Consumer's Guide to Breast Reduction
08.10.06 11:39 AM
Consumer's Guide to Breast Reduction
Breast Reduction Assessment of Value and Outcomes (BRAVO) Study
Where should I have the surgery?
Are there different techniques for breast reduction?
Are there different types of scars?
Can the surgery be done without scars?
How long does the procedure take?
What type of anesthesia is used for breast reduction surgery?
What are the risks and complications of breast reduction?
Are there alternatives to surgery?
1. Where should I have the surgery?
Breast reduction surgery should only be performed by a board-certified plastic surgeon at a JCAHO (Joint Commission for Accreditation of Healthcare Organizations) accredited hospital or outpatient surgery center. Facilities with this certification have been required to meet high standards for patient care and safety.
2. Are there different techniques for breast reduction?
Pedicle Techniques
This is the most common type of breast reduction surgery. Pedicle techniques use a variety of designs, all of which raise the nipple and areola to a higher position while leaving these tissues attached to portions of the underlying breast tissue. Areas of surrounding skin and breast tissue are removed to create a smaller breast. The remaining skin and breast tissue are then fitted around the nipple in its new location. The result is usually a breast which is smaller and less "saggy" than before the operation.
Nipple pedicle techniques for breast reduction offer patient several advantages. In most cases, these approaches result in very low rates of nipple loss, a reported complication of breast reduction (see below). Also, pedicle operations usually preserve nipple color and sensitivity. Finally, most plastic surgeons believe that these techniques produce the best cosmetic appearance.
Some patients may not be good candidates for pedicle reductions. Women with very large (E cup or larger) or with very pendulous (saggy) breasts, may have problems with nipple circulation or nipple loss after these operations. Because pedicle techniques take longer to perform (compared with nipple graft approaches—See below), they may not be the right operation for older patients or for women with serious medical problems.
Free Nipple Graft Techniques
This procedure is both fast and safe. Therefore, it is often recommended for the elderly, women with major medical problems, or in cases where very large amounts of mass will be removed (>1500g per side).
At the beginning of this procedure, the nipple/areola region is removed from the breast and preserved until later in the operation. Next, areas of excess breast tissue and skin are removed, and the remaining tissues are reassembled to form the new breast shape. The skin usually is closed in an upside-down "T" shape. Finally, the nipples are trimmed to a smaller size and sewn onto the breasts as skin grafts.
While the free nipple techniques offers the advantages of speed and safety, there are also disadvantages. Because the nipples have been totally detached during the operation, breast feeding is no longer possible following this surgery. Also, because the operation cuts the nerves which supply the nipple with feeling, this approach results in a longer time interval before return of feeling and full recovery of feeling is less certain.
3. Are there different types of scars?
The scars that remain after the incisions heal depend on the technique used. Generally, there are two scar types. The first is a vertical scar which starts under the nipple/areola region and continues down to the base of the breast. In addition, there also is a scar running around the edge of the areola. The second type is the anchor shaped scar. Like the first type, this version also has a vertical line from the nipple/areola to the base of the breast as well as a scar around the edge of the areola. However, with this second design, there is also a scar in the fold under the breast, often running along the full width of the breast.
Breast scars are permanent and may vary considerably in their appearance. Scars can be thick (almost rope-like) or more minimal. They may become less obvious over time but they will never entirely disappear. Research has shown that smokers tend to have more healing problems and wider scars.
4. Can the surgery be done without scars?
Some surgeons offer the alternative of liposuction to reduce breast volume. However, there are limitations to this approach in that there is no repositioning of the nipple so droopiness is not fully corrected. In addition, breasts are made up of fat and gland tissue in different proportions and it is only the fatty tissue that can be removed with liposuction. Only a small percentage of women are candidates for this approach to breast reduction.
5. How long does the procedure take?
The length of the operation will depend on the type of surgery. Most breast reductions take between two and four hours. Discuss with your plastic surgeon the length of your operation.
6. What type of anesthesia is used for breast reduction surgery?
In the BRAVO study, almost all surgery was done under general anesthesia. Only one of 179 cases was done with local anesthetic. However, there are some surgeons who perform the surgery with local anesthetic and sedation on a routine basis. Check with your surgeon about the anesthetic technique that is routinely used in the center where you will have surgery.
7. What are the risks and complications of breast reduction?
Like all other types of surgery, breast reduction is associated with a number of risks. Briefly, these include postoperative bleeding, infection, delayed wound healing, and abnormal scarring. In rare cases, breast or nipple skin doesn't heal and a skin graft is needed to close the wound, meaning more surgery. About ten percent of women report some loss of nipple sensation, which may be permanent. Breast reduction is performed under a general anesthetic and this involves it own risks. In extremely rare cases, serious heart, lung or kidney problems can result. Also, allergic reactions to surgical materials or medications are possible (but unusual). Your anesthesiologist can answer any specific questions on these issues.
Below is a list of some of the most common complications of breast reduction and their rates of occurrence. The complication rates listed are drawn from the BRAVO Study and other published reports:
Hematoma- Occurs in 4% of patients who undergo breast reduction surgery. A hematoma is a localized collection of blood in the wound, usually occurring in the first 48 hours after surgery. Large hematomas may need to drained in the operating room, under a general anesthetic.
Infection- May appear as redness around the incisions (called "cellulitis") or as an abscess (puss collection) inside the wound. Although infection usually can be effectively treated with antibiotics (medication), abscesses require surgical drainage under anesthesia. About 1-2% of patients who undergo breast reduction experience infection after the surgery.
Delayed Healing- Healing difficulties may range from minor problems such as small areas of wound separation to major issues such as extensive skin loss. Most of these complications are treated with daily dressing changes which allow the wound to heal in on its own (called "secondary healing")However, large areas of skin or nipple loss may require additional surgeries to repair these problems. Diabetics, smokers, obese patients and the elderly are all at increased risk for delayed healing after breast reduction. Among all patients having breast reduction surgery, up to 21% will have at least minor problems with delayed healing.
Breast Asymmetry/Shape Irregularities- Often seen in "normal" breasts, problems with breast symmetry and shape may become more obvious after reduction surgery. In rare cases (less that 5% of reductions), additional surgery may be carried out to correct these (usually) cosmetic problems. However, as noted above, patients considering breast reduction surgery should be aware that this operation is not designed to improve cosmetic appearance. Furthermore, virtually all patients have some minor differences in size and shape between the two sides following breast reduction.
Nipple-Areolar Complications- These problems can occur as results of injuries during reduction to either the blood vessels or nerve to the nipples and areoli. Partial or (in very rare cases) total nipple loss result from disruption of circulation to the nipple. Some amount of nipple loss is seen in about 4% of reduction patients. In rare instances, this problem may require additional surgery. Changes in nipple sensation (decreased sensitivity, numbness or hypersensitivity) due to nerve injuries are seen in about 13% women receiving breast reduction and may be permanent.
Recurrence of Breast-Related Symptoms- Although initially satisfied with the results of their reductions, some patients find that, after weight gain or pregnancy, their problems with breast size and symptoms have returned. This is one of the most common reasons given by patients for requesting re-operation.
Scarring- Although this operation always results in permanent scarring, reduction scars fade up to a year after surgery. In some cases (from 2-10%, depending on the study), patients develop abnormally heavy scars ("hypertrophic" scars) or, in extreme cases, scars overgrowing the original wound site (called "keloid scars"). Heavy scarring may improve with medications or with re-doing the wound closure (a scar "revision").
Fat Necrosis- This problem occurs when fatty tissue inside the breast dies in the first days following reduction and is replaced by scar tissue. Fat necrosis may appear as a hard and (sometimes) painful breast lump in about 2% of patients. Surgical removal of the lump often is recommended to rule out the possibility of other breast tumors.
Pain- Following breast reduction, pain levels vary tremendously from patient to patient. However, it’s safe to say that everyone has post-operative pain. The good news is that, for most women, this is easily controlled with prescription medication. You should discuss any of your concerns about pain control with your surgeon. After the procedure, breasts may feel numb, bruised, and swollen for several weeks. You may also feel sharp pains, especially when you move or cough for a few days. In some cases, women report occasional shooting pains and soreness for several months after the procedure.
Seroma- After reduction, many surgeons use small plastic drain tubes for several days to remove excess fluid from the breasts. However, wound fluid ("serum") can still collect inside the wounds after the drains are removed. Called "seromas", these fluid pockets may be absorbed by the tissues (in cases of small seromas) or require needle drainage (for large seromas). Seromas occur in about 1-2% of reduction patients.
8. Are there alternatives to surgery?
A number of non-surgical options have been suggested for women with oversized breasts and the accompanying symptoms. Weight loss is sometimes recommended for these patients in the hope that breast size and symptoms will decrease with declines in body mass. Also, physical therapy and pain medications have been prescribed for women with excessive breast size and associated back, neck or shoulder pain. However, the Breast Reduction—Assessment of Value and Outcomes (BRAVO) Study (described in Part I.) found that non-surgical remedies provided little long-term symptomatic relief for women with these breast-related complaints.
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