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Stony Brook, NY

Reduction Mammaplasty Breast Reduction

Large breasts can cause neck and back pain, improper posture, rashes, breathing problems, skeletal deformities, and lower self-esteem. Breast reduction surgery is usually done to provide relief from these symptoms. Performed under general anesthesia, the two to three hour procedure removes fat and glandular tissue and tightens skin to produce smaller, lighter breasts that are in a healthier proportion to the rest of the body. The breast is also lifted as part of the procedure.

Candidates for Breast Reduction

Ideal candidates for breast reduction surgery are women with oversized breasts that cause medical problems, low self-esteem, physical or social discomfort or frustrations with the size of their breasts. Women must not be pregnant or breastfeeding while undergoing this procedure. Although the procedure is generally recommended for mature women with fully developed breasts, breast reduction surgery can be performed on younger women if their breasts are causing serious pain and physical discomfort. In these cases it is preferable that the breasts have reached their adult size and are not still growing. Dr. Epstein will not perform this type of surgery in women who are actively smoking, as the risk of post-operative complications is much higher in the smoking population, as opposed to the non-smoking population.

It is important for patients to understand the details and risks associated with this procedure, and to have realistic expectations in order to be satisfied with the results of their surgery.

INITIAL CONSULTATION

It is important to consider each aspect of the breast reduction procedure and how it will impact upon your life after surgery before deciding upon the procedure. Prior to undergoing the procedure, Dr. Epstein will meet with you to discuss your expectations for breast reduction surgery. He can then evaluate which goals are realistic and outline a plan for the breast reduction operation. At that time, Dr. Epstein will inform you about the risks and possible complications of breast reduction surgery and the long-term effects of undergoing a breast reduction.

BENEFITS OF BREAST REDUCTION

Women with large, heavy breasts may suffer physical pain (neck, back, shoulder and breasts) from the weight of their breasts. This excess weight produces a physical strain on a woman’s body. The extra weight of heavy breasts can be harmful to posture and may lead to spinal problems. In addition to causing back, neck, and shoulder pain, excessively heavy breasts may also lead to breathing problems and other serious health issues. Furthermore, women may experience social discomfort due to unwanted attention to their breast size. Because of this, many women turn to breast reduction as a remedy from the physical as well as psycho-social discomfort and limitations imposed by having excessively large breasts. Breast reduction surgery can help a woman correct her posture and remove strain on the back, neck, and shoulders, reducing overall pain. Breast reduction surgery can help a woman regain her self-confidence and positive self-image, as well as provide the motivation to participate in a wide range of physical and social activities.

Breast Reduction Procedure

The breast reduction procedure is performed under general anesthesia and takes about two to three hours, depending on the techniques used and each patient's individual case. There are several different types of incisions that may be used for this procedure. Your doctor will determine the best type for you after evaluating your breasts. Breast reduction surgery generally takes one and a half to two and a half hours, depending on the patient’s specific case, and is performed under general anesthesia. The size and shape of your breasts, as well as the desired amount of reduction, helps determine which type of incision is right for you. The different types of incisions for a breast reduction include:

  • Wise-Pattern ("Anchor") Reduction - This technique involves an anchor-shaped incision and is ideal for women with extremely large breasts, although scarring is usually more apparent. Skin, fat and tissue can be removed from the lower breast and the nipples and areolas may be repositioned as well. This traditional approach to breast reduction surgery is a very effective method for alleviating discomfort caused by large, heavy breasts. This method is often the best choice for women requiring a large amount of tissue removal.In the traditional breast reduction surgery technique, incisions are made horizontally under the breast in the crease and extend vertically up to and around the areola (the pigmented skin encircling the nipple), creating an anchor pattern. The areola is made smaller and the nipple/areola complex is lifted. The nipple is left attached to the breast to preserve circulation as well as nerve supply (sensation) to the nipple. Because traditional breast reduction surgery allows for excess skin removal both vertically and horizontally, it is typically the best method for women with extremely large breasts. The anchor shaped incision also allows surgeons to remove more tissue than other methods, maximizing the degree of reduction in breast size.Although the anchor pattern method can be useful in reducing excessively large breasts, it leads to more scarring than other breast reduction surgery techniques. These scars can often be hidden by bathing suits and even low cut tops. The scar around the areola and the vertical scars are hidden by just about all bathing suits, but it is possible that with some swimwear, the lateral (outer) portion of the breast crease incision may be visible. One of the criticisms of the anchor pattern is that the breasts often look flat and “boxy”, and later "bottom-out" after reduction with this method.
  • Short-scar ("Lollipop" Incision, Vertical) Reduction - Also known as short-scar, this technique involves incisions that extend around the areola and down to the breast crease for a lollipop shape. Vertical incision is ideal for women with moderately large breasts and creates shapelier results with less scarring for women who do not require extensive tissue removal. This technique typically results in shapelier breasts and less scarring than traditional breast reduction surgery. Vertical incision breast reductions are a popular alternative to the traditional method, especially for women who do not require extensive tissue removal. Although the breast shape is somewhat “distorted” after this type of surgery (very full on top, flat and tight on the bottom of the breast), the breasts remodel within a couple of months. Women undergoing breast reduction using this method typically enjoy some of the nicest, most naturally shaped breasts seen after breast reduction. Incisions in this technique extend around the areola and vertically down to the breast crease, making a lollipop pattern. Vertical incision breast reductions eliminate the need for the horizontal incision along the breast crease that is used in traditional breast reduction surgery, resulting in much less scarring. Furthermore, the scars tend to be much better than those seen with the “Wise-Pattern" or "Anchor" results discussed above.Women with moderately large breasts are the ideal candidates for vertical incision breast reductions. Vertical incision breast reduction surgery may not be a good choice for women requiring the removal of excessive amounts of fat and breast tissue. This is the technique that I use in the vast majority of my patients.
  • Scarless Breast Reduction - Scarless breast reduction uses liposuction techniques to reduce the size of the breast with little to no scarring. Since liposuction only removes fatty tissue in the breast, patients should have more fatty tissue than glandular tissue. This technique is commonly used on men with enlarged breasts. The scar-less breast reduction technique also leaves the nipples intact so that the patient has a reduced risk of breastfeeding complications and losing sensation in the nipple area.Because liposuction can only reduce the amount of fatty tissue in the breast, ideal candidates for scar-less breast reduction are women whose breasts have more fatty tissue than glandular tissue. Men with gynecomastia (excess breast tissue) can also achieve desired results with male breast reduction through liposuction. Breast reduction using only liposuction is typically not the best option for more slender women with large breasts, women with extensive sagging, or women with excessively large breasts. If the fat pattern within the breast is such that the fat is dispersed within small lobules amidst the glandular breast tissue, it will not be as amenable to removal as fat within larger located collections within the breasts.
  • Free-Nipple Graft Breast Reduction Surgery - The scars with this procedure are similar to those with the Wise pattern method. The difference is that the nipple/areola complex is lifted off the breast, the lower breast tissue is removed, the breast mound re-created and the nipple/areola complex reattached to the new breast mound. This is a highly effective procedure which gives a nice result and high degree of patient satisfaction. It is important to note that there will not be any sensation in the nipple/areola complex and there will be no ability to breastfeed after the surgery. This technique is reserved only for women with the largest of breasts. Some surgeons use this technique in smokers; however, Dr. Epstein prefers not to perform any type of breast reduction surgery in women who actively smoke due to the higher risk for wound healing and other complications.

Will my insurance cover the breast reduction procedure?

Breast reductions may be covered by medical insurance if the purpose of the breast reduction surgery is to alleviate physical discomfort and pain caused by oversized breasts. Many factors determine your eligibility, including the specific terms of your insurance policy and the amount of breast tissue to be removed.

Initially, third party payers (insurance companies) required surgeons to remove a specific weight of tissue from each breast in order for the procedure to be deemed “medically necessary”. Usually, this was a weight between 350 – 500 grams of tissue per breast. This was not very fair, as a petite, thin, 4’10″, 98 pound woman with large breasts is treated the same as an obese 5’10″, 220 pound woman. Clearly, in the latter case it will be much easier to remove 350 grams of tissue (about ¾ pound) than in the case of the thinner, petite woman. In 1991, Paul Schnuur, a plastic surgeon from the Mayo Clinic, looked at women who had breast reduction surgery for “medically necessary” reasons versus those who had the surgery purely for “cosmetic” reasons”. In order to eliminate the issue of a woman’s height and weight, they used body surface area, as calculated from a chart based on height and body weight. This allowed a more fair comparison between women of varying body types. They looked at the amount of breast tissue removed per breast in women who underwent surgery for both “medically necessary” as well as those who underwent surgery for “cosmetic” reasons. They determined that women who had breast reduction surgery for “medically necessary” reasons had an amount of tissue removed above the 22nd percentile, and those who underwent breast reduction surgery for ‘cosmetic” reasons had tissue removed under the 5th percentile. So now for many years, the way the insurance company determines whether or not they will pre-certify surgery is based on your height, weight and the amount of tissue the surgeon believes he will remove. If the surgeon in fact removes less than this amount of tissue, the insurer can deny the claim for payment, although in the vast majority of cases in Dr. Epstein’s experience, this has not been the case. Other variables that enter into the payer’s decision as to whether or not to pre-certify surgery is whether or not you have tried weight loss (often not indicated or possible), chiropractic care, analgesics, wide-strap bras, and other treatments which rarely make any difference in your symptoms.

Recent studies by Carolyn Kerrigan, Paul Schnuur and others have brought new information and concepts to light. In essence, they have found through several well conducted studies that breast reduction surgery is highly effective in relieving a woman’s symptoms of pain and discomfort due to large breasts. Furthermore, and this is what is among the most interesting findings, is that the amount of tissue removed at surgery bears no correlation (relationship) to the degree of relief of the symptoms. Therefore, as the goal of the surgery is the improvement in quality of life by relieving the pain caused by large, heavy breasts (a medically necessary reason) and the insurer’s position that they will pay for medically necessary treatment, the insurer should no longer be using weight of breast tissue removed as a criteria as to whether or not to pay for the surgery. Of course, it goes without saying that the third party payers would not like this because this reduces their control (“veto power”) as to who is or is not entitled to breast reduction surgery benefits (assuming it is a covered benefit under their health insurance plan). It remains to be seen what will happen with this issue. For now, the request for insurance pre-certification for breast reduction surgery will remain basically the same: a letter from your plastic surgeon, supporting letters from your medical doctor or chiropractor, photographs and any other supporting information.

Recovery from Breast Reduction

After the breast reduction procedure, patients will likely experience soreness, swelling and occasionally bruising for several days. The wounds are dressed with a dermabond glue impregnated thin mesh tape called Prineo. This creates a water-proof barrier to reduce the risk of infection. This tape is removed at three weeks. From the very beginning, you may shower as desired. There are no sutures to remove. Physical activity should be limited for one to two weeks, while exercise and other strenuous activity should be avoided for at least three weeks. I do not use drains in my breast reduction procedures. For extra support, a special soft surgical bra or athletic bra is best worn after the first day or two.

The results of the breast reduction procedure are noticeable immediately after surgery and will continue to improve as swelling and bruising subside. Scars will continue to fade with time and can usually be concealed by a bra, bathing suit or low-cut top. I often employ the use of lasers to reduce the redness in the scars and soften them.

breast feeding after a BREAST REDUCTION

There is a chance that breastfeeding may not be possible after breast reduction. The level of risk depends on the surgical technique used for the procedure.

  • After a free nipple graft breast reduction procedure, you will not be able to breastfeed because the milk ducts under the nipple have been all cut.
  • Wise-pattern breast reduction surgery has the next highest risk of affecting the ability to breastfeed. During this type of breast reduction, many of the milk ducts are removed, making it more difficult to breastfeed in the future.
  • Short-scar breast reduction surgery has a lower risk than traditional incisions since a portion of the nipple will remain connected to the milk ducts.
  • Scar-less breast reduction surgery has practically no risk of affecting breastfeeding because this breast reduction technique leaves the glandular and connective tissue largely untouched.

Risks and complications

I perform breast reduction surgery with great care and precision, ensuring safe results that generally meet the expectations of my patients. As with all surgeries, however, complications can occur. Potential risks that are specific to breast reduction surgery include asymmetrical breasts (breasts are rarely symmetrical both before and after breast reduction, nor are they usually symmetrical in the general population as a whole), or an altered or lost nipple and areola sensation. You may not be able to breastfeed. Breast reduction surgery may also have potential complications that are possible for all surgeries, including bleeding, infection, hematoma, adverse reactions to anesthesia, and scarring. Although breast reduction is considered safe for most patients, there are certain risks associated with any surgical procedure. Most patients undergo this procedure with no serious complications.

Scar formation after surgery

The various techniques for breast reductions produce different types of possible scarring. Wise-pattern breast reduction surgery will produce anchor-like scars that extend around the nipple, down the middle of the breast, and under the breast. Vertical incision breast reduction surgery creates shorter scars which also circle the nipple and extend vertically down the breast, but do not continue under the breast. Scar-less breast reduction surgery typically only leaves minor, inconspicuous scars that are usually under the breast crease.

Avoiding breast reduction surgery because of possible scarring is ill-advised, since the benefits of a breast reduction usually outweigh the appearance of scars. Scars from breast reductions also tend to fade over time and can usually be hidden under bras, bathing suits, or a low cut top.

Longevity of results

After breast reduction surgery, breasts will remain smaller than they would be if the procedure had never been performed. Unless you gain or lose a significant amount of weight or become pregnant, your breast size should remain fairly constant. However, the effects of aging and gravity may cause breasts to sag over time. If, after a period of years, you become dissatisfied with the appearance of your breasts, you may choose to undergo a breast lift procedure to restore their more youthful contour.

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