Information for Patients Undergoing Breast Reduction

 

Breast reduction surgery is becoming more common as women realise that they do not have to put up with having breasts which they perceive as overly large for whatever reason.

However, it is important to point out that breast reduction does not prevent breast pain or eradicate it once it exists. Also, breast reduction does not always rectify painful shoulders or an arched back although it can improve it.

Why do women request breast reduction?

  1. Breasts considered too large/heavy. Unable to carry out normal activities like sport or even work without discomfort.
  2. The large breast size means that women are unable to find clothes that fit well, especially bras, without excessive expense.
  3. The woman considers her large breasts cosmetically unattractive affecting body image and self esteem.
  4. The heavy breasts are causing the shoulders to drop leading to a stooping posture, back pain & painful marks from bra straps.
  5. Red marks and skin infections under the breasts (intertrigo)
  6. One breast is a different size leading to cosmetic and practical problems.
  7. Because they just want smaller breasts.

 

What breast reduction will not prevent?

  1. Breast pain –breast tissue is responsive to hormonal changes, and after breast reduction, there is still plenty of breast tissue.
  2. Breast cancer – whilst there is some evidence that reducing breast size may decrease the risk of breast cancer it should be remembered that all women have at least a 1 in 8 life time risk of breast cancer regardless of the size of their breasts.
  3. An aching back or stooping shoulders. Unfortunately, once the back has taken a different shape and the shoulders have dropped, although the breast reduction will be more comfortable, it will not always rectify the previous posture. Physiotherapy might help.

What are the alternatives?

  1. Get a professional fitted bra and accept your current shape and size.
  2. Reduce your body weight until your body mass index is normal.
  3. See a physiotherapist and concentrate on correcting your posture.

How do I get referred for breast reduction?

Private patients may self- refer by contacting Mr Turton’s secretary directly. Breast reduction is usually bilateral (both sides) but in some situations may be unilateral (one side). So any woman with very large breasts or unevenness may be a suitable candidate. We realise that breast size is relative and there is always an element of subjective body image perception. We therefore strive to achieve what you want rather than any preconceived idea of perfection or an exact cup-size. Please get a GP referral if you are able as they enables a summary of your medical history to be included.

Preoperative Assessment

You can review photographs of examples of breast reduction (before and afters) performed by Mr Turton in advance of your consultation. Mr Turton will make a detailed assessment of your breasts at the consultation. This There are several different methods of performing a breast reduction. The commonest method results in an upside down “T” type scar with a circular scar around the nipple. Other methods may involve just a scar around the nipple if these are appropriate, although the reduction is limited and much less reshaping possible. Your surgeon will discuss which method is suitable for you and the possible advantages/disadvantages. Mr Turton is a specialist breast surgeon and will use an optimal technique that enables a pathologist to examine your tissue (if this has been agreed). This will provide much more useful information if an abnormality is found as to where it was, and if it is clear of the margins, than lumps of breast tissue being simply removed.

If you wish you may also discuss breast surgery with our breast care nurse. You will have the opportunity to fully discuss the operation, its effects and the recovery and decide if you really want the operation.

After examination of your breasts a preoperative mammogram may be advised depending on your age and other risk factors that your surgeon will discuss with you. A private mammogram usually costs approximately £150. It should be considered if you are over 40 and have not had one in the preceding 12-months. Please discuss this with Mr Turton or see if your GP will refer you for one on the NHS before you have your appointment.

Mr Turton will discuss with you the amount of breast tissue that should be removed and an estimated reduction in bra size. It is not possible to guarantee the final cup size as we cannot measure this during surgery and it is very variable when you go for subsequent bra fittings (there is no universal bra size technique that all bra manufacturers use, and comfort varies from one bra to another). But it is important to clarify whether you wish predominantly for the breast to be re-shaped with the nipple raised with little reduction in size (this is more alongs the line of an uplift or mastopexy) or whether you wish a significant reduction with the removal of a large amount of tissue. Breast tissue can be sent to the pathologist after it is removed and some private hospitals charge approximately £150 for this. You have to request that this is done otherwise the tissue will be discarded permanently. One reason to consider it’s analysis is that even with a normal mammogram abnormalities may be found (pre-cancerous of even cancerous) on pathological examination of tissue under a microscope, which could influence further treatment without which your prognosis may alter. However, the chance of finding such an abnormality in most people is less than 1 in 400. Furthermore, the very tiniest of abnormalities may not always even be picked up under a microscope! Please discuss this with your surgeon. It should at least be considered in all women over 40, or any with a family history of breast cancer.

Following the initial consultation you will be given at least a 2 week “cooling off” period during which time you can make a final decision.

 

Smoking

It is imperative that you completely stop smoking within 6-weeks of the surgery and for at least 6-weeks after surgery. If you cannot do this you should not undergo the operation. Most patients are 100% successful with this, and some use nicotine patches initially to help. Mr Turton will discuss this with any patient that does smoke and please always be 100% honest. The blood supply to healing tissues through the tiny capillary network at the skin edge of incisions is reduced in smokers (or when using nicotine products or vape) and severely reduced whilst smoking (even passive inhalation) and for many hours after a single inhalation. This would cause necrosis (death of tissue) at vulnerable sites in the operated breast. The nipple and areola are also much more vulnerable as the blood supply to them is being reduced during the operation, and any additional insult such as constriction of the capillary network from smoking or nicotine can de catastrophic. The result can include delayed healing, serious infection, loss of breast tissue, loss of the entire nipple and areola complex needing major revisional or reconstructive surgery, but without good result. Although these drastic complications are rare and although they can occur in non-smokers they are more common in smokers. Do not undergo this surgery if you smoke or use nicotine. Give up first and then you will have placed yourself in a better position to have an excellent outcome. Please discuss this with Mr Turton if there are any aspects that you do not understand.

 

Sunbed use

Regular use of sunbeds or regular sunbathing damages skin. It becomes more vulnerable to healing complications. In particular, if you smoke and use sunbeds regularly the risk of delayed healing or wound separation increase. It is, therefore, important not to use a sunbed in the preoperative period. Please also inform Mr Turton of previous regular sunbed usage. Scars should be covered with sunblock in the future as they can become permanently red otherwise.

 

Medication

Mr Turton prefers that you tell him about all medication, herbal preparations or supplements that you take. He will normally ask that you avoid the vitamin and herbal supplements in the weeks before surgery and any non-essential medication. In the two weeks before surgery, if you have a headache (or hangover) or period pain, then you should have Paracetamol and avoid anti-inflammatories such as Brufen or Aspirin. These recommendations help to risk unnecessary oozing after surgery, output from the drains, and also lowers the risk of a return to theatre in the first 24-hours to evacuate a haematoma.

 

Preoperative Management

You will be admitted to one of the surgical wards. You will be seen by Mr Turton before the operation and a final check of any pre-operative tests or questions will be made. Pre-operative tests can include a blood test, a chest X-Ray, a tracing of your heart beat and a general medical history. A Consultant anaesthetist will visit you and talk about putting you to sleep for the operation. You will be kept Nil By Mouth (nothing to eat or drink at all) for 6-hours prior to surgery. On the morning of the operation, you may still take a bath or shower. Prior to surgery, you will put on an operation gown and the nurse looking after you will complete a routine checklist. She will also give you an elasticated Tubigrip to wear around your waist- this is pulled up over the breasts after the operation. Please ensure you are given this before coming down to theatre!

Mr Turton will see you to obtain your signature for consent and to “mark up” the breasts with the measurements for the reduction. A photograph is normally taken once the measurements have been marked (this excludes your face to protect your anonymity).

Antibiotics are given during the procedure so it is important to highlight any allergies.

 

Post Operative

Please review the FAQs section on this website. You will have an infusion (drip) in your hand until you are able to eat and drink. There may be two drainage tubes, one in each breast if you have had bilateral (both sides) breast reduction, and one if unilateral (one side) reduction and these are normally in place overnight but sometimes need to stay in for longer. Women can expect to return home the day after surgery, once they are mobile and self-caring. It is recommended that you wear the elasticated support dressing (Tubigrip) day and night for support and comfort. Mr Turton prefers that it is not removed for washing- please take a shallow bath with the water just run up to your lower waist, sponge wash under your arms, and ask someone else to help with hair washing- this is for the first 2-weeks after surgery- it keeps your dressings dry, and removes the need for these to be changed, reduces infection and minimises discomfort.

You are encouraged to move your arms as soon as possible to prevent stiffness, but keep your elbows in and avoid raising your arms above shoulder height. Avoid lifting anything heavier than a kettle for the first 2-weeks. Avoid opening or closing heavy doors. Avoid using a pull-type cork screw or grating cheese! A sudden haematoma can occur in rare circumstances if you do too much after discharge.

The wounds are covered by steristrips and on top of these are the dressings. The dressing is designed to absorb small amounts of exudate and blood. Do not be alarmed if you see blood spots on the dressing! It does not mean you are bleeding! The old blood that can collect there is usually a tiny volume that hasn’t come out of the drains and it can seep out in tiny quantities and look worrying! It will remain sterile as long as the dressings are in place. The dressing should feel dry and are is removed if obviously wet. This is very uncommon.

The dressings stay in place for around seven to ten days unless there is a problem. They are then changed.

 

Complications / Side Effects

Breast reduction surgery involves a general anaesthetic and takes several hours. General risks of any operation include both chest infection (very rare) and thrombo-embolic problems (very rare- not occurred to any of Mr Turton’s cosmetic surgery patients)- clots in the legs that may even travel to the lungs= Pulmonary emboli, and whilst very rare, can prove fatal). If there is any family or past history of blood clots please inform Mr Turton. Steps are taken to reduce the risks even when they are already very low: these including the use of compression stockings, and flowtrons (automatic calf compression during anaesthesia) as well as becoming mobile again early after your operation. Smokers should make every effort to give up or not have the surgery.

Only very rarely would a blood transfusion ever be required, even if a haematoma (large deep collection of blood) occurs postoperatively. Sometimes it is necessary to return to theatre to remove a haematoma.

Nipple Sensation:

Nipple sensation can either be lost completely or there may be some small loss or indeed increased sensation. Permanent loss of sensation occurs in up to 50% of cases and a temporary loss in about 30% or cases- up to 12-months to improve.

Nipple Necrosis:

There is also a small possibility that the nipple may lose its blood supply and become necrotic (the skin may become non-viable and heal by scarring with loss of pigmentation) or you may even lose the nipple-areola complex in extreme cases. Fortunately, this very rare. Smokers must completely abstain for 6-weeks after surgery (no passive inhalation either) and avoid use of nicotine supplements for 2-weeks after surgery.

Skin Necrosis:

Occasionally the blood supply to the skin on the flaps used to reconstruct the reduced breast is inadequate. This is significantly more common in smokers. The involved skin dies (becomes necrotic) and heals by scarring. The commonest place for this to occur is at the apex of the “T” incision so the resultant scarring remains hidden. However, it can be extensive. In this situation, the time to heal can be delayed by many weeks, and the dead skin may require surgical removal (very rare). Minor healing problems at the T-Junction are more common, but more easily managed, and again causes a delay before the dressing is removed for good.

Infection:

Infection is another possibility despite the routine administration of antibiotics and meticulous wound care during and after the procedure. It is usually caused by the patients own natural skin bacteria infecting the healing wound. Any signs of spreading redness, heat, mucky discharge or a raised temperature need to be reported to your Consultant, through the ward from which you were discharged, or other members of your Consultant’s team. If possible an earlier appointment to the breast clinic can be made, or a visit to the ward arranged. If there are any areas that are slow to heal, you may be given a course of antibiotics. Very very rare serious infections causing tissue necrosis are occasionally reported in the literature (necrotizing fasciitis) and are more common in diabetics.

Scarring:

If you do get an infection, the scars can become a little thicker and the eventual scars you are left with may not be as fine as you expected. Even without infection, some women develop thick unsightly scars due to a condition called “keloid and hypertrophic scarring.” If you have had problems with such scars before special dressings may be required to try to reduce it and you should discuss this with Mr Turton. The scars may also become quite broad with time. Hiding the scars under the breast, obviously. This helps but does not always solve the problem. Keeping scars supported with a strip of “mepore tape” for several months after surgery can help to prevent the scar from stretching – this will be discussed at the post-operative clinic review. At the ends of the horizontal scar where it meets your normal tissue there can be a slightly raised piece of skin which is termed a “dog-ear” -this is commonly apparent, and usually diminishes in part over the next year. It is caused by the residual excess tissue that has not been excised as the incisions have to stop short of the breast-bone area on the inside and the arm-pit area on the outside. Additional surgery can be performed at that time to flatten it further, usually under local anaesthetic although there is likely to be a charge for this. This is also rarely needed.

Redness to scars fades gradually in most patients over the course of 12-months. Additional scar treatment may be used after 3-months which speeds this process up. Avoid sunburn to your scars, otherwise, the redness may persist permanently.

Skin Sensation:

In addition to alteration in the nipple sensation it is normal for the breast skin sensation to change with areas of numbness or tingling. This is always the case on either side of a scar.

During the healing phase, it is common to have fleeting sharp sensations in the breasts for several months. This is the normal healing process.

Haematoma (Bruising):

Bruising may cause the breast to become a little discoloured and this may spread downwards on to the abdomen. The body will absorb this bruising over a few weeks but if you are worried please contact your surgeon. In some patients, an operation is required to drain a haematoma. This tends to occur suddenly in the first 24-hours after surgery when a little vessel that was previously sealed bleeds. It overwhelms the drain and collects under the wound. It feels quite painful suddenly and the breast swelling is really very obvious. The nursing staff are trained to recognise this. The surgeon will normally drain this out with you back under anaesthetic, soon after it is recognised. Avoiding aspirin and anti-inflammatories prior to surgery helps to prevent this, as does a good normal healthy blood pressure. However, this is one of the more common complications (approximately 5% risk) that can occur despite all precautions, and as long as it is appropriately dealt with causes absolutely no detrimental effect.

Fat necrosis:

Fat necrosis is a condition that can occur when breast tissue is remodelled in a breast reduction or mastopexy. It results in a small hard lump within an area of the breast that sometimes causes anxiety to a patient. The condition is benign and does not carry any risk. However, all lumps should be investigated by a specialist regardless of whether a reduction has been performed or not.

 

Returning Home

Once discharged home, you can have shallow baths as discussed earlier. The stitches in your wound are under the skin surface and will dissolve slowly over many months. Mr Turton will let you know if there are any that need to be removed. The dressings are changed only when necessary, and in the early post operative stage, care is needed not to bang or knock the breasts. Mild pain killers will be required after your operation until you feel comfortable. An appointment will be made for you to come back to clinic in approximately 1-week for a dressing change, and again at approximately 2-weeks. Mr Turton will review you again a few months laster too. You can expect some bruising in both breasts if having bilateral reduction, but in the very unlikely event that a wound discharges any offensive smelling fluid, you need to be seen, assessed and to have a swab taken and to start antibiotics if needed. You can also expect your breast/breasts to be swollen. This will last approximately 6-8 weeks and, therefore, you will not always begin to see the total benefits of the reduction until such time- the final effect may take several months to become apparent. You can normally stop wearing the Tubigrip from 2-weeks and then you can buy a sports bra. This should be worn for at least a further 3-4weeks. Please watch your diet whilst not exercising as usual, to avoid excess weight gain. If you gain weight your breasts will get bigger!

 

Follow Up

Mr Turton advises patients to ask for the annual follow-up if they are worried about something. A routine breast check-up may be given. Beyond the first post-operative consultation, follow-up visits are always charged at the standard rate. Annual or bi-annual mammography can also be offered where appropriate as part of the follow-up with costs in addition to the consultation fee payable to the hospital. Long term follow up is not normally required.

 

Note: This information is for general guidance only and represents the views and opinions of Mr Turton, Consultant Breast Surgeon. It should in no way be regarded as either definitive or representing the views of any other institution.