimes it never comes back. Occasionally patients with very drooping breasts actually get better sensation after having a breast reduction because the nerve is no longer stretched. Results are variable but the norm is to retain sensation even if temporarily disrupted.

It’s been said that breast reduction surgery can reduce the risk of cancer, any truth in this?

There are several scientific articles which show a marginally decreased risk of breast cancer. If you have a certain volume of breast tissue, you have a certain amount of duct tissue and that duct tissue carries the risk of becoming cancerous.  If you cut some of that out, you will have a smaller risk.  Note that breast reduction surgery is not a risk reduction procedure. It does not obviate the need to go for mammograms and to do regular self-examinations. You can still get breast cancer after having a breast reduction, but because you have less breast there is a slight decrease in the risk.  If someone has a family history of breast cancer, having breast reduction will NOT sufficiently reduce their risk. Women who have had breast reduction surgery should still go for regular mammograms. I send all my patients six months after surgery for a new baseline mammogram because the entire architecture of the breast has been rearranged. It is therefore important for all patients to have a pre-op (pre-operative) mammogram and then a post-op (post-operative) mammogram. Ultrasound screening is generally used in patients under the age of 35.

How long is the recovery period for patients?

From a recovery point of view, the operation is less onerous than the extent of the surgery would suggest. The breast tissue is sparsely supplied with pain receptors and thus not very sensitive, the skin however, is richly supplied and is quite painful, at least initially. However, compared to other operations such as augmentation or tummy tuck, it’s not that painful. The first 5 days are usually the worst, when patients will require some strong pain killers. During recovery I suggest that patients don’t drive for at least 2 weeks after the operation. I also restrict my patients from exercise for at least the first 6 weeks. Most patients are relatively pain free and able to cope with activities of daily living after 2 weeks. Wound strength rises to 90% of its final strength after 6-8 weeks. The tissue may take 12 months or more to settle and the final result to become apparent.

If a patient is not happy with the result what recourse would they have?

If there is a small issue, I generally would not rush into another surgery for at least 3 months and would suggest even longer if possible. If for instance, the scar is not to the patient’s satisfaction, I would ask them to wait for up to a year to see what the final result is, after which I would then do a scar revision. Obviously, there are major disasters that could happen, although such occurrences are fortunately very rare. Most medical aids will not cover patients for subsequent revision of cosmetic surgeries. Patients could take out cosmetic insurance for this, but companies offering this would audit a plastic surgeon’s practice to establish what their complication rate is. This insurance usually covers acute complications only. The biggest issue patients have is either that the surgeon took too much off or took too little. Unappealing scarring is occasionally a complaint.

Does the operation mark the end of drooping? Is the ‘new look’ forever?

Breasts start drooping from the minute a patient leaves theatre because of the continual downward vector of gravity. Unlike the older techniques, the short scar technique does not rely on the breast skin as a bra, the shape is not created by the tension on the skin, but by remodelling the underlying breast tissue into a better shape afterwhich the skin is closed over it. With the old fashioned technique, the skin is reshaped and used to hold the breast in its new shape. The new technique’s results are longer lasting, but all breasts will eventually droop. The breasts will age but they will age differently after having had the operation. If patients have good results after a year, they will probably have relatively good results for a number of years after that.

Is there any truth to the advertised non-surgical “breast reduction”?

There are several products being advertised, including “firming creams” you can rub on to firm and lift the breast, but there is absolutely no scientific evidence of success. There are also so-called “herbal” pills which may (or may not) contain active ingredients that can harmfully affect your health, but there has been no scientific evidence or publications asserting that taking any herbal remedy will decrease the size of your breasts.

There are several non-invasive technologies that claim success. One such technology uses focused ultrasound beams. When the machine’s ultrasound beams meet the sub cutaneous tissue it literally breaks up the fat cells. The fat cells rupture and are then released and absorbed by the body.  There has been some medical literature about the success of this technology. I would personally be concerned about ultrasound damage to breast tissue. This technology is not approved by the FDA for this purpose. There is also a new FDA approved technology, which basically freezes the fat cells. However, there has also been no scientific evidence to support its use for breast reduction.

What about liposuction? Is that not less invasive?  

Liposuction is an option for highly selected patients. The problem with liposuction of the breast in older patients, who have a lot of breast ptosis (sagging), is that just emptying the mound and leaving the envelope will leave them with cosmetically unappealing results. Although there is some skin contraction in liposuction, it will still end up in more ptosis in an older patient. Liposuction of the breasts is limited in younger patients as young breast tissue tends to be firm and doesn’t have too much fat in it. Liposuction could probably result in a one cup size decrease. You certainly couldn’t get a large reduction, so I find it a very unrewarding procedure. It’s a lot of hard work with minimal results. I almost always perform a limited liposuction to contour the lateral aspect of the chest wall during the breast reduction procedure and this additional step often significantly improves the final result.

What advice would you give to any woman considering breast reduction surgery?

Know why you want the surgery and understand the results and changes that will take place. The biggest thing I will advise they consider is the scarring. Look at examples of what a good result and an average result of the surgery would look like. Do not be in a hurry. Go for a consultation, take time to think about the surgery, discuss it with your family and with your partner. Discussing it with your partner is crucial because the breasts will be scarred afterwards – so make the decision together. Patients who want the surgery for cosmetic reasons need to be counselled more because they need to understand that scarring is irreversable. You must be absolutely convinced that you want the breast reduction despite the scars and the potential complications. Make sure you see a qualified plastic surgeon (as registered by the Health Professions Council of South Africa). Don’t feel bad seeking a second opinion. You need to feel absolutely comfortable with your plastic surgeon.