Today we’re going to be talking about breast reduction. Breast reduction is one of the surgeries in plastic surgery that has the highest patient satisfaction rate. The reason why it does is because the back, neck and shoulder pain that are associated with macromastia or hyppermastia, large breasts. Now I think that back pain, neck pain and shoulder pain is caused by the weight of the breast and the fact that the breast are low. I think that when you do a breast reduction, which also includes a lift, the lift is playing a role in making the back feel better and the reduction is also playing a role in making the back feeling better. Now, because that lift is playing a role in improving the back, you don’t have to reduce somebody to an A-cup in order to reduce the pain and you really cannot reduce somebody too much with a breast reduction because the nerves in the nipple, the blood supply in the nipple are all going through the breast tissue. If you take too much of that tissue away, you’re taking away too much nerve supply, too much blood supply and you can get death of the nipple. You can get decreased nipple sensation if you take too much. I generally don’t reduce people smaller than a C and when you take away four pounds, five pounds, ten pounds away, if you’re going from a G cup to a D cup, their back pain and things, it’s solved. Their shoulder pain and things go away. It’s not that you have to have nothing left in order to treat the back pain.
When you put that weight on the chest, you’re doing a lot to improving the back, neck and shoulder pains. The lift is really the thing responsible for eliminating the strap pain. I don’t care what the weight is. If it’s on your chest, the strap from the bra is useless because the weight is on the chest. There’s nothing pulling on the bra strap. The weight is on the chest. You can wear a sundress without a bra when you want to because the weight is secured the chest. So both the reduction in size and the lift is playing a role in getting the back, neck and shoulders to feel better. Now the lift that I do is a short scar, central pedicle type of breast reduction. There are different types of breast reductions. The short scar breast reduction means that we’re not putting a horizontal scar on the breast. We’re just putting a scar around the nipple and vertical without the horizontal scar. 1 The central pedicle means we are taking away breast tissue from the sides and the top of the breast. We’re taking tissue away from the outside of the breast and keeping the center of the breast. The most common breast reduction done in the United States is an inferior pedicle with a wise pattern.
A wise pattern is the scar around the nipple, a vertical, and a horizontal scar. The inferior pedicle means we’re saving most of the breast tissue from the bottom of the breast and taking off breast tissue from the top. There are also superior pedicles where we’re keeping the breast tissue from the top. There’s a superior and inferior pedicle both, and then there’s also the superior medial pedicle meaning that we’re saving the breast tissue from the superior medial is we’re saving the tissue where the cleavage is. That’s kind of the idea. But there are different types. They do different things. But what I’m doing is a short scar central pedicle. Something unique that I do with the breast reduction is I don’t throw away the extra tissue. When I take away that extra tissue from the bottom, I take off the top of the skin, which is called the epithelium, save the dermis, the bottom of the skin and then use the bottom of the skin for extra support under the breast. So now at the bottom of the breast, we have two pieces of skin instead of one. Because scars never heal to the full strength of the original skin, a scar will only heal to 80 percent of the original strength of the tissue. Weakness in the bottom of the breast causes the bottoming out, the breast to falling again. So the more strength we have on the bottom of the breast, the less likely that is. The better we secure the breast tissue to the fascia of the chest wall, something that has strength, the less chance of the breast falling down again. So these are the things we’re trying to do to give longevity to the breast lift and also to give a better shape to the breast lift. If you have that strength in the bottom of the breast, you can have more cleavage. You can develop more cleavage and things like that. So that’s the idea of what I’m trying to do with the breast lift. Now, what we physically what you’re doing when you do a breast lift is we are picking a new nipple location. The new nipple location is some place near the level of half way up the elbow.
We would like the nipple to be some place near the level of the inframammary fold, which is about halfway of the arm. So we’re choosing a new nipple location here. Here I’m making an incision like an upside down V and moving the skin away from the breast tissue, expose the nipple and breast tissue, taking away tissue from the sides to the top of the breast, moving the breast, nipple and breast tissue back to the chest wall, putting sutures around 2 the breast tissue to secure it to the chest wall and then closing the skin behind using the extra skin to create a hammock and get more support under the breast. Now, so far as recovery, breast reduction is not a terribly painful procedure as surgery goes. The pain is more a throbbing swelling type of pain more than a sharp knife type of pain. Initially the breast is like Madonna breasts. You know, torpedoes and it’s very high in the neck. As the swelling goes down, you get the normal slope and the shape and things like that. You’re doing everyday things right after the breast reduction. You can brush and comb your hair, eat normally, you jest can’t do heavy lifting. You’re moving, stretching but you can’t do any lifting or pulling. You’re not exercising because the breast cannot take that. The wound is going to open and things like that. But everyday things you’re doing from day one after the breast reduction. At one week, the swelling will start to go down. By two weeks, the shape appears more like a normal shape. Most people take two weeks to three weeks off work after the breast reduction.
There’s no exercise for one month. It will take three months, even four months for 90 percent of the swelling to go away and to get the final look and shape of the breast. It could be one year or even more that the scars get better and the scars look their best. So it takes time for the healing and the swelling and things to go away with the breast reduction. Now, the first day, most of my patients are not terribly painful. I have patients that would maybe take narcotics once or maybe the first day and not need so much the second day. It’s very rare for people to need narcotics four or five days in my experience with this procedure. So, most people are off for two weeks. Two weeks they’re going back to work. They feel pretty good, but swelling is still there, but it’s reasonable. At one month, they’re starting to exercise and things like that. So that’s kind of the ideas of the recovery. The complications you have to worry about. The two main complications have to do with the breast reduction taking away tissue. The nerves and blood vessels to the nipple go through the breast tissue. So when you cut away breast tissue, you take away nerves and blood vessels. So if you take away too many blood vessels, the nipple will die. So necrosis of the nipple is a complication of breast reduction. That is why it’s not wise or not really safe to over-reduce. The other thing is to nurse the nipple. If you take away too much breast, that you lose sensation to the nipple. The nerves to the nipple usually run from the fourth and fifth intercostal space from the outside in. Some nerves go near the ribs. Some nerves go near the skin. When you lift the skin away, you automatically take the nerves near the skin. You’re trying to save the nerves near the ribs. So decreased nipple sensation is a complication of breast reduction. You can also have increased nipple sensation and the idea or the theory behind this is that the breast ptosis has been stretched 3 the nerves have been stretched so long with the weight of the breast that they no longer function. When you relieve the stress in the nerves, the nerves work better. You have increased sensation. So that’s a possibility. Inability to breastfeed or not being able to generate enough milk.
They say that 60 percent of people with this type of breast reduction should be able to generate milk. Forty percent shouldn’t. Now, you could have the loss of the elevated skin. You can lose blood supply there and have a wound healing problem. You can have separation of the skin. You could develop a hematoma. A hematoma is bleeding underneath the skin. One breast would be swollen and big and the other one is small. Small hematoma can heal by itself. A big hematoma, you have to go back to surgery and drain. Infection, abscess, small infection you treat with antibiotics. An abscess you got to go back to surgery and drain the abscess. Hypertrophic scars and keloids. Now the short scar is less likely the keloid than the horizontal scar because there are keloid-prone areas of the breast of the body. So the shoulder is keloid-prone. The earlobes are keloid-prone. The sternum is keloid-prone. The ribs are keloid-prone. I did a lot of breast reductions on black patients and I always found keloids here and here. So that’s why I wanted to eliminate the horizontal scar. Much less common to get keloids are in the center of the breast. So that was a big reason why the short scar I think is a better operation. Another reason why the short scar breast reduction is a better operation, I think it generates a better shape. If you think about it, if you take tissue from the middle and pulls things to the side, that’s how you make a cone. That’s how you make a projecting breast. If you cut horizontally and pull down, you’re making a flatter breast. If you pull things in together, you’re improving the skin on the lateral side of the chest. If you pull down, you’re making the side of the breast bunch up and worse. So I think these are the reasons why the short scar is a better procedure and the additional reason has to do with the strength of the bottom of the wound.
The less scar you put on the bottom of the breast, the stronger the bottom of the breast, the less likely the breast is to fall down at a later time. So all those reasons are the reasons why I think the short scar is a better procedure than the typical wise pattern scar. Now, other complications would have to be the complications of anesthesia, pulmonary embolism, DVT, laryngospasm, atelectasis, pneumothorax, pneumonia, allergy in anesthesia. So I think these are the complications and things you have to think about with the breast reduction surgery. But again, the reason why the breast reduction surgery has a high patient satisfaction is because it does such a nice job on relieving the back, neck and shoulder pain. 4 Now I always hear from the insurance companies that losing weight will make your back pain go away. I have yet to see one person since I’ve been a surgeon lose weight and their back pain go away on a person who have real macromastia. Like a person like this. I don’t think that happens. I’ve never seen it and I doubt I will ever see that where a person lost 20 pounds and their back pain felt better. The reason why is because you can lose weight but the center of your weight is still below the chest. Until you put the weight back on the chest, you still have the strained back all day long and the back, neck and shoulder pain. So that idea that you lose weight and then all of a sudden the back pain is going to go away, I just don’t think that’s real. So this is an example of the breast reduction and you can see the nipple here is by the elbow. If you go to this fixed point, the xiphoid, the bone here, there’s no breast tissue here. There’s no cleavage. Now we go to the same fixed point. Now we have breast tissue above that and cleavage. If you shape the cleavage to look like an implant, the breast reduction will look like an implant. So this person doesn’t have an A-cup breast. But her back, neck and shoulder pain are relieved. Here’s another example and again you can see the nipples are – you know, one is below the level, at the level or a little bit of the shoulders. You see this breast goes to the – more to the side. This one is more straight so it still – this one goes to the side. You can’t change the morphology of the chest wall. So it’s going to be the same way that it was before. But again, after there’s breast tissue above it. Now there’s none. Another example and again, nipples are below the elbow.
Afterwards, nipples are about halfway up the arm, in the level of the inframammary fold. The scar is here and here without the horizontal scar and again there’s cleavage above the xiphoid where there was very little breast tissue above the xiphoid before. Now this patient is a breast lift or mastopexy. I’m trying to show that you can use the same skin operation and just not remove breast tissue and still get a good result. So again, I think this short scar is the better procedure for breast lifts. Now we did not take away an ounce of breast tissue with this breast lift. Essentially, if she likes the size she is in a bra, it will be the same size with this lift that I do after the surgery. But now instead of all the breast tissue being on the stomach, now it’s all in the chest and you can argue this almost looks like the shape of an implant. Here all the breast tissue was down there. Now if you look for the xiphoid, this is six, seven inches below the xiphoid. Now we got breast tissue above the xiphoid.
So this works for a breast lift too. Now this next one is actually a mastopexy augmentation or a breast lift with an implant. This is a patient who lost all her breast volume with pregnancy. 5 Most times, most of the times in breast reduction, people have had a pregnancy, gotten more volume and the volume didn’t go away after pregnancy and then we have the problems with the back pain. This person had the opposite. Breast tissue went away after the pregnancy. So we do the implant in order to fill volume but you see her nipples are pointing down. So we would have to do a lift to bring the nipple back to the level of inframammary fold. So we did that short scar again. Same skin operation, but now I’ve just added an implant. So the point of this is that same skin surgery can be used for breast reduction, breast lift and for mastopexy augmentation. In conclusion, I think the breast reduction procedure is a very good procedure because having pain every day is a rough situation. When you can relieve that pain, now you can go to work all day and not be in such pain, do more exercise without pain. Sometimes the people have so much back pain, they can’t exercise. Then they gain weight and things get worse. When you liberate somebody from that pain, now they can start moving more. They can exercise and do the things they want to do. They can go to work and at the end of the day, be functional when they go home instead of being in severe pain when they go home. So the breast reduction, it is a good procedure. Unfortunately, the insurance companies are starting to eliminate it as a covered procedure. So if you’re getting your insurance and things like that and you think this could be something that you need, you must check the fine print because some of the insurance companies now just have it as a non-covered procedure. Whether or not you need it or not is just not covered. So you must start checking your insurance policies. That’s something that’s going on the last few years. So we will try to do more videos on more topics. I hope you enjoyed it and you have a good day and if you ever have questions on any of these things, you can email me and I will try to answer the question to the best of my ability. OK. Take care. Bye.