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.

Instructions before & after surgery:

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.

Breast Reduction