Reduction Mammoplasty (breast reduction)
The size of women's breasts may be determined by several factors, such as inherited genes, body weight and hormonal influences. They can, therefore, be a problem to some women early in adolescence or may not become uncomfortable until middle age following the menopause or the use of HRT. The problem of large breasts, however, may cause similar problems at all ages and these are chiefly backache, neck pain, grooves in the shoulders from bra straps, rashes under the breasts and the feeling of self consciousness. Because of the sexual nature of breasts the undue prominence may attract unwanted attention from the opposite sex, comments and sexual innuendoes. These can cause psychological distress to many women. One of the commonest complaints of women with large breasts is that it is very difficult to wear fashionable clothes and indulge in active sports, particularly in the summer months.
What can be done?
Reduction mammaplasty is an operation which removes the excess fat and skin from the breasts, which are reshaped and the nipples repositioned to form newer smaller breasts. This should result in more attractive breasts and reduce many of the problems outlined above. There are several different surgical designs to reshape the breasts and are illustrated opposite. All of them will involve a scar around the areola of the breast. Each method will use different scars and will have advantages and disadvantages and your surgeon may select with your approval the best technique in your particular case. Reduction mammaplasty may be used to correct asymmetry of the breast, where one breast is very much larger than the other and where it is considered to be the least normal of the two.
What are the consequences?
Apart from the change of shape and reduction in size the most obvious consequences are the scars. These are designed to be invisible whilst wearing normal clothing and as far as possible are designed to lie under the average bra or bikini top. Over the months following surgery the scars will fade from being red, possibly thick and uncomfortable, to becoming much more pale and less obvious. However, they will always be present and visible when clothing is not worn and the scars will vary from one woman to another. In some they may be very thin, in others they may stretch and become quite red and possibly ugly. In the vast majority of women, however, the scars are acceptable and a small trade off for the benefit of dealing with the problems of large breasts. Very few women are able to breast feed following breast reduction surgery as the nipples are separated from the underlying milk ducts and at the time of pregnancy the milk supply will gradually dry up, sometimes with the assistance of hormone treatment. Breast reduction is no contra indication to pregnancy but young women may well wish to take the fact that they are unable to breast feed into account before embarking on this procedure.
The nipples are likely to be very much less sensitive following surgery due to the nature of the cuts and the nerve supply and it is quite possible that numbness will extend over part of the breast as well.
Will the improvement last?
Unless your operation is done at an age when your breasts are still growing, they should not regrow afterwards. They will, however, increase in size if you either put on weight or become pregnant and decrease in size if you lose weight. Even normal breasts have a tendency to droop with time and you can expect some change in shape to occur after a reduction mammaplasty. You can delay this tendency by supporting your breasts in well-fitting bras.
What are the limitations?
It is very important that you discuss thoroughly with your surgeon beforehand the size of breasts you wish to achieve. Many women wish for a very radical reduction but in order to achieve this the shape and aesthetic quality of the breasts may be compromised. It is also possible that there may be a degree of asymmetry. This is often less than existed before the surgery. In women with very large breasts the benefits of a significant reduction may outweigh the potential imperfections of poor shape and loss of nipple function and sensitivity. However, in women with breasts which are only slightly larger than normal very careful thought must be given to the scarring and the potential shape and size as the outcome of the surgery may not be as aesthetically pleasing as a normal breast appearance.
What are the risks?
Any major operation with a general anaesthetic carries a small risk of chest infection particularly among people who smoke and there is also a small risk of thrombosis in the veins of the leg, particularly for patients who are taking the contraceptive pill.
Occasionally, heavy bleeding can occur after the operation is finished which may need a further operation and a blood transfusion.
Occasionally, infection from germs harbouring in the ducts of the breast can be troublesome. Infection can be treated with antibiotics but it will delay the healing process, scars are likely to be worse to start with and there may be a need to restitch them at a later date. If you have a discharge from your nipple, it is most important to tell your surgeon about it before your operation.
Occasionally, skin can become sloughy and form a scab which gradually separates to leave a broad scar. The nipple disc and the skin where the scar meets underneath the breast are parts most likely to be affected. People who smoke are at greater risk of this happening. Usually the scars settle well to end up as white lines but they will always be noticeable. However, some people have an inborn tendency for scars to stretch and sometimes they can stay thick, red and irritable for a long time.
When reducing large breasts it may occasionally be necessary to adjust the folds of skin at the end of the scar, both between the breasts and at the sides. This can simply be carried out under local anaesthetic several months later.
There is no evidence that reduction mammaplasty causes breast cancer. Nor does it prevent your breast from being examined for cancer in the usual way.
What you should do before your operation?
Your surgeon is likely to recommend that you reduce weight if you are overweight and to make alternative arrangements if you are on the contraceptive pill. Smoking does seriously effect the healing of the breast wounds and should be discouraged and attempts to give it up made.
What can you expect at the time of the operation?
This procedure is carried out under a general anaesthetic and when you wake at the end of the operation there will be some discomfort which will last for two or three days. You will be given suitable pain killing injections or tablets. Drainage tubes are frequently used and will be removed within a short period of time. You may need to remain in hospital for three to four days. The stitches will normally be removed between ten to fourteen days and you will be tired and require help at home for a period of time, from two to six weeks depending on your age and general fitness. A well-fitting bra will need to be worn following surgery but because of the post-operative swelling the final size of your breasts may not be obvious for several weeks. There is likely to be some tenderness and lumpiness of the breasts for several weeks or even months following surgery but there is no reason why you cannot sunbathe and go swimming once the scars have fully healed.
Cosmetic Surgery is carried out by members of several different organisations and, therefore, your general practitioner is the best person to advise you on whom you should see.
Before the operation
After the operation, showing the scar lines around areola of the breasts in a 'T' shape
Gynecomastia (pronounced guy-ne-co-mastia) is a medical term meaning male breast enlargement. In the majority of cases there is no known cause and, although rarely talked about, it is a common condition. For men who feel self-conscious about their appearance, breast-reduction surgery can be helpful. The procedure removes tissue from the breasts, and in extreme cases excess skin. This information sheet will give you a basic understanding of what is involved if you are considering surgery to correct gynecomastia. It can't answer all of your questions, as a lot depends on your personal situation.
Most teenage boys experience some degree of breast enlargement affecting one or both breasts. However, by early adulthood less than 10% have a residual problem. This incidence rises with age, reaching approximately 30% (1 in 3) in older men. Rarely, the breast enlargement can be caused by medicines (for high blood pressure, heart disease and prostate cancer), drugs (such as marijuana and anabolic steroids), some diseases (such as liver failure and some cancers) and some very rare congenital abnormalities (errors of development that one is born with). These causes should be excluded by the surgeon during an initial consultation. Additional information will be needed at this consultation regarding overall health, chest size and body shape, previous chest surgery, any bleeding tendencies and healing capabilities, some of which will be affected by smoking, alcohol and various medications.
The breast is made up of two main components, glandular tissue (firm and dense) and fatty tissue (soft). The ratio of glandular to fatty tissue in any breast varies from individual to individual and in gynaecomastia there may be an excess of both. If there is predominantly a diffuse fatty enlargement of the breast, liposuction is the usual treatment. This involves sucking out the tissue through a small tube inserted via a 3-4mm incision (see information sheet on liposuction for more detail). If excess glandular tissue is the primary cause of breast enlargement, it may need to be excised (cut out) with a scalpel. This will leave a scar, usually around the nipple edge. This excision can be performed alone or in conjunction with liposuction. Major reductions that involve the removal of a significant amount of tissue and skin may require larger incisions that result in more obvious scars. Most operations for gynaecomastia take about 90 minutes to complete and are performed under general anaesthesia, or in some cases, under local anaesthesia with sedation.
Following the surgery the chest is swollen and bruised for a while and it can be difficult to assess the full effect of the operation. To help reduce swelling, patients are often instructed to wear an elastic pressure garment continuously for one or two weeks. It is advisable to refrain from exercise for about three weeks and, in general, it takes about six weeks before one can return to completely normal activities. The potential complications of the surgery are relatively rare. They include inadequate removal of breast tissue, an uneven contour to the chest and reduced nipple sensation. If an excision has been performed, rather than liposuction, then a blood clot can form that may need to be drained at a second operation.
Causes of small breasts
The size of breasts is genetically determined. Once developed, the breasts may fluctuate in size in response to changes in weight, pregnancy and breast feeding.
The aging process causes the shape of the breast to change so that they gradually droop (called ptosis). This effect is greater following pregnancy, breast feeding and in particular after a large weight loss. Most women have breasts of slightly different sizes, but occasionally a very marked difference may develop.
Breasts can be made larger by placing an implant either under the breast tissue or behind the muscle on which the breast lies. Implants are usually inserted through incisions in the fold under the breast (i.e. inframammary fold). Alternatively, the incisions may be made around the areola or in the armpit.
A breast implant consist of an outer shell and a filling material which is most often silicone gel or sometimes salt water (referred to as saline). Some implants are round and others are shaped more like a natural breast referred to as tear drop or anatomical implants. Either can give excellent results. The manufacturers life expectancy of breast implants is 10 or more years, although implants can stay in without problems for a much longer time.
Expectations and complications
Breast augmentation has for many years been the most common cosmetic procedure in the UK which is testimony to its safety and ability to achieve a satisfying outcome in most patients. However no surgical procedure is without risk and understanding these risks as well as having a realistic expectation is essential.
When any foreign material is inserted in the body it makes a protective coating around it which in most women forms a thin membrane that remains undetectable externally. In a few women however the reaction to the implant is greater and this is referred to as a capsule as the membrane becomes much thicker. The capsule around the implant can become thickened and contracted. The newer designs of implants have features to reduce the likelihood of this happening. This problem occurs to some extent in around 5 or 6% of patients and usually starts at about a year after surgery although it may take many years to become noticeable when looking at the chest. This can lead to pain, and/or an abnormally hard feel of the implant in the breast. Treatment may be needed and occasionally removal of the implant. Breast augmentation does not usually interfere in breast feeding, and there is no evidence that any silicone is found in breast milk. The presence of breast implants may interfere in mammography, which is an X-ray screening method for breast cancer. Special X-ray views can be taken to minimize this interference and studies have shown that the sensitivity of detecting a breast cancer in patients who have had implants is not reduced compared to normal women who do not have implants.
Most women have some degree of asymmetry between breasts and breast augmentation may occasionally exaggerate this difference. A breast that has an underlying implant will not necessarily feel like a normal breast, and some women may be acutely aware of the implant as a foreign body within the breast. The size and shape of the breast following breast augmentation surgery will adjust with time and can be unpredictable. It is also not always possible to create a cleavage with breast augmentation. Please remember that the weight of the implant may influence the age-related changes that normally take place in breasts. Movement of the fluid which fills the implant may occasionally be seen through the skin, this being more likely in the saline (salt water) filled implants, and less likely in the more viscous silicone implants, which also have a more natural feel. Breast augmentation will always leave scars on the breast or in the armpit, and although the scars will settle over 12 or more months, the appearance of the scars does vary between different individuals. This scarring is placed in such a position as to minimize visibility even when wearing a swimming costume. Complications that occur with breast augmentation include those associated with all forms of surgery, as well as the specific problems of bleeding and infection. Any infection that may occur in the tissue around the implant can usually be treated with antibiotics, but may require surgical removal of the implant.
Safety of silicone
Whatever the filling of the implant, the outer layer is made of silicone which is a firm type of material referred to as silicone elastomer. Silicon is a naturally occurring element which becomes silicone when it is combined with carbon hydrogen and oxygen. Silicone is manufactured into many items including cosmetics, foods and medical implants. Many studies have been conducted to establish whether silicone breast implants cause certain diseases. As a result of these studies we can say that at present there is no evidence to suggest that silicone breast implants are associated with an increased incidence of breast cancer. There is also no evidence to suggest that these implants cause autoimmune diseases such as rheumatoid arthritis.
Implants placed either under the breast tissue or behind chest muscle
Possible incision areas for breast implant
Mastopexy (up-lifting of droopy breasts)
Droopiness of the breast is a common legacy of motherhood, nursing and the force of gravity taking their toll, and the effect of pregnancy and a distension of the breasts with milk causes the fibrous bands which support the breasts in their youthful shape to break down and the skin to stretch. With the subsequent shrinking the unsupported breasts settle into the stretched skin and gravity pulls them down. Putting on weight and then losing it can have the same effect. So too does the ageing process, which is why women dislike the appearance of their droopy breasts.
What can be done?
Whilst it is not possible to recreate surgically the natural supporting structure of the breast, it is possible to reshape the breast into one which looks more youthful and feels more firm. The operation is called a Mastopexy. Pleats of surplus skin are removed from underneath the breast, the breast itself is remodelled into a tighter cone and the nipples are repositioned at a higher level so that they lie at the points of the tightened breasts. Mastopexy can also reduce the size of the areola ( the darker skin surrounding the nipple). If the breasts are too small as well as droopy, their size can be increased during the operation by placing silicone breast implants underneath the tightened breasts. The best results are achieved in women with small sagging breast although breasts of any size can be lifted. The results may not last as long with heavy breasts. Many women seek mastopexy when their families are complete so if you are planning to have further children it may be a good idea to postpone the operation for though there is no risks for future pregnancy and mastopexy does not usually interfere with breast feeding, pregnancy is likely to stretch the breast again and reduce the effectiveness of the procedure.
What are the consequences?
This is a good operation to improve the appearance of droopy breasts but you would be left with scars, possibly some numbness of your nipples and you may not be able to breast feed again. Mastopexy can be carried out by a number of different techniques and the scars will differ accordingly. The most common technique involving scars are illustrated below. It may be possible for the operation to be performed with less scars and your surgeon will discuss the possibility of this with you. Usually these scars are fine but they are not invisible and could be noticed by others for example, if you were topless on the beach.
What are the limitations?
Because it is not possible to recreate the natural attachment of the breast to the tissues underneath, a mastopexy alone will not greatly increase the fullness of the breasts above the nipples. Fullness above the nipples can be achieved, however, by increasing the size of the breasts with silicone implants. The extra weight of the silicone implants may accelerate the return of the droopiness of the breasts and in any event there is a tendency for the breast to sink downwards as time goes by. You can lessen the rate at which this happens by supporting your breasts in a bra as much as possible.
What are the risks?
As with any major operation under general anaesthetic, there is a small risk of chest problems particularly if you are a smoker and a small risk of thrombosis of veins in your legs, particularly if you are taking a contraceptive pill. In addition there is a small risk of one or more of the following complications.
Rarely heavy bleeding from the broken blood vessels can occur after the operation, which requires treatment in theatre under another anaesthetic. Occasionally, infection (usually from germs that are lying dormant in the ducts of the breast) can cause part of the wounds to break down which prolongs the healing period and worsens the quality of the final scars.
Some people have an inborn tendency for scars to stretch and some people produce scars which remain thick, red and irritable for a long time.
If silicone implants are used you will need to refer to the leaflet on breast augmentation which will discuss the issue of breast implants and the potential complications in much more detail.
What you should do before the operation?
If you smoke, you should stop now. If you are taking the contraceptive pill, change to an alternative method at least six weeks beforehand. If you are overweight, reduce it beforehand.
What you can expect at the time of the operation?
This surgery is normally carried out under a general anaesthetic and will often involve an overnight stay in hospital depending on the extent and size of the procedure. Your surgeon will need to mark the size and shape of the breast while you are standing and following the operation you may find that you have two small tubes emerging from each of your breast so that any collection of blood can drain. These will remain in place for a short period of time. You will be given painkillers for the discomfort you experience in the first few days. Your surgeon may encourage you to wear a firm bra or dressing following surgery which will continue until the stitches are removed some 10 days to 2 weeks later. You should refrain from strenuous physical exercise including swimming, for a month and you will probably require at least two weeks off work. Over the next 6 to 12 months the scars will gradually fade from red to pale. Your surgeon will make every effort to make your scars as inconspicuous as possible but it is important to remember that the scars are extensive and permanent. It is not possible to reshape droopy breasts without significant scars for although the use of breast implants alone will improve the fullness they will not deal with any significant drooping. Breast lift will not last forever and the effects of gravity, pregnancy and weight gain will take their toll, as will time.
Cosmetic Surgery is carried out by members of several different organisations and therefore your general practitioner is the best person to advise you on whom you should see.
Breasts after a mastopexy
Different types of scarlines after a Mastopexy
Fat Transfer to Breast
Fat transfer or lipofilling for use as a breast implant has been around for about 100 years and it’s combination with liposuction has been used for over 20 years but In that time the technique has been criticised as it can lead to the fat dying, leaving cysts in the breast or calcification, which can be seen on mammograms and, it was thought, mimic cancer. The standard for breast augmentation remains silicone breast implants but these are not without their own problems. Implants can lead to a ‘foreign body reaction’ with hardness and a capsule forming around the implant, distorting the breast in a small proportion of patients. In thin skinned patients the edge of the implant and wrinkles in the outer shell can be visible. Implants cannot be expected to behave like normal breast tissue. The ideal breast augmentation/reconstruction will always be the patients own tissue but historically these procedure have required complex surgical procedures, including microsurgical techniques, and extensive, visible scars.
Techniques of transferring fat using liposuction and lipofilling have evolved and are being developed to augment and reconstruct the breast. One of the major potential problems remains the possibility of changes on mammogram, which can mimic cancer. More than 500 cases have now been done in Italy and France and it has been found that, whilst there are changes on mammogram, experienced radiologists are able to differentiate these from cancer. If the fat cells are carefully placed under the skin in small tunnels, but not in the breast tissue, the fat cells will take and grow and increase the volume of the breast. However, this technique is not for every patient. It is best suited to those who wants to increase bra size by one cup size, those who requires increased fullness in the upper pole of the breast, and after ‘conservative’ breast cancer surgery.
Patients who undergo this type of treatment must have been screened by mammogram and ultrasound before surgery according to the guidelines laid down by the American Society of Aesthetic Surgeons, and followed up with regular mammograms and ultrasound for several years. The state of knowledge is not yet sufficient for patients to walk in off the street, have the procedure and be discharged from follow up. If patients are not treated within these guidelines, fat transfer will be used inappropriately, damaging patients and causing difficult breast problems.
The technique has great potential, but should be used carefully to avoid it getting a bad reputation.