Breast Reduction is usually performed to alleviate the physical discomfort and restricted activity caused by very large breasts.
You may be a good candidate for breast reduction if you have one or more of the following conditions:
Since breast shape varies among each individual, knowing and understanding the anatomy of your breast ensures safe surgical planning. The breast generally refers to the front of the chest and medically specifically to the mammary gland; the word “mammary” comes from “mamma,” the Greek and Latin word for the breast, which derives from the cry “mama” uttered by infants and young children, sometimes meaning “I want to feed at the breast.”
The mammary gland is a milk-producing structure that is composed largely of fat cells. The fat deposits are contained in your breast under the influence of the female hormone estrogen. Just as the surge of estrogen at adolescence encourages this process, androgens, such as testosterone, discourage it. Within your mammary gland, there is a complex network of branching ducts (tubes or channels) and the ducts exit from sac-like structures called lobules. The lobules in your breast are the glands that can produce milk in females when they receive the appropriate hormonal stimulation. The breast ducts transport milk from the lobules out to the nipple and the ducts exit from your breast at your nipple.
Your breast can be visualized as a cylinder, especially when you lean forward and your breast hangs. Regardless of the level on the cylinder at which breast tissue is removed, the distance around the circumference of the cylinder should be the same. This means that the vertical limb of your breast reduction should be manageable at any size. On the converse, if the pedicle (part of a skin or tissue graft that is left temporarily attached to the original site) is to be retained, the large breast has a long pedicle, which makes reducing lower-pole fullness more difficult. As with most breast reductions, small reductions often give the best cosmetic results.
The specific technique used to reduce the size of your breasts may vary. On the day of your surgery, you will meet with Dr. Moelleken prior to undergoing anesthesia. He will mark your breasts while you are sitting up as the incision lines are based on a standing position. Your breast shape is much different while prone and the marks offer Dr. Moelleken guidance for incisions during your breast reduction surgery. After you are marked for surgery, anesthesia will be administered. The vast majority of breast reductions are performed under general anesthesia, which means you will be asleep during your entire surgery. Local anesthesia is mostly used in liposuction/liposculpture-only breast reduction procedures. Once sedated, Dr. Moelleken will perform your breast reduction surgery according to the pre-chosen technique.
Though there are a variety of breast reduction techniques, most surgeries involve removing tissue from your breast and realigning your nipple areolar complex. One of the most common procedures involves an anchor-shaped incision that circles your areola, extends downward, and follows the natural curve of the crease beneath your breast. In most cases, the nipple stays connected to the remaining gland and fatty tissue but they are moved upwards on the wall of your breasts. In extremely large breasts, it is sometimes necessary to detach the nipple and areola and graft them into a higher position.
A circular piece of skin is removed from a suitable area and this method is used for both large and pendulous breasts. Dr. Moelleken will remove the excess tissue, fat, and skin to reduce the size of each breast before he moves your nipple and areola into their new position. He will then bring the skin from both sides of your breast down and around your areola, shaping and contouring your new breast. Cosmetic contouring may be used to remove excess fat from your armpit and lateral chest area to give you a more aesthetic appearance at this time as well. When only fat needs to be removed, liposculpture/liposuction alone can be used to reduce your breast size. Some women choose to combine their breast reduction with a breast lift in order to achieve a better breast position in addition to size. During your consultation, Dr. Moelleken will help you decide if any of these options are right for you.
After the skin and tissue are removed, Dr. Moelleken will make sutures deep in your breast tissue. He will make every effort to make your scars as inconspicuous as possible, but remember breast reduction scars are permanent and will take several months to fade. Sometimes, a small tube may be placed to drain off excess blood and fluids. Your procedure will last anywhere from one to three hours and the length of the surgery depends on the number of incisions and amount of skin and tissue removed. You will be taken to a room to recover from your anesthesia before traveling home and Dr. Moelleken will check on you before you leave. Your breasts will be wrapped with a dressing and you will be given a medical brassiere for support for the next several days. Breast reduction is an outpatient procedure however, you cannot drive after surgery and you will need to enlist someone to serve as your driver for the ride home.
The first days after surgery will require a lot of rest. Your breasts will be slightly bruised and swollen and Dr. Moelleken will prescribe medication for your pain and discomfort if you need it. You will be instructed to continue to wear your surgical brassiere around the clock to prevent gravity from putting pressure on your sutures. Dr. Moelleken will want to meet with you 24 to 72 hours after surgery to ensure that recovery is on the proper course. New dressings may be applied and any drainage tubes removed. Dr. Moelleken will also answer any questions about further recovery that you have and what to expect going forward.
For the first two weeks after your breast reduction surgery, it is very important to avoid any strain or physically strenuous activity. Your arms should not be raised above your head even if there is no pain as doing so could cause additional scarring under your arms. After the first week of recovery, the swelling and bruising will subside and you may return to your normal routine. You will still need to continue wearing your 24-hour support bra to avoid strain. During the third and fourth week of your recovery, you may begin more physical activity if Dr. Moelleken approves. At the end of the fourth week, your scarring will have subsided greatly and the long-term results of your surgery will be visible. Results of a breast reduction procedure vary between each patient as everyone heals differently however most patients see their final results between six months and one year. Following Dr. Moelleken’s instructions and guidelines will ensure proper healing with minimal complication.
Milk Production Capability After Breast Reduction
The purpose of breast reduction surgery is to reduce the volume of the breast and nearly all techniques used are likely to reduce milk production capability. The surgeries that have resulted in the least negative impact are those in which the areola and nipples were not completely severed (even though they may have been moved) and the lower portion of the nipple and areola remains intact. The weight and size of your breast can be reduced using various surgical techniques however two main technical aspects should be considered when detailing surgical options for reduction mammoplasty.
The aspects include:
The most common techniques used today are the pedicle techniques in which your areola and nipple are moved to a higher position while attached to a mound of tissue, or pedicle that contains the still-connected ducts, nerves, and blood supply. The pedicle method of breast reduction reduces breast appearance, volume, and contour, while maintaining breast function and nipple sensation. The pedicle method refers to the location of the blood and nerve supply: not where the incisions are placed. Although there is a scar completely around your areola with each of the pedicle techniques, your nipple and areola have not been completely severed. The pedicle selected by Dr. Moelleken will have a discrete vascular and nerve supply and is very important in determining your final breast shape.
Other names that are used for the pedicle method are: Anchor method, T-Scar, T-Incision, Inverted T pattern, Wise Method, Lollipop, Vertical, LeJour, Short scar, Circumareolar, Keyhole, Donut, and Robertson. There are surgical and scar pattern differences to some of these methods, and not everyone is a candidate for all of the different types of reductions. One of the ways the pedicle method varies is by the way the blood and nerves are maintained from different areas of the breast.
As previously stated, in the pedicle methods of breast reduction, nipple-areola sensation and milk production are typically preserved. In the case of very large breasts, however, women are sometimes faced with the Free Nipple Graft procedure (FNG). The pedicle, along with its blood and nerve supply, must be severed, and the nipple-areola complex is detached and grafted back after the reduction is completed. Function and sensation are lost with this method.
Breast Reduction Techniques
The two most common skin patterns used in breast reduction surgery include:
The Wise Pattern technique is also known as the Inferior Pedicle, Inverted T, Keyhole, and the Anchor breast reduction technique to name a few. The Wise Pattern places incisions along the inframammary border of your breast, a vertical incision from the fold up to your areola, and an incision around the border of your areola. When using this technique, Dr. Moelleken will remove skin, fat, and tissue from your lower breast area to reduce the mass of your breast. Your nipple and areola will be moved to a higher location on your breast, but not removed from the breast mound itself. After your nipple is moved to its new position, the skin above your nipple is brought down and around the breast mass before being stitched back to close the incisions. This procedure works well on women who are looking to significantly reduce the size of their breasts; more than 750 grams of tissue to be removed from each breast. In addition, this procedure is effective when the patient has poor skin quality, usually from massive weight loss, and the breast is very loose or when the nipple-areola complex has to be moved a long distance.
The Wise Pattern breast reduction technique is the original breast reduction surgery procedure. It is known as the anchor technique because the incision leaves an anchor-shaped scar. Robert Wise first developed this technique in 1956 when he published his experience on refining previous patterns of surgery by designing an incision in the form of a keyhole. The Wise Pattern breast surgery technique is the basis of most breast reduction techniques used because it is versatile and can provide predictable outcomes in very large reductions. To date, the Wise Pattern remains the most common method of skin excision performed in the United States, although current trends show other methods that have been designed with the purposes of shortening and hiding the scar.
The Vertical breast reduction technique, also known as LeJour or the Lollipop method, involves smaller incisions than the Wise Pattern technique. It also requires less surgical time, a shorter healing period, and less scarring which is causing this procedure to grow in popularity. Although the LeJour or Vertical breast reduction is a newer technique, the procedure can only be performed on women who fit the criteria. Also known as the “short scar” technique, women can be no larger than a DDD or less to qualify for this method.
During this procedure, Dr. Moelleken will commonly employ a vertical breast reduction technique (a modified LeJour) that minimizes the amount of scarring on your breast using a “lollipop-type” pattern that encompasses a circular incision around your areola with a lower breast vertical incision. This eliminates the use of a transverse incision along the lower breast fold that is placed as part of a more traditional “anchor type” procedure. This technique is often used when a reduction of less than 750 grams is required to be removed, when the patient’s skin quality is good, and the nipple areola complex does not have to move a long distance.
For patients with poor skin quality and significant breast ptosis, a Wise Pattern skin incision would probably be most beneficial to achieve your desired result. For massive weight loss patients, Dr. Moelleken may use both types of skin incision designs to achieve optimal results.
This breast reduction technique is performed using liposuction only. It is sometimes called the ‘scarless breast reduction’, but in fact, there are small incisions resulting in scars where the lipocannula is inserted. Generally it is performed as an outpatient procedure under IV sedation instead of general anesthesia.
Performed like a normal liposuction procedure, a five-millimeter incision is made under each breast and fluid is injected, which separates the tissue from the fat. The excess fatty breast tissues are extracted by the use of a cannula or a medical tube. The results include a decrease in the size and weight of your breasts with less physical trauma to the breast tissue and minimal risk of complication and scarring.
The main drawbacks to traditional breast reduction are that the scars from the skin removal can sometimes be visible and the repositioning of your areola can sometimes result in a loss or sensation or feeling. Patients who have good skin elasticity and only need a mild to moderate reduction are good candidates for breast reduction using liposuction only. The scars are minor and normally hidden under the breast fold crease and the preservation of your breast and the ability to breastfeed can be achieved with using the liposuction method. Liposuction breast reduction can be a good procedure for women who only need a reduction, not a lift. This means that going into the procedure, your breasts and nipples are in optimal position, have a good natural shape, and they only need to be reduced in size.
Liposuction has been used as an adjunct to other breast reduction procedures for quite some time, but it is not common to perform breast reductions using liposuction alone. Liposuction used alone for a breast reduction cannot adequately “lift” your breast or reduce the skin envelope that will potentially be looser after your procedure. It cannot remove excess glandular tissue and it is less able to completely reshape your breasts. Some patients report a ‘deflated balloon’ type effect and that liposuction alone has also left their breasts much more dense. It is certainly worthwhile to take care of the burden of excess breast weight, but this technique will usually not improve the aesthetic appearance of your breast.
Breast tissue usually swells after liposuction. While you will be able to see the difference in the size of your breasts immediately, it will take several months for your body to heal and for the new size of your breasts to emerge. A compression garment is worn after the procedure for approximately four weeks to help support your new breast shape and assist in the healing process.
In this procedure, using a laser and the skin that would normally be discarded during surgery, Dr. W. Stevens developed the technique that creates an internal bra to produce a permanent support system and a more natural effect in the long term for patients. The incision patterns are the same as with most of the Anchor style pedicle methods, as is the preservation of the pedicle. The Laser Bra is attached internally to your chest wall, creating an internal bra support structure however you will not be able to see or feel it. Because it is your own tissue, you cannot reject it and patients who have had this technique have done extremely well and do not experience problems with early sagging.
Most women interested in breast reduction also need a breast lift, as it is a matter of size and weight working in conjunction with gravity. Breast reduction surgery can successfully remove the excess fatty or glandular tissue making your breasts large and heavy but a breast reduction alone will not bring your breasts back to a desirable position on your chest. That is why breast reductions are often combined with a breast lift so that your new, smaller breasts are situated higher up on your chest for an attractive and more youthful appearance. You can learn more about the benefits of combining breast reduction with a breast lift during your consultation with Dr. Moelleken.