Disclosure Patients with large breasts experience a significant range of symptoms, some severe enough to interfere with activities of daily living. Patients with large heavy breasts commonly complain of significant neck and shoulder pain. They may develop grooves in their shoulders from the weight of the bra straps, experience difficulty wearing clothes, and find that the heaviness of their breasts interferes with sports activities, even eliminating some from their lives. Patients may present to plastic surgeons for reduction mammoplasty from puberty through older age. If reduction mammoplasty is performed at an early age, such as age 14 years, the patient should be advised that she may require an additional procedure at a later time. If breasts are significantly large, surgery should be performed in the teenage years so the teenager's activities will not be restricted, nor will she experience harassment. The true genetics of breast development are not known. Even within the same family, one sister may have small breasts while the other has large breasts.
In general, a patient is considered a candidate for breast reduction if she has significant neck and shoulder pain. Criteria have been established by some insurance companies as to the amount to be removed from each breast according to a patient's height and weight, although recently, insurance companies have relied more heavily on symptomatology, such as neck and shoulder pain, to approve the surgery. Small reductions in which the breasts are not reduced by at least two cup sizes usually are not covered by insurance and would be considered more of a lift or mastopexy.
Contraindications: The only real contraindication to breast reduction surgery is if the patient is not medically able to undergo the surgery. There is an increased risk of loss of the nipple with patients who are smokers. Scars are the main risk that should be discussed with the patient. The scars extend around the nipple-areolar complex, vertically between the nipple-areolar complex and the inframammary fold, and under the inframammary fold. The scars are placed such that the scar around the nipple-areolar complex blends in when the color change occurs. The wound under the breast is placed under the fold to be hidden by the natural overhang of the breast. Fortunately, the vertical component of the scar tends to heal very well, even in patients who may form hypertrophic or very noticeable scars elsewhere. Keloids are a risk in some patients. The most common place for keloid formation is in the inframammary fold, principally in the medial portion. Patients who have a history of keloids should be warned of the risk for keloid formation. However, in general, the scars will respond to steroid injection and pressure. Patients with extremely large breasts have a higher risk of problems, principally loss of the nipple-areolar complex. In smaller-breasted women, this risk is almost negligible. In extremely large-breasted women, the possibility of a conversion to a free nipple graft should be discussed with the patient. The possibility of loss of nipple sensation exists as well as possible loss of the inability to breastfeed. Women have successfully breastfed following reduction mammoplasty but patients should be warned that this may not be a possibility. In general, if loss of nipple sensation does occur, it usually improves over the course of the year or so following surgery. |
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Lab Studies:
Surgical therapy: The breast reduction reduces the skin envelope and the volume of breast tissue. The markings are critical for the procedure and need to be made in the preoperative situation before the patient has received narcotic medication. At the time of the markings for the patient's reduction adjustments are made for correction of asymmetry problems. The most important marking is for the new position of the nipple-areolar complex. This should be marked at a position commensurate with the inframammary fold, which is also 21-25 cm from the sternal notch. This should be at a position approximating one third of the way up the upper arm. The nipple-areolar complex can be reduced in size if large. A 4.5-cm nipple-areolar complex is appropriate for a reduced breast. The vertical limb is then marked. In general, this should be short (4.5 cm) to minimize the chance of eventual bottoming out of the breast. A longer vertical limb will lead to premature bottoming out. The horizontal limb should be marked. The total length of the upper portion of the horizontal limb should be equal to or greater than the inferior limb to allow for closure around the volume of the breast tissue. Once the markings are done, the patient is taken to the operating room, both breasts are prepped and draped, and surgery is begun. The inferior pedicle of breast technique involves leaving a pedicle tissue with the nipple in the superior portion of the pedicle, creating a wedge-shaped pedicle down to the chest wall. The pedicle should be an 8-cm base in smaller reductions and a 10-cm base in larger reductions. The pedicle is de-epithelialized. Originally, this was thought to preserve blood flow and nipple sensation. This is probably not absolutely critical but remains standard for the reduction process. In extremely large reductions, the position where the nipple is going to be moved to can be de-epithelialized. In case the nipple should become cyanotic during the procedure, the surgery could be converted to a free nipple graft. However, in general, reductions using the inferior pedicle technique can be performed in all except the most extremely large-breasted patients. The excess breast tissue medially, laterally, and superiorly is then excised and the upper breast flap is then elevated off the pectoralis fascia. The upper breast flap is then thinned to create the desired volume in the breasts. The breasts should not be reduced down to a standard size but to one that is compatible with the remainder of the patient's body habitus. This may range from a B to a D cup or even bigger in larger women. Breast tissue should be carefully preserved, marked, and protected so that each specimen sent separately from each breast can be evaluated by a pathologist. Rarely, an occult malignancy has been found in a breast reduction specimen. Therefore, it is critical to know in which breast the cancer has arisen. When excess breast tissue is being excised, it is important not to let the pedicle fall to one side, as this causes undue cyanosis of the pedicle and may increase the chance of nipple loss. After irrigating the wounds and obtaining hemostasis, the wounds are temporarily closed and the patient is placed in a sitting position to ensure that symmetry exists between the two breasts. The volume of breast tissue resected is weighed to provide data to the insurance companies. It is also helpful for determining that symmetry has been achieved during the reduction process. The wounds are closed with buried sutures and then either a subcuticular suture or Dermabond on the skin. The patient is generally kept in the hospital for one night following the surgery, during which the viability of the nipple-areolar complex is monitored. The patient is placed in a surgical bra immediately following the procedure, as this helps minimize postoperative pain. The patient then should be followed as needed postoperatively to ascertain healing of the wounds. In general, the scars do very well around the nipple-areolar complex. Vertically but in the inframammary incision, some thickening of the scar may occur, particularly in the medial portion. This may require a Kenalog injection. The patient should be reminded to establish a new baseline mammogram at approximately 6 months following the reduction mammoplasty.
The most devastating complication following a reduction mammoplasty is total loss of the nipple-areolar complex. This is extremely rare. There is a higher incidence, of course, in patients who smoke or extremely large-breasted patients. In patients with extremely large breasts, consider the possibility of a free nipple graft, and, as mentioned earlier, consider de-epithelialization of the upper portion from where the nipple is to be removed, which would allow for the nipple to be placed as a graft. The patient should be converted to a free nipple graft in the case of impending loss of the nipple-areolar complex. Otherwise, hematoma formation is the main complication that could arise. Some surgeons opt for drain placement, though the risk of hematoma or seroma is small. Infection is also unusual in a reduction mammoplasty.
Patients who undergo reduction mammoplasty are, in general, the happiest patients treated by plastic surgeons. They tend to have immediate relief of their neck and shoulder pains. Even the older members of the population, who have had heavy breasts for an extensive period of time, experience relief from their neck and shoulder pain. A study published in 1999 found that the risk of breast cancer was not increased after breast reduction; in fact, the risk of developing breast cancer was significantly decreased after breast reduction.
In general, the changes that have been made in the reduction mammoplasty are in shortening the amount of the scar extending laterally. Some surgeons now propose using just a vertical component but this may leave a scar that descends onto the upper abdominal wall. In general, the scars heal very well. Care should be taken that the inferior scar is as narrow as possible to prevent it from extending into the axillary area or medially where it may be visible when wearing certain outfits. Occasionally, some redundancy is left laterally on the breast area, which may require liposuction.
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