Information for Patients Undergoing Breast Reduction

Download the Information sheet for patients here: Breast Reduction Info-Mr Turton May 2019

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 to Breast Reduction?

1. Get a professionally 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.
4. Occasionally liposuction can reduce the breasts a little instead of surgery, but it only removes fat and not gland. It does not reshape.

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 that would usually include a summary of your medical history.

Out-Patient Clinic and the Preoperative Assessment for Breast Reduction Surgery

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.

Once you have confirmed that you would like to have a consultation, you will be booked to see Mr Turton in the out-patient clinic for the detailed consultation. We encourage you to bring a friend or family member with you to the consultation. Although this is not compulsory, most patients find this helpful. Your surgeon will ask you lots of questions about your reasons for wanting surgery, about any family history of breast cancer, any previous breast problems, about previous surgery, medication or other pills you may take and allergies. We also need to know about smoking, hobbies, work and whether you have had children or intend to have any more. Your current weight and height will be recorded and it is helpful to now if you are at your usual weight or intend to lose weight as this may affect results. If you have any past surgical history, and past medical problems at all, any hospital admissions, anything for which you are currently being treated for by your GP it is very important that it is fully disclosed. Please also disclose if you are on any treatment for anxiety or depression. This is not a barrier to having surgery but it is important that we are aware of it.

We make a detailed assessment of your breasts at the consultation. 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-areola structure. Other methods may involve just a circular scar around the nipple-areola structure with or without a vertical scar from the areola to the crease under the breast. The reduction may be more limited with less scope to remove redundant skin and less reshaping with some techniques- your surgeon will discuss which method is most suitable for you and the possible advantages/disadvantages.

If you would like the removed tissue to be analysed by a pathologist we recommend removing the tissue as a whole piece wherever possible and this will be discussed as well.  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.

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. It should be considered if you have a family history of breast cancer in first or second degree relatives. Please discuss this with your surgeon or see if your GP will refer you for one via the NHS before you have your appointment.

Mr Turton will discuss the approximate amount of breast tissue that should be removed and an estimated reduction in bra size might be given. 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 only a little reduction in size (this is more along the lines of an uplift or mastopexy), for a proportionate amount to be removed to better balance your breasts with your body shape, or whether you wish a significant reduction with the removal of a large amount of tissue that can make your breasts smaller for your frame. If the removed breast tissue is to be sent to the pathologist after it is removed, please be aware that some private hospitals charge approximately £250 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.  It is also possible that the very tiniest of abnormalities may not always even be picked up under a microscope. Some very early abnormalities that are discovered with histology testing might never progress to anything more sinister, and finding them might cause anxiety that you would otherwise not have had. On the other hand finding a lesion in this way, that is in-situ cancer or a small invasive cancer, also provides the opportunity for further screening, further surgery or other treatments which may reduce the risk of recurrence. There are therefore pros and cons to sending tissue. 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 and then return to ask further questions and consolidate your understanding.

Once you are ready to proceed with surgery and have confirmed an operation date, you will be booked for a pre-assessment and MRSA screen by the hospital.

 

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. Your surgeon will discuss this with any patient that does smoke and please always be 100% honest.

The blood supply to healing tissue through the tiny capillary network at the skin edge of incisions is reduced in smokers (or when using nicotine products or nicotine 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 be 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 a guarantee of a 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 your surgeon  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 dramatically. It is, therefore, important not to use a sunbed in the preoperative period for at least 6-weeks. Please also inform Mr Turton of any previous regular sunbed usage. Scars should be covered with sunblock in the future as they can become permanently red otherwise. It is not advisable to expose your scars to regular sunbed usage after surgery.

 

Medication

Mr Turton must be informed about all medication, herbal preparations or supplements that you take. He will normally ask that you avoid high dose vitamin or 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 it is preferable to take Paracetamol and avoid anti-inflammatories such as Naproxen, Brufen or Aspirin. These recommendations help to lower risk of 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.

Ensure you discuss any allergies that you have, even if you are uncertain.

 

Preoperative Management – before your Breast Reduction Surgery

You will be admitted to one of the surgical wards. You will be seen by your surgeon 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 (only occasionally required), a tracing of your heart beat (ECG) depending on your age, and a general medical history. A consultant anaesthetist will visit you and talk about the proposed anaesthetic for the operation. You will be instructed on fasting for your operation. This is called being “Nil By Mouth” and it means you are not allowed anything to eat or drink at all. Not eating or drinking any liquids other than water is usually required for the period  6-hours prior to surgery. We will instruct you as to drinking pure water, as we require at least 2-hours of no fluids AT ALL. If in any doubt, please always ask, otherwise it can lead to cancellation of surgery. On the morning of the operation, you may still take a bath or shower. Prior to surgery, you will be given an operation gown to wear, and disposable knickers. The nurse looking after you will complete a routine checklist. You will be fitted with compression stockings for your lower legs. 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!

Your surgeon will see you to obtain your signature for consent if this was not already done in clinic. He will “mark up” the breasts with the measurements for the reduction. With your consent, a photograph is normally taken once the measurements have been taken (this excludes your face to help protect your anonymity).

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

 

Post Operative Management – after your Breast Reduction Surgery

Please review the FAQs section on this website.

You will wake up in recovery. You will have an infusion (drip) running slowly through the venflon  in the back of your hand. This is usually discontinued once you are able to eat and drink and your blood pressure is completely normal. The venflon is removed prior to you going home. 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. Your surgeon prefers that it is not removed for washing- please take a shallow bath with the water no higher than your lower waist. Then you can 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 fine to move your arms to prevent stiffness, but it is better to 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 jerking movements such as 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 from the wound edge for the first day or two. It should not pool under the dressing making the dressing very damp and if that were the case please attend the ward for assessment. Otherwise, the dressing will remain in place and be changed after 1-2weeks.

 

Complications / Side Effects After Breast Reduction

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). This is where clots in the legs form (deep vein thrombosis or DVT) and these may even travel to the lungs (pulmonary emboli or PE), and whilst very rare, can prove fatal. If there is any family or past history of blood clots please inform your surgeon and the nurse. 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.

Haematoma (Bruising):

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 blood 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 having 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 no detrimental effect. Only very rarely would a blood transfusion ever be required.

Bruising may cause the breast skin to become a little discoloured and this may spread downwards on to the skin on your upper tummy area. The body will absorb this bruising over a few weeks but if you are worried that it seems more extensive or swollen please contact your surgeon.

Infection:

Infection is another possibility despite the routine administration of antibiotics, meticulous surgical techniques, and subsequent wound care after the procedure. It is usually caused by the patient’s own commensal skin bacteria infecting the healing wound. Any signs of spreading redness, heat, purulent discharge or a raised temperature need to be reported promptly to your Consultant, through the ward from which you were discharged, or other members of your Consultant’s team. If you do not need to be readmitted and it is more minor in extent, an earlier appointment to the breast clinic should be made, or a visit to the dressing clinic or ward. If there are any areas that are slow to heal, you may be given a course of antibiotics. Very rare serious infections causing tissue necrosis are occasionally reported in the literature (necrotizing fasciitis) and are more common in diabetics.

Nipple and Skin Sensation:

Nipple sensation can either be lost completely or there may be some small loss or indeed increased sensation. The same occurs with the skin of the breast where it is much more common to get areas of numbness. Permanent loss of sensation occurs in up to 50% of cases and a temporary loss in about 30% of cases. If there is some loss of sensation it may take over 12-months to improve. During the healing phase, it is common to have fleeting sharp sensations in the breasts for several months. This is part of the normal healing process. A mild dull ache can persist in the breast after reduction surgery, but it is uncommon.

 

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, turn purple then black, and heal by scarring with loss of pigmentation) or you may even lose the nipple-areola complex in extreme cases. This is a rare complication although if you have had previous breast surgery or previous radiotherapy to your breast (as part of breast cancer treatment for example) the risk is significantly higher. Smokers must completely abstain for 6-weeks before and 6-weeks after surgery (no passive inhalation either) and completely avoid use of nicotine supplements too.

 

Skin Necrosis:

Very occasionally the blood supply to an area of the skin flaps that are lifted during breast reduction surgery, can become inadequate early after surgery. This is significantly more common in smokers. The involved skin dies (becomes necrotic) and turns black. The tissue left behind heals by scarring. The site most at risk during recovery is at the apex of the “T” incision so the resultant scarring is not as obvious as if it were higher on the breast. However, it could be more 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. They still cause a delay before the dressing can be removed for good.

 

Scarring:

Scars go through different stages of maturation during wound healing and don’t fully mature until 1-2 years after surgery. Redness, lumpiness and thickening that is apparent initially fades and softens gradually, usually being less obvious at 3-6 months and fading by 12-months. Additional scar treatments may be used, which speeds this process up. Avoid sun exposure, UV light exposure and sunburn to your scars, otherwise the redness may persist permanently.

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 due to stretching. We may recommend that you keep the scars supported with a strip of “mepore tape” for several months after surgery to help 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 slight contour irregularity- this is commonly apparent, and usually diminishes 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 lateral chest or arm-pit area on the outside. Additional surgery can be performed if required to flatten it further, usually under local anaesthetic although there is likely to be a charge for this. This is also rarely needed.

 

Fat necrosis:

Fat necrosis is a hard area of dead fatty tissue. It can occur from breast reduction or uplift surgery and results in a hard area within the breast. It is not normally troublesome, but if large can be tender. Your surgeon would need to assess you if there was a lump and you would need to check for other causes of a breast lump. Sometimes a biopsy would be required to check the diagnosis.

It can cause anxiety to a patient, but 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 after Breast Reduction

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 usually over 3-6 months depending on the type that are used. Your surgeon 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. Your surgeon will review you again a few months later too.

 

You can expect some light bruising in both breasts after bilateral reduction, but in the very unlikely event that a wound discharges any offensive smelling fluid, you should always be seen promptly and to have a swab taken. Antibiotics are started if needed. You can also expect your breast/breasts to be a little 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 start to wear a sports bra. This should be worn for at least a further 3 to 4-weeks until you are comfortable. Please watch your diet whilst not exercising as much usual, to avoid excess weight gain. If you gain weight your breasts will get bigger!

 

Follow Up after Breast Reduction

Your surgeon advises patients to ask for annual follow-up only 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. Please attend any appointments for breast screening, but let them know when you had surgery.

 

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.