Breast Reduction (Reduction Mammoplasty) and Breast Lift (Mastopexy)

Authors:
Dr. Bryce J Cowan BSc MSc MD PhD FRCSC
(Reconstructive & Cosmetic Plastic Surgeon, The Skin Care Centre, Vancouver, BC, CANADA)
Dr. William deHaas BSc MD FRCSC
(Reconstructive & Cosmetic Plastic Surgeon, The Foothills Hospital, Calgary, AB, CANADA)

Breast reductions are very popular surgical procedures. Women seeking this procedure perceive themselves as having large breasts. Reasons for desiring a breast reduction are personal and various, but here are some of the more common reasons for desiring the procedure:

1. Marked breast asymmetry
2. True gigantism
3. Unacceptable aesthetics (excess drooping, disproportion, etc.)
4. Neck, shoulder, and back symptoms perceived to be related to breast weight (sometimes not the only contributing factor)
5. Skin problems in the breast fold
6. Difficulty fitting in clothing
7. Social / Psychological

It is important to realize that all women have some degree of asymmetry with respect to:

1. Breast volume
2. Breast shape
3. Chest wall placement of each breast
4. Nipple-areolar size and shape
5. Nipple-areolar placement on the breast mound

Some degree of breast asymmetry will persist after your surgery no matter how carefully the surgery is done as precise measurements and excision of the redundant tissue is possible.

Patients seeking a breast lift procedure are generally very satisfied by the volume of their breast tissue. Breast reshaping techniques can help to improve the breast shape of those who are unsatisfied with their natural breast shape. In some cases, women who seek breast reshaping also wish to have a breast lift and augmentation performed.

LOCATION

Breast reductions are performed in a local hospital setting for insurance covered procedures, and in private surgical facilities for uninsured procedures. Breast lift procedures are generally performed in private surgical facilities, as they are rarely insurance covered procedures. In all cases, the patient should be accompanied home following surgery, and monitored for a night following surgery.

CONTRAINDICATIONS (some may be relative)

1. Multiple surgical procedures on the breasts
2. Undiagnosed breast lump(s) or known breast cancer
3. Obesity
4. Likely or planned future pregnancy
5. Medical conditions prohibiting elective surgery
6. Unrealistic expectations

PREPARATION

Prior to any body contouring procedure, it is important to take appropriate preparations to increase safety, and maximize the benefits of the procedure. Patients should not take anti-inflammatory drugs such as Aspirin®, Motrin®, Ibuprophen, or Advil®, due to their effects on the body's blood clotting, for at least two weeks prior to surgery. Tylenol ES®, is a painkiller that can be used for those who suffer from chronic pain. Any use of herbal supplements or other alternative medicine should be discussed with your surgeon. Finally, alcohol should be avoided for at least a week prior to the surgery date.

All medical conditions and medications must be disclosed to your surgeon prior to the operation. Medical conditions such as high blood pressure must be controlled before any invasive surgery can take place, as bleeding and hematomas are a real risk.

Smoking is a very important factor in any invasive surgery. Chemicals from smoking can cause vasoconstriction of blood vessels, which restricts the blood supply to the newly re-draped and transferred tissues. Smoking must be stopped at least 2 to 3 months prior to surgery in order to eliminate the risk of further tissue loss. It is important to understand that all smokers, regardless of quantity, are at an increased risk of tissue death following body contouring procedures like breast reductions.

THE PROCEDURE

There has been much debate over the ideal method of reducing unwanted breast tissue and providing a predictable and sustainable shape with the least conspicuous scars. Even today, many debates persist over whether reductions using the most commonly performed Wise-pattern (anchor) incisions are to be eventually replaced in favour by vertical reduction patterns. Other still have designs on eliminating the vertical scar portion on the breast, leaving only the scar in the breast fold. These debates exist because there is no perfect solution.

Once a skin pattern has been chosen and marked on the breast(s), a method of shifting the nipple-areolar complex is required. There are two basic choices:

1. To move the nipple and areola as a free tissue graft
2. To leave the nipple and areola attached to a dermoglandular pedicle of tissue (through which circulation is maintained).

There are several methods of accomplishing the latter, which include:

• Dermal pedicles
• Breast pedicles
• Combinations of the two methods listed above.

A variety of factors related to you the patient (i.e. age, degree of ptosis, size of breasts, etc.) determine which method will be implemented. As there are proponents of each technique, I think it is fair to say that they all produce comparable results. Although many skin patterns have been described, most surgeons prefer to use one pattern in the majority of cases. The most commonly used Wise or "keyhole" pattern of skin incision allows surgeons to adequately remove the redundant skin in both the vertical and horizontal dimensions (which may be less reliably done through the use of short scar techniques). This leaves a resulting anchor type scar with the lower scar often hidden in the fold below the breast.

Once the nipple and areola have been isolated, the excess skin and breast tissue is excised. Bleeding is controlled. The breast is then re-assembled by suturing the medial and lateral components to each other and to the chest wall. The nipple and areolar complex are then inset and the skin incisions are closed. Difficulties in breast-feeding have been reported with some approaches where all glandular breast attachments have been separated from the nipple.

A mastopexy or breast lift is carried out in much the same fashion but the nipple and areola are always left attached to the breast substance, and only excess skin is removed. The skin incisions may vary (periareolar) and no glandular breast is removed. It is simply reshaped and anchored (using pillar techniques and in some case facial slings) to the chest wall muscles.

THE RECOVERY

The typical recovery time following breast augmentation is 3 to 4 weeks. During this period, a contouring garment or bra is often used. Pain is controlled with prescription medication for the first days, up to a week. Generally, over the counter pain medications should suffice. In some cases, stool softeners may be helpful if a prescription narcotic is required. Bruising and swelling can become noticeable 3 or 4 days after the procedure. This is a normal part of the recovery process, and will subside within 2 to 3 weeks following the procedure.

We recommend a recovery time of a week or more. Booking time off of work, and completing physical chores such as cleaning the house, should be taken care of prior to surgery as you will be unlikely to be able to perform these chores for at least a week. Preparations such as having prepared meals on lower shelves, or arranging childcare for the first few days after the procedure are some of the many preparations that may help you recover.

Work activities should be avoided for 2 to 4 weeks post surgery, and longer in the case of manual labour. It is important to allow 3 to 4 days before engaging in any activities that require any use of the arms. Activities which cause a rise in blood pressure, including sex, should be avoided for 2 weeks. Sports may be resumed after 1 or 2 months. It is important to note that these are only guidelines, as recovery is an individual process, so listen to your body.

Pain and bruising around the general breast area is a common and expected experience following surgery. This should resolve within 2 to 4 weeks. Another common effect is a clear or blood-tinged weeping at the incision site, which should clear within 2 to 4 days. The wound itself will remain red and raised for 6 to 9 months following procedure, which will slowly fade in colour. Altered sensations on the breast generally resolve between 6 to 12 months after the procedure, though in some cases, this sensation is permanent. The final breast shape, and look including the surgical scar will take up to 18 months to establish.

UNAVOIDABLE CONSEQUENCES

If a breast reduction is performed, there are many unavoidable consequences of this surgery. These aspects are so common and expected that they should not be confused with unexpected complications. These include:

1. Scars (which may vary in nature from good to adverse)
2. Sensory changes / loss over the breast (including the nipple and areola) which may be minimal to marked in nature
3. Possible restricted ability to nurse a child (breastfeed)
4. A period of recovery
5. Bruising at the incision sites and weeping at the incision sites for a few days

If a mastopexy (breast lift) procedure is done instead of a formal reduction, the same consequences are incurred with the possible exception of the patient's inability to breastfeed.

POTENTIAL COMPLICATIONS

It is important to understand that any list of potential complications is incomplete, as it is impossible to list all possible outcomes. The following list are the most commonly seen complications of this procedure:

LOCAL SURGICAL COMPLICATIONS	DISTANT SYSTEM COMPLICATIONS
Wound infection Hematoma (blood collection) Seroma (fluid collection) Loss of portion or all of nipple and areolar complex due to inadequate blood supply (or failure of graft to take) Changes in nipple-areolar sensitivity Unsatisfactory scars	Respiratory problems - many possible causes Circulatory system collapse - many possible causes Disturbances of the blood clotting mechanism leading to: Excessive bleeding Excessive clot formation

It is important to understand that surgical complications can be life threatening, and result in death, however slight the possibility. In most healthy patients, however, the results are satisfactory without any complications. On occasion, complications of surgery can cause aesthetic problems, and a secondary surgical procedure can be required to correct this. For more detailed discussion on expected results, recovery, and specific complications, please see your individual surgeon.

WHAT TO EXPECT

Pain perception varies widely from individual to individual, but in most cases, the post-operative pain is underestimated. New techniques have been developed to help with this problem. Also, early in the post-operative period, the implants may sit high on the chest wall, usually for 4 to 8 weeks, but this will settle over time. Many women comment that initially, the breasts feel very firm, but will begin to soften over time, although they will never be the same consistency as natural breast tissue. Finally, bruising in the arm pit or abdominal region can occur, and in some cases, can be significant with the trans-axillary or TUBA procedures.

Scarring from the procedure will take approximately 12 to 18 months before they can be assessed in their final form. Prior to assessment, it is essential that the scarred area is protected from the sun (using 45 o 60 SPF sunscreens) to prevent permanent darkening of the scars. Residual abdominal wall numbness may occur. Breast sagging is often reversed as well as the "pseudo-blanches" or stretch marks becoming less noticeable. Despite this, patient satisfaction with this procedure is typically high.

COST

Breast reduction surgery is commonly covered under the Canadian Medical Plan. Breast lifts with or without augmentation are generally considered elective, and are not covered. The final cost for such a procedure is at the discretion of the performing surgeon. The costs generally range from $6000 to $12,000, as published by the Canadian Society of Aesthetic Plastic Surgery. Costs will vary based on the required augmentation and type of implant.

DISCLAIMER

This website does not cover all of the medical knowledge related to breast augmentation nor does it deal with all possible risks and complications of surgery on the breasts. Although it is designed to provide the patient with greater depth of information in some areas, it is not intended to substitute for the in depth discussion between patient and surgeon that must occur prior to any surgical procedure.