A breast reduction is a surgical procedure to make the breast smaller and lighter. The breast is normally lifted and the nipple is positioned higher. (Breast reduction is also called a reduction mammoplasty, Lejour breast reduction, Wise pattern breast reduction).
Breast reduction is usually carried out for large heavy breasts which are uncomfortable and cause neck, shoulder or back ache. Often the breast cause the bra straps to cut in and some people suffer rashes in the fold under the breast. Frequently large breasts may lead to embarrassment and attract unwanted attention or comments. Where the breasts are different sizes (asymmetry) a reduction operation may help to even the breasts up.
You would come into hospital on the day of your operation. The time you come in varies on when your operation is scheduled. The operation is carried out under a general anaesthetic (asleep). The operation usually takes between two and half to three and a half hours. The stitches are usually absorbable (‘dissolving’) and are placed under the skin, so that you can not see them. A dressing is place over the wounds at the end of the operation. Drain tubes may be placed into the wound to reduce the build up of blood and tissue fluid under the wound. You will be prescribed regular painkillers while you are in hospital and to take home. Usually the drains are removed the next day or on the second day after the operation and you are discharged home. You are advised to where a supportive (not wired) sports type bra for 4-6 weeks following surgery. You are offered a dressing check one week after surgery and you have a follow up consultation with your surgeon four weeks after the operation. If you are worried at any time after you have gone home you can phone the ward, phone the cosmetic nurse advisor or the consultant’s secretary for advice. If necessary you can return to the ward at any time for a check (please phone first).
There are many different techniques for breast reduction. They vary in which pieces of skin are removed, which parts of the breast tissue are removed and how the nipple is kept alive. As far as the end result is concerned the main difference is the position and extent of scarring.
Peri-areola breast reduction (sometimes called the Bennelli technique)
The peri- areolar technique reduces the breast with a scar placed around the areola only. This technique is limited in its use for breast reduction, although it can be very good for breast uplifts (mastopexy).
Vertical scar breast reduction (also called Lejour or SPAIR breast reduction)
The vertical scar techniques are widely used. The tissue below and behind the nipple is usually removed. The scar runs around the areola and then from the bottom of the areola down to the fold under the breast. Sometimes a short horizontal scar is placed at or above the this fold. The projection (how the breast protrudes form the chest) of the breast is often better with these techniques. It may not be possible to get the breast as small as with the Wise pattern approach.
Wise pattern breast reduction
The Wise pattern approach has been widely used for the longest time of the and may enable a greater reduction than with the other techniques. The scar runs around the areola and then from the bottom of the areola down to the fold under the breast. The scar also passes the whole length of the scar under the breast. The final shape of the scar is that of an anchor.
What is a free nipple graft breast reduction technique?
The free nipple graft technique involves removing the nipples from the breast and replacing them at the end of the operation as a graft. The advantage is the blood supply is then determined by the graft ‘take’ which in larger breasts may be more reliable than trying to keep the breasts alive on a strip of tissue (called the pedicle). The free nipple technique is seldom used unless there is anticipated to be a problem with the nipple blood supply.
What about liposuction?
Liposuction can be used to reduce the size of the breast. It does not allow skin to be removed and so the effect on the position of the nipple may be difficult to predict. There is concern that the effect of liposuction may make the interpretation of mammograms more difficult. It is not widely used on its own as a technique for breast reduction although it may be used with other techniques or for an adjustment or revisional surgery.
The great majority of breast reductions involve lifting the nipple but it is not normally removed form the breast. The nipple is kept alive on a strip or segment of tissue called a pedicle. The pedicle can be from below the nipple (inferior), above (superior), the inside (medial), the outside (lateral) or behind the nipple (central). Surgeons vary in which technique or techniques they favor and certain techniques may better for particular breast shapes. It is possible to remove the nipple completely and replace it on the breast as a graft. This is called a free nipple graft breast reduction. Most surgeons would consider this an old fashioned technique. The nipple tends to loose its projection afterwards and may be slow to heal. It is still used under certain circumstances particularly if the blood supply to the nipple is failing with the other techniques or where a problem with the blood supply is anticipated.
The great majority of people who undergo a breast reduction are very pleased with the results of their surgery. Their breasts are smaller, lighter, more comfortable and lifted. It is important that you understand what is involved, how much time you need to recover and the potential risks. For most people it is an operation that was well worth it. Frequently sensation in the nipples is reduced or even lost following reduction. Feeling may return but this can not be guaranteed. Usually it is not possible to breast feed following a breast reduction. In the longer term most peoples breasts will not increase in size significantly following surgery unless they put on weight or go through pregnancy. Under some circumstances where there is rapid breast enlargement and surgery at a young age then the breasts may enlarge again significantly following surgery. This is a very unusual.
The scars depend on which technique is used (see above). The majority will be either a vertical scar technique with a scar around the nipple and down to the fold under the breast or a Wise pattern which has an additional scar running along the fold under the breast. Scars themselves vary from a thin line which rapidly becomes pale through to stretched or lumpy scars that take time (months sometimes years) to settle. ‘Dog ears’ are where the end of a scars sticks up. They are usually the result of trying to keep the scar as short as possible. If they do not settle over time then they are easily removed with a small local anaesthetic procedure.
People vary a lot in the time they need to recover from surgery. The following gives some idea. Some people will require less time and others more. If you experienced complications then recovery may take longer.
When can I go home from hospital?
Most people go home from hospital either the day after surgery or on the second day after surgery.
When can I shower or have a bath?
There is usually no problem in having a shower after 48 hours. Soaking the wounds for long periods in the bath is best avoided until the wounds are fully healed, usually at least 2 weeks.
When can I start driving a car?
It is illegal to drive with in 48 hours of a general anaesthetic. Most people return to driving after 10-14 days. The most important consideration is that you feel comfortable and safe to drive. You have to be able to react appropriately in an emergency. If you are taking medication such as painkillers you need to check and consider whether these may affect your ability to drive.
When can I return to work?
Usually people return to office type work about two weeks after surgery. Some people are back sooner or work from home. More active work using the arms may require longer 2-4 weeks. Very active work will require 4 to 8 weeks off vigorous activity. You will need to be guided by your body, if you are causing pain and swelling you may be doing too much. A good supportive bra is essential.
When can I start picking things up?
Lifting small things around the house is not a problem. It is best to be guided by your body, so if it hurts stop. It is best to avoid lifting anything heavy for 2 weeks. You should not be straining to lift anything for 2-4 weeks.
When can I go back to exercise / the gym?
Walking only for 2 weeks after surgery. Light lower body exercise (e.g. exercise bike 2-4 weeks). Light upper body 4-6 weeks. Back to normal 6-8 weeks.
When can I start swimming?
You should avoid swimming until the wounds are fully healed. You should normally avoid swimming for 4-6 weeks following surgery.
When can I have sex again?
Sex should be avoided until you feel comfortable and ready. Sex will not do any actual harm as long the breasts are not squashed or squeezed. It would be sensible to keep a supportive bra on if having sex less then 6 week after surgery.
When will I be back to normal?
Most people feel they get back to normal between 4 and 6 weeks after surgery. Although the breasts may still be tender at this stage.
The great majority of healthy people undergoing a breast reduction have an uneventful recovery and are very pleased with the outcome of their surgery. However as with all surgery there is the potential for complications. Complications include those of having a general anaesthetic, complications that may occur with any operation and those that need particular consideration for breast reduction.
There are the risks of having a general anaesthetic such as allergic reactions, chest problems such as a chest infection and the possibility of clots in the legs (deep vein thrombosis). Underlying medical conditions e.g. asthma can be aggravated. In general if you are healthy modern general anaesthetics are very safe. If you are concerned about your anaesthetic we can arrange for you to meet with an anaesthetist before your surgery to discuss your concerns.
Bleeding and haematoma:
During surgery great care is taken to stop bleeding. However after the end of the operation, particularly if the blood pressure is raised, a bleeding point may start bleeding again. This causes a build up of blood under the wound called a haematoma. Small haematomas usually are absorbed by the body over time. Larger haematomas may need to be removed with a further operation. Most people will then recover normally. It would be most exceptional to need a blood transfusion following a breast reduction.
During the operation the nipple has to be moved. Normally the nipple is not removed from the breast but kept alive on a block of tissue called a pedicle. It is possible for there to be an insufficient blood supply for the nipple in this block of tissue, in which case the nipple can loose its blood supply and die. In healthy non smoking women this is a very rare complication. Problems with the blood supply to the nipple are more likely with reductions of very large breasts. With very large breasts it may be advisable to use a free nipple graft technique where the nipples are removed and put back on the breasts as a grafts.
Infection and slow wound healing:
As breast reduction surgery is quite extensive there is a significant potential for wound infection. Most wound infections settle down with a short course of antibiotics. If a wound becomes badly infected the wound may open up and take time to heal up. If this happened regular wound dressings would be required until it was fully healed.
Most women have some difference in size or shape of their breasts. One breast may be larger, the nipple may be at a different position on the breast or at a different level. The brown area around the nipple called the areola may be a different size. With a breast reduction the aim is to produce breasts which are as similar as possible. However, particularly where breasts are different before the operation, it is not uncommon for there to be some difference after the operation.
Fat necrosis is what happens when areas of fat in the breast either loose their blood supply or are damaged. The fat dies and becomes a hard and frequently tender lump. The main issue is that these need to be diagnosed and distinguished from more serious causes of a lump in the breast. These lumps may resolve on their own but sometimes fat necrosis needs to be removed.
Seroma is a build up of tissue fluid in the wound. This causes swelling which may need to be drained but usually resolves on its own. Draining a seroma is usually done with a needle and syringe as an outpatient.
Deep vein thrombosis (DVT):
A breast reduction is a long operation. This does increase the risk of a thrombosis (clot) in the deep veins of the legs, a DVT. A serious complication of a DVT occurs where a thrombus breaks off and travels to the lungs in what is called a pulmonary embolus or PE. A large pulmonary embolus can be life threatening. During your operation and time in hospital we will take measures to protect you from DVT formation although these can not guarantee complete protection. Once you go home the best protection is regular walking.
The combined oral contraceptive pill (the pill) increases the risk of DVT with surgery. If you are on one of these pills you should discuss this with your surgeon. If you stop the pill four to six weeks before your surgery then your risk returns to normal. If you stop the pill and are having intercourse then you must use alternative contraception otherwise you may become pregnant.
As the scars may be quite long it is important to understand that scarring varies from one person to another. Some scars can be thin pale lines but this can never be guaranteed. Poor scars may stretch and be wide or become lumpy, hypertrophic or keloid. Keloid scars are lumpy and grow out from the incision that caused the original scar. Hypertrophic scars are frequently seen after breast reduction but true keloid scars are much rarer.
Drooping and ‘bottoming out’:
Over time breasts tend to droop because of the effect of gravity. The degree to which this happens varies with the weight of the breasts and the natural strength of the breast tissue. The breast tissue strength varies from person to another. Bottoming out is where the breast tissue droops but the nipple stays in an elevated position following a breast reduction. It is more likely where the nipples are placed higher with the surgery.
Mammography before surgery: The national breast screening program recommends a mammogram every 3 years between the ages of 50 and 70 (this may change to 47 to 73). If you are in this age group you should consider ensuring you are up to date ie you have had a mammogram with in the last 3 years. If you have any additional risk factors or would like additional reassurance you can discuss having a mammogram anyway prior to surgery. If you are between 40 and 50 years consideration may be given to obtaining mammograms before surgery. Under the age of 40 it would be unusual to have mammograms with out a specific reason. Mammography after surgery If recommended by a doctor there is no reason not to have a mammogram because you have had a breast reduction. It may be uncomfortable or painful for 3 to 6 months following surgery.