Overview of Breast Reduction
Breast reduction surgery, more formally known as reduction mammoplasty, is a medical procedure designed to make the breasts smaller, keep the nipple and the surrounding area (areola) healthy, and create a shape that looks good.
Before a person is chosen to have this surgery, the doctor needs to know a lot about their health and lifestyle. They will need to know things like when the person’s breasts started to develop, whether they have children or are planning to, whether they have had any significant weight changes, whether they smoke, and any other significant medical conditions. The doctor will also want to know if anyone in the person’s family has had breast cancer.
It’s also important to share if the person is experiencing symptoms related to the weight of their breasts, like pain in the neck, back, or shoulders.
The doctor will conduct a detailed examination before the surgery, looking at factors such as the size and shape of the breasts, how elastic the skin is, and whether there are any other issues such as rashes or indents from bra straps. They will also check for any lumps and the consistency of the breast tissue.
The doctor will also look at where the nipple and areola are in relation to the crease under the breast (the inframammary fold). They’ll measure the distance from the hollow at the base of the neck where it meets the chest (the sternal notch) to the nipple, and also the length from the nipple to the inframammary fold, to understand how much they may need to lift the breast.
Sometimes a person might come in thinking they need a breast reduction, when what they really need is a mastopexy or breast lift. These are different procedures, but they use a lot of the same methods. A lift might be needed if the breasts are sagging severely.
Anatomy and Physiology of Breast Reduction
The breast is a part of the body that starts at the fourth space between the ribs and is located under the skin. Its position is maintained by connections to the skin and tissue at the lower part of the breast and the sternum (the breastbone) but it’s not attached to the tissue covering the chest muscles. The areas of the breast near its bottom and near the sternum are less flexible, compared to the top and sides of the breast.
When it comes to reducing the size of the breast, the most crucial thing to understand is the blood flow and how the nerves function, especially around the nipple and the area surrounding it. The breast receives blood from three main sources, and it has distinct sections based on its sensory nerve supply.
The largest portion of the breast tissue (60%) gets blood from the internal mammary artery, mainly the part of the breast closest to the middle of the body. The skin on the inner part of the breast is served by nerves that come from between the second to seventh ribs. The superior, outer, and lateral parts of the breast receive about 30% of their blood supply from the lateral thoracic artery. The upper part of the breast gets sensation from the supraclavicular nerves, which originate from the third and fourth nerves of the neck.
The remaining outer lower section of the breast gets its blood supply from the anterior and lateral branches of the arteries that run between the third, fourth, and fifth ribs. The nipple obtains its blood supply from the overlap of these blood pathways and its sensation from a nerve branch that reaches the fourth space between the ribs.
Why do People Need Breast Reduction
Many women consider a breast reduction procedure due to both physical discomfort and emotional distress. Usually, this operation is primarily performed to relieve pain and discomfort connected with heavy, sagging breasts. Common complaints include chronic back and neck pain, headaches, shoulder pain, deep indentations from bra straps, and skin irritation beneath the breasts. In some cases, the breasts themselves can become persistently painful.
Large breasts can also cause nerve pain in the upper extremities (arms and hands) and alter a person’s posture. Skin problems such as rashes, chafing, and other skin irritations are also common. An excessively large breast size can interfere with daily activities and make it difficult to exercise or find clothes that fit properly.
Besides the physical discomfort, having excessively large breasts (a condition known as hypermastia) can also affect a person’s mental wellbeing. Many people may feel embarrassed or overly self-conscious about their size. A procedure called reduction mammaplasty, or breast reduction surgery, can alleviate or reduce these issues in most cases.
This surgery might also be recommended to correct uneven breast size caused by one breast growing larger than the other (unilateral hyperplasia) or to create balance after one-sided breast reconstruction.
When a Person Should Avoid Breast Reduction
It is crucial that anyone considering an elective surgical procedure, such as breast reduction, is generally healthy and able to meet the standard requirements for surgery. There’s no strict age restriction as long as the individual’s health is satisfactory. It’s important to manage any existing health conditions like diabetes or high blood pressure (hypertension) before surgery.
For smokers, it’s recommended to stop smoking around two weeks prior to surgery. It’s vital to let them know about the increased risks that smoking poses, including damage to skin flaps, loss of the nipple-areola area, and slow wound healing after surgery.
For those who are over 40 years old, or have a family history of breast cancer, a mammogram is necessary. A mammogram is a special type of X-ray of the breasts used for early detection of breast cancer. In case any potentially harmful results are found, these should be evaluated by a surgical specialist who deals with cancer (oncologist) before going ahead with the elective breast reduction surgery.
How is Breast Reduction performed
Choosing the best method to reduce breast size (a procedure known as reduction mammoplasty) often depends on several factors, including the individual’s body shape, attitude toward having potentially visible scars, the surgeon’s judgment and professional experience. Three common methods presently in use are: superior pedicle technique, inferior pedicle technique, and breast reduction with relocation of the nipple-areola area with grafting.
The inferior pedicle technique is popular and can be used for almost any breast size and shape. People who undergo this procedure usually end up highly satisfied, as it allows for the nipple-areola area to be relocated considerably without causing loss of sensation or the ability to breastfeed. Moreover, it is also useful for rectifying uneven breasts and sagging (a condition known as ptosis).
Different version of superior pedicle techniques exist. A specific one is the vertical mammoplasty method. This reduction functions without leaving a horizontal scar under the breast. This technique relies mostly on the skin’s natural ability to retract when excess skin tissue is removed. It also incorporates steps for facilitating better-looking results in the long term. This type of reduction method is best for small to moderate reductions.
If you are significantly bothered about having scars or if your body is prone to excessive scaring (hypertrophic scarring), the superior pedicle technique is a good option, because it does not leave a scar under the breast. Nonetheless, a point to consider is that the desired shape of the breasts only becomes evident after a few months, during which time the breasts may have a temporarily deformed and wrinkled appearance.
Sometimes, a grafting method that involves relocating the nipple-areola complex is chosen for patient safety or when it is important to maintain the viability of the nipple-areola area. This technique is generally used when moving the nipple-areola complex on an inferior pedicle would be too extensive for safety. It’s also used when a large volume of glandular tissue (the milk producing cells in the breast) needs to be removed, leaving no choice for the creation of a vascular pedicle (tissue containing blood vessels), or when there are heightened risks associated with anesthesia or previous breast surgeries that may have compromised the blood supply in the breast. Although this method is quick and effective, it comes with certain drawbacks, such as a loss of nipple-areola sensation, the inability to breastfeed, and possible discoloration of the nipple-areola area due to some loss of the graft and healing that follows.
No matter the method, it is essential to have a thorough discussion with the surgeon about the benefits and risks of the procedure, your preferences, and the limitations because of your personal physical characteristics. Correct marking before surgery is incredibly crucial to help achieve the final shape and symmetry of the breasts. This is usually done during the operation after some tissue has been removed.
After finalizing the positions of the nipple-areola complex, ensure its viability by properly maintaining the blood supply to the pedicle or the graft bed. Be careful not to undermine the pedicle to maintain a healthy blood supply. If there’s doubt at the end of the procedure about whether the pedicle will remain viable, then it should be changed into a free graft.
If the pain after the surgery is severe and hard to manage, consider staying at the hospital overnight. No laboratory tests are required post-surgery. Old dressings can be replaced with clean gauze or a surgical bra on the next day following the procedure. You should continue to wear a supportive bra both during the day and night for about two months post-surgery.
If the surgeon places drains (tubes to remove excess fluid), carefully note the drain output to remove them when the output is less than 30 mL within 24 hours. You can shower on the first day after surgery as long as drains have not been placed. If drains are in place, showering can only occur once the drains have been taken out. Do not lift heavy things for at least four weeks after surgery.
After six to twelve months post-surgery, mammograms (breast X-rays) are necessary for everyone over 40 as the new baseline images will show the changes in the breast following the surgery.
Possible Complications of Breast Reduction
There can be some issues after breast reduction surgery, but they’re usually small and don’t often need extra operations. Two things that can make these issues more likely are having a Body Mass Index (BMI) over 30 and smoking. Also, the more breast tissue removed during the surgery, the higher the chance of complications.
Common minor issues seen just after surgery can include a buildup of blood (hematoma), a buildup of fluid (seroma), skin infections (cellulitis), infections in the surgery wound, slower than normal wound healing, and small wound separations (minor wound dehiscence). More serious complications that often need another surgery to fix include large wound separations (major wound dehiscence), tissue death (flap or nipple-areolar necrosis).
Once all wounds are healed properly, there might be complications related to how the breasts look. This can include unevenness, a bad shape, excess skin at the end of an incision (dog ears), taking out too much or too little tissue, and noticeable scars.
What Else Should I Know About Breast Reduction?
If it’s determined that a person is suitable for a breast reduction surgery, a specific surgical method will be chosen. This method should have a low likelihood of major issues such as the reopening of the surgical wound, death of tissue due to lack of blood flow, excessively high placement of the nipple, and loss of nipple due to insufficient blood supply. The operation aims to reduce breast weight, improve aesthetics, and leave as few scars as possible. Ultimately, the surgery should efficiently reduce the size of the breasts, minimizing the risk of needing additional corrective surgery.
