Article: Breast Reduction Often Good Medicine

by Marilynn Larkin

Breast size usually isn't considered an appropriate topic for social conversation. But for a woman suffering the medical and social consequences of having large, pendulous breasts, talking with someone who has undergone breast reduction can be a "life-changing experience," says Mary-Margaret Richardson, a public affairs specialist with the Food and Drug Administration in St. Louis, Mo.

Before surgery, Richardson, 53, had adapted to a "lifetime of discomfort--bras that never fit and caused deep grooves in my shoulders, plus neck and back pain, heat rashes under my breasts in the summer, and ever-increasing stooping under the weight of them."

After talking with Kellie Feldman, a neighbor who had undergone breast reduction, Richardson decided to have the procedure done herself. "I had gone for a cancer screening several months earlier, and the doctor who did the examination looked at my rutted shoulders and asked whether I had ever thought of having reduction. The seed was planted then," Richardson said. "Then I talked with Kellie, and she was so positive about it."

Feldman, 27, is a special education teacher in St. Louis. "Actually, my father had been encouraging me to have the surgery," she says. "I was a bit put off, wondering why he was looking at my breasts. But he said that when I got older, they would look terrible. And I knew I already had deep shoulder indentations from my bra. In addition, the male students in school were always looking and commenting, which made me feel uncomfortable."

Margie, 40, an advertising executive in New York City who asked that her last name not be used, had a very different reason for undergoing breast reduction. "I have breast cancer and had a mastectomy on my right breast and then an implant," she says. "My surgeon recommended reduction for the left breast so that it would look more like the right."

Medical Concerns

Although very different from one another, these women share a mix of medical problems and cosmetic concerns that led them--and thousands of other women across the country--to undergo breast reduction surgery. "I can move my head and neck without pain, my shoulders have healed, and I just feel so much better," says Richardson. "I think about my grandmother, who had this problem all her life and was always stooped in pain. I wish she could have had something like this done then."

"Among my patients, I find there are certain age clusters with similar concerns," says George Beraka, M.D., a board-certified plastic and reconstructive surgeon who is assistant professor of surgery at Cornell Medical Center in New York City.

"Those in their late teens realize they don't want to live with such large breasts. Women who have finished childbearing and breast-feeding say to themselves, 'Now I'd like to look and feel better.' And older women often are referred by their internists because of neck and back pain."

In some women, breast examination and mammography may be easier to perform after reduction. "From the standpoint of the physical exam, it may be more difficult to pick up a very small lesion [lump] in a woman with very large breasts," says Charles Finder, M.D., a radiologist in FDA's Mammography Quality and Radiation Program. "Imaging large breasts for mammography may be a bit more technically demanding, since the technician may have to get each view done twice, or do two images per view."

Richardson notes that she "kept getting abnormal mammograms with 'dense tissue' reports that made me think I had breast cancer." She is "looking forward to a normal result this time."

But Finder cautions that this may not be the case. "If the breasts are reduced uniformly, then the tissue may still be dense, and she could still have problems with mammography," he says.

Contraindications to the procedure "would apply to any major elective surgery," says Beraka. "The woman should not have any significant illness, either physical or mental."

Patricia McGuire, M.D., a board-certified plastic and reconstructive surgeon on staff at Parkcrest Surgical in St. Louis, says she prefers not to perform breast reduction on women who are heavy smokers because of a loss of blood supply, or on those with diabetes, since they may not heal well. Also, "if a woman is really overweight, I encourage her to get her weight down first. This is particularly a problem with teens with large breasts, since they may try to gain weight so that their bodies look more balanced," says McGuire, who performed the reductions for Richardson and Feldman.

Both physicians believe it is best to wait until a young woman's breasts are fully grown, usually by age 18, before doing a reduction. The procedure is not recommended for women who intend to breast-feed, according to the American Society of Plastic and Reconstructive Surgeons.

Breast Cancer

Concerns that breast reduction might increase the risk of breast cancer are unfounded, according to Beraka. "There are no data to suggest that women who undergo breast reduction are at greater risk for breast cancer, or that those with a family history of breast cancer should not have the procedure," says Beraka. "In fact, reduction is like a giant biopsy of the breast, because all tissue that is removed during surgery is examined by a pathologist."

During 20 years of performing the procedure, Beraka says, malignant tissue was found among his patients "maybe half a dozen times." McGuire, who has been performing reductions for five years, had one patient in whom cancerous tissue was discovered.

Preparing for Surgery

During the initial consultation, the surgeon explains the surgery in detail, including risks, limitations and scarring, which is an inevitable consequence of the procedure. The surgeon also discusses where the surgery will take place, how long the woman will remain in the facility, any steps that need to be taken preoperatively, and what to expect postoperatively. Any questions a woman has are answered at this time.

In preparation for surgery, the woman has a complete physical examination. The surgeon measures the woman's breasts and usually photographs them for reference during surgery and afterwards. These photographs can also serve as documentation for insurance purposes.

Unlike a rhinoplasty (nose reduction), in which computer imaging may be used to show a prospective patient what her nose is likely to look like after surgery, the new breast size and shape, as well as positioning of the nipple and areola (the darker skin around the nipple), are usually determined during a discussion between the physician and patient.

"Preoperative imaging of any sort is of limited value for this procedure. It's a marketing tool more than anything else," says Beraka. "After assessing the size of the breasts, I ask the patient how much smaller she would like them, taking into consideration what makes sense in terms of the rest of her body. I then estimate how much tissue will need to be removed."

Most surgeons provide guidelines for eating, drinking, smoking, taking medication, and other activities before surgery. Generally, the patient should not take aspirin or similar medications for a week or two before surgery, since these medications may lead to increased bleeding. Beraka suggests women take 1,000 milligrams of vitamin C daily to promote healing, but avoid vitamin E supplements, which may also lead to increased bleeding.

If a patient smokes, she may be advised to stop. This is always a good idea, but it's especially important when general anesthesia is used, since smoking limits the amount of oxygen the body has available during surgery and recovery.

Because the size, shape, and amount of tissue in the breast will change after reduction, most women are advised to have a preoperative mammogram and a postoperative mammogram six months to a year after surgery for comparison.

The Surgery

Breast reduction is generally done on an inpatient basis. The procedure itself usually takes from two to four hours and requires an overnight stay in the hospital. In most cases, surgery is performed under general anesthesia. Generally, breast reduction involves the removal of fat, glandular tissue, and skin from the breasts; in some cases, the areola may also be reduced.

Surgical techniques vary, but according to the American Society of Plastic and Reconstructive Surgeons, "the most common procedure involves an anchor-shaped incision that circles the areola, extends downward, and follows the natural curve of the crease beneath the breast." After removing excess tissue and moving the nipple and areola into their new positions, the surgeon then "brings the skin from both sides of the breast down and around the areola, shaping the new contour of the breast."

[three steps in typical breast reduction surgery] The typical procedure is shown at right:

  1. The outlined areas show where skin, breast tissue, and fat are typically removed and how the areola and nipple are repositioned.
  2. The arrows show how skin formerly above the nipple is brought down and sutured together to reshape the breast.
  3. After surgery, scars will appear around the areola and in the crease under the breast.
Liposuction (a procedure in which excess fatty tissue is removed from a specific area of the body by means of a suction device) is sometimes used to remove excess fat from the armpit area, although some surgeons also use this procedure to remove excess fatty tissue from the breast. In some cases, if only fat needs to be removed, liposuction alone may be used to reduce breast size. The fatty tissue is also reviewed by a pathologist.

Beraka notes that newer surgical techniques, such as those popularized by Belgian surgeon Madeleine Lejour, can result in significantly less scarring around the undersurface of the breast, making the procedure "less frightening to patients contemplating reduction." However, McGuire says that while the Lejour technique can be appropriate "for specific patients," she does not believe it should be used for everyone. "The scars are shorter, but the surgeon has less control over the shape of the breast," she says. If the type of incision is important to the patient, she should discuss it with the surgeon.

Post-Op

After surgery, "they wrapped me in a bandage to hold everything in place," Richardson explains. "I was a bit uncomfortable, but I had very little pain. In fact, I never took anything stronger than extra-strength acetaminophen during recuperation."

The bandage is removed a couple of days after surgery, after which the woman wears a surgical bra 24 hours a day for about a month. "I could shower--I was up and active and doing things," says Richardson. Nevertheless, she took several weeks off from work to give her body a chance to recover before resuming a full schedule. Like most women who undergo reduction, Richardson was advised not to lift or push anything heavy for three or four weeks.

According to the American Society of Plastic and Reconstructive Surgeons, the first menstruation following surgery may cause breasts to swell and hurt, and the woman may also experience shooting pains in her breasts for several months. Patients may be advised to avoid sex for a week or so to avoid arousal that can cause the incisions to swell.

"I was relieved that my surgeon has an assistant who answered all my questions during the recovery period, like 'when will my bruises go away?' and 'when can I drive again?'" Richardson notes.

Adjusting to Change

Like most women who undergo reduction, Mary-Margaret Richardson, Kellie Feldman, and Margie were pleased with the results. "Of all the procedures I do, this one has the highest patient satisfaction, even when the results are less than perfect," Beraka says.

"I'm amazed whenever I go shopping. I can buy a dress, not separates with the top four sizes larger. My posture is so much better, and there's no rutting in my shoulders. Most of all, the pain in my neck and back is gone," Richardson says.

"I no longer have rashes under my breasts or shoulder indentations," Feldman adds. "Plus, I went on a diet and lost a total of 28 pounds, 7 of which was breast tissue. I feel much healthier."

"People ask, 'why did you wait so long?'" Richardson notes. "I tell them that when it began to be debilitating, everything sort of came together. I was scared up until the night before the surgery. But the time was right. I don't regret one minute of it."

Marilynn Larkin is a medical writer in New York City.

(The illustration was drawn by Renée Gordon based on information provided by the American Society of Plastic and Reconstructive Surgeons.)


Source: U.S. Food and Drug Administration
Cache Date: December 16, 2004

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