Breast reduction is a reconstructive procedure, but it’s also an elective operation that has grown in popularity among physicians as well as patients.
According to the American Society of Plastic Surgeons, from 2000 to 2007 the number of women receiving breast-reduction surgery increased by 25%. Last year’s tracked number of cases topped 106,000, a substantial percentage of which were girls younger than 18 years.
Many factors influence a patient’s decision to have this operation, including her size and age, her insurance coverage, and her recovery.
It is a common procedure, though, and one that often yields fabulous results and very happy patients.
This PSP Roundtable interview includes Jane Petro, MD, FACS, a board-certified plastic surgeon in Mount Kisco, NY; Robert A. Shumway, MD, FACS, a La Jolla, Calif-based diplomate of the American Board of Cosmetic Surgery and the American Board of Facial Plastic and Reconstructive Surgery; and W. Grant Stevens, MD, FACS, a board-certified plastic surgeon in Marina del Rey, Calif. These surgeons discuss the procedures, techniques, and complexities of this surgery.
Explain your breast-reduction procedure’s technique and recovery. What makes your technique different from that of your colleagues?
Petro: I like to think of patients as three different categories, with specific considerations for each group: young adults with primary hypertrophy, women during childbearing years, and perimenopausal women.
For teenagers with primary hypertrophy I prefer doing an inferior pedicle reduction with the traditional “anchor” scar.
These breasts are very dense and glandular, very firm, and can be significantly painful and very disabling in terms of the patient’s ability to participate in sports and other physical activities.
I’ve actually done breast reductions on kids as young as 9 who were physically handicapped because of the size of their breasts. I did a reduction on a 12-year-old once who was a champion horseback rider and was having trouble keeping her seat when she was jumping. We did her again when she was 16, and she did fine both times.
By using the inferior pedicle technique, the sensitivity of the nipple and the possibility of breast-feeding are likely to be protected.
Also, in those cases where a future re-reduction may be required (like the 9- or 12-year-old), this is a safer type of pedicle to be reoperated.
The second category of reductions is women who either have primary enlargement of their breasts—who didn’t do it as teenagers—or who get enlargement of the breasts while on the birth control pill or during pregnancy.
In this age range, you also find patients with large breasts who are also quite large themselves. The breast reduction that you do in these adult women can vary depending on their needs, the size of the breasts, and the redundancy of the skin.
Either a medial pedicle short scar, or an inferior pedicle anchor scar, is usually chosen. And, in some cases, the breasts may be large enough that you even need to do a free nipple-graft reduction.
With this technique, you cannot protect the nipple sensation but you can preserve the appearance of the areola and the nipple projection. A free nipple is necessary if you are removing 2 to 3 kilograms of breast tissue.
I do not make patients lose weight before doing reduction mammoplasty. When exercise is impaired by the breast size, weight loss is extremely difficult. It’s so uncomfortable, they’re embarrassed to get into gym clothes and may have real pain with attempted exercise.
After the women get the breast reduction, they look down and they see this massive abdomen and it’s a big motivator to get them to go to the gym, to begin changes in their diet so that changes in their lifestyles will lead to weight loss.
|Following a partial loss of the right breast after reduction, reconstruction was accomplished using tissue expanders and implant.|
I think it’s cruel to require patients to lose significant amounts of weight before reduction. Weight loss after the breast reduction has not had a bad effect on the results of the surgery. So, in my practice, I see breast reduction as a very effective health-motivation tool.
The third category of breast-reduction patients are perimenopausal patients. These women tend to have a more fatty enlargement of the breast with not so much glandular tissue, so you can actually do a liposuction reduction for some of these patients with or without a mastopexy.
If the patient doesn’t have a lot of sagging of the breast, then you can just do the liposuction and the skin should tighten up pretty nicely. With the liposuction breast reduction, you are unlikely to lose the erotic nipple sensation.
As a general rule, teenagers recover faster than adults. I tell patients not to engage in any heavy physical activity for about a week. Most people are going to need some type of mild narcotic medication for 2 or 3 days—most should return to work within 1 week. If they do strenuous work, I tell them to take 2 weeks off.
Pain in the immediate time after surgery is not nearly as bad as after other major procedures. It helps that I infuse the tissues with a significant amount of marcaine before closing, so my patients are relatively pain-free for several hours after surgery.
Shumway: I use a superiorly based pedicle for smaller reductions and the vertical bipedicle McKissock procedure for intermediate-sized reductions.
Inferiorly based pedicles are excellent for larger reductions, while I reserve free nipple-areolar grafting for extensive breast reductions.
Also, I perform breast liposculpting and shifting with or without breast implants, to help reshape the breast.
Sometimes, I will reshape breasts using autologous fat transfers and/or adipose repositioning procedures coupled with directed liposculpting and lipodissection.
Various breast-lifting approaches, such as Bernelli, vertical, Wise pattern, and internal mastopexies, are necessary to shape a “reduced” breast.
The key issues regarding the above procedures are volume, shape, position, symmetry, function, and cicatrix.
Frequently, patients ask for breast and body sculpting or shaping concomitantly. I believe it is in the patient’s best interest to keep overall operating time under 4 hours, if possible.
My breast surgeries usually range between 1 and 4 hours. I also feel that the 5-liter supernatant fat lipoextraction rule should be followed, as supported by the American Academy of Cosmetic Surgery.
Therefore, I generally concentrate on the breast area and try not to perform too many other procedures at the same time.
|A patient with previous radiation to treat breast cancer (note radiated skin) was treated with inferior pedicle reduction on both sides.|
Abdominoplasty and extensive liposuction operations should be done separately, because it is easier on the patient and they will thank you during their recovery.
Recovery from breast reductions will average from between 10 days to 4 weeks, depending on the extent of the surgery. The patient must endure surgical drains from 1 to 3 days and wear compression garments for at least a month to 6 weeks.
I check my patients every day initially and then at least semiweekly, making sure that the garment is positioned correctly and that they are healing appropriately. Long-term follow-up is most certainly required.
Stevens: My breast reductions are very different in many ways. I started using the CO2 laser to deepithelialize my breast reductions back in 1996. I use the CO2 laser to deepithelialize the pedicle. It’s a bloodless procedure. It’s rather efficient. It’s quicker than doing it with the knife.
The first thing I do is inject the breast with 250 cc’s of saline with  mg of epinephrine and 20 cc’s of 1% xylocaine, so the breast has anesthetic and epinephrine in it before we start the case. Then I do the laser, and then we prep the skin and do the breast reduction. The resection usually takes about 15 minutes on each side, and then the closure.
When I use the CO2 laser, I have never had to use a free nipple graft. I don’t transfuse my patients. I don’t use any sutures that have to come out; everything is dissolvable.
I don’t use any drains. Everything is just taped, and then we use a restrictive bra. My patients are never hospitalized; they’re always outpatient.
None of the surgeries take more than 2 hours, and most average an hour-and-a-half to an hour and 45 minutes. It’s not uncommon for me to do three or four breast reductions in a day.
|In this case, the patient’s extremely large breasts were treated with inferior pedicle.|
My patients do extremely well. They’re asleep for a much shorter time than what people think about; and out-of-towners stay 5 to 6 days and fly home.
When I used to do breast reductions, it wasn’t a very pretty operation. It was bloody; patients were hospitalized; they had drains. I have made it very simple for the patient.
After the case, I tell them to go home and take a shower, and to resume full physical activities as they feel fit. I have them walking the very first day and to the gym in less than a week—can’t do upper body.
I’ve done this thousands of times. Women want to do the laser-assisted breast reduction; that’s why they come from all over the world.
What was the most complicated case you had, and how did you handle it?
Petro: The most challenging cases I have handled are those with medical complications—patients referred to me who have had infections or necrosis of tissues, leading to loss of the nipple or even part or the entire breast.
Wound complications that are minor are common and usually self-limited. Major wound issues require knowledge of the principles of healing, a willingness to reoperate, and a great deal of patience on the part of the physician and the staff.
Recently, I took care of a young woman who lost a major part of her breast, whose surgeon and nurses complained to her that she was taking up too much of their time. She wasn’t demanding at all; they just couldn’t tolerate providing the care she needed.
Shumway: In general, the most challenging breast-reduction cases involve high-volume reductions associated with extensive preoperative ptosis and asymmetry.
Even large, tuberous breasts can be quite difficult to reshape into a more aesthetic appearance.
High-volume cases of more than 1,000-gram-tissue-removal-per-side usually require an inferior pedicle or free nipple grafting technique.
Unfortunately, free grafts deinnervate the nipple-areolar complex and, of course, lactation is no longer possible.
The use of various sizes and shapes of saline or silicone breast implants with liporeduction may help improve one’s results.
Ideally, a patient’s expectations must be realistic and within the realm of creative possibility, or I will not attempt the surgery.
One particularly difficult case for me involved a massive bilateral tubular breast-reduction procedure with previous unilateral lumpectomy and radiation, where the patient possessed Grade III ptosis.
This asymmetrical challenge required 1,500-gram left and 1,200-gram right breast reductions with free nipple grafts, lateral thoracic liposuction, mastopexy, different-sized silicone breast implantations, postoperative hyperbaric oxygen treatments, and meticulous follow-up care.
Stevens: Many breast reductions are 500 to 1,000 grams. It’s not true for every woman because it depends on her size, but it’s very rare that you’re going to go over 1,000 grams; 2,000 would be pretty much unheard of.
I did a woman in her early 30s just recently, who was 4,500 grams on one side and 3,800 grams on the other side. She was over 8 kilos—it was about an 18-pound reduction. The distance from the sternal notch to the nipple was 58 cm on the large side and 54 cm on the small side.
Just about everybody would say that it needs a free nipple graft, and I did not do that. The blood supply was preserved to the nipple, and she did just fine and [her] breasts healed great. And she is obviously a greatly relieved patient.
That was a difficult one because of the enormity of the breast and the distance to the nipple. I had to have assistants to hold the breasts just so I could mark on them. It’s amazing to me—I’ve never seen breasts this large in my life.
The other case that comes to mind was a gross asymmetry. It was a woman with a very, very, very large breast on one side and sort of a nominally large breast, maybe a D with a little ptosis. But, for whatever reason, the way she developed this one breast was enormous and the other one was big, full, and saggy, but not one that you’d just say, “Wow! That person definitely needs a reduction.”
You’re always doing a bilateral reduction; you couldn’t just reduce the big one because the other one that was just sort of full was too saggy. So, I had to do a lift and small reduction on the right side and a giant reduction on the left side. And that was very challenging to get the same look when we were done.
Breast asymmetry cases are challenging but very rewarding. These patients are the happiest patients in my practice, bar none. They say three things to me after surgery: “Thank you,” “I can’t believe I waited that long,” and, “You’re right. I can’t believe it doesn’t hurt.”
Jane Petro, MD, FACS, is a plastic surgeon certified by the American Board of Plastic Surgery who specializes in breast-reduction surgery for teenagers. Twenty percent of Petro’s practice is breast-reduction surgery; she performs approximately 100 of these surgeries per year on women of all ages. Her practice is located in Mount Kisco, NY, and she can be reached at www.drjanepetro.com.
Robert A. Shumway, MD, FACS, is a diplomate of the American Board of Cosmetic Surgery and the American Board of Facial Plastic and Reconstructive Surgery. He performs approximately 50 breast-reduction procedures per year, which constitute approximately 20% of his practice. His practice, Shumway Cosmetic Surgery, is located in La Jolla, Calif. He can be reached at www.shumwaycosmeticsurgery.com.
W. Grant Stevens, MD, FACS, is an American Board of Plastic Surgery-certified plastic surgeon who specializes in bloodless breast-reduction surgery. He performs approximately 200 of these procedures per year, which is approximately 20% of his practice. His practice, Marina Plastic Surgery Associates in Marina del Rey, Calif, can be reached at www.marinaplasticsurgery.com.
Amy DiLeo is a contributing writer to PSP. She can be reached at [email protected]