Women with heavy, pendulous breasts can suffer from a skeletal imbalance that contributes to back, neck, and shoulder pain. Some experience numbness in their hands and breathing problems due to nerve compression as their breasts pull down on their shoulders. Many women actually have grooves cut in their shoulders by their bra straps. They can develop a rash under their breasts, especially during warm weather. Psychologically, many patients have felt self-consciousness about their breasts since they were young.
Women who have breast reductions are usually DD-cups or larger. The goal of the procedure is to relieve symptoms. The surgery is done for medical purposes, but appearance can be enhanced too. Breast reduction, or reduction mammoplasty, involves removing excess fat, breast tissue, and skin. It’s similar to a classic mastopexy, except volume is removed as well as excess skin. The areola is reduced and a smaller, better-supported breast is constructed. The nipple is moved up. Occasionally, in women with very large breasts, the nipple-areolar complex may be completely removed and grafted onto the breast mound.
Insurance may cover breast reduction for some women. It depends on the patient’s breast size, body type, and symptoms. Most insurance companies have a formula based on your height, your weight, and how much tissue your surgeon estimates should be removed. Usually, removal of about one pound from each breast is required for insurance coverage.
Health care providers are mercenary about denying coverage for breast reduction. They don’t care if your clothes don’t ﬁt or you can’t exercise. In my experience, they don’t even care about your pain and discomfort, much less psychological embarrassment. It all boils down to your height and weight versus how much breast tissue will be removed. You can’t necessarily pick your desired breast size or shape. Less removal than the amount required by the insurance company’s formula places the procedure in the realm of cosmetic surgery. That means you pay the bill.
Your plastic surgeon should receive a detailed medical history, as some health-care providers demand a history of treatment for back pain to authorize coverage. I measure the breasts and often take photographs to be mailed with the insurance letter. If I don’t comply with the rules, the insurance provider— who holds all the cards—may not authorize payment for the procedure.
Breast reductions are performed in Minneapolis at an accredited, same day plastic surgery facility. They are done under general anesthesia and last two to three hours.
Techniques for breast reduction vary, but the most common procedure involves an anchor-shaped scar pattern. The incision surrounds the areola, proceeds down the breast’s center, and ends slightly above the breast crease. Surrounding breast and subcutaneous tissue are removed along with excess skin, and the nipple and areola are raised to the level of the natural breast crease. The blood supply that originates from the chest wall to the areola is preserved. Skin is folded around the central breast tissue to form a new breast shape. Liposuction is often used to remove the excess roll on the side of the breast. This leaves a shorter scar than surgical removal of the excess.
If the breasts are extremely large or if the nipples are very low, your surgeon may completely remove the nipple and graft it higher. If this is done, you will not have sensation in the nipple. Some surgeons try to eliminate the scar along the breast crease with a minimal incision approach. The problem with this approach is that it sometimes causes a puckering of the tissue at the base of the breast, which often requires revisional surgery.
Before deciding on a procedure, request photos of a surgeon’s prior patients. This helps you understand what the scars will look like and, roughly, how big your breasts will be afterward. Photos really help settle a patient’s nerves and build realistic expectations. You will be shown videos and receive educational material. Your surgeon should describe the procedure in detail.
I put my patients in a support bra following breast reduction. I sometimes use drains which are generally removed in a day or two. Buried sutures will dissolve on their own. Your breasts will be bruised and swollen for a week or two. Pain is moderate. Pain pills and possibly an antibiotic may be ordered.
You may feel a little depressed in the week or so following surgery. This is a normal reaction to the anesthesia and the changes your body has undergone, and shouldn’t last long.
Patients should wear a bra day and night for the ﬁrst month. They should avoid direct contact and sleeping on their stomachs. Swelling should be minimal to moderate and will last several weeks. Avoiding salty foods will reduce excess swelling. Patients should avoid vigorous activity for approximately one month after surgery.
Risks and Limitations
Numbness in the nipple or breast skin can occur. Bleeding may occur, which sometimes requires a secondary drainage procedure. Infection and separation of incisions in high-tension areas is possible. Blood can collect in the breast area, despite the use of drainage tubes. A small portion of skin, or the nipple, may die. Most patients are able to breast-feed after breast reduction surgery, but this cannot be guaranteed.
Deﬁnite post-operative scars are the trade-off for this surgery, although your clothing will hide them. Some women experience bad scarring or poor healing. This can be associated with smoking or even second-hand smoke, so don’t smoke and take precautions if you think you might be exposed to second-hand smoke. Follow your surgeon’s instructions to the letter.