What is breast Reduction?
Breast reduction is an operation whereby breasts are made smaller by removing breast tissue and then reshaping the breast.
Who will the operation help?
As any woman who has very large breasts can tell you, large breasts cause significant problems. They can cause severe ache in the back, neck, shoulders and in the breasts themselves. The shoulder straps from bras dig in to such an extent that they create permanent grooves over the shoulders. In warmer months a sweat rash often develops beneath the breasts.
In addition to these functional problems ladies with large breasts encounter social difficulties. It is usually impossible to buy clothes “off the peg” as they need much larger tops than bottoms and choice of clothes is usually limited. Exercise is usually severely limited due to heavy breasts bouncing, whilst self-consciousness often prevents activities such as swimming. One particularly irritating effect of large breasts is unwanted sexual attention. Men often talk to large breasts rather than making eye contact, or pass rude comments. As a result women with large breasts will often keep themselves overweight, preferring to appear fat rather than being slim with obviously large breasts.
A breast reduction operation may improve or solve all of the above problems. In several recent studies looking at the improvement in quality of life of all surgical procedures undertaken in the NHS (including open heart surgery, cancer operations, hip and knee replacement surgery amongst many others) breast reduction surgery came out top. It improves your quality of life each year for the rest of your life.
What size will my new breasts be?
The size of breast you will be reduced to, is a personal decision, but there are certain limitations that apply. It is very difficult to reduce a very large breast to a very small size (eg to an A or small B cup) as there needs to be some breast tissue left to form a natural breast shape. The most commonly requested cup size is a C cup. However, it is not always possible to exactly predict what size you will end up with and I will ask whether you wish to err on the smaller or the larger side of your ideal cup size.
Is breast reduction available on the NHS?
As a result of the above it is not surprising that many breast reductions are undertaken on the NHS. However, women seeking breast reductions are increasingly being turned down for NHS treatment for financial reasons. At the current time, you should discuss your problem with your family doctor and enquire whether they are still making NHS referrals for breast reduction.
How is the operation done?
The operation is done under a general anaesthetic (with you asleep). The ideal position for a nipple is level with the crease under the breast. In large breasts, the nipple is often much lower than this ideal position. Therefore, the first thing to do is to move the nipple upwards to its ideal position. The skin of the upper breast is cut to accommodate the nipple, and the nipple is moved with a block of breast tissue in order to keep a blood vessel (and hopefully a nerve) with it, to keep it alive! Once this has been done, a block of skin and breast tissue can be removed in order to make the breast smaller. Following this, you will be sat upright on the operating table to ensure your breasts are of equal size. A drain is then usually placed in each breast which emerges from your skin close to your armpit. The remaining skin is then tailored, trimmed and closed using buried, dissolvable stitches. Your wounds are then dressed and surgical tapes are applied all around your new breasts. The tapes help to support your new wounds and shape your breasts until they have healed a little.
Which incision is best?
Two different scar shapes are commonly used the anchor scar and the vertical scar:
- The “anchor” scar is the more traditional pattern and is best used for very large breast reductions or for women who are more likely to experience problems with wound healing, due to heavy smoking or problems with their general health.
- The “vertical” scar is a more recent development designed to result in less overall scarring. A second benefit is that the breast shape is usually more pert and longer lasting. This scar pattern seems to be best for fit, healthy non-smoking women undergoing a more modest breast reduction.
For really massive breasts it may be better to completely remove the nipple altogether, undertake a breast reduction using the anchor scar and then graft the nipple back on at the end of the procedure.
How long is the operation?
Breast reduction surgery usually takes about 3 hours
How many days in hospital?
Most women undergoing a breast reduction stay in hospital overnight and go home on the day after surgery. Occasionally the drain bottles may be quite full the next day and may need to stay in for a further day or two, delaying discharge from hospital.
Postoperative period in hospital
When you wake up you will have surgical tapes over your breasts. The operation causes a moderate amount of discomfort and you will receive regular painkillers which should keep you comfortable. You should limit your arm movements and wear your sports bra before being discharged from hospital.
Postoperative Follow Up
After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect your wounds, which may or may not have healed at this time. If they have, you will be given advice on wound care, bathing and exercise advice. If they have not quite healed by this one week visit, she will reapply the dressings and arrange to see you again the following week. Once your wounds have healed you will be given an appointment to see me six weeks after your operation. At this appointment I will check on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.
Will a breast reduction operation cause breast cancer?
Breast reduction surgery does not increase your risk of developing a breast cancer. Any tissue that I remove during breast during surgery is routinely sent to the laboratory to be examined to exclude breast cancer. I shall tell you the results of this test at our 6 week review in clinic.
Will a breast reduction operation affect my ability to feel or detect breast cancer?
Breast reduction will not affect your ability to feel or detect a breast cancer. Your breast will, however, feel different after your operation. You should allow six weeks for the breast to properly heal and then you should start to feel your breast so you get to know how it feels. There will be some internal scarring and lumpiness. This is normal. The important thing to do is to learn what is “normal” for your new breast, and with subsequent regular breast self examination you will be looking for any new change from this “normal”.
What are the possible risks?
All surgery carries the potential for complications. The specific complications that may occur with breast reduction are:
- Infection; infection is not uncommon with breast reduction and can result in swelling, redness and tenderness at any time up to 3 weeks after surgery. This usually responds well to a course of antibiotics. Occasionally however, it can result in some opening of the wounds. This wound breakdown is not a disaster and is usually managed by regular wound dressing and usually heals in four to six weeks.
- Bleeding: bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid any strenuous exercise over this time. Arm movements should be limited for the first week. Should a bleed occur into the breast, the breast can swell quite dramatically and you may develop visible bruising and tenderness. If this happens you usually need to return to theatre to have the blood removed and the bleeding stopped.
- Ugly scarring: although most scars settle very nicely to leave a pale flat line, occasionally scars may become red, raised, wide, itchy or ugly. This is fairly uncommon in breast reduction, but any wound breakdown which occurs in the early postoperative period (particularly of the vertical limb of the anchor scar or the vertical scar) may result in a stretched flat scar.
- Wrinkling: this is seen almost without exception with the vertical scar technique. The skin under the breast is puckered and very wrinkly for the first six weeks after surgery. This is a necessary part of the operation and happens because we are trying to limit the size of the final scar. After six weeks, these wrinkles will have mostly disappeared to leave a fine scar. In about 5% of cases these wrinkles may persist up to 6-9 months after surgery. If they do not settle after this time, they can be simply cut out in a minor procedure under local anaesthetic.
- Dog ears: dog ears are small folds of skin which occur at either end of the scar, caused by a natural folding of the skin when the wound is closed. Great care is taken during the operation to avoid producing dog ears, but occasionally (5%) they cannot be avoided. Small dog ears seen in the early postoperative period will eventually settle on their own in the first 6-9 months after surgery. If they do not settle after this time, they can be simply cut out in a minor procedure under local anaesthetic.
- Nipple loss: One of the worst complications of a breast reduction procedure is complete or partial loss of a nipple. As mentioned above, the nipple is moved on a block of tissue which preserves a blood vessel and nerve, but if this blood vessel becomes kinked or damaged, the blood supply to the nipple will fail and the nipple will die. If this happens, the nipple will become darker and darker and eventually blister and disappear. Fortunately this is a very rare occurrence and only happens approximately once in every 2000 breast reductions.
- Altered nipple sensation; in the same way, the nerve that we try to preserve to the nipple may be damaged at the time of the operation and results in a numb nipple. This is a much more common occurrence. If the nerve to the nipple is damaged, the nipple will be numb when you wake up. About 7 in every 10 women will experience a reduction in nipple sensation, but a few will find their nipples become very sensitive and even clothes brushing against them will be unpleasant. About half of all women who do experience altered nipple sensation will eventually regain some sensation.
- Breast skin numbness: in a similar way, some women will develop numb patches over the skin of part of their breasts. Again, this usually improves with time, but can occasionally be permanent.
- Asymmetry: no two breasts are almost ever the same, and some degree of asymmetry is common both before and after this procedure and cannot be avoided, it is one of the limitations of any given pair of breasts. Great care is taken to ensure that the two breasts are as symmetrical as possible, but occasionally an unacceptable asymmetry results. If this happens you will be advised to wait for 9 months for all scarring and swelling to settle fully before we reassess the final outcome. At this time you may have to return to theatre to have minor asymmetries of breast volume corrected by a small liposuction procedure or minor asymmetries of nipple position corrected by relocating the nipple under local anaesthetic.
- Blood clots: occasionally a blood clot may form in the deep veins of the legs (deep vein thrombosis). These clots can have the potential to break off and travel inside the veins into the lungs (pulmonary embolism). Any surgery carries a small risk of causing a blood clot in the leg viens. To reduce the risk of this happening, you will be given surgical compression stockings to wear throughout the first 2 weeks after surgery, special inflating compression devices will be applied to your legs in theatre and worn for the first 24 hours in hospital, and you will be given a daily injection to slightly thin your blood.
- Fat necrosis: in the same way that a nipple may die, if the blood supply to part of the breast tissue within the breast is damaged during the operation, a piece of breast tissue may die. This usually becomes apparent about 2-4 weeks after the operation. The breast may appear to be healing well, but then a firm, tender lump may develop. This lump of dead fat is called fat necrosis and does not usually require any treatment. It usually settles on its own over the following few months; though occasionally may discharge old liquid fat and fluid through a small hole in the scar on the breast and need regular dressing until this heals on its own.
- Breast feeding: It is usually not possible to breast feed after a breast reduction procedure because the milk ducts under the nipple have to be divided when relocating the nipple to its ideal position.
- Drooping: your new breasts should be firm and well shaped. However, with time, these tissues may become lax and the breasts may start to droop. This is just a part of the natural aging of your own tissues but may be helped by wearing a bra to support your new breasts.