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 often significantly improves it.
Why do women request breast reduction?
- Breasts considered too large/heavy. Unable to carry out normal activities like sport or even work without discomfort.
- The large breast size means that women are unable to find clothes to fit well, especially bras, without excessive expense.
- The woman considers her large breasts cosmetically unattractive affecting body image and self esteem.
- The heavy breasts are causing the shoulders to drop leading/stooping posture, back pain & painful marks from bra straps.
- One breast is a different size leading to cosmetic and practical problems.
- Because they just want smaller breasts.
What breast reduction will not prevent?
- Breast pain –breast tissue is responsive to hormonal changes and after breast reduction there is still plenty of breast tissue.
- 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 1:12 life time risk of breast cancer regardless of the size of their breasts.
- 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.
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. However, good medical practice dictates that your GP is kept informed of any treatments you have or refers you for such treatments. Breast Reduction Surgery is performed by Specialist Breast Surgeons with general surgery training, cosmetic breast surgery training and reconstructive breast surgery training. It may also be performed by some Plastic Surgeons. A Specialist Breast Surgeon who comes from a General Surgical background but whose usual clinical workload relates almost entirely to women with breast disorders, will usually have a specialised interest in this type of surgery. It is worth checking that the surgeon is a member of the relevant specialty organisation. This includes the Association of Breast Surgery of the British Association of Surgical Oncology (ABS of BASO) and is registered as a Specialist with the GMC. The National Care Standards Commission is a new agency set-up by the government to ensure the regulation of cosmetic surgery in private hospitals and if you approach a surgeon offering breast reduction surgery in the private hospitals within Yorkshire they will have had to fulfil the requirements to be allowed to provide this surgery. It is obviously our opinion that any surgical intervention is better carried out by local experts rather than travelling far and wide. Mr Turton is a Specialist Breast Surgeon and performs Cosmetic Breast Surgery including breast augmentation, reductions, mastopexy and correction of nipple inversion. He is a general surgeon whose specialist training is in Breast Surgery and his special area of interest is cosmetic breast surgery and breast reconstruction. He is an accredited member of Association of Breast Surgery of the British Association of Surgical Oncology and on the GMC register as a Specialist.
You will be shown photographs of the procedure and the results, and instructed to review Mr Turton's web site: www.cosmeticbreastsurgeon.co.uk. There are several different methods of performing a breast reduction. The commonest method results in an upside down “T” type scar but other methods may involve just a scar around the nipple, if these are appropriate. Your surgeon will discuss which method is suitable for you and the possible advantages / disadvantages.
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 after effects and decide if you really want the operation.
After examination of your breasts a preoperative mammogram may be ordered 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 your surgeon.
You need to discuss with the surgeon, the amount of breast tissue you want removed and the estimated reduction in bra size. It is not possible to guarantee the final cup size 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 (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 £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 200. 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.
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 and severely reduced whilst smoking (even passive inhalation) and for many hours after a single inhalation . This can 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 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 can occur in non-smokers they are more common in smokers. Do not undergo this surgery if you smoke. 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.
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.
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.
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.
Please review the FAQs on Mr Turton's web site (www.cosmeticbreastsurgeon.co.uk). 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 for 48 hours. Women can expect to return home 2 days post op, 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 lower waist, sponge under 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 avoid raising your arms above shoulder height. Avoid lifting anything heavier than a kettle for the first 2-weeks. Avoid opening heavy doors. Avoid using a pull-type cork screw or grating cheese!
The wounds are covered by steristrips and on top of these are the dressings. The dressing is designed to absorb exudate and blood. Do not be alarmed if you see blood spots on the dressing! It doesn't mean you are bleeding! The old blood that can collect there is 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 only 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). More 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 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 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 cause anxiety to a patient. The condition is benign and does not carry any risk. However, all lumps should be investigated by specialist regardless of whether a reduction has been performed or not.
Once discharged home, you can have shallow baths as discussed earlier. The stitches in your wound will dissolve. 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 at approximately 3-weeks after discharge. 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. 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 3-weeks and then you can buy a sports bra. This should be worn for at least a further 3-weeks. Please watch your diet whilst not exercising as usual to avoid excess weight gain.
Mr Turton advises patients to ask for annual follow-up, so that routine breast check ups 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.
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.