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Breast Reduction and Breast Lift

Important Information for you From Dr. Tebbetts About Breast Reduction (Reduction Mammaplasty) and Mastopexy

Difficulties with Large or Sagging Breasts

Reduction Mammaplasty is the term we use for procedures which reduce the size and weight of disproportionately large breasts. Excessively large breasts can cause pain in the neck and back area, discomfort in the shoulders, deep grooving of the shoulders from bra straps, a feeling of tightness and pulling on the chest, inability to wear many types of normal clothing, and inability to wear any type of clothing without a bra due to the discomfort. The skin beneath your breasts can become quite irritated during warmer months when perspiration accumulates in this area. In addition, excessively large breasts often make it almost impossible to do many forms of exercise, and can make your breast self-examination as well as your mammograms difficult to perform adequately. Mastopexy is a procedure which lifts the breasts, but does not significantly reduce the size of the breasts.

How Size Affects Breast Shape

To understand how we correct this problem, think of your breasts as being made up of two main components: a skin envelope, and glandular tissue within that envelope. When this glandular tissue within this envelope becomes extremely large, the effect of gravity pulling on the excessive weight of the tissue stretches the lower portion of your breast skin envelope. As the lower envelope stretches, your breast sags or elongates, and the nipple areola complex moves downward. The result is a large breast which is elongated or sagging, with most of its “fill” in the lower portion of the breast, leaving the upper portion of the breast flat and empty. The same effects can occur from pregnancy and nursing.

Why Do Breasts Become Excessively Large?

Excessive enlargement of your breasts may be due to many factors. Large breasts can be an inherited familial tendency, with most enlargements occurring around the time of puberty. Hormones – either during pregnancy or occasionally as a result of certain hormonal medications may also play a role. Once a breast excessively enlarges, it virtually never becomes significantly smaller as a result of weight loss or exercise. There are no exercises which can make your breast predictably smaller or larger.

What are the Benefits of Reduction or Mastopexy?

Patients who decide to have a breast reduction notice many improvements, but the things they seem to appreciate most are a feeling of tremendous weight being removed from their chest, the ability to wear virtually any type of clothing they desire with or without a bra as they choose, and a feeling that they are significantly more attractive and comfortable. When weighing the benefits of the procedure against the tradeoffs involved, patients are overwhelmingly positive that they would do the procedure again.

How is Breast Reduction Done?

In a reduction mammaplasty, three separate components of the breast are modified to improve excessive size as well as the shape of the breast.

  1. The amount of glandular tissue or “fill” within the skin envelope is reduced.
  2. The skin envelope is tailored, removing excessive stretched skin from the lower portion of the breast and tightening this area to reposition the breast mound upward and tailor it to fit the smaller amount of breast tissue.
  3. The nipple areola complex is repositioned and moved upward to be centered properly on the new breast mound.

In a mastopexy, the lower skin envelope is tailored to lift the breast mound and the nipple-areola is repositioned upward onto the new mound. The amount of breast tissue is not substantially reduced as in a reduction mammaplasty. In some cases, if additional fill is necessary for the best breast aesthetics, a breast implant is placed after lifting the breast.

What Type of Breast Reduction is Best?

The specific type of reduction procedure best suited to your breast depends upon several factors. The specific size and shape of your breast, the shape of your frame and torso, your desires regarding the amount of reduction and repositioning, and the limitations of specific procedures are all important. At your consultation, after examining you, I will discuss in much more detail the specific type of procedure I feel will best correct your breasts.

Tradeoffs You Should Consider

In order to reduce your breasts and tailor the lower envelope, it is necessary to make incisions on the lower part of your breast mound. These incisions are precisely made and meticulously closed, but nevertheless any surgical incision produces a scar. Scars in reduction mammaplasty are carefully placed in locations to minimize visibility, but are nevertheless present. In every case, I attempt to minimize the amount of scar necessary to achieve the best breast shape and always try to maximize the quality of the scar. I will show you exactly where the scars will be located during your consultation, and you can review before and after pictures of other reduction patients to get a better idea of scar appearance.

Scar appearance varies according to your healing characteristics. Scars require approximately 6 months to 1 year to completely mature. Initially, you will notice only a very fine line along the incision. As healing progresses, your body will lay down collagen (a protein necessary for incision healing). This causes some firmness along the incision line and also some redness. As the collagen softens and remodels over a period of months, the redness and firmness subside and the scar lightens in color and becomes more inconspicuous. The length and specific location of these scars depends on the specific type of procedure necessary to optimally reshape your breasts, and I will discuss this in detail with you during your consultation. In all cases, scars are placed in the fold and the lower portions of the breasts as much as possible to minimize visibility.

In order to reposition the nipple areola complex, it must be partially detached from the surrounding breast tissue leaving a bridge or stalk of tissue to provide blood supply and nerve supply to the nipple and areola. The amount of detachment necessary depends on the size of your breast and the distance the nipple must be moved upward. In mobilizing or separating the nipple areola complex, it may be necessary to detach both some of the nerves to the nipple as well as some of the milk ducts and blood supply. Obviously, if this is necessary, there may be reduction of your nipple areola complex (especially early after the operation) as well as some obstruction of milk ducts due to scar tissue within the breast which may interfere with your ability to nurse. As little as 5-7 years ago, we advised all patients that there was an extremely high likelihood that they would loose a significant amount of sensation in the breast. Improvements in our surgical techniques have dramatically increased our ability to preserve sensation in the breast after reduction. At the present time, most patients notice a temporary reduction in sensation for 3-6 months, usually in the lower portion of the breast, with significant return of sensation occurring the first year following the procedure. Only in cases of massive breast enlargement where it is necessary to completely detach the nipple areola complex is sensation predictably and permanently reduced.

In a mastopexy or breast lift procedure, the distance that the nipple-areola must be moved upward is less than in a reduction, so blood supply and sensory compromise may be less common.

The size and shape of the breasts vary significantly from one side to the other in most women. Size differences are often 10-20%, and the specific shape of the breast is determined by the shape of the skin envelope. During your reduction, I make every attempt to equalize the size and shape of your breasts within the limitations of what your tissues will allow. Following surgery, your breast size will be more nearly equal than it was before surgery, but in all cases slight differences in size, shape, and nipple position will be present following surgery. I precisely measure and position all components exactly symmetrically at the time of surgery, but your tissues will stretch slightly differently on the two sides and scar forces can pull slightly different on the two sides following surgery. Any differences which persist between your breasts will be well within the range of normal breast size and shape variations for a normal individual.

Subtle Shape Changes You Will Notice After Your Breast Reduction

In order to move your breast mound upward, it is necessary at the time of your reduction to tighten the lower portion of the envelope significantly, since in the first few months following your operation it will stretch again slightly due to the weight and downward pressure left in the breast. Although this effect is minimal, it will produce slight shape changes which you will notice in the first few months after your surgery. Immediately after your procedure, you will notice that the skin from the nipple to the fold beneath the breast will be quite tight and slightly flatter in contour than before surgery. As your breast tissue settles slightly downward, the skin will stretch and “round out”. The tightness of the lower breast after surgery causes the nipple to point slightly downward. As the lower breast skin relaxes in the first 3-6 weeks after surgery, you will notice that the nipple will appear more relaxed and tilt forward or slightly upward. All of these changes are quite subtle, but you will enjoy looking at your breasts following reduction and will notice these subtle changes as they occur. All of them are necessary to give you the best final result.

At Your Initial Consultation Visit

When I visit with you in the office, I will review with you in more detail the information contained here and how it specifically applies in your case. After examining your breasts, I can be much more specific to the type of procedure which I think will be necessary. I will review your medical history, particularly with regard to your breasts, and examine your breasts to assure that there are no breast diseases present which require attention.

If we decide to proceed with surgery, photographs will be taken preoperatively which include only your breasts and chest area. These photographs are necessary in planning and executing your procedure and become a part of your medical record. I use them frequently during surgery for reference, since when you are lying down, the shape and position of your breasts is significantly different than when standing or sitting.

My staff will discuss with you the surgical fees for your procedure and answer any questions which you may have. If the size and weight of your breasts is causing significant functional impairment, some health insurance policies may cover a portion of your surgical and hospital costs. Mastopexy or repositioning of the breasts without significant reduction in the size is considered a cosmetic procedure and is not usually covered by health insurance. Fees for cosmetic surgery such as mastopexy or cosmetic breast reductions are payable prior to surgery. My surgical fees include the cost of the surgery as well as postoperative care and office visits and your pre- and post- operative photographs.

Before Your Breast Reduction or Breast Lift

My nurse and office manager will make all arrangements regarding scheduling of your surgery and will give you specific instructions as well as reconfirm these with you by telephone and /or letter. Since my schedule and your desires must be coordinated with hospital and anesthesia schedules, please allow my personnel a reasonable amount of time to make these arrangements. They will make every attempt to accommodate your requests.

Both breast reduction and mastopexy are day surgery procedures requiring that you check into the surgery center the morning of your surgery date. Routine laboratory work including blood tests and a mammogram if you are over 30 years old and an electrocardiogram if you are over 40 years old will be performed prior to surgery. These tests are necessary as screening procedures to assure maximum safety in the administration of any type of drug or anesthesia. I will see you immediately prior to surgery, and will draw certain lines and landmarks on your breasts while you are in the sitting or standing position to use as guidelines during your surgery.

Your anesthetist will visit with you briefly prior to surgery, and you will receive some sedative premedication prior to surgery.

You must not eat or drink anything after midnight the evening prior to surgery. Your stomach must be absolutely empty for this length of time to assure maximum safety with anesthesia.

You should not take aspirin or aspirin-containing drugs for at least two weeks prior to your surgery. Aspirin retards the function of platelets which are important components to the normal blood clotting mechanism. Many types of medications contain aspirin, so check the labels of absolutely any medication you take carefully prior to surgery and avoid aspirin. Tylenol or similar medications may be substituted without any untoward side effects.

You may shower or bathe normally the evening prior to surgery. Additional antiseptic cleansing of the skin areas will be carried out by our nurses immediately prior to your surgery.

What Your Breast Reduction or Breast Lift Surgery Will Be Like

These procedures are performed using general anesthesia in a surgery center environment.

During your surgery, incisions are made according to the marked guidelines prior to surgery, the skin envelope and glandular tissues are appropriately reduced, the breast mounds repositioned, the nipple areola complex repositioned, and all incisions carefully closed. Depending on the extent of the breast reduction and anticipated fluid drainage following your operation, small silicone rubber drains may be placed at the time of your operation. These are very small tubes which will exit through the corner of your incision and will be removed 24-48 hours following surgery. They are placed to prevent accumulation of excessive fluid within the breast following surgery. Mastopexy procedures do not require the placement of drains. All sutures used to close your incision are placed beneath the skin surface and are absorbable over a period of weeks. This avoids placing any stitches through the surface of the scars as well as minimizes your inconvenience and discomfort which might be associated with suture removal. Small tapes (Steri-strips) are placed over your incisions with an adhesive substance on the skin. These are left in place and will remain in place even if wet over a period of several days. Very light dressings are placed initially and are removed the first day following your surgery.

After Your Breast Reduction or Mastopexy

Discomfort or pain following mastopexy or reduction mammaplasty is mild, and decreases markedly after the first 24 hours. You will receive Ibuprofen as your post operative medication – this anti-inflammatory will be all you need for discomfort.

We routinely use anti-nausea medications during your operation, so there is no need to continue these once you are discharged from the surgery center. Nausea is rare following this procedure, but if it should occur, routinely gone with in four hours following surgery.

A light dressing will be present beneath your breasts. It is normal to have a slight amount of drainage under this dressing, and the dressing will stay in place for 24 hours as a gentle support. If drains are placed at the time of surgery, they will exit from this dressing as very tiny tubes connected to small rubber reservoirs which will be pinned to your dressing. These will need to be emptied periodically and will be removed by my staff within 48 hours.

All of your incisions are closed with sutures placed beneath the skin which will absorb following surgery. This technique avoids any discomfort and inconvenience from suture removal as well as the small “cross hatch’ or “railroad track” marks which may result from stitches placed in the skin. I encourage you to rapidly resume normal activity -within two hours following your surgery, including full mobility of your arms, since discomfort will decrease more rapidly if you do so. Your incisions are closed with many, many sutures and can withstand tremendous pressures. You will receive detailed instructions for your 24 hour recovery process.

When you arrive home following your surgery, make yourself comfortable in any position you desire. You may sleep for two hours, then get up, eat and take your first Ibuprofen, wait 30 minutes, then begin to move your arms above your head in a slow jumping jack motion – a set of 5 every hour on the hour! The only thing you cannot do the day of surgery is drive and shower. You will be doing BOTH the very next morning.

You may wear or not wear a bra or any other breast support entirely at your discretion. If you are more comfortable in a bra then certainly wear it. For the first two to three weeks following surgery, the most comfortable type of bra for most patients is one that will change with you as your breast tissue changes during the first few weeks. Avoid buying new, expensive bras until you are approximately three months post op for optimal fit. There is absolutely no untoward effect in not wearing a bra for the first days to weeks following surgery. As swelling and discomfort resolve, the breasts assume a final shape over a period of weeks to months, and slight bra changes may be desirable. After the first two weeks, we recommend wearing a bra always when exercising to minimize recurrence of hanging or ptosis.

Following surgery, you will have small tapes (Steri-strips) placed over your skin incisions. These should be left in place, and are “glued” to the skin with a special adhesive. There will be some drainage which will stain the Steri-strips, but they should nevertheless be left in place for approximately two weeks until they begin to come loose, at which time you may gently remove them by pulling along the line of the incision. You may shower the day following surgery. Allowing the Steri-strips or the incisions to be wet by the shower is harmless, and they should simply be towel dried following showering. Do not immerse the incisions in water for long periods such as sitting in a tub. If your Steri-strips seem to stay adherent, leave them in place until you see us back in the office.

You may resume all normal activity immediately. Do not participate in strenuous athletic activities for at least two weeks following surgery.

As I discussed with you preoperatively, there may be areas on the skin of the breast or nipple which seem to have decreased sensation following surgery. This is normal and as swelling subsides, and skin nerves regrow, some of this sensation will return.

Please contact me if any of the following occur: marked increase in swelling in either breast, marked increase in discomfort in either breast, marked increase in redness or bruising in either breast, or temperature above 101 degrees taken orally.

On the day of surgery, we will schedule a follow up visit with our staff two days following your surgery. I would like to see you for follow up approximately 3 weeks following your procedure.

Should you have any additional questions or should any problems at all arise, please contact my office.

Limitations, Risks or Possible Complications of Breast Reduction and/or Breast Lift

Risks and untoward complications with either reduction mammaplasty or mastopexy are rare, and I mention them not to frighten or alarm you, but only to completely inform you prior to your decision regarding surgery. If any of these concern you greatly, please discuss them with me during your consultation.

Whenever anesthetic drugs are administered unpredictable and untoward reactions to a drug may occur, and although rare, can be even life threatening. I perform your surgery in an atmosphere totally equipped in every aspect to handle any type of problem with appropriate equipment and backup medical personnel immediately available.

Separation of the glandular tissue from the skin envelope, removal of glandular tissue (in reduction mammaplasty), tailoring of the skin envelope to reposition the breast, and repositioning the nipple areola complex all require severing some skin nerves to the skin and/or nipple. In addition, these maneuvers require the repositioned tissues to acquire blood supply from a more distant source. With current procedures, complications from loss of nipple sensation and/or insufficient blood supply are greatly reduced, but nevertheless may occur.

Sensation may be decreased in the skin and/or nipple areola area, and may be totally absent in the nipple in 5-10% of patients. If sensation to the skin or nipple is decreased, it usually returns over a period of weeks or months as the nerves to these areas regrow.

If there is inadequate blood supply to the skin, this usually occurs either in the fold beneath the breast or in the nipple areola area (areas most distant from blood supply). Decreased blood supply can cause blister formations with crusting and subsequent superficial or even deeper tissue loss. Actual tissue loss occurs in less than 3% of cases. It is treated conservatively in most cases by allowing a crust or scab to form over the area, continuing normal activity, and allowing the wounds to heal beneath the crust. In these situations (less than 3% of cases) subsequent scar revision may be necessary. In extreme rare cases, an additional skin graft or other operative procedures may be necessary.

Repositioning the nipple areola complex in many cases requires severance of milk ducts draining into the nipple. In many, but not all cases, this may subsequently affect your ability to nurse.

Asymmetry (difference in size and shape) of breasts which is always present to some degree preoperatively will also persist to some degree postoperatively. Scars present are usually located in the fold beneath the breast, around the areola, and from the lower edge of the areola down to the fold beneath the breast. As discussed above, the appearance of these scars improves with time, with the actual extent of scarring depending upon your individual healing mechanisms.

Significant bleeding in the breasts following operation occurs in 2-3% of cases and may require reoperation or surgical drainage. A small amount of drainage from the incisions for 2-3 days is normal.

Infection is an extremely rare problem, particularly with the administration of antibiotics prior to and following your operation, but may rarely occur and require operative drainage of the infected area.

The approximate figures listed above concerning the occurrence of the various complications are based on statistics obtained from a large series of patients published in the plastic surgical professional literature by Board Certified Plastic and Reconstructive Surgeons. All of them are extremely unusual, but may occur occasionally despite the most vigorous standards of medical practice.

Conclusion

Reduction mammaplasty and mastopexy are highly reliable, extremely rewarding procedures in selected patients for reducing and/or repositioning the breast. In properly selected patients, these procedures significantly reduce the weight and hence symptoms occurring from excessively large, heavy, pendulous breasts. In addition, they improve the appearance of the breasts, often allowing you to wear clothing without a bra if you desire. Most patients experience a very positive improvement in self-image, comfort and greater flexibility in choosing clothing styles.

As you review the information here, please write questions in the margins, so that we may answer in more depth and detail specific questions during your office consultation.

John B. Tebbetts, M.D., Dallas Plastic Surgeon

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