In this episode of PodMD, Australian and British-trained Specialist Plastic and Reconstructive Surgeon Dr Shiba Sinha will be discussing the topic of breast reduction, including how the surgery is performed, the common reasons women undergo the surgery, the benefits and risks, the developments in this type of surgery, advice for GPs in terms of referring and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Shiba Sinha
Dr Shiba Sinha is an Australian and British-trained Specialist Plastic and Reconstructive Surgeon practicing in Melbourne. Dr Sinha obtained her medical degree at the University of Leeds, England. Following this, Shiba undertook a higher research degree focusing on the tissue engineering of fat at the O’Brien Institute in Melbourne and advanced Plastic and Reconstructive Surgery training in New South Wales and Victoria.
Shiba then undertook further fellowship training in breast reconstruction at the world-renowned Queen Victoria Hospital, East Grinstead in the UK. She also undertook numerous observorships in aesthetic breast and body surgery in the UK, Europe, and Australia.
Today, we’ll be discussing the topic of breast reduction surgery.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Shiba, thanks for talking with us on PodMD today.
Shiba : Thank you for having me.
The topic of today’s discussion is breast reduction surgery. Shiba, can you give us a brief overview about breast reduction surgery?
Shiba: Breast reduction surgery or reduction mammoplasty is a surgical procedure that removes excess breast glandular and fatty tissue which results in a lifted breast and nipple position and improved breast shape. Breast reduction has FUNCTIONAL/RECONSTRUCTIVE outcome which alleviates back/neck and shoulder pain, help with preventing breast fold skin rashes and an AESTHETIC component in improving breast shape and volume to made to be more in proportion with a women’s frame. It is an operation that has a very high patient satisfaction with approximately 7000 breast reductions done in Australia per year.
How is breast reduction surgery typically performed?
Shiba: The goal of breast reduction is to surgically reduce the breast parenchyma; elevate the nipple which retains its blood supply on a dermoglandular pedicle (a pedicle is a finger of tissue which carries a blood supply) and then to redrape the skin envelope around the new smaller breast.
It is performed the majority of times under general anaesthetic; takes 2-3 hours and typically involves an overnight stay. The first stage involves marking the patient standing up. The surgeon marks the midline, the breast meridian which is where the nipple should ideally lie and then the position of the new nipple position. The surgeon will then mark the pedicle on which the nipple will survive and typically this will be in the supero-medial orientation.
Then the skin excision pattern is marked: usually this is the Wise pattern which produces a circumareolar scar and an anchor shaped scar or in some cases it is possible to do a vertical pattern skin excision which results in a “lollipop” scar. In a breast reduction the areolar diameter is reduced and the nipple is rotated into a new elevated position. Surgeons will use internal sutures to improve the breast shape and reduce the breast width. All the breast tissue that are removed are weighed and sent for pathology.
What are some of the common reasons that women choose to undergo breast reduction surgery?
Shiba: The majority of patients who I see want to be relieved from the discomfort of large heavy breasts and they have been considering getting a breast reduction for years. Patients will have generally had large breasts out of proportion with their frame since adolescence. In youth this can lead to body esteem issues; unwanted attention and difficulty finding clothes that fit (underwear and swimwear). Some patients experience increased breast size post menopause. The functional reasons for getting breast reduction surgery include improving back and neck pain, shoulder pain from the bra straps digging in as the day progresses poor posture; and skin issues. Patients will have always experienced limitations in exercising such as running, yoga, swimming.
What are the benefits and risks associated with breast reduction surgery?
Shiba: The benefits are the improved sense of self after achieving a reduced breast size and shape and many patients tell me how empowered they feel after having a breast reduction and the positive effect it has had on their lives.
The specific risks of breast reduction can be divided into early, intermediate or late. Easrly complications occur within a week and include a haematoma rate of about 1-2%; infection; wound breakdown; nipple ischaemia is a dreaded complications and results from the nipple having a poor blood supply. This is more common in women who have a sternal notch to nipple distance of 40 cm and the surgeon should pre-operatively warn them of the risk of a free nipple graft. This is where the nipple is not moved on a pedicle but removed and regrafted in a new position.
Intermediate complications which occur with 6 weeks include suture spitting, delayed wound healing; seroma and fat necrosis. Late complications after 6 weeks include breast asymmetry, scar issues (including hypertrophic and keloid), permanent reduction in nipple sensation and potentially expectation mismatch where the patient is disappointed in the outcome and may require require further surgical correction.
How does a plastic surgeon determine the best approach for breast reduction surgery for a patient?
Shiba: The initial consultation between a surgeon and a patient is important to collaboratively achieve the best outcome. It is important to consider the motivations for surgery and manage expectations. A surgeon will take a detailed history with particular attention on changes of breast during adolescence, family history of breast cancer, pregnancy history and whether family is complete and desire to breast feed. In terms of examination the surgeon will assess the patient’s skin quality, location of any breast scars or piercings, nipple position and the ptosis (droop) of the breasts.
The surgeon will then be able to determine the appropriate pedicle and skin reduction pattern. It is difficult to predict the final cup size but a surgeon will aiming to achieve balance and a volume that is in proportion to a person’ frame. In patient’s where the nipple needs to be moved a large distance the surgeon will counsel them of the need for a free nipple graft.
Is there a role for breast reduction surgery in a paediatric population?
Shiba: So breast reduction surgery is something that’s becoming increasingly considered in patients who are below the age of 18. So the development of really large breasts, macro or gigantomastia through puberty can have a significant psychological impact on a young girl. They have body image issues. They may have unwanted attention due to the size of their breasts and it also limits their participation in certain sports. Secondly, through the avenue of social media, breast reduction surgery is being increasingly popularised in this under 18 cohort.
My advice really for GP, who see potentially a young girl under the age of 18 who wants a breast reduction, is to. And listen to their concerns and assess the degree of psychological distress. And it’s something that should ideally be referred to a plastic surgeon, both in either the public system or the private system. There are two public hospitals in Melbourne, the paediatric centres that do accept referrals for breast reduction in patients who are under 18. There they’ll be assessed by. A surgeon. Over a couple of consults, this is certainly something that needs more than one conversation with both the. Patient and their relatives. In order for a young girl to understand the potential implications of breast reduction surgery in terms of scars and the effect on nipple sensation and the future effect on breastfeeding, which are probably things that someone who’s in their 15 or 16 year olds are not going to necessarily consider.
It would then be up to the the plastic surgeon who would assess the level of psychological distress where. That patient would benefit from a psychology referral, and it’s all part of that multidisciplinary management. For a young patient considering this type of surgery. So paediatric breast reduction is a very specific cohort of patients that we do encounter, but it’s one where the. Potential positive benefits over a lifetime can be quite significant for that patient, if appropriately counselled.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Shiba: Breast reductions performed today is a relatively standardised procedure with most surgeons using a supero-medial pedicle and a Wise pattern skin reduction which has been shown to have a better blood supply to the nipple. This compares to 20 years ago where the inferior pedicle was commonly used but this leads to a long term bottoming out of breast shape. Liposuction only breast reduction can be used in moderate breast enlargement with good skin quality and minimal ptosis of the nipple. It removes fat only. Skin tightening can be unpredictable and no lift can be expected.
More surgeons are moving towards drainless breast reductions. Drains have been shown to not reduce the haematoma rate in breast reduction. Not having drain allows patients to go home the day of surgery. This is obviously surgeon and patient specific.
What can patients do to prepare for the surgery?
Shiba: Patients can do a number of things that optimise the result from a breast reduction and maintain it longevity. The first thing is weight management: ideally you should be at your goal body weight. If you have to loose weight to achieve this; ideally we would want this weight to be stable for 6 months. It has been shown that patient who have a BMI > 35 have a 2 fold increase in wound healing complications. Furthermore weight gain post surgery will increase breast size.
Smoking/vaping cessation is also important for 6 weeks prior to surgery date as smoking can lead to up to a 2 fold increase in complications. If patients are on blood thinners or over the counter supplements such as fish oil, evening primrose oil, St Johns Wort will need to be ceased 7 days prior to surgery. Furthermore for patients aged over 40 their surgeon will send them for a mammogram performed to rule out any unsuspected breast problems prior to any breast reduction procedure.
What can patients expect during the recovery process after the surgery?
Shiba: Breast reduction surgery is not particularly painful. Most surgeons will use local anaeshetic that lasts for a few hours and patients are discharged with analgesia and antibiotics. Patients wear a soft non wired bra to support their reduction. Initially the breasts will be swollen, feel slightly firm and be sitting higher on the chest. It takes about 3 months for the breasts to settle and soften. Bruising of the skin and nipple is normal in the initial few weeks and patients do experience a change in nipple sensation.
Commonly this is a loss of nipple sensation which improves after 6 weeks; however the larger the reduction the increased risk that the nipple sensation does not return to pre-operative levels. in rare cases increased (oversensitive) nipple sensation can occur. Each surgeon will have their own protocol for scar management but is likely to include scar and breast massage; taping of the scar for 6 weeks. In terms of return of activity most patient’s will require about 2 weeks of work depending on the demands of their job. I encourage patients to begin gentle mobilisation soon after surgery, however there is a decreased activity level for 6 weeks. Driving is usually when it is comfortable to put on a seatbelt and make an emergency stop usually around 7-10 days.
What advice do you have for GPs in terms of referring or assisting patients for breast reduction surgery?
Shiba: I do recommend that patients see a GP prior to seeking a breast reduction. GPs have a holistic view of a patients health and maybe able to institute some of the weight management/ smoking cessation initiatives that will improve the breast reduction outcomes. GPs are able to advocate for their patients and refer them to an surgeon to discuss breast reduction and help empower patients to make a decision to undergo a breast reduction.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on breast reduction surgery.
1. Breast reduction is largely a procedure with functional benefits with an aesthetic side effect
2. Breast reduction results can be optimised by achieving a stable ideal body weight and smoking cessation
3. Patients not willing to accept scars on their breasts or reduced nipple sensation should not consider breast reduction
Thanks for your time and the insights you’ve provided.
Shiba: Thank you