BEFORE AND AFTER PHOTOS
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Problems With Very Large Breasts: Physical and Psychological
Women who have large breasts endure at least as much psychological pain as those with small breasts. Added to this are the common physical symptoms—back, neck, and shoulder discomfort. Physical activities and sports are limited. Usually patients with large breasts have lived with these symptoms for years. Many have had chiropractic care. Patients regard their breasts not as a positive part of their anatomy, but as a negative. Sometimes patients will declare to me, “I want them off!” After surgery, it is common for patients to say, “I wish I had done this earlier.” The quality of life for women with very large breasts is surprisingly bad. One study found that living with excessively large breasts is comparable to the burden of living with moderate angina or a kidney transplant!
Often, women with very large breasts develop poor posture and know this compromises their attractiveness. Some have indentations on their shoulders from their bra straps. They can suffer skin irritation and infections under their breasts (“intertrigo”).
Young women often tell me they have problems participating in sports since their breasts can literally get in the way. In order to jog comfortably, they must wear two sports bras, which is hot and uncomfortable. Large-breasted women have difficulty finding clothing that fits well and bras that give enough support. I had one patient whose breasts were so large she always wore a bra to bed out of fear that one might smother her as she slept!
Happily, we have the tools to help these women. It is hard for me to imagine past generations of women who went their whole lives with this encumbrance, a literal weight on their chests, without the benefit that a 2-hour procedure could make in their lives.
Today, breast reduction surgery aspires to more than just a functional benefit in relief of symptoms. It is also a procedure to improve the appearance of the breasts. For the majority of breast reduction patients (90%), improvement of appearance is part of the reason they are having surgery.
Turning Point: Making a Change With Breast Reduction
Breast reduction is one of the most satisfying procedures for the patient and plastic surgeon alike. I particularly enjoy the procedure both from a technical standpoint because of its demands for finesse and rewards for attention to detail and from the immense satisfaction of patients afterward. The significance is so profound that patients will often think of events in their life in chronological terms before and after their breast reduction. For example, “We went on that cruise 6 months after my breast reduction.” Similar to breast augmentation, a breast reduction brings an immediate smile to patients’ faces. Patients are often happy even in the recovery room waking up after surgery. There is much to be said for immediate gratification.
The breasts are simultaneously tightened and reshaped, so patients also receive the benefit of a breast lift when they undergo a breast reduction. Not only may the breast size be reduced, their appearance may also be improved. Women find they now have a flattering torso that was previously obscured. They look thinner. Friends think they’ve lost weight. They can wear dresses that they could not wear before. They can go braless. They can exercise without the encumbrance of heavy breasts and unwanted attention. A weight has been lifted off their chests, literally and psychologically. This can be a turning point in a woman’s life. Patient satisfaction rate is very high, on the order of 95%. This level of patient satisfaction in plastic surgery is rivaled only by breast augmentation and abdominoplasty.
Despite the fact that the surgery takes longer and there are more incisions, a breast reduction is usually less painful than a breast augmentation, because there is no lifting of muscle or stretching of tissues. The average pain score of patients having a breast reduction is 3.3 on a scale of 1–10, compared to 5.9/10 for patients having a breast augmentation.
Older age is not a barrier, and older women often elect to have this surgery because with age their breasts have gotten larger and become more uncomfortable.
It is uncommon to perform this surgery on teenage girls until their breasts are fully developed. Occasionally I make an exception for a teen who has developed very large breasts at puberty and will suffer psychological damage if this problem is left unattended. Too many large-breasted women have related such stories to me of traumatic teenage years to ignore this reality. Breasts may continue to enlarge after a reduction, so young women need to know that another operation may be necessary later on, but the scarring will be no more extensive because the same incision is used for redos.
Because of the physical problems associated with large breasts, which have been well-documented in numerous studies, insurance companies may provide coverage. When a woman comes to see me to discuss this surgery, I take photographs and send a preauthorization request to her insurance company. The insurance company has physician reviewers who make the decision as to whether the procedure is medically necessary.
Insurance companies sometimes deny applications for women who will truly benefit both physically and psychologically from this surgery. There may be a clause excepting breast reduction, or the reviewer may simply turn down the application, judging the breasts not large enough to qualify. Of course, the reviewer’s job is to sort out the cosmetic patient, whose interest is largely her appearance, from the breast reduction patient who has physical complaints due to breast size. This is a judgment call because there is obvious overlap. We now know that women with smaller degrees of breast hypertrophy, even less than 300 grams per side, can be symptomatic (Swanson E. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg. 2013;66:937–949). And, not surprisingly, almost all women are at least partially concerned with the appearance of their breasts.
A woman considering this surgery must know that she will have visible scars on her breasts, identical to the scars left by a breast lift. The skin incisions are the same. In a breast reduction more excess breast tissue is removed. A breast lift typically removes less breast tissue. The number of grams of breast tissue separating the procedures is arbitrary. Some insurance companies use an estimated resection of 500 grams per side as a benchmark, which is too high. I define a breast reduction as removal of at least 300 grams from at least one breast.
Most women consider the scars a small price to pay for the benefits, which in the case of a breast reduction go beyond improved shape and position to also include physical relief. The cost/benefit ratio heavily favors the procedure, so much so that women with suboptimal scars are still almost always glad they had it done. All of the breast reduction patients in our survey reported they would “do it again.”
Ironically, many women with large breasts find they cannot breastfeed successfully even before breast reduction surgery. Modern techniques that preserve the nipple on a pedicle allow for the possibility of lactation because breast tissue is preserved in continuity with the underlying tissue. The proportion of women able to breastfeed after breast reduction surgery is in the range of 62–72% according to one study. This range is similar to the rate for women with large breasts who do not have surgery. But any woman having a breast reduction needs to accept the possibility that she may not be able to breastfeed afterward.
Nipple Grafting Is Obsolete
Free nipple grafting is an old technique that involves removal of the nipple as a graft during surgery and replacement as a graft. This operation divides the attachments of the small ducts leading into the nipple and the nerves. Patients who have this procedure cannot breastfeed and lose feeling in their nipples. That is why it is done very infrequently today. In fact, I have never had to resort to this procedure in practice. Now that we have learned how to elevate the breast tissues using the vertical technique and minimize nipple transposition, nipple grafting has become unnecessary.
Like a breast lift, breast reduction undermines skin flaps and partially divides the circulation. Nicotine further reduces circulation by causing the small blood vessels to clamp down, choking off the flow of oxygen and nutrients to the skin edges. This means the skin furthest out on the skin flap may not survive. This leads to skin loss, usually along the edges of the incisions. A crust forms and gradually the skin heals in on its own, but the wound takes longer to heal and the scar is wider than it would have been. Because the vertical technique avoids skin undermining, this procedure may be done safely on smokers, but patients are still informed of the risks and asked to stop smoking at least temporarily 2 weeks before and 2 weeks after surgery, to allow a margin of safety.
Breast Reduction Over 50
Women who have put off this procedure for years invariably wonder why they did not do it when they were younger. There is no specific age limit, and women of all ages can enjoy an improved quality of life afterward. Recovery is easy.
Breast Reduction for African American Patients
Skin color does not make much difference when it comes to cosmetic breast surgery. Everybody seems to know that black patients have a higher frequency of hypertrophic or raised scars than white patients. This may be true, but the difference is small and individual wound healing characteristics are more important. The majority of my black patients heal with very inconspicuous scars after this surgery. And of course I’ve had a number of white patients develop hypertrophic scars.
Usually women who form poor scars know this from childhood. A scrape on the knee left a nasty scar, they formed lumps in their ears when they had their ears pierced, or previous surgical sites healed with unattractive scars. Plastic surgeons check existing scars for clues, such as an old C-section or laparoscopy scar.
If a raised scar develops, it may be treated in the office using a steroid solution injected directly into the scar tissue. This may be repeated two or three times. Very gradually, a hypertrophic scar tends to soften, flatten out, and lighten. But this process might take 2–3 years in some women. Alternatively, I may recommend a scar revision, particularly to treat a scar that has widened excessively, called a spread scar. The existing scar is cut out (excised) and the wound is repaired again. With less wound tension, the scar is likely to heal better.
Interestingly, when scar deformities occur after breast reduction surgery, they typically involve the old horizontal scar. The vertical scar tends to heal better and is the most favorable of the scars, according to patients.
No Vertical Scar Breast Reduction
One method of doing a breast reduction avoids a vertical scar. There is just a circular scar around the areola and a horizontal scar in the inframammary fold. This sounds like an attractive option. However, in avoiding a vertical scar, there is no tightening of the lower breast pole from side to side, leaving an unattractive boxy appearance to the breast. There is still a long horizontal scar, which is the scar patients find objectionable. From either a scar or shape perspective, this approach is suboptimal and it has not been adopted by many plastic surgeons in practice.