- Breast Reduction
- Breast Reconstruction
- Mastopexy (Breast Lift)
- Breast Augmentation
Breast reduction surgery is performed in the operating room in a surgicenter or hospital. I usually meet you one or more days before surgery to perform markings; these markings are critical. When you shower, be careful not to scrub so hard that the markings come off, because they are important for the surgery. The marker that is used usually stays on the skin for multiple days and resists soap and water. The night before surgery, make sure not to eat or drink anything after midnight. Finally, please make sure to have absolutely no exposure to tobacco, marijuana, or any other substance (such as hookah, nicotine patch, and so forth) for at least one month before and after surgery.
Surgery usually lasts four to five hours. Patients go home the day of surgery, and you need a responsible adult to take you home and then stay with you for at least 24 hours.
There is a detailed instruction sheet that you will receive from the office; this instruction sheet is sent to you at the time of scheduling surgery and is the only source of information that you should follow. Sometimes the facility will give you instructions that vary from this instruction sheet; please follow the instruction sheet from my office. Essentially, you can shower the day after surgery, and there are drains on each side that are emptied twice a day; the drain is removed about one week after surgery. For pain control, use acetaminophen and ibuprofen around the clock, and there is a pain medicine that is prescribed but should only be used for breakthrough pain (it should not be used regularly, but only if needed). Starting the day after surgery, you can shower and do gentle activities and walking. Driving can resume once there has been no narcotics taken for 24 hours.
I place steristrips (white tapes) on the incisions, and the longer these tapes remain, the better the quality of the scars. They accumulate moisture and might become irritated. They can be removed at any time, but I prefer them to stay on for at least four weeks, and they are the best way to improve the quality of the final scar. If the tapes begin to fray, you can trim it at those sites. Once the tapes come off, I recommend cocoa butter or shea butter on the scars, applied daily for three months. Please do not reapply tapes to the skin. There are a number of products on the market for scar care and you can use them, but I have not found them to be better than cocoa butter or shea butter. The single biggest factor in the quality of the scars is the time that the initial tapes remain on the skin.
It is common for fluid to egress from the wounds and small areas, particularly where incisions meet, to have some separation in the superficial layers of the skin; these areas are often sutured loosely by intention. Fluid egress and mild areas of skin separation are usually of no concern and heal on their own over the first six to eight weeks.
Drains are placed at the time of surgery as they reduce swelling and help the breasts recover more rapidly. Once they are removed, about a week after surgery, the tissue still produces fluid. The body will absorb much of this fluid. There are areas in the suturing that are left slightly loose so that any excess fluid can egress rather than stay trapped. Therefore, it is very common for fluid to come out of the incisions, usually in the weeks following drain removal. This fluid is usually clear or red-tinted, and often has white fibrin protein in it. It is better if the fluid comes out, and gauze on top of the tapes changed once or twice a day as needed can help absorb any fluid egress. After a few weeks, the body can absorb all of the fluid that is produced, and any egress stops. I find this approach more effective than leaving the drains in for a prolonged period beyond one week.
Patients are often concerned about infection and bleeding. Fortunately, infection is extremely rare in this operation, and occurs only if there is tissue with poor blood supply. A lot of the fluid that egresses have a white tinge to it (protein); however actual pus is incredibly rare in this operation. Similarly, while bleeding can occur, it is quite rare, and more commonly there is fluid production that is red-tinged, and that can egress from some of the areas that are sutured loosely. It does take about two months for all of these fluid shifts to resolve and the breasts to soften.
The result after surgery becomes apparent after a few weeks, and the appearance matures over time. Within two to three months most of the changes will be achieved; the final appearance of the scars and contour takes longer to completely mature. The scars reach their final appearance at about one year, as do the corners and edges of the scars which are often the last areas to mature to their final appearance.
Breast reduction is one of the most common procedures performed by plastic surgeons, and I perform many these operations each year. They tend to have a high satisfaction rate as patients feel markedly better following the operation. A breast reduction can be performed as a medical (reconstructive) or as a cosmetic (aesthetic) operation; while the medical and cosmetic operations are similar, the primary endpoints differ. While there are cosmetic overtones, the goal of a medical breast reduction is to improve symptoms (back and neck pain). Similarly, while cosmetic breast reduction patients often feel better, the main goal in a cosmetic procedure is to look better.
Most of my breast reduction patients suffer from four main problems: their back aches, their neck hurts, they have deep grooves in their shoulders from bra straps, and they have moisture and often an outright rash under their breasts. The excessively large breasts attach to the shoulders and neck by a deep thick tissue (fascia), and this thick, soft tissue circles and connects around the back of the neck. The heavier the breasts, the more this thick fascial sling pulls the base of the neck, and the more the person must arch to resist the excess pull. Over time, these stresses create severe and progressive neck and back changes. Many patients have been to back doctors and chiropractors, have needed prescription-strength pain medication, and use support or sports bras to try to reduce their symptoms.
In a patient who is suffering, a breast reduction can markedly if not completely resolve these symptoms. In a breast reduction, a certain amount of breast tissue is removed from each side and then the breast is put back together. The nipple areolar complex is often too low in these patients, and when putting the breast back together, the nipple areolar complex is brought up to a more appropriate location. Finally, many patients with large breasts have breasts that are too wide, and I often narrow the breast to make it more proportionate.
There are several techniques that can be used for breast reductions, and these techniques can be divided into those of the skin and those of the breast tissue (parenchyma) itself, and during surgery a technique for the skin is selected and a technique for the breast tissue is selected.
For the skin, the most common excision technique is the Wise pattern, which is what I favor. Essentially, the nipple areolar complex is raised higher, and skin is removed in vertical and horizontal dimensions; these maneuvers result in three scars: a circular scar around the areola, a vertical scar from the bottom of the areola to the bottom of the breast, and a horizontal scar along the inframammary fold and often continuing to the side. There are variants that reduce the scar pattern, but these do so at the cost of worsened contour. I am not impressed with these alternate techniques and find the Wise pattern scar to give the most attractive shape.
The internal breast tissue in a breast reduction can be reduced using different techniques. The most common and oldest technique uses the inferior pedicle; pedicle refers to the breast tissue that provides blood supply to the nipple areolar complex when it is moved. Another technique is the central mound technique, and a third technique uses the superomedial pedicle (with variants of superior or medial pedicle). My favored technique is the superomedial pedicle. While this technique can be more difficult to perform and takes longer to complete, it often results in a more attractive contour that has a more durable shape. The only exception is if a patient had a previous breast reduction, the same technique must be performed on a revision as they had in their initial operation, so if I operate on a patient who previously had an inferior pedicle breast reduction by another plastic surgeon, in my revision I would use the inferior pedicle. Beside that circumstance, I use the superomedial pedicle and find it to give optimal results.
Tissue expander reconstruction:
Most patients go home the day of surgery or the following morning. There is some tenderness, but the pain protocol usually can keep the pain very well-controlled and most women are able to have a light level of functioning the next day. There are drains that are placed to reduce discomfort and risk; these are emptied twice a day and are usually removed in one to two weeks. Within one week, the patient can slowly start increasing activity levels, which usually improves each subsequent week. Full recovery is often achieved within six weeks.
When a tissue expander is exchanged to a permanent implant, the patient goes home from surgery the same day, and recovery is usually quite rapid. Drains are occasionally used, but only if there is more significant work performed in the breast (such as adjusting the pocket). Activity can be increased within a few days and recovery usually is achieved in one to two weeks.
DIEP flap reconstruction:
This operation is more extensive than other breast reconstruction procedures. Most patients are in the hospital for two to four days, and recovery lasts about six weeks. There are drains in the breast and the abdominal wall that are emptied two to three times a day. Most of the tenderness following the DIEP flap is in the abdominal wall. The pain management protocol is effective in greatly reducing discomfort, but there is tenderness and weakness in the abdominal wall. Recovery can take from six to eight weeks and does vary considerably from one person to another. Walking and gentle activities are highly encouraged and can be slowly increased with each subsequent week.
Breast cancer is treated with one of two types of surgery: lumpectomy (also called partial mastectomy) or mastectomy. Most women who have lumpectomy do not need reconstruction; in contrast a mastectomy removes the entire breast and reconstruction should be offered to all women who have a mastectomy (although not all women elect to have reconstruction).
Breast reconstruction is best viewed as a series of operations, as it is very common that it entails multiple procedures to achieve the optimal result. Most reconstruction begins at the time of the mastectomy, although it can be performed any time afterwards.
There are two main categories of reconstruction: implant-based and autologous. In implant-based reconstruction, a temporary or permanent implant is placed into the breast. In autologous reconstruction, a woman’s own tissue is used to rebuild the breast.
The most common reconstruction in the United States today is implant-based reconstruction. Most frequently, at the time of mastectomy, a temporary implant called a “tissue expander” is placed in the breast, and the woman goes home the day of or the following day. This tissue expander is deflated to minimize tension on the breast skin—it keeps pressure to a minimum, reducing discomfort and the risk of healing problems. Following several weeks, this tissue expander is made larger using a port in the device; slowly expanding the expander allows the breast to enlarge with minimal discomfort and risk. After several months, this tissue expander is removed, and a permanent implant (or the body’s own tissue) is placed into the breast for a final reconstruction.
Using a woman’s own tissue is increasingly common approach to reconstruction. The historical origin of this approach is that in the early days of breast reconstruction, women who had radiation therapy were believed to not be able to have implant-based reconstruction, so techniques to use her own tissue were developed. Since then, we have developed strategies to be able to use implants in women who have radiation therapy, and similarly many women who do not need radiation therapy use their own tissue. There are multiple anatomic areas that can be used to rebuild the breast, but the most common uses the lower abdominal wall in an operation termed the deep inferior epigastric artery, or DIEP, flap. This operation removes skin and fat to rebuild the breast; the tissue is placed in the breast and the supplying vessels connected to those in the chest using microsurgery. It is an extremely attractive option to rebuild the breast for many women.
This surgery is performed in an operating room under general anesthesia. You will go home after surgery and need a responsible adult to drive you home and stay with you for the first 24 hours. On the day of the procedure, wear loose-fitting clothing, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. Make sure you have absolutely no exposure to tobacco, marijuana, or any products (hookah, nicotine gum, or any other agents) for at least 30 days before and after surgery. Please keep in mind that second-hand exposure can be just as damaging as direct use of these products, so please avoid any exposure at all for at least 30 days before and after the procedure. Exposure to any of these products can be particularly damaging in this operation and can lead to problems with tissue survival and wound healing.
After surgery, you will be in a bra, and there will be tapes on the incision site. The day after surgery, remove the bra and shower. Try to keep the tapes on for as long as possible. You can place the same bra back on, or wear another bra, but it is helpful to have a bra on during the daytime and then at night if possible. A support or sports bra tends to work quite well during the recovery period.
The scars on these procedures tend to heal particularly well, but it can take about three to six months for them to improve. The tapes that are placed at the time of the procedure help the quality of the scars, and it is best if they can stay on for four to six weeks, although they can get macerated. If they start to fray, please trim them with a scissors.
The shape of the breasts, at first, is overcorrected. Because there is no horizontal (inframammary fold) incision, there is excess skin at the lower part of the breast that will contract over time. This contraction process usually takes about four months but can take up to six months. Both breasts will go through this process and arrive at the same final location, however it is common for the two breasts to have different timing—making them look asymmetric at specific time points. Once they have both fully settled, they usually look remarkably similar, appropriate, and attractive.
In a mastopexy (breast lift), the location of the nipple areolar complex is raised upwards, and the breast is lifted with it, to a more appropriate position. The size of the breast remains approximately the same, although a small amount of skin and sometimes a small amount of breast tissue is resected. A mastopexy is ideal in a woman who likes the size (volume) of her breast, but just wants it lifted.
There are several techniques for a mastopexy but find that one technique works the best on most patients. The circumvertical mastopexy is a technique that removes some of the skin around the areola and below the areola, and results in a scar around the areola and a second going straight down. In addition to the nipple areolar complex being raised to a more appropriate position, the breast is narrowed, and these two maneuvers usually result in a significantly more pleasing appearance. While the nipple is raised significantly and the breast narrowed, at the time of surgery it is usually overcorrected, because there is some relaxation that invariable occurs. Once this relaxation occurs, the breast usually assumes a highly-pleasing, natural, attractive appearance.
One variation of this technique involves auto-augmentation, which I use in selected patients who want some more fullness in the upper part of the breast. In a standard mastopexy, some of the breast tissue below the areola is usually resected, and then the two edges sutured together, to tighten (narrow) the breast. In the auto augmentation procedure, this tissue which would be excised is kept attached to one part of the breast, and then tucked underneath the upper part of the breast, giving more fullness to the upper part. It is a variant that I find useful in patient who want slightly more upper pole fullness than they currently have.
This surgery is performed in an operating room under general anesthesia. You will go home after surgery and need a responsible adult to drive you home and stay with you for the first 24 hours. On the day of the procedure, wear loose-fitting clothing, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. Make sure you have absolutely no exposure to tobacco, marijuana, or any products (hookah, nicotine gum, or any other agents) for at least 30 days before and after surgery. Please keep in mind that second-hand exposure can be just as damaging as direct use of these products, so please avoid any exposure at all for at least 30 days before and after the procedure.
You will be in a bra, and there will be tapes on the incision site. The day after surgery, remove the bra and shower. Try to keep the tapes on for as long as possible. You can place the same bra back on, or wear another bra, but it is helpful to have a bra on during the daytime.
The implants will rise on the chest wall and then come back down; they usually do not go up and down at the same rate, so that occasionally one might seem higher than the other. Eventually they both settle at the same position. Similarly, as the implants rise and fall, the nipples will appear to point downwards and then back upwards. Please give at least three months, and sometimes up to six months, for the migration to resolve.
During the postoperative visits, the tapes and any external sutures will be removed. You can then use a scar gel on the incision site to optimize the quality of the scar. These scars usually heal extremely well. After about two to three weeks, massaging can begin, which is a single gentle massage of each breast, performed daily. This maneuver keeps the pocket supple.
Breast enlargement with implants is one of the most common procedures in plastic surgery and can be achieved with implants that contain either saline or silicone gel. The goal of the operation is to increase the volume of the breasts, and to increase the projection, or the degree to which the breasts project from the body. There are basically four decisions that have to be made, and these four decisions lead to selection of the details of the procedure and the implant used.
The first decision is the incision used to place the implant. There are four options: inframammary (in the crease on the bottom of the breast), periareolar (on the lower border between the areola and surrounding skin), umbilical (belly button), or transaxillary (armpit). The latter two—umbilical and transaxillary—became popular about two decades ago but have had limited use as precise placement of the implants can be compromised. The inframammary fold incision and periareolar incision both allow direct access to the pocket and precise dissection. While I find work both quite well, I have a slight preference for the inframammary fold incision as it sits in or near the actual crease, making it difficult to see, and the dissection goes underneath the breast, avoiding the need for dissection through actual breast tissue.
The second decision in breast augmentation is the placement of the implant, either subglandular (above the pectoralis major muscle) or subpectoral (under the pectoralis major muscle); most subpectoral placements are technically partial subpectoral, as the muscle does not go as far down as the lower part of the muscle. Except for patients with very thick muscle (such as bodybuilders), my preference is subpectoral placement as it gives more protection for the implant, and more fullness in the upper part of the breast.
The third decision during breast augmentation is the implant size. Most implants are round, meaning the bottom is a circle, and from the side they appear as a dome. While there are shaped implants, these have become less common, and their use is increasingly limited; I use shaped implants occasionally but find that they have several significant limitations. In round implants, there are three dimensions (width, height, and projection) and volume. The width and height are the same as the bottom is a circle. My preferred approach to selecting the correct implant is to begin by accurately measuring the base width (BW) of the patient’s chest, on each the left and right sides. This provides the width of the “footprint” of the breast, where an implant would sit. Once the optimal width has been measured, two of the three dimensions are determined (width = height in a round implant). The next step is to determine the ideal volume. For volume, I like to use sizers which are soft plastic moulages of precise volumes (in ml or cc) that the patient can try on, ideally with a non-padded bra and tight shirts. I have the patient try on a variety of volumes until a particular volume is selected. Once the volume is selected, the precise dimensions of the desired implant can be selected. I find this approach to be structured and rational and allows the patient to control the volume of the implant.
The final decision before proceeding with surgery is selecting the implant type, saline or silicone. An enormous number of studies have been performed to research the safety of implants, and I encourage all patients to read as liberally as they wish the actual studies (rather than the interpretations that might be misleading). Fundamentally, both saline and silicone implants are available to the public and their use is controlled by the FDA. For silicone implants, the FDA has instructions on imaging surveillance following surgery that they update as necessary, and safety is the at the forefront of the FDA’s mission. I do not have a particular preference of using saline or silicone implants, I leave this decision up to each patient, and believe that each patient has their own preferences and concerns when making this decision.
These four decisions drive the selection of the preferred implant and size, incision placement, and location of the implant. The operation is performed in an operating room under general anesthesia. The operation takes approximately two hours, and the patient goes home the day of surgery. Recovery is usually approximately one week, although it can take several months for the tenderness to resolve and the implants to settle in their final location.