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Breast

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Breast Augmentation  |  Breast Lift  |  Breast Reduction

 

The size and shape of a woman’s breasts can often play a critical role in a woman’s self image.  Women who are discontent with their breast size can often feel self-conscious or even embarrassed about their appearance.  We offer a variety of breast enhancement procedures that will give the breasts a more balanced, symmetrical look while still appearing natural and beautiful.  Talk to the doctor during your initial consultation about the available breast enhancement procedures.

Breast Augmentation

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Breast augmentation, also known as augmentation mammoplasty, is a surgical enhancement procedure to accentuate the size and shape of a woman's breasts. While breast augmentation will make the breasts larger, the surgery will not move the breasts closer together or lift sagging breasts.  Breast augmentation is tremendous help to patients who desire a fuller profile, who have lost breast volume due to pregnancy or nursing, or who have undergone breast reconstruction and want to gain a more natural look again.

Reasons for Considering Breast Augmentation:

  • Enhance body shape if breasts are too small.

  • Increase breast volume after pregnancy and nursing.

  • Equalize a difference in breast size (cup size) to gain breast symmetry.

  • Reconstruct breasts following a mastectomy or injury.

Breast augmentation is one of the most common cosmetic operations done in the United States. In assembling this information sheet, we have tried to answer many of the common questions patients ask us during consultation. At Aesthetic Surgery Associates, our emphasis is on educating patients so that they can make the best possible decision for their care. 

Q & A

There is a lot of information of the web, how do I know what is accurate? The two web sites at the bottom of this page have helpful information that covers many “basics” of breast augmentation. It can be difficult to “sort things out” given the volume of material (both right and wrong) available on the web that is made available by both proponents for, and opponents of breast augmentation. Please also be aware that many sites are “sales oriented” and refer you to surgeons that pay to be listed on the site. Surgical referrals on the web have become a major industry, and the cost is passed on to patients. Many excellent surgeons are not listed simply because they do not wish to pay for the privilege. Your personal “filter” should put information to the test of some simple questions:

1. Does it make intuitive sense? The information should be easy to understand and based on explanations, not opinions. The opinions should be your own after you have been educated.

2. Do I feel that they are trying to sell me something? If you have this feeling, it is probably accurate. A good doctor is not a good salesman, but rather a good counselor and educator. You should leave a web site with the feeling that there is a genuine interest in helping you make the right decision for you.

3. Do I feel as though there is some other “agenda” on the web site? Some web sites present augmentation in a very blithe and overly positive light. This can be a genuine attitude based on happy patients and good results. Similarly, there are sites that are highly negative and are based on a clear agenda to dissuade patients from undergoing an augmentation. These can also be based on genuine attitudes that have arisen from bad experiences or poor outcomes. The truth lies somewhere between, so try to balance your information.

4. Does the site refer you to other reputable third-party sources of information? There should be links to sites with information from the government or reputable societies to help balance the perspective.

What is the best source of information about Breast Augmentation? The answer is simple! You should ask for feedback from women whose opinions you value, and who have the same outlook on lifestyle and appearance that you do. Many women are hesitant to invade the privacy of friends and acquaintances. Surprisingly, most patients are very forthcoming about their augmentation, and are usually happy to answer questions that are not overly intrusive.

What are the most important “issues” I need to understand that will help me make the correct decision? Your decision to undergo breast augmentation involves a list of long-term “issues” related to implants. Failure to be informed of these issues is one of the principle causes of dissatisfaction among patients who are unhappy with their augmentation.

1. The need for future surgery. Over a lifetime, a significant percentage of women will need additional surgery on their breast which can include changing the size of their implants, “lifting” the breasts (mastopexy), or correcting problems with the implants or the scar capsule that naturally forms around them (hardness, leaking, or asymmetry). Additional surgery can be necessary due to changes in the breasts caused by pregnancy, large changes in weight, or skin laxity with aging. You must be aware of this potential to intelligently decide if an augmentation is right for you.

2. The potential for capsular contractures. Any artificial device placed in the body that cannot be broken down and absorbed forms a thin layer of scar around it termed a “capsule”. This is true of shunts for hydrocephalus, artificial joints, implantable pumps or catheters. With breast implants, the scar capsule can shrink with time, which is a potential of all scar tissue. Shrinkage can be aggressive in some women resulting in “hardening” of the implant. The implant is actually normal, but the constricting scar tissue makes it feel hard. You can demonstrate this at home by placing a water balloon in a pillowcase, then twisting the loose pillow case until it “squeezes” the balloon. If you twist it tightly enough, the balloon will feel as hard as a baseball. There is nothing wrong with the balloon. Surgery is necessary to correct this problem if it occurs with breast implants.

3. The amount of soft-tissue coverage present on your chest. Breast implants are covered by the soft-tissues of the chest. These include skin, fat, muscle (if the implant is placed below the muscle), and existing breast tissue. Thin coverage of the implant can make it difficult to camouflage the breast mound created by the implant. This is why very thin women with small breast have a more “obviously augmented” look. An artificial-appearing result is even more common if larger implants are placed in a thin patient. Thicker subcutaneous fat layers, or a more generous amount of native breast tissue yield a more “natural” appearing result.

4. The need for procedures to raise the nipple position and reduce excess skin in addition to an augmentation. Some breasts have been “stretched out” by pregnancy or massive weight gain. In these patients, the nipple has descended and typically points toward the floor. Augmentation alone is not sufficient to raise the nipple to a more natural position. In this circumstance, surgery must also be done to raise the nipple position and remove excess skin (mastopexy). These operations leave a scar around the areola, and sometimes on the breast below the nipple. If you are unwilling to accept these scars, an augmentation alone will not give you a satisfactory result, and a second procedure to “lift” the breast will be needed.

5. Do I plan future pregnancies? Nothing changes the female form as dramatically as pregnancy. During pregnancy, existing breast tissue increases in size and weight and stretches out the skin. After delivering the new baby, the breast volume and weight decreases leaving “hollowness” of the upper part of the breast, and causes the nipple to hang loosely and lower. If you undergo an augment and have subsequent pregnancies, the same changes can occur in the breast tissue over the implant. This may result in the need for a breast “lift” after completion of child-bearing.

6. What is the underlying shape of my chest and native breast tissue? Some women have that are located low on the chest. Since the implant needs to be centered on the nipple, it too will be low on the chest. The width of the implant determines how high on the chest the upper border of the implant is located. If its location is low on the chest, it will not create the fullness of the upper chest that some women desire. Similarly, if the fold that the breast makes with the chest at the lower extent of the breast (the infra-mammary fold) is close to the nipple, the fold will need to be lowered so that the implant is centered on the nipple. The point here is that a women’s individual anatomy plays a large role in determining how the augment will appear.

All of these issues should be addressed in some form during a consultation for breast augmentation. It is an excellent idea to ask how they apply to your particular case during the interview with your doctor. You should have a clear idea of how they apply to you prior to making the decision to proceed. Once you decide to have an augmentation you will need to make some choices.

1. Where do I want the scar placed? A scar is needed to allow access to the breast and insert the implant. There are several choices:

a. Infra-mammary fold. This scar is slightly above the crease the breast makes with the chest and upper abdomen, and well below the nipple and areola. This is the most commonly used location, and is typically used for secondary procedures if the scar capsule needs to be removed. It is also the scar of choice for placement of silicone implants since they need a slightly larger opening for access due to the larger size of the implant (saline implants are inflated after they are inserted and can thus be placed through a smaller incision).

b. Peri-areolar. The scar with this technique is at the border of the areola. It is typically a cosmetic scar, but is still a scar on the breast. Silicon implants can be placed using this approach. 

c. Trans-umbilical. This is termed a TUBA, or Trans Umbilical Breast Augmentation. A small incision is made in the umbilicus (belly button), and a tunnel made from the umbilicus to the lower part of the breast. A special balloon dissector is placed in the breast to stretch out a pocket for the implant. A saline implant is then substituted for the balloon dissector and subsequently inflated. The entire procedure is done “blindly” (no visualization of the pocket being made). It can be very difficult to control bleeding if it occurs with this approach due to the lack of visualization. It is also difficult to precisely place the implant below the muscle due to the distance between the incision and the pocket. 

d. Trans-Axillary. The axilla is the medical term for the arm-pit. With this technique, small incisions are made in the natural skin crease in the armpits, and a short tunnel is made to the breast, or under the chest muscle. A pocket is made under direct visualization using a special operating telescope (endoscope), and a saline implant is placed and subsequently inflated. The muscle can be very precisely released with this technique, and any bleeding can be controlled. The scars are not on the breast, and are difficult to see even with the arms raised. It is not suitable for silicone implants due to their greater volume. This is our preferred approach at Aesthetic Surgery Associates. 

2. Do I want the implants under the muscle, or on top of it? This choice depends principally on the amount of soft-tissue coverage that is needed (see above explanation). In thin patients, the thickness of the muscle will help to “camouflage” the upper and middle portions of the implant’s border, which will yield a less “obviously augmented” result. Placing the implant under the muscle can also reduce the likelihood of capsular contractures and the resulting “hardness” of the implant. Patients who choose placement under the muscle need to be aware that attachments of the muscle to the lower chest wall need to be released to allow the muscle to “re-drape” over the implant. In competitive athletes (tennis, golf), this can have performance implications but is not a noticeable difference is the vast majority of patients. 

3. How do I decide on an appropriate size implant? This is strictly a matter of personal taste. Long-term problems are more common with large-volume breast augmentations, and the result appears more artificial with larger sizes. Since bra sizes are highly variable (as any women who shops for bras can tell you), it is difficult to precisely relate implant volume to cup size. The best way to approximate the appearance of an augment is to place various size implants in your bra, and inspect your appearance in a mirror with your shirt on. Alternatively, some surgeons use external breast prosthesis that approximate the volume of an actual implant to simulate the result. This is our approach at Aesthetic Surgery Associates. We encourage multiple visits to help decide what is right for you. At home you can fill plastic bags with different volumes of water and place them in your bra to make sure. The final decision is yours, and yours alone. We support our patient’s decisions once we are assured that they understand the implications of their choice.

4. Do I want saline or silicone implants? Silicone is a viable option, and is once again available since questions about their safety have been resolved. Many patients prefer them due to their texture when compared to saline. With older silicone implants, capsular contracture (hardness) was more common, and follow-up has not been long enough to determine if this is true with newer devices. The silicone implants are much more expensive (3 to 4 times the cost of saline) and require a larger access incision when compared to saline. Saline implants tend to project somewhat more than silicone, and are a bit more uncomfortable for patients who like to sleep on their stomach due to their firmer consistency. If saline implants rupture or leak, they are easier to replace and the saline that leaks out is the same as that used in IV solutions.

What are possible complications from the surgery?

Early Complications

a. Infection. As with all surgery, infections can occur despite meticulous technique and antibiotics. The incidence is less than 1%. If it occurs, the implant will need to be removed for at least a month to allow resolution of the infection. It can then be replaced. Attempts to treat the infection and salvage the implant are seldom successful.

b. Bleeding or Hematoma. Bleeding in the pocket with the implant can create collections of blood termed “hematomas”. These collections create significant bruising, and need to be evacuated in the operating room. Leaving a hematoma can predispose to capsular contractures and an abnormally firm breast. Post-operative increases in blood pressure due to pain, or inappropriate physical activity (sexual relations or athletic activity) can cause the bleeding. Bleeding should be suspected if one breast is significantly larger and more painful than the other after an augmentation. 

c. Seroma. Rarely, collections of clear fluid can accumulate around the implant. This is most likely in patients who have had lymph-node dissections in the axilla on the side of the augment. They are more common in patients who are augmented after lumpectomy and radiation for cancer.

d. Synmastia. This complication is where the two implant pockets connect across the midline. It is due to over-aggressive dissection of the pockets combined with the choice of large implants. The two implants actually touch in the midline. It is a very difficult problem to correct even with additional surgery.

Late Complications

a. Asymmetry. Rarely, the implants can shift position, typically in association with capsular contracture. Asymmetry that occurs early in the post-operative course usually “settles out” during the first six weeks after surgery. Asymmetry that evolves later (six months to a year) will usually need surgery to correct.

b. Capsular Contracture. This is “hardness” of the implants caused by shrinkage of the scar capsule around the implant. The precise cause is unknown, but it is more common in smokers. Surgery is needed to remove the capsule (capsulectomy), or open the capsule (capsulotomy) to provide more room for the implant. This complication was more common with older silicone implants than with saline (15% life-time risk). Newer silicone implants have not been used long enough to determine if contracture is more common. Placing the implant below the muscle reduces the risk of this happening. 

c. Rupture or leakage. For saline implants, the lifetime risk of this happening is approximately 4%. The incidence for newer silicone implants is unknown due to the limited follow-up time. If leakage occurs, the implant needs to be replaced soon after recognition of the problem. 

d. Rippling or “folds”. These are visible creases that form as the implant “pulls” on the scar capsule. They are more common with saline implants, and also more common in thinner patients. The best means of correcting this problem is replacing the saline implant with silicone. Even this may not entirely resolve the problem.

e. Calcification. This is a fairly rare problem. Occasionally, the scar capsule can become calcified, similar to an eggshell. It is typically associated with capsular contracture and surgery is needed for correction.

What about “shaped” implants? Shaped or “anatomic” implants are offered by some surgeons as an option to the more typically used round implants that constitute the vast majority of breast augmentations. They are a controversial subject among plastic surgeons, some of whom believe strongly in their use. These implants are shaped more like a typical breast and the principle is attractive in concept. If shaped implants are used, the pocket needs to be very precisely dissected or the implant can rotate in the pocket. There is evidence that even minimal capsular contractures will make the implant assume a rounder configuration, thus eliminating the supposed advantage of their use. Anatomic implants are also significantly more expensive than round ones. Many surgeons use the option of anatomic implants as a marketing tool to differentiate their services from competitors. Suffice it to say that shaped implants continue to make up a small minority of breast augmentations.

Is there an advantage to “textured” implants? Implants are available with a “fuzzy” or textured coating. This coating is designed to reduce the incidence of capsular contractures by “breaking-up” the scar capsule. They are rarely used in primary breast augmentation, and are normally reserved for use in patients undergoing surgery for capsular contractures, or for reconstruction after surgery for breast cancer. The coating results in a thicker shell on the implant that can be palpable through the skin.

Is there an increase in my risk of cancer after an augmentation? Breast implants do not increase the chance of developing breast cancer. This issue has been well studied, and there is little question that there is no additional risk.

Will augmentation interfere with my mammograms? Mammograms after augmentation will require additional views of the breast to allow visualization of all of the breast tissue. Studies show that mammograms following breast augmentation are as effective as those performed on un-augmented breasts.

Will I be able to breast feed after breast augmentation? Since the implant is under the glandular tissue of the breast, they do not interfere with breast feeding. 

Is it sufficient to be counseled only by the surgeon’s office staff? Although office staff are an excellent source of information and advice (some of whom have undergone augmentation), there is no substitute for adequate counseling by your surgeon. Your surgeon is in a unique position to determine which “issues” involved in augmentation are most important in your particular case. Never let discussions with office staff take the place of focused conversation with your surgeon.

What is the best approach to making my decision? 

1. Talk to several other women who have undergone augmentation

2. Talk to more than one surgeon before deciding. This will re-assure you that you are choosing a surgeon that you are comfortable with. Remember, it is best to seek care locally with a board-certified plastic surgeon than to travel to a distant city to have your surgery. Complications can occur, and if they do, it is best to have continued care close to your home given the expense and logistical difficulty in continuing your care at a distance.

3. Do your homework ! Get as much information as possible from the web, from literature, and from your surgeon before deciding. 

4. Never get in a hurry. Make your decision when you are sure it is right for you!

Additional information can be found on the following web sites:
plasticsurgery.org
surgery.org

To arrange a consultation, please call Aesthetic Surgery Associates at (254) 526-5106 or toll-free 1-866-232-0469

Breast Lift

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A breast lift, also known as a mastopexy, is a procedure to raise and reshape sagging breasts.  As a woman ages, skin loses some elasticity which can cause the breasts to lose their natural shape and firmness.  This procedure is designed to elevate the breasts and give them a more youthful appearance.  A breast lift may also be completed in conjunction with breast enlargement surgery (augmentation).

Reasons for Considering a Breast Lift:

  • Elevate the breasts due to sagging caused by the effects of aging and gravity.

  • Firm the breasts if they have lost substance due to pregnancy and subsequent breast-feeding.

  • Re-align your nipples/areolas if they point down or to the side.

  • Bring back natural suppleness after weight loss.

Breast lifts are frequently requested operations that have many features in common with Breast Reduction Surgery. The principle difference between the procedures is that breast reduction is designed to remove volume from the breast, while Mastopexy is designed to redistribute or add to existing volume, tighten the skin envelope of the breast, and change the position of the nipple. 
 

Q & A

What is a breast lift? A breast lift is an operation designed to reposition the breast tissue to a higher level on the chest while tightening the skin envelope and raising the nipple position. In some cases, placing a breast implant will accomplish all of the goals of a mastopexy simply by adding volume to the breast that has been lost due to aging or childbirth.

What happens to the breast that makes a mastopexy necessary? In some cases, patients are born with an abnormally shaped breast, or a nipple position that is unusually low. The majority of patients have changes in the breast that have evolved over time. These changes include a loss of soft-tissue volume, stretched-out skin, and a nipple position that points down. Most commonly, the changes occur as a consequence of pregnancy. During pregnancy, hormonal stimulation causes the breast tissue to swell and increase in volume. Women can commonly experience an increase of up to a cup size during their pregnancy. While the increased breast size can be welcome, it disappears after delivery – with or without breast-feeding. As hormonal stimulation is removed and volume decreases, an unwelcome side-effect of breast enlargement becomes evident – stretched skin. The combination of stretched skin and loss of breast volume leads to an “empty” or “floppy” appearance to the breast which is most evident in its upper half. In addition, the nipple assumes a lower position on the breast that points downward instead of outward. These changes are termed “post-partum atrophy of the breast”.

How is the operation done? There a many types of operations designed to re-shape the breast. The choice of operation depends on what changes need to be corrected, and their severity. Each operation must be customized to the needs of the individual patient. Choices include:

Breast Augmentation: For less significant changes in the breast, restoring lost volume can effectively raise the nipple position and “re-fill” the stretched skin envelope. 

Peri-areolar mastopexy: This operation makes an incision around the edge of the areola to detach it from the skin and allow its position to be moved. A circle of skin around the areola is then removed to help tighten the skin envelope. Suture material is then passed around the skin edge as a “purse string” and tightened. After healing, the operation will leave a scar around the entire areola. 

Vertical Reduction patterns: Vertical patterns are similar to the peri-areolar mastopexy, but include removal of skin between the areola and the infra-mammary fold (the natural crease between the bottom of the breast and the chest). In addition to leaving a scar around the areola, there is a scar in the midline of the breast below the nipple. 

Modified Wise pattern: Mastopexy performed using this technique is essentially a breast reduction without removing volume. Scars left by the operation are the same as those created by the vertical reduction pattern, but also include a scar in the infra-mammary fold. This pattern is also known as an “anchor” or “inverted T” pattern due to the overall shape of the scar.

Regardless of the technique used to lift and tighten the breast, breast implants can be placed through the incisions if needed to restore lost volume. The combined procedures are commonly done and termed “mastopexy-augments”. Similarly, every patient who needs their nipple raised to a higher position on the breast will have to accept a scar around the areola. In most cases, the decision to have a Mastopexy is a conscious choice to trade scars on the breast for an improved shape. The major issue is the amount and location of the scarring.

Will Mastopexy change my mammogram? Yes, however this does not represent a problem. This issue has undergone extensive study and the changes in the mammogram do not create confusion in the detection of cancer. In patients old enough to need annual mammograms, they should be done prior to surgery to insure that no “surprises” occur during or after the operation. Abnormalities on a mammogram should be thoroughly evaluated prior to undergoing any type of breast surgery. A new baseline mammogram should be done approximately six months after the surgery.

Can I breast feed after a mastopexy? In most cases, Mastopexy does not disturb the milk glands or ducts of the breast, and should allow breast feeding post-operatively.

Will a mastopexy get rid of all of the stretch marks on my breast? Unfortunately, stretch marks above and on either side of the areola are not removed by a mastopexy. Excess skin below the nipple is removed and usually takes some of the stretch marks with it. In some patients, the existing stretch marks can become red after a Mastopexy - as they were when they first appeared. This is due to tension being placed on them from the “repackaged” breast tissue. The good news is that they fade to a silvery-white as they did following pregnancy.

What are the risks of surgery? Most risks are the same as any operation and include bleeding, infection, wound separation, and fluid collections. Potential problems specific to mastopexy are: Loss of nipple sensation; necrosis and loss of part, or all, of the nipple; asymmetry of the breasts; scar hypertrophy; and stretching or widening of the areolar diameter. Serious complications are most common in patients who smoke due to poor wound healing and impaired blood supply to the tissues. As with most cosmetic surgery, the overall rate of significant complications is low.

Can the breasts drop again and require another operation? In patients who gain significant weight after surgery, the breast can increase in size due to increased fatty tissue volume. Similarly, if pregnancy occurs after Mastopexy, the breasts can increase in volume as do breasts that have never been surgically altered. For this reason, Mastopexy is ideally done on patients who have completed child-bearing, and have a stable base-line weight. Waiting for surgery until after pregnancies are completed assures a more long-lasting result.

Can I have a Breast Lift at the same time as a Gynecologic operation such as a hysterectomy, tubal ligation, or laparoscopy? The answer is yes for many types of gynecological surgery. Ask you GYN doctor if combined procedures are right for you.

Why would I want to combine these types of operations? Cost savings are realized by reducing the total operating time. If you are having gynecologic surgery for medically indicated reasons, there is usually a recovery time involved that includes time off of work. By having your breast operation at the same time as your gynecologic procedure, you can recover from both at the same time!

Additional information can be found on the following web sites:
plasticsurgery.org
surgery.org

To arrange a consultation, please call Aesthetic Surgery Associates at (254) 526-5106 or toll-free 1-866-232-0469

 

Breast Reduction

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Breast reduction (or reduction mammaplasty) is an enhancement procedure that reshapes the breasts in order to make them smaller, lighter, and firmer.  Reduction is accomplished by removing excess fat, glandular tissue, and skin.  Large breasts can cause physical pain as well as emotional and social anxiety.  Women who take advantage of the breast reduction procedure find that they are able to lead a healthier, more comfortable life, in addition to enjoying a beautiful, more proportionate appearance.

Reasons for Considering a Breast Reduction:

  • Back, neck or shoulder pain caused by heavy breasts.

  • Sagging breasts produced by their large size.

  • Disproportionate body frame attributed to oversized breasts.

  • Restriction of physical activity due to the size and weight of the breasts.

  • Painful bra strap marks and/or rashes as a result of large breasts.

Breast Reduction surgery is one of the most commonly requested operations in Plastic Surgery. It is a very similar operation to breast lifts (mastoplexy) but is typically a much more extensive procedure.

Q & A

With so many women wanting their breast enlarged, why would they want to have them reduced? Excessively large breasts (macromastia) can lead to, or aggravate, a variety of symptoms. The symptoms are related to the weight of the breasts and skin conditions caused by chronic moisture exposure. Simply put, having large heavy breasts is the same a strapping large water balloons to you chest using a bra. The weight leads to deep grooves in your shoulders from the tension on the bra strap. This tension is transmitted to your shoulders, upper back, and neck leading to muscle strain, and chronic discomfort or pain in these areas. The weight also “pulls” on the attachments of the breast to the chest leading to additional discomfort. The physical size of the breasts interferes significantly with many activities. The momentum transferred to the breast tissue results in bouncing and swaying that can amplify the discomfort associated with the weight of the tissue. Picture yourself trying to jog with large breasts and you can easily imagine how they might be functionally limiting. Limitations may be severe enough to interfere with activity that is an essential part of a weight loss program. 
As if the weight were not enough of an issue, skin-on-skin contact at the border of the breast and the chest wall creates a chronically moist area. Most large-breasted women are forced to apply liberal amounts of powder to the area to help combat the moisture. Despite these precautions, fungal infections and chronic irritation of the skin are common. It is important to medically document any rashes or infections that require treatment in order to build a strong case for insurance reimbursement for the operation.
In addition to physical problems associated with macromastia, there are also significant emotional and psychological issues. Psychological problems can range from excessive self-consciousness and shyness, to an inability to form normal relationships. More severe emotional disturbances are typically associated with the onset of macromastia at an early age. In these crucial formative years, a patient’s interactions with the world can become defined by her breasts. Surgery can offer a new opportunity for socialization free from a long-standing stigma.

What needs to be changed in order to reduce the size of the breasts? If you look at a large pendulous breast from the side, it has a shape like “Snoopy’s nose”. The bulk of the breast volume collects in a round mass at the lower portion of the breast, and the nipple points down. For the breast to be re-shaped and reduced in size, three things must be changed: 1. The amount of excess skin; 2. The breast volume or weight; 3. The nipple position. Operations properly designed to reduce the breast must address all three variables.

The fact that skin needs to be removed from most large breasts is not immediately obvious to many people. The weight and size of the breasts gradually stretches the skin over time. Stretched skin will not shrink to fit a smaller volume as does the rubber on a balloon after air is let out. Instead, the excess skin sags even more and takes on the appearance of an “empty sack” – similar to photos in the National Geographic. In order to create a more normal breast shape, skin typically needs to be removed to fit the new, smaller, volume. Removing skin unfortunately leaves significant scars on the breast regardless of the technique used to perform the reduction. The pattern of the scars is one of the principle differences between techniques.
Decreasing the breast volume or weight is usually done by surgically excising it using the incisions in the skin to gain access. If the attachments of the ducts to the nipple are preserved, breast feeding can still be possible after the operation. In some patients who have a preponderance of fatty tissue in the breast, liposuction can adequately reduce the volume. Liposuction will not, however, reliably remove excess skin or change the nipple position.

In order to move the nipple to a higher position on the breast, an incision around the areola is used to detach it from the surrounding skin. Most women with large breasts also need reduction of the diameter of the areola at the same time. The nipple remains attached to the underlying breast tissue to preserve blood supply and to retain attachment of the nipple to the underlying milk ducts and sensory nerves. Less commonly the nipple needs to be completely removed from the breast and re-applied as a skin graft. This is known as a “free nipple graft” and is needed in patients having a long distance from the nipple to the natural crease between the breast and the chest wall. 

There are many techniques used to accomplish all three of the above changes to reduce the size of the breast and reconstruct a more normal shape. Each technique differs principally in the location and size of the scars, and no single procedure is appropriate for every patient. Similarly, results using a given technique can differ significantly when performed by various surgeons.

How is the surgery done? This depends on the technique used. If the nipple position needs to be moved, a scar around the areola will be created regardless of the procedure. The principle difference in the more commonly applied techniques is in the pattern of the scars created by removing excess skin from the breast. Commonly used techniques include:

Liposuction: This is a procedure most appropriate for breast having a higher percentage of fatty tissue. It can reduce the weight of the breast, but relies on the reduced weight and unpredictable skin shrinkage to reduce the amount of skin and the position of the nipple. It is somewhat controversial as the sole means of accomplishing reduction of breast size, and is not appropriately applied to all patients.

Modified Wise Pattern: This is the most commonly used method of reducing breast size, and is considered the “gold standard” by which other procedures are compared. It has the longest track record of any operation, and reliably addresses all three of the “issues” involved in large breasts. The disadvantage of the technique is the significant scarring caused by removal of excess skin. Typically, there is a scar around the areola, a scar in the midline of the breast extending from the bottom of the areola to the infra-mammary fold (the natural crease between the bottom of the breast and the chest wall), and a scar along the infra-mammary fold itself. 
Vertical or “short scar” 

Mammaplasty: This technique differs from the Modified Wise Pattern by eliminating the scar in the infra-mammary fold. It is most suitable for smaller reductions and “gathers” skin in a “pucker” at the inferior limit of the midline scar on the lower portion of the breast. Results can be highly dependant on the level of experience of the surgeon performing it. Even in the most experienced hands, the breast initially has a highly abnormal shape which settles during subsequent months.

Peri-areolar Reduction: Small reductions can be done through an incision around the areola. A small amount of excess skin can also be removed with this approach, and the nipple position elevated. It is a technique most commonly used for mastopexy or “breast lifts”.

Is Breast Reduction covered by insurance? This depends on your insurer. Most insurers (including Medicare) will cover Breast Reduction as a reconstructive or medically indicated procedure. Other government-sponsored coverage such as the military’s TRICARE program also cover breast reduction. In the current insurance climate, most plans put great effort in avoiding coverage of as many procedures as possible. The only reliable means of determining if your carrier includes Breast Reduction as a benefit is to call them and ask.

Can I breast feed after a breast reduction? In approximately 40% of patients, the answer is yes. There is a chance that breast feeding may not be successful as with patients that have never had a reduction.

Will Breast Reduction change my mammogram? Yes, however this does not represent a problem. This issue has undergone extensive study and the changes in the mammogram do not create confusion in the detection of cancer. In patients old enough to need annual mammograms, they should be done prior to surgery to insure that no “surprises” occur during or after the operation. Abnormalities on a mammogram should be thoroughly evaluated prior to undergoing reduction mammaplasty. A new baseline mammogram should be done approximately six months after the surgery.

What are the risks of surgery? Most risks are the same as any operation and include bleeding, infection, wound separation, and fluid collections. Potential problems specific to Breast Reduction are: Loss of nipple sensation; necrosis and loss of part or all the nipple; asymmetry of the breasts; scar hypertrophy; and necrosis of fat within the breast. Serious complications are most common in patients who smoke due to poor wound healing and impaired blood supply to the tissues. The overall rate of significant complications is low and breast reduction patients are among the happiest in Plastic Surgery.

Can the breasts grow and require another operation? In patients who gain significant weight after surgery, the breast can increase in size due to increased fatty tissue volume. Similarly, if pregnancy occurs after Breast Reduction, the breasts can increase in volume as do breasts that have never been surgically altered. For this reason, Breast Reduction is ideally done on patients who have completed child-bearing. Younger patients who have not yet started a family are still good candidates for Breast Reduction depending on their degree of symptoms and motivation.

Can I have a Breast Reduction at the same time as a Gynecologic operation such as a hysterectomy, tubal ligation, or laparoscopy? The answer is yes for many types of gynecological surgery. Ask you GYN doctor if combined procedures are right for you.

Why would I want to combine these types of operations? Cost savings are realized by reducing the total operating time. If you are having gynecologic surgery for medically indicated reasons, there is usually a recovery time involved that includes time off of work. By having your breast operation at the same time as your gynecologic procedure, you can recover from both at the same time!


Additional information can be found on the following web sites:
plasticsurgery.org
surgery.org

To arrange a consultation, please call Aesthetic Surgery Associates at (254) 526-5106 or toll-free 1-866-232-0469

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254.526.5106
800 West Central TX Expressway 
Suite 100, Harker Heights, TX 76548

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