LMSSA(Lond), LRCP(Lond), LRCS(Eng), MS,FRCS
Consultant Oncoplastic Breast Surgeon
Breast Reduction
The ideal breast size is in proportion to the frame of the individual. In some people the breasts become disproportionately large and this can cause many problems ranging from social embarrassment to functional problems including back and neck pain, bra strap indents and chafing under the breast. Breast reduction surgery aims to not only reduce the size but also to uplift the breast. At the same time the nipple is elevated to a more ideal position and when required the areolae are reduced in size. The aim is to produce an aesthetically pleasing breast both in terms of shape and size, with scars that are discreet and designed to be hidden when wearing a bra or a bikini.
There have been many types of breast reductions described over the years. Mr. Sarakbi routinely undertakes the two most popular types of breast reduction – a short scar technique (Le jour breast reduction) which leaves a scar around the areola and one going down from the areola to the chest wall, and the inferior pedicle technique (which leaves an additional scar close to the crease under the breast). Which of these is suitable is discussed at the initial consultation.
In order to optimise the result and minimize the risks a number of factors should be considered. Smoking significantly increases the risk of wound infections and breakdown as well as vascularity problems with the nipple. It is therefore advised that patients should refrain from smoking for ideally four weeks prior to, and four weeks following surgery. Patients should also avoid Aspirin and equivalent anti-inflammatory agents for two weeks prior to surgery as these can increase the risk of bleeding.
It is recommended that patients on the combined oral contraceptive (not HRT) should stop taking the pill for four weeks prior to surgery, as it is associated with an increased risk of deep vein thrombosis (DVT). During this period alternative forms of contraception should be used. Patients who are overweight also have a higher risk of complications. If patients are dieting they should aim to get close to their desired weight pre-operatively not only to reduce the risk of complications but also because significant weight loss following surgery may have an undesirable impact on the aesthetic result.
All patients are screened before surgery as described below.
At the initial consultation with Mr. Sarakbi and after discussing the specific concerns, a full medical and surgical history will be obtained. Details regarding the operation, the aims, the limitations, the recovery and the risks will be discussed. Before the operation you will usually attend a pre-operative nurse led assessment. You may require a blood test. Any significant health problems not previously identified may be discussed with Mr. Sarakbi or the anaesthetist, and a further assessment may be required to determine suitability for the procedure.
On admission you will again be assessed by the nurses and you will be measured for a pair of compression stockings. These are worn to reduce the risk of thrombosis formation (clots in the legs or DVT) and should be worn for a minimum two weeks post-operatively. You will be seen by the anaesthetist prior to surgery and be able to discuss issues pertaining to the anaesthetic and also pain relief in the immediate post-operative period. You will also see Mr. Sarakbi who will make some pre-operative markings and will take photographs for the medical records.
Breast reduction surgery takes between 2-2.5 hours and is undertaken under general anaesthetic. Before starting the operation when the patient is asleep the breasts are infiltrated with a dilute solution of local anaesthetic and adrenalin, not only to provide postoperative pain relief but also to reduce bleeding. At operation skin is removed as well as breast tissue. The nipple is elevated to a more ideal position. The locations of the incisions will have been discussed and marked preoperatively. In some patients liposuction is also undertaken especially to the armpit region to reduce any bulging. The wounds are all sutured with self-dissolving stitches and dressings applied. Drains are inserted into each breast. The tissue that is removed is routinely sent for histological analysis.
On return to the ward patients will have an intravenous drip to provide fluids for the 24 hours following surgery. Drains are placed into each breast to allow any oozing or bleeding to accumulate into either a small bottle or bag by the side of the bed. These are usually removed at 48 hours prior to discharge. If any pain or discomfort is experienced following surgery, painkillers are given either by injection or as tablets. Pain is not a significant feature in breast reduction surgery. The patients will note dressings over all of the wounds with small windows over the nipples allowing these to be inspected on the night following surgery.
Your length of stay in hospital is variable and depends on many factors but is usually 2 days. Following the breast reduction procedure dressings are applied in the operating theatre as follows: butterfly tapes are applied directly to the wound and then an absorbent dressing is placed over this. These dressings are usually left intact for five days following surgery unless they become messy, in which case they are changed prior to discharge. Patients are invited to re-attend 5-7 days post discharge for a wound check by the nursing staff and a change of dressings. Dressings are then required twice a week for a total of about two to three weeks following surgery. The tapes that are applied directly to the wound should be left longer if possible. From two to four weeks postoperatively (once the tapes have dropped off) the wound should be massaged once or twice a day with Vitamin E containing cream or lotion.
The wound should be kept dry for approximately ten days following surgery and during this period of time patients are advised to wash with a flannel. After this ten day period the patients can get the wound wet provided there are no significant wound problems. Prolonged soaking in a bath should be avoided for three weeks postoperatively.
The breasts will feel tight and firm for two to three weeks and then gradually soften. Some bruising may occur especially if liposuction has been undertaken. Some lumpiness within the breast is common, most will soften with time but the breasts will have a new pattern of lumpiness that should be learnt for breast self-examination purposes. Some numbness around the breast is inevitable and will gradually resolve over many months. Nipple sensation may be altered either down or up – this may be permanent. Hypersensitivity of the nipple may on occasions occur. If this does happen the nipple/areola complex should be massaged and desensitised by gentle tapping.
At discharge a letter will normally be sent from the ward to your General Practitioner informing them of your admission and of the procedure undertaken. Patients are encouraged to keep their GPs informed however should they wish the admission to remain confidential please inform the ward staff and no communications will be sent.
Initially the breasts will not look correct. The mound of the breast will be too high and rounded, and the lower half of the breast will seem flattened and will appear to be squeezing the breast. Some bulging into the armpit is also very common, and the breast may have a boxy appearance. With short scar techniques there may be some wrinkling of the skin under the breast. All of this is normal. Over the first few weeks following surgery the up-down scar under the breast will stretch and the breasts will start to assume a more natural shape. However it will take up to six to nine months to fully normalise. natural shape. However it will take up to six to nine months to fully normalise.
A support or sports bra that gives firm all round support should be worn as much as possible day and night for six weeks following surgery. After this period normal bras including underwired varieties can be worn. It is probably prudent however to wait for a total of three months before assessing the new bra size and getting a new wardrobe. If undertaking vigorous sporting activities a sports bra is advised.
The scars will inevitably go red, become lumpy and may widen. After two to four weeks when healed, massaging two times a day with Vitamin E containing ointment is advised. This should be continued for at least 2 months following surgery, and longer if the scars are not settling. Full scar maturation may take 6 – 24 months. Ultimately the scars will become pale and flat, however if this process is delayed other treatments including silicone therapy, steroid injections and laser treatment may be required. In rare cases a scar revisional procedure may be beneficial, though this will set the clock back in terms of scar maturation.
For the first one to two weeks following surgery patients should rest and convalesce. They should refrain from driving or from undertaking any light housework. After this period light housework and gentle activities can be undertaken, gradually building up to normal over a six to eight week period. Gentle gym activities and jogging can be resumed at 3-4 weeks however heavy lifting or any vigorous sporting activities (aerobics, tennis, and badminton) should be avoided for two to three months following surgery. Most patients refrain from work for 1-2 weeks, however in those with physical jobs or whom recovery is delayed an additional 1-2 weeks may be required.
Sexual activities can resume when patients feel comfortable but usually no earlier than two weeks following surgery.
Despite the extent of the surgery breast reductions are not usually associated with much pain. However regular pain relief is advised for the minimum of at least one week following surgery (usually a combination of anti-inflammatory medication and Paracetamol or Paracetamol / Codeine mixes). These should be prescribed prior to discharge from the hospital. Following the initial week pain relief should be taken as required.
After discharge patients require a wound check usually 3-5 days post discharge. This can either be by the nursing staff in the outpatients where the surgery was undertaken or by the General Practitioner (their agreement would need to be sought). Dressings are then required for two to three weeks postoperatively. Appointments for the initial dressing change are made prior to discharge. You will also be reviewed by Mr Sarakbi at one and six months postoperatively. These appointments will be sent in the post.
Initially many patients find it too uncomfortable to sleep on their side or on their front. This discomfort will settle after two to three weeks. Patients who sleep on their front may experience difficulty as a result of the presence of their new breasts though lying on them after two or three weeks will not cause any problem.
For the first week following surgery patients are advised not to drive as not only will the safety belt potentially put undue pressure on the breasts but also because patients will not be able to react properly in the event of an emergency stop. Most patients take one to two weeks off work although some patients return after a shorter period of time. Some patients where work involves a lot of manual activities including heavy lifting may require a longer period of time off. Advice regarding this will be given at the initial consultation. For patients with children, especially young babies or toddlers, help will be required in the initial two weeks following surgery.
Sporting activities including gym work, tennis and badminton should be avoided for between four and six weeks following surgery and any vigorous sporting activities where contact is possible should be avoided for three months. There are no specific restrictions on sexual activities but the breasts should be handled with care for several weeks following surgery.
After discharge patients require a wound check usually 3-5 days post discharge. This can either be by the nursing staff in the outpatients where the surgery was undertaken or by the General Practitioner (their agreement would need to be sought). Dressings are then required for two to three weeks postoperatively. Appointments for the initial dressing change are made prior to discharge. You will also be reviewed by Mr Sarakbi at one and six months postoperatively. These appointments will be sent in the post.
In all cases the tissue that has been removed will be sent for routine histological examination. The results usually come back within a fortnight and patients receive a letter confirming the results. Very rarely something untoward is detected and patients will be recalled back for urgent review. If a cancer is detected it is highly likely that the treatment that will be required will involve a mastectomy as it is impossible to locate the exact site of the tumour within the breast. Obviously on the positive side the cancer will have been picked up at an early stage. Patients over the age of 45 who have not had a mammogram within a year of surgery should consider whether it would be appropriate to have one pre-operatively.
The scarring in the breast may be visible on routine mammography but will not affect the interpretation of the investigation. Breast cancers are not triggered by surgery to the breast and there is good evidence to show that rates of breast cancer are actually reduced following breast reduction almost certainly a result in the reduction of breast tissue.
What are the risks?
In the first few hours on returning to the ward bleeding may occur and this can accumulate resulting in a haematoma. The breast swells massively and patients need to return to the operating theatre for evacuation of the haematoma. This occurs in about 1:100 cases. There are usually no long-term side effects.
Sensory disturbance to the breast skin and nipple are described above. Some pain and discomfort will occur but usually resolves after a week or two. Some patients do experience a mastitis-like pain for a longer period and occasionally a course of medication is required. Some patients develop painful lumps in the breast. These are usually due to small areas of fat necrosis, and they will usually settle down over 2-3 months.
The commonest complication is wound infection. Occasionally antibiotics are required and dressing may be required for a longer period. In severe infections wounds can breakdown, usually at the bottom of the up/down scar at the T-junction. This is a relatively unusual complication in non-smokers, and patients of normal body weight. Patients who do smoke should refrain for 4 weeks before and at least 4 weeks after surgery. Usually the wounds will heal with simple dressings alone, though occasionally secondary surgery may be required.
In very severe infections the tissues can be damaged and skin loss can occur. Secondary surgery will almost certainly be required; very rarely this involves the use of skin grafts.
All attempts are made to make the breasts the same in terms of size, shape and nipple position however small differences are almost inevitable. If marked then revisional surgery may be required though this is usually deferred for several months as some differences may reduce as all the swelling settles.
The most serious complication following breast reduction surgery is nipple loss. Fortunately this is extremely rare. Should this occur the nipple and areola dies and a scab is formed which will eventually heal up leaving a scarred area. A new nipple can be reconstructed at a later date however these are poor imitations.
Following any surgery there is a risk in developing a deep vein thrombosis (DVT). This is a clot in the calf vein of the leg. In itself it may result in pain and swelling. The risk is that should the clot separate from the vein it can move to the lungs resulting in a pulmonary embolism. This is a potentially life threatening situation. All attempts are made to reduce the risk using compression stockings during and for two weeks after surgery, using pneumatic compression devices on the legs at surgery and in the immediate post-operative period, by encouraging early mobilisation, advising patients to stop the combined oral contraceptive pill four weeks prior to surgery and where it is felt appropriate using injections of blood thinning agents.
When complications do occur all attempts are made not only to remedy the problem in as speedy a manner as possible but also to optimise the final result. As with all cosmetic surgical procedures undertaken by Mr Sarakbi, there is a fixed fee policy which means that no further surgical charges are incurred for complications that occur within one year following the initial surgery. There may however (depending on the local hospital policy), be a charge for the hospital and the anaesthetist for repeat procedures occurring over 30 days from the original operation.
Should there be any concerns then the patient should seek advice. The contact numbers are provided below.
Most patients are delighted with the result of surgery and breast reductions are associated with very high rates of patient satisfaction. In many cases the operation is not simply a cosmetic procedure. Patients frequently experience functional benefits as a consequence of the reduction in the heaviness of the breasts. These include improvement of neck, shoulder and backache as well as a loss of the dragging sensation and chaffing in the crease under the breast.
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