40 D Size Bra

BREAST REDUCTION

Breast reduction is surgery to remove excess fat, breast tissue, and skin to achieve a breast size proportional to a woman's body. It not only improves an individual's appearance and relieves social discomfort, but also corrects the functional symptoms of physical discomfort and pain that are associated with large breasts. This article explains what it takes to achieve good results, describes the techniques available, lists the possible complications, and suggests the steps someone considering this surgery should take.

Introduction

The emphasis placed by our culture on the breast as a symbol of sexual attractiveness has led to the popular notion that a well-endowed woman is fortunate and an object of desire and envy. Our advertisements, magazines, and visual media continually reinforce the notion that big breasts and impressive cleavage are desirable. Yet in reality, women with large pendulous breasts often relate a different story of discomfort, embarrassment, and feeling unattractive.

Natural, non-implanted big breasts may be upright in some young persons, but they become pendulous and droopy as the weight of tissue stretches the skin. The heaviness creates strain in the muscles of the shoulders, neck, and back which can cause chronic pain. It becomes increasingly difficult to maintain good posture and women with large breasts can become round-shouldered - many say in part to try to hide their huge breasts. Clothing selection is limited, exercise that involves running or jumping is painful, and the large breast makes the torso look heavy and bulky even when the rest of the body is slender.

Breast reduction, also called reduction mammaplasty decreases the size of the breasts, but also lifts and reshapes the breasts in order to correct the drooping and to increase projection of the breast at the correct level on the chest wall. It is the fifth most common reconstructive surgical procedure performed by Board-certified plastic surgeons. In 2007, 106, 179 patients in the United States had a breast reduction. Despite the magnitude of the surgery, to be discussed below, multiple outcome studies and patient satisfaction surveys report that women who have a reduction mammaplasty are statistically among the happiest of plastic surgery patients.[1]

The patient photographs in this Knol are from the website for the American Society of Plastic Surgeons. These photographs and additional ones can be viewed at www.plasticsurgery.org

Breast hypertrophy

The term used for disproportionate overgrowth of the breast is hypertrophy, which means excessive development without any pathologic or disease process. Breast hypertrophy can be a familial trait and the typical onset is during puberty and pregnancy. It is thought that the hormonal changes during these periods exert an abnormal influence on growth in some individuals. Studies have shown that women with hypertrophy have normal levels of estrogen and the usual number of estrogen receptors in their breast tissue, but these receptors appear to have an abnormal sensitivity to circulating estrogens. The tissue that enlarges is largely fibrous tissue and fat; the glandular parts of the breast tend to remain average in volume.[2] A higher incidence of breast cancer is not associated with larger breasts. The risk of breast cancer does not appear to be any higher in women with large breasts unless the individual also has a positive family history or another risk factor such as proliferative breast disease.

Who is a good candidate for breast reduction?

Breast size that is out of proportion to a woman's body build has an effect on the supporting musculature of the shoulders, neck and back. Studies in the plastic surgery literature have shown that about one half of the women with bra cup sizes D or larger who seek surgery are experiencing pain all or most of the time in the upper back, shoulders, neck and lower back.[3] In addition to back pain, other symptoms that are reported commonly include headaches, pain in the breast tissue itself, abrasions, and deep grooves over the shoulders from bra straps, stretch marks, shortness of breath when lying on the back, and trouble sleeping due to difficulty finding a comfortable position due to the weight and bulk of the breasts. A nearly universal problem is irritation of the skin under the overhanging breasts where moisture, redness, itching, and rashes can develop. Less commonly, degenerative arthritis of the neck and upper back and numbness in the hands due to nerve stretching in the shoulder area are problems.

Due to the physical constraints, women with abnormally large breasts find it difficult to exercise or play sports and may struggle to maintain a normal weight. The more sedentary life-style, weight gain, and difficulty finding attractive clothing can have a material effect on well-being and social interaction, and by extension on personal and professional opportunities. For such individuals, it is helpful to know that studies of women after breast reduction show significantly higher scores in all the health domains of quality-of -life assessment, including mental as well as physical components.

Surgical principles

There is no single best, or ideal size for a human breast. There is wide variation in height, weight, body shape, and physical activity among women and these factors influence what would be an optimal size for any given individual. A woman's personal preferences are very important and there are surgical limitations to changing the size and shape of a breast based on a person's original anatomy.

The principles guiding reduction mammaplasty for breast hypertrophy are

• Improve the patient's symptoms
• Decrease the volume of the breast
• Reshape the breast to correct drooping
• Raise the breast tissue to an anatomically correct position on the chest wall
• Reposition the nipple and areola, the colored skin around the nipple, on the reduced and reshaped breast
• Preserve the nerve supply to the skin, nipple, and areola
• Maintain the blood supply of the breast tissue
• Minimize scars
  

A number of surgical techniques are available to address these principles. These tend to be described in one of two ways: by the location of the block of tissue to which the nipple and areola are left attached, or by the pattern of the incisions and subsequent scars. Some of the methods include

Inferior and central pedicle techniques. The pedicle is the portion of breast tissue that is preserved with its nerve and blood supply while the surrounding breast tissue, fat and skin are removed. The most commonly used is a pedicle arising from the lower part of the breast but there are also central, superior, medial, lateral, and doubly attached vertical and horizontal pedicles. All of these variants are designed to maximize blood supply while allowing adequate tissue removal. No one pedicle is best in all cases, and most surgeons use different approaches depending on the amount of tissue to removed.

The keyhole incision pattern. In order to elevate the nipple and areola, an incision is made around the areola and it is reduced in size by removing skin at its perimeter if this is necessary. An opening is created higher on the breast and the nipple and areola, still attached to the underlying tissue, are lifted into the "keyhole" opening where they are sutured in place. The resultant scars will have a racquet like shape with a round scar around the areola and a vertical scar running down to the breast crease.

Periareolar technique. In smaller breasts, reduction and reshaping can be accomplished by removing a ring of tissue around the areola. The advantage of this is a single round scar, but the amount of tissue that can be removed is limited.

Vertical technique[4]. This developed in an effort to limit incisions and scars running horizontally in the crease under the breast. The periareolar and vertical scars remain.

Suction assisted lipectomy (liposuction). Often used along with excision techniques to remove excess fat under the arm areas, liposuction occasionally is used alone. There are a small number of patients with mild to moderate breast hypertrophy, fatty breasts, good skin tone, no drooping, and a good breast shape. In these persons, liposuction alone will reduce volume with only tiny scars and the results are good provided the skin will tighten, or retract, after the volume is reduced.

Removal and transplant of the nipple and areola. In the very large, pendulous breast where the pedicle would be exceptionally long, the blood supply needed for survival of the nipple and areola is not certain. In these cases, the nipple and areola are removed entirely and transplanted as grafts to a higher position on the breast. This technique is useful also in patients who have a systemic disease or condition that affects vascularity or interferes with wound healing.

Special considerations

Teenagers

For the adolescent with breast hypertrophy, breast reduction is deferred until the patient has achieved full breast maturation and the breasts have ceased growing. Most plastic surgeons do not adhere to a set age limit, such as 19 years of age or older, but do insist that breast size must be stable with no continuing growth for at least 12 months before considering surgery.

Repeat breast reduction

The importance of waiting until breast growth is complete is underscored by reports documenting a higher complication rate with repeat breast reduction than with the first surgery. Problems associated with damaged blood supply, such as delayed wound healing and loss of the nipple and areola, are seen when the tissue and pedicle are surgically developed and moved a second time in a previously reduced breast.[5]

Breast feeding

Lactation and breast feeding is not always possible after breast reduction. Significant amounts of breast tissue may have been removed, and many of the lactiferous, or milk, ducts passing from the breast tissue to the nipple are detached or scarred when the nipple and areola are repositioned during breast reduction. There have been a number of studies looking at the ability of women who had breast reduction to nurse their children subsequently. Most have shown that milk production varies widely and often is insufficient for complete infant feeding. In a survey of 78 women who had children after their surgery, 53% did not attempt to breast feed, 19% breast-fed successfully, 18% were unsuccessful, and 10% breast-fed with formula supplementation. [6]

Cancer screening

Prior to reduction mammaplasty, evaluation should be done according to the American Cancer Society recommendations for breast cancer screening which include a clinical breast exam and mammography for women 40 and older. Many plastic surgeons recommend mammograms in patients 35 and older, and under the age of 35 if they have very fibrous breasts. Even with this, a small number of breast cancers are discovered coincidently at time of reduction mammaplasty either by finding a suspicious area or during routine pathology study of the breast tissue. From this have come guidelines that all reduction tissue removed surgically should be sent for histopathologic study.

Breast reduction after radiation therapy

Breast reduction in women who have had previous lumpectomy and radiation for breast cancer requires some special considerations. Radiation induces vascular changes in the breast tissue that can impair wound healing. It has been recommended that delay between radiation and mammaplasty will allow some of the vascular changes to subside, and that the technique for the reduction be modified. Using pedicles that are broader and shorter than usual and minimizing adjustments of the breast tissue may help to mitigate the effects of the radiation.

Aftereffects of breast reduction

Ideally, there are three consequences of breast reduction that one would like to avoid if the "ideal" surgical technique could be developed. These include:

visible scars and these vary depending on myriad factors including how different persons form scars when wounds are healing

possible loss of the ability to breast feed children after the surgery (see comments above)

a change in the sensibility of the nipple and areola in about 20 - 25% of cases and this can be either an increase or a decrease in sensation

Plastic surgeons encourage patients to consider these three important consequences carefully before making a decision about going forward with this surgery.

Over the years, a number of studies have looked at outcomes after reduction mammaplasty for breast hypertrophy. The vast majority of patients gain relief from their symptoms of pain and discomfort, are able to engage more actively in physical activities, and are happy with the results. In one study of 133 women, 93% reported a decrease in symptoms.[7] In another survey of 185 women, 97% reported improvement in back, shoulder and neck pain, 95% said they were happy or very happy with the results of surgery, and 98% said they would recommend it to others.[8] In this study, only 4% of the patients considered their scars unsatisfactory, but when studies focus specifically on questions about scarring, larger numbers of patients will voice complaints about the prominence of their scars.

Complications with reduction mammaplasty

Healing problems with the incisions under the breasts, bleeding from incisions, infection requiring antibiotics, and loss of skin around and within the nipple and areola are the most common complications. Less commonly, extensive portions of the skin may be lost due to inadequate blood supply and this can involve partial or total loss of the nipple, and fat necrosis , a situation where firm nodules of fat without sufficient blood supply can be felt within the breast. This problem may prompt later investigation or biopsies to differentiate these lumps from those associated with breast cancer.

Other postoperative issues that arise have to do with lack of symmetry between the two breasts, removal of too much tissue, removal of too little tissue, poor shape, pain in or around the breast tissue, and recurrence of breast drooping over time. As a rule, women who are dissatisfied with the results over the long-term refer to problems with breast size, breast shape, and scars.[9]

Steps potential patients should take

Given the magnitude, the consequences, and the complications of reduction mammaplasty, it is critical for an individual who is considering this surgical procedure to have a frank and comprehensive consultation with a plastic surgeon. There is wide variability among women with regard to the amount of breast hypertrophy at the outset and the size of the breast they would prefer at the endpoint. Given this variability, communication between the surgeon and the patient is essential. This includes review of family history of breast cancer and personal history of breast health, and obtaining any necessary diagnostic breast studies. With the challenges to wound healing with this surgery an evaluation of general health is equally critical. Factors to be considered are

Medical problems or medications that can impair healing, such as steroids

Medical conditions or medications that impede blood supply or cause bleeding, such as blood-thinners

Smoking, since oxygen delivery and blood supply are damaged in smokers

Obesity, since fatty tissue is less well vascularized and fat necrosis and wound breakdown are more prevalent in heavy-set patients

Finding a competent, communicative, and skillful doctor should start by looking in the ranks of trained, Board certified plastic surgeons credentialed at an accredited medical facility. Resources are available to help with this, and the following websites can provide further information and the names of surgeons who have met professional criteria, including requirements for ongoing medical education and interval reexamination for maintenance of certification.

American Society of Plastic Surgeons
www.plasticsurgery.org

Plastic surgeon referral service 1-888-4-PLASTIC (1-888-475-2784)

American Society of Aesthetic Plastic Surgery
www.surgery.org

Financial planning

Different health insurance carriers have different policies about paying for reduction mammaplasty. It is helpful at the outset to review written information about the insurance program or contact the carrier to see if there are statements or guidelines about reduction mammaplasty. In general terms, health insurance payers are interested in determining the medical necessity of treating a condition such as breast hypertrophy. Almost all carriers require information about a patient's age, height, weight, and expressed reasons for wanting the surgery before making a determination about coverage benefits. In addition, many base a determination of medical necessity on the weight of the breast tissue removed and consider a patient's body mass index which is the ratio of person's height and weight. Some require efforts with conservative measures such as weight reduction and physical therapy for back pain before considering a request for coverage benefits for this surgery. Many carriers also ask for photographic documentation of breast hypertrophy.

While plastic surgeons do not make the final decision about insurance coverage for reduction mammaplasty, many work with their patients on this and are familiar with the process of submitting necessary information to the insurance carrier. Other plastic surgeons have decided to decline becoming involved in the insurance process, and do reduction mammaplasty on a patient paid basis only. When making an appointment to see a plastic surgeon, it is useful to ask about whether he or she accepts insurance payment for reduction mammaplasty.

[1] Serletti JM et al: Long-term patient satisfaction following reduction mammaplasty. Ann Plast Surg 28:363, 1992.

[2] Jabs, AD et al: Mammary hypertrophy is not associated with increased estrogen receptors. Plast Reconstr Surg 86:64, 1990.

[3] Collins ED, Kerrigan CL, Kim M, et al: The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg 109:1556, 2002.

[4] Lejour M: Vertical mammaplasty: early complications after 250 personal consecutive cases. Plast Reconstr Surg 104:764, 1999.

[5] Hudson DA, Skoll PJ: Repeat reduction mammaplasty. Plast Reconstr Surg 104:401, 1999.

[6] Brzozowski D, Niessen M, Evans HB, Hurst LN: Breast-feeding after inferior pedicle reduction mammaplasty. Plast Reconstr Surg 105:530, 2000.

[7] Miller AP, Zacher JB, Berggren RB et al: Breast reduction for symptomatic macromastia: can objective predictors for operative success be identified? Plast Reconstr Surg 95:77, 1995.

[8] Dabbah A, Lehman JA Jr, Parker MG et al: Reduction mammaplasty: an outcome analysis. Ann Plast Surg 35:337, 1995.

[9] Maxwell Davis G, Ringler SL, Short K, et al: Reduction mammaplasty: long term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg 96:1106, 1995.