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Introduction

 

Breast reduction

Breast reduction

 

Female breast reduction, also known as reduction mammoplasty, is an operation to reduce the weight and volume of the breasts.

During the procedure, fat, glandular tissue and skin are removed from the breasts, which are then reshaped and the nipples repositioned.

Breast size is determined by genes, hormones, body frame and weight. For most women, breast size is proportionate to the body, but for some women the breasts are particularly large.

Breasts are sensitive to the hormone oestrogen. They can grow during adolescence or later in life after the menopause, or because of the use of hormone replacement therapy (HRT). Some women also develop a noticeable asymmetry (difference in size or shape) between their breasts.

Breast reduction surgery can help women who are unhappy with the shape, weight or droop of their breasts by making them smaller and more lifted. However, breast size alters with body weight, so your breasts may increase in size if you put on weight or become pregnant even after surgery.

Men can also have breast reduction surgery to treat enlarged breasts, known as gynaecomastia. Read more about male breast reduction.

Availability of breast reduction surgery can be variable depending on the policy of your local clinical commissioning group (CCG).

If breast reduction is done to improve appearance rather than for health reasons. Instead, you will need to pay for private treatment.

To receive cosmetic surgery, you will normally need a referral from your GP. You will need to have a consultation with a breast or plastic surgeon and possibly an assessment by a psychiatrist or psychologist. They will consider whether there is enough social, psychological or physical benefit to justify surgery – for example, if your breasts are causing you significant pain or mental health problems.

The final decision is usually made by a cosmetic exclusion panel of your local CCG, which will take into account the information from your assessments and review your individual case.

You may be considered for a breast reduction operation  if you have physical discomfort from having large breasts, such as:

  • backache 

  • neck pain

  • skin irritation

  • poor posture

  • excessive sweating, rashes and skin infections under the breasts

  • grooves on the shoulders from bra straps

  • an inability to exercise or take part in sports

Large breasts can also cause psychological distress. Common complaints from women with large breasts include not being able to wear fashionable clothes and finding it difficult to take part in active sports. Psychological distress may also include unwanted attention or harassment, self-consciousness and depression.

Some CCGs may also have specific eligibility criteria for breast reduction  that can include the size of your breasts, your weight, whether you smoke, and whether other options – such as wearing professionally fitted bras – have been tried but have not helped.

 

Before having surgery

It is important to discuss your problems and options with your GP and an appropriately qualified surgeon before going ahead with a breast reduction. This will help you to get a clear idea of what changes you can expect to see and to ensure you are aware of any risks involved.

Any type of surgery carries risks. The potential complications specific to breast surgery include:

  • scarring

  • unevenly shaped breasts or nipples

  • wound healing problems 

  • loss of nipple sensation

  • being permanently unable to breastfeed

 

The operation

Bilateral breast reduction surgery (reduction of both breasts) takes two to four hours under general anaesthetic. You will usually need to stay in hospital for one to two nights afterwards.

There are several techniques the surgeon could use. The most appropriate method for you will depend on the size of your breasts and the desired result.

You will need to take it easy for two to six weeks while you recover from the operation, but recovery time depends on your age and general fitness. It is likely you will have sore breasts for a few weeks.

The final appearance of your breasts may not be obvious for several weeks or months after the operation.

 

Alternatives to surgery

For both women and men, breasts can become large because of fatty deposits within them. This means that you may be able to reduce the size of your breasts by losing weight.

 

Things to consider 

Breast reduction should only be considered after taking medical advice from a qualified cosmetic, plastic or breast surgeon.

Many patients gain a better quality of life after a breast reduction as symptoms such as back pain are often dramatically reduced. However, any kind of cosmetic surgery should not be undertaken lightly.

You may feel it will improve your appearance and quality of life, but it can be expensive and time consuming and, as with any form of surgery, there are a number of risks.

The decision to have a breast reduction should only be taken after a lot of careful thought and questioning.

 

Do your research

If you feel you will benefit from a breast reduction, it is important that you are as well informed as possible.

Talk to your GP to get information and general advice on the procedure, and look into the surgeons, hospitals and clinics that perform breast reductions.

Your GP may refer you to an appropriate surgeon, who can discuss your problems, examine you and advise you about the options available, along with their advantages and disadvantages.

Don't be nervous about asking for detailed information from your GP or a surgeon about the procedure.

 

Choosing a surgeon

Surgeons who are trained in general surgery should have FRCS (Fellow of the Royal College of Surgeons) after their name. Surgeons trained in plastic surgery in the UK will usually have FRCS (Plast) after their name.

Doctors who are also considered to be suitably trained are listed on the specialist register kept by the General Medical Council (GMC).

You can find out if a doctor is on the specialist register by using the GMC website to check whether a doctor or surgeon is registered. The website gives details of the surgeon's primary speciality, but it doesn't provide information about any other specialist qualifications that they may hold.

Before choosing a surgeon, find out about their experience of doing breast reductions and make sure you meet them before committing to surgery.

When you find a surgeon, be honest and clear about your expectations and find out if a breast reduction can really give you the results you want.

A surgeon should provide full details of the procedure before you decide to go ahead with it. Expect the consultation to take half an hour or longer.

 

Expected results

It is important to discuss your expectations with your surgeon. Sometimes a very radical reduction will alter the shape and look of the breasts. There will be scarring and sometimes also lost or altered nipple sensation.

For women with very large breasts, the benefits of a reduction may outweigh any potential imperfections. For women with only moderately large breasts, the benefits may not be worth the potential risks and side effects.

Your breasts can still change in size and shape after surgery. They should not regrow, unless the operation is done at an age when your breasts are still growing, but they can increase in size if you put on weight or become pregnant. They can also decrease in size if you lose weight. Normal breasts also have a tendency to droop over time.

As your breasts can get bigger during pregnancy and there is a significant chance that you won't be able to breastfeed after a breast reduction, you may be advised to postpone having surgery until you are sure you don't want to have any more children.

When having private treatment, you will be asked to sign an agreement form before having your breast reduction operation. Make sure you understand and are happy with the agreement before you sign.

The agreement should include details of cost. Make sure you understand what this covers, especially in terms of aftercare and any revision surgery (surgery to treat any complications or problems) that may be needed. There may also be financial penalties if you decide to cancel the agreement.

 

Your records

The provider of your procedure, a private clinic or hospital, will keep a record of your treatment that may contain before and after photographs of you. Think about whether you would mind the provider showing these to other potential patients. The provider should ask for your consent before showing any part of your records to other patients.

 

Surgery abroad

Cosmetic surgery may sometimes be cheaper abroad than it is in the UK. However, this needs to be weighed up against the cost of travel and accommodation and any follow-up care or revision surgery that may be needed.

The Care Quality Commission (CQC), which is responsible for regulating and checking private cosmetic surgery in England, does not cover procedures abroad and will not be able to help if you experience any problems.

If you are not confident that the procedure you are having is safe, it could end up being more costly in terms of risk, pain, revision surgery and aftercare.

 

The cosmetic surgery checklist

1. Think about your expectations.

2. Check out potential surgeons. Make sure you meet them before committing to surgery.

3. Have a thorough consultation to plan your treatment. Make sure you know the risks involved and the likely results.

4. Cool off before you commit. Take time to think about whether the procedure is right for you and if you are happy with the surgeon.

5. Care about your aftercare. Make sure you know how you will be looked after, especially if there are any complications after surgery.

Further details on the cosmetic surgery checklist can be found on the British Association of Plastic, Reconstructive and Aesthetic Surgeons  website.

 

How a breast reduction is performed 

You will be asked to undergo some general health tests before your operation to check that you are fit to have surgery.

 

Before the operation

If you smoke, you may be asked to quit in the weeks before your operation. This is because smoking increases your risk of chest and wound infections and can slow the healing of your wounds, leaving you with worse scarring.

Being overweight can also slow the healing process, so if you are overweight you will be encouraged to lose weight before your operation.

If you take the oral contraceptive pill or hormone replacement therapy (HRT), your surgeon may advise you to stop taking it a few weeks before your operation as these drugs can increase your risk of developing deep vein thrombosis (a blood clot in a leg vein). You should also avoid aspirin and anti-inflammatory drugs.

Before your operation, you will be asked to sign a consent form. This is to confirm that you understand the risks, benefits and possible alternatives to the operation.

 

The operation

Breast reduction surgery is usually done under general anaesthetic (when you are asleep). You will be asked to follow fasting instructions before your operation. Typically, you cannot eat or drink for six hours before having the anaesthetic.

Surgery takes between 90 minutes and four hours. You may be required to stay in hospital for up to three or four nights afterwards, although most women only need to stay one or two nights.

The surgeon will use a pen to mark the areas of the skin where the incisions (surgical cuts) will be made. With your permission, the surgeon may also photograph your breasts for confidential before and after images for your records.

Most breast reduction surgeries begin with the nipple, which is moved to its new position, usually while still attached to the blood supply. If you have extremely large breasts, the nipples may be removed and repositioned as a skin graft. They will naturally develop their own blood supply.

Excess skin and breast tissue are then removed. The remaining breast tissue is reshaped to create smaller and more elevated breasts.

 

Breast reduction techniques

There are various different ways to do a breast reduction. Your surgeon will decide which is most appropriate for you depending on the size of your breasts and the desired outcome. The most common techniques are described below.

Anchor type or inverted T reduction

This isthe most common type of breast reduction. It results in an anchor-shaped scar starting around the areola, travelling down vertically and then horizontally across the breast crease.

Vertical pattern breast reduction

This technique results in a circular scar around the areola, and a vertical scar passing downwards towards the breast crease (sometimes described as a "lollipop" scar).

Vertical pattern breast reduction has the advantage of leaving no scarring under the breast and a lower chance of wound complications.

However, this technique may leave a small fold of skin initially at the lower end of the vertical scar. This usually resolves itself within a few months, but may require removal under local anaesthetic if it does not resolve. It is also not always suitable for particularly large breasts.

Circumareolar reduction

This technique results in a circular scar around the areola, but it is only suitable when removing a small amount of tissue.

 

Recovering from a breast reduction 

It is likely that your breasts will be swollen and feel tender and lumpy after surgery. The final appearance of your breasts may not be obvious for several weeks or months.

 

After surgery

When you wake up after having breast reduction surgery, your breasts will be bandaged and plastic tubes may be attached to your breasts to drain blood away.

After one to two days, any tubes will be removed and you will usually be able to go home. You may experience some pain for a few days, which can be relieved with painkillers.

 

Getting back to normal

Once you have returned home, you will need to take it easy for two to six weeks depending on your age and general fitness.

The length of time you need to keep the dressings on will depend on how quickly your wounds heal. After one or two weeks, your stitches will either dissolve or be removed at an outpatient clinic.

At your follow-up appointment, your surgeon will advise you when you can resume your normal activities and return to work. You may need to take two to four weeks off, depending on what your work involves.

Avoid stretching, strenuous exercise and heavy lifting for up to six weeks after your operation. You also need to keep your breasts supported by wearing a well-fitting wireless sports bra day and night for up to three months.

You should avoid driving until you no longer experience any pain when wearing a seatbelt, which may be several weeks. Before starting to drive again, contact your car insurance company to see what their policy is on driving after having surgery.

Scars are usually quite red for the first six weeks after surgery. They then change to a purple colour over the next three months before fading to white. Most scars heal well, but some women are left with red and lumpy scars that do not improve in appearance.

 

When to seek medical advice

While you recover, it's important to look out for signs that suggest you may have developed an infection, such as:

  • increasing redness, swelling and pain around your breasts

  • discharge from your wounds

  • a high temperature (fever)

  • vomiting

If you develop any of these symptoms, contact your GP or the hospital unit where the surgery was carried out for advice.

 

Risks associated with breast reduction

The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot.

Complications specific to breast reduction surgery are described below.

 

Scarring

The main disadvantage of having breast reduction surgery is that you will be left with permanent scarring. The operation, when done using the more common anchor technique, leaves three scars:

  • one around the nipple (areola)

  • one from the nipple to the crease below the breast (this is the most significant scar)

  • one from the breast bone to the armpit along the crease below the breast

The severity of scarring largely depends on the individual. Some women are left with red and raised scars, but most scars fade over time and should be invisible under normal clothing and most bras or bikini tops.

 

Uneven shape

Your breasts will change shape after reduction surgery. There is a chance that they may end up slightly lopsided or lumpy and the nipples may be uneven.

 

Wound healing problems

Wound healing problems after breast reduction surgery are common, particularly after the anchor scar procedure where the vertical and horizontal scars meet.

Most wound problems are minor and can be simply managed and treated. More severe wound complications, such as infection, skin loss and wound separation, may take longer to heal.

Occasionally, some fat in the breasts dies off, leaving them red and lumpy. This is called fat necrosis and can take some time to settle. There can also be some excess skin left around the scars. It may need to be surgically removed if it does not settle after a few months.

If you smoke or have diabetes, you may have poor circulation, which will affect how quickly your wounds heal.

 

Loss of nipple sensation 

Some women lose sensation in their nipples after a breast reduction and the nipples may also lose their ability to become erect. This is because the nerve supply to the nipple can be damaged during surgery.

Very rarely, a disrupted blood supply may cause your nipple to die and fall off. This is more likely if you smoke heavily or you have poor circulation.

 

Inability to breastfeed

Some women are unable to breastfeed after having breast reduction surgery as some operations involve separating the nipples from the milk ducts.

 

Haematoma

Occasionally, bleeding occurs inside the breast tissue, making it swollen and painful. This is called a haematoma and generally occurs within the first 24 hours after the operation. If this happens, you may need to have another operation to drain the blood and stop the bleeding.

 

Male breast reduction 

Men can also have breast reduction surgery if they have enlarged breasts, a condition known as gynaecomastia.

Large breasts in men are often believed to be a result of obesity, but this is not the only cause. Men, like women, can have an abnormal growth of glandular breast tissue, usually because of a hormone imbalance.

Other causes of enlarged male breasts include:

  • excessive alcohol intake

  • use of certain drugs, particularly anabolic steroids

  • certain diseases, such as liver failure and cancer

  • congenital abnormality (a problem from birth)

  • dramatic weight loss, which can cause the skin to sag

For men who feel self-conscious about their appearance, breast reduction surgery may be considered to flatten the breast area.

 

Before surgery

When breast enlargement is caused by obesity, poor health or excessive alcohol intake, breast size may be reduced through a healthy diet and regular exercise.

Consult your doctor and consider all your options before choosing to have breast reduction surgery.

 

The reduction procedure

Male breast reduction surgery is usually carried out under general anaesthetic (where you are asleep) and takes around 90 minutes or more.

The surgeon will make an incision around the nipple (areola) and liposuction may be used to suck out excess fatty tissue. If there is a lot of tissue to remove, cuts may extend down the chest from the areola, and the nipples may need to be repositioned.

You will be required to stay in hospital overnight, take a few days off work to rest, and avoid lifting or strenuous physical exercise for up to six weeks after the operation.

An elastic garment also needs to be worn day and night for a few weeks after the operation to encourage good results.

 

Results

Male breast reductions are an effective way to reduce the size of the breast area and give a flattened shape.

The results are usually permanent, but weight gain, hormonal imbalances and the use of certain drugs can cause the breast area to enlarge again.

 

Risks

Surgery can leave red and lumpy scars. These may last for several months, but should gradually fade over time.

Other risks include uneven results and loss of sensation in the nipples.

 

Having an operation

If your GP has suggested you may need surgery, this guide is for you