A breast reduction, also known as a reduction mammoplasty, is a surgical procedure that removes excess skin and tissue in the breasts to reduce their size and improve their shape. This is different from a breast lift after pregnancy, in which only skin is removed. During a breast reduction, you are getting a reduction in volume as well as a lift. A breast reduction actually is a breast lift, while also removing tissue. It reshapes the breasts, giving them a younger, perkier appearance. This is a popular Los Angeles Mommy Makeover procedure for mothers who are looking to reduce their breast size even after breastfeeding.
With a breast reduction after pregnancy, patients not only experience increased comfort due to reduced weight on their chest, they also experience a surge in self-esteem and confidence. It is interesting to note that breast reduction patients are generally the happiest group of patients. They have increased activity with less pain. Additionally, they have a broader selection of clothes available. All told, breast reduction patients get relief from both a cosmetic as well as physical burden that has been with them their whole life. If you are looking for some great results from breast reduction, then schedule a consultation with Dr. Rahban, who provides some of the best Mommy Makeovers Los Angeles has to offer.
Plastic Surgery Uncensored - Episode 52 - Teenager's Journey in Breast Reduction Part 1
Plastic Surgery Uncensored - Episode 53 - Teenager's Journey in Breast Reduction Part 2: The Aftermath
There are primarily two types of breast reduction(s). The type selected depends upon the shape and size of a patient’s breasts. While most patients would like to avoid scars, the type of incision used is based on what the patient needs in order to produce the best size and shape of breasts. It is therefore crucial that you and your surgeon have an educational discussion regarding your various options and why one approach is more ideal than another.
The lollipop or vertical incision is performed around the areola and down the front of the breasts in order to remove the excess skin and tissue. This technique is used when there is not a significant amount of horizontal laxity. That is to say, when there is not a significant amount of skin between the crease and the nipple, requiring a horizontal excision.
This incision is performed around the areola, down the front of the breast, and within the breast crease. This technique is used when a patient has excess or redundant tissue in both the horizontal as well as vertical dimensions. In patients who need the anchor incision, the distance between the nipple and the breast crease is quite long, necessitating an incision to remove the excess skin in that dimension. If the horizontal incision is not added within the crease, the breast may have a very pendulous look following surgery. This incision allows for a tighter breast shape, which is desirable.
When a breast reduction post pregnancy is performed, it is necessary to remove breast tissue from some part of the breasts, which means the surgeon is also removing crucial blood supply to the nipple. In order to lift the breast while doing a reduction, the nipple areolar complex (NAC) needs to be attached to a pedicle or blood supply for survival. There are many different pedicle types, depending on a surgeon’s preference. Discussing pedicle types is often neglected during a breast reduction consultation, as the surgeon either uses only one type or more commonly, feels this concept is too technical to discuss with patients. Dr Rahban, however, feels it is very import to educate patients regarding the various pedicles, as the type used will determine the final aesthetic outcome.
The most commonly used technique is called the inferior pedicle technique. This means the nipple remains attached to the inferior, or lower pedicle arising from the bottom of the breast. However, Dr. Rahban prefers a different technique in which he uses the superomedial pedicle. This pedicle arises from the top and cleavage area rather than the bottom of the breast.
His preference is for the following reason: the most common aesthetic complaint among women with large, sagging breasts is the lack of breast tissue in their upper chest with excess in their lower chest.
The superomedial pedicle technique preserves this crucial breast tissue located in the upper pole. Since the NAC is surviving from the upper breast tissue it is preserved and the reduction is accomplished by removing the heavy and excess breast tissue below. This is contrary to the inferior pedicle technique, in which the NAC is surviving from the bottom breast tissue, and as such, the upper breast tissue is removed to accomplish the reduction.
As a result, the inferior pedicle technique is notorious for the late complication called bottoming out. This can occur six months or later when the lifted breast tissue descends, creating a hollowness or emptiness in the upper chest and redundant fullness in the lower chest. This happens because the inferior pedicle, which is attached to the bottom of the breast, is simply pushed into the upper chest where the crucial tissue has been removed and held in place by the skin that’s brought together in a tight fashion to temporarily create an attractive shape. As we know from the original presenting issue, skin under tension will stretch with time and cannot hold the weight of the pedicle in place. This is what leads to the breast bottoming out after surgery. For this reason, Dr. Rahban prefers the superomedial technique—because the crucial tissue is never detached from the upper chest, thereby limiting any bottoming out. The heavy tissue, in exchange, is removed from the bottom, allowing the breast the proper support from the upper pole.
When selecting a breast reduction after childbirth, it is crucial that a patient understands what a pedicle is, and must discuss with her surgeon their approach and why.
In general, women with large breasts that cause discomfort and embarrassment are candidates for a breast reduction. Specifically, breast reduction candidacy includes one or more of the following:
Candidates for a post partum breast reduction should have fully developed breasts, which may occur as early as 16. Because a breast reduction also lifts the breasts to a higher position and may affect milk production, women are encouraged to undergo a breast reduction after they are done having children. This is because pregnancy can reverse some of the effects of surgery, creating the need for revisional surgery.
Often patients want to know if insurance will cover their breast reduction. The question of candidacy then becomes “is this a medical necessity as deemed by my health insurance?” Remember, a breast reduction can be as minimal as a hundred grams or as significant as a thousand grams, all of which are called breast reductions. Therefore it is important to make the distinction between what a patient feels is medically necessary and what the insurance company feels is medically necessary. Each patient’s insurance has strict guidelines by which they determine candidacy for breast reduction.
Cautionary note: Make sure that your breasts are not over-reduced in an effort to meet insurance guidelines. Many insurance companies have strict volume reduction requirements in order for you to qualify. Some doctors may remove too much breast tissue in an effort to meet these requirements, leaving patients with breasts that are now too small and appear flat. Sadly, Dr. Rahban has had to perform breast augmentations in patients with a history of breast reduction due to over-reduction. Do not lose sight of your aesthetic goals when undergoing a breast reduction. Mommy Makeover breast reductions are not simply about reduction of volume--it also must ensure a beautiful shape.
One of the areas where people make the largest mistake is in selection of the final size. Dr. Rabhan spends tremendous time in helping his patients determine what the final breast size should be. While it would be nice for a patient to simply say, “I’m a double D and would like to be a small C,” unfortunately that’s not the case. There is no magic wand that simply reduces a breast into a more attractive, smaller breast. Breast reduction is a three dimensional, geometric puzzle that requires a great understanding of spacial relationships.
Often, patients will tell their surgeon that they would like to be a small C, and to their dismay, when the swelling settles and 6 months have gone by, their breasts look wide and flat, not small and round like an attractive breast. This occurs because the one element that cannot be changed during a breast reduction is the width of the breast and chest. Therefore, if you are beginning with a very wide and large breast, you cannot reduce the width of your breast, only the size of your breast within that width.
A good way to think of breast reduction is to envision a slinky that simply retracts towards the breasts without narrowing its base. If the slinky is made too short, it now appears flat like a pancake. The length of the slinky has to be proportionate to its inherent width, otherwise it looks disproportionate and unattractive.
When it comes to breast reductions after pregnancy, it is better to compromise on the size to ensure the breasts are pretty--meaning they are round and projecting. If this is not considered, patients may get a smaller breast that is unattractive.
Note: while each surgeon approaches the consultation process differently, Dr. Rahban feels they should all have the same basic elements, ensuring patients leave very well informed regarding surgery. Below is how Dr. Rahban conducts his consultation.
Your consultation should be done by your plastic surgeon and not by his staff, such as his coordinator. In many cases, patients are offered free consultations, but you must understand that often means you’ll get a hurried consult. As a point of reference, Dr. Rahban on average spends up to an hour with each patient, reviewing not only what the patient came in for, but also explaining all the nuances such as the risks and alternatives to what that patient has requested.
There is no way to accelerate the dissemination of knowledge when it is so complicated and crucial.
During a post pregnancy breast reduction consultation, Dr. Rahban covers several crucial points. Firstly, he listens and understands what you think your issues are. After all, your satisfaction is what matters, and addressing your concerns in particular is one way to ensure this occurs. Second, after an examination, Dr. Rahban will explain in detail what he sees as the main concerns, allowing you to better understand the exact issue at hand. Next, he lays out your options, including which incision pattern and pedicle will be best, as well as the degree of reduction that is realistic for your body. Dr. Rahban’s philosophy is that breast reduction surgery is not just about making small breasts, but rather about making pretty breasts. All too often, patients end up with smaller, unattractive breasts that would have rather been slightly larger but with better shape if the proper breast reduction were performed.
To summarize, Dr. Rahban covers three crucial aspects of breast reduction:
As an extension of this, Dr. Rahban also reviews what patients should not expect from surgery. He is well known for telling his patients the truth and establishing a healthy level of expectation. Most patient dissatisfaction is related to inaccurate understanding and expectation of their surgery. Dr. Rahban deals in full disclosure to prevent this from occurring.
Finally, in the interest of helping his patients fully understand the procedure, Dr. Rahban will take this opportunity to review all potential risks. While some risks are quite unlikely, he still wants his patients to be aware of the potential downsides of a breast reduction. All surgeries come with risks. Therefore, he believes the only time to engage in surgery is if the benefits far outweigh the risks. If you will only have a mild improvement, Dr. Rahban will most definitely recommend you do not undergo the procedure.
During a consultation, Dr. Rahban has one primary purpose—total patient education. He wants each patient to fully understand the nuances of breast reduction surgery, as well as every risk and exactly how the procedure applies to them. This will allow them to make the best decision for themselves rather than be told what is best. With his honest, candid approach, Dr. Rahban brings a new level of care to Mommy Makeover breast reduction surgery.
Note: while no two surgeons perform this procedure identically, most techniques have similar steps. Below is a brief overview of Dr. Rahban’s technique, allowing you to gain a more detailed understanding of how your surgery will be performed. The more you know, the more you can be in control.
The most crucial step in a breast reduction is marking the breasts prior to surgery. The markings will determine how well the surgery is performed in terms of symmetry and overall shape. The goal with a breast reduction is reducing volume while creating a beautiful shape. Many errors in breast reduction procedures are done during the marking step, as physicians either are quick or inaccurate with their markings. A very strong grasp of three-dimensional geometry is necessary in order to get amazing results.
In many cases, breast reductions are considered solely from a size perspective and aren’t approached with the same aesthetic consideration as other cosmetic procedures. Doctors may feel that a patient with smaller breasts will be happy irrespective of the shape, as the primary goal is reduction in volume. However, without proper markings, patients may find their breasts are boxy or misshapen after breast reduction surgery.
Additionally, some physicians feel they can do the markings during the surgery. This may lead to incisions that are longer than necessary, leading to one of the most common complications, which is a visible scar within the cleavage and the axilla or armpit. Doctors who try to do their markings on the table don’t have the benefit of a standing patient to guide them.
In the operating room, patients’ arms should be secured on arm boards, allowing them to be safely sat up during surgery. One of the main methods to ensure accuracy and attractive outcomes is sitting the patient up multiple times throughout the surgery. While this may take extra time for a physician, this critical step allows for him to see the progression of his breast reduction and create symmetry.
Once incisions are made, the excess skin is removed, exposing the underlying breast tissue. Incrementally, depending on the pedicle selected by your physician, the excess breast tissue outside the pedicle is removed. Care must be taken to remove only what is necessary, leaving behind crucial breast tissue. Additionally, the tissue removed must be weighed in order to allow for symmetry between two breasts.
Once the pedicle has been created and the excess tissue removed, the breast tissue should then be brought together, creating a conical or cone-like shape to the breast. This allows for the breast shape to be created by the breast tissue, not by the breast skin. Some techniques rely on the breast skin in order to provide the breast shape, such as the inferior pedicle technique. However, this leads to poor aesthetic results several months later, as the breast skin will stretch under tension.
Now that the breast tissue has been brought together in an attractive shape, the skin can then be closed under less tension. Technique of skin closure is the single most important factor determining how your scars will look down the line. Dr. Rahban believes strongly that this step needs to be done with multiple layers of compulsive suture placement. This should be done by no one besides your surgeon, as sometimes other surgical staff are allowed to close the incisions such as the surgical tech.
The final step is the placement and creation of the new nipple-areolar complex. With the patient sitting up, the desired location for the new nipple areolar complex is marked and subsequently opened in the outer skin. Underneath the outer skin, the existing nipple-areolar complex is surviving on its pedicle. This should easily and without tension be brought through this new opening to the skin’s surface and sutured into place. This key step is where many doctors falter, creating an oblong or irregular-shaped areola. Like with every other step, great care must be used in order to create a round and appropriately placed nipple areolar complex.
Note: Your surgeon may have a different protocol but most of the core elements will be the same. Below is how Dr Rahban prepares his patients for surgery.
For patients undergoing a breast reduction, preparation begins about a month before the procedure. Our office will provide you with a full list of instructions to guide you. Each item on the list is intended to ensure you get a beautiful cosmetic result and that the surgery is as safe as possible. A few basic preparatory steps are listed below to give you an idea of what will be expected.
If you have any questions prior to your surgery, our office is available to you. Call or email us any time, and we will help with anything you need. Our goal is for you to have a successful surgery, which we believe is contingent on research and preparation.
Note: the recovery listed below is according to Dr. Rahban’s routine. Other surgeons may have a different approach to the recovery process.
Directly after surgery, you will awaken from anesthesia, at which point you will have little to no pain, as both the general anesthesia and the local anesthesia are still present in the breasts. You will have a surgical bra, as well as bandages underneath your bra. Dr. Rahban’s approach is to leave everything in place for one week until he sees you for your first post-operative visit.
During this initial period, many patients feel as though their incisions are getting dirty, prompting them to want to wash the incision themselves. This is contrary to what should be done. When patients leave the operating room, the dressings are well secured and keep the incision sterile. Because most infections occur from contamination, patients who “clean” their wounds actually introduce bacteria from their hands and water, increasing the risk of early infection. Therefore, the incision will remain clean if the dressing is simply left alone, allowing the wounds to close on their own.
Learn moreNote: While some doctors may use drains, Dr. Rahban does not with his breast reduction. He feels that with meticulous hemostasis or control of bleeding and accurate technique, drains are not necessary with breast surgery. Only in rare cases of complex revision does he use drains.
At one week, you will see Dr. Rahban, at which time your bandages will be removed along with most of your sutures. He will then begin telling you how to care for your incisions. Refer to Dr. Rahban’s scar management protocol for more information.
During the initial post-operative one-week period, you’ll have bandages on. The surgical bra will be tight and there will be moderate pain.
Most patients return to work after about 7 days. During this time, you will still be wearing your surgical bra, but it can be taken off to shower. It may seem counterintuitive, but there is nothing magical about this bra. It does not hold the breasts in a specific position, nor does it provide proper support. In fact, it’s what this bra DOESN’T do that makes it special. If a normal bra or sports bra were to be worn during this period, it may lead to the implants healing higher than one would like. Therefore, this surgical bra ensures the breasts heal properly and that you get the best cosmetic result from breast augmentation.
The second visit occurs at 2 weeks after your surgery, at which time your pain is significantly less, and the focus is on wound care. During this visit, Dr. Rahban will continue to ensure you know how to care for your incisions. As many of his patients come from out of town, it is usually this two week milestone that marks their return home. Ideally, he wants patients to remain close to his office for the first two weeks after surgery to monitor their healing and ensure they are on the right track.
At 6 weeks you should essentially have no more pain. Your scars should be well healed, and therefore you can begin to resume all previous activities with the exception of lying completely flat on your breasts, such as during a massage. Dr. Rahban doesn’t recommend this kind of activity until 3-5 months after the procedure.
Note that at this juncture, your scars will start to become more inflamed, and perhaps more obvious, as your body is beginning the proliferation phase. It is now beginning to do its healing work.
At three months, the final shape of your breasts will be obtained. That being said, your scars will most likely be slightly redder or more colored or more inflamed. This is because your body is now at its peak of healing. Therefore, it is important for patients to know that their breasts look their best after one year, at which point the scars will have fully healed.
After one year, Dr. Rahban schedules the final follow-up appointment. Dr. Rahban believes strongly in this appointment, because it allows him to do a final breast check and make sure that everything is how it ought to be. This also gives Dr. Rahban an opportunity to check on the scars, allowing him to know his final result. Most doctors should be able to see their patients at the end of a year so they can assess their work. If a physician is not seeing you once you are completely healed, he can’t see his final results and therefore refine his technique. It takes a year for the wounds to heal, and your surgeon should be seeing you at that time.
For his out of town patients, Dr Rahban is flexible and will schedule follow ups around their ability to visit him. He knows that travel and time off of work requires coordinating, so his staff will make sure to assist with follow ups. If need be he can even utilize telemedicine technology such as Skype or Facetime.
Your relationship with Dr. Rahban continues long after your breast reduction is over. At any point after your surgery, he and his office are available to help with any questions or concerns that arise. Even several years later, his door is open to patients who have concerns about their breasts.
Breast reduction risks include but are not limited to:
This means the right and left breasts will not be identical in size or shape. No two breasts are ever identical before surgery, nor will they be after surgery. The goal, however, is for the breasts to be very close in size and shape. Hence, if there is any asymmetry to begin with, Dr. Rahban will attempt to correct it. This may include the removal of more tissue from one breast.
Nipple-areolar complex necrosis, also known as gangrene. While this is the most dreaded complication, it is extremely rare. In order to lift the nipple areola complex during a breast reduction, the nipple-areolar complex must be released from some of its surrounding tissue to allow it to be lifted. Therefore, great care must be taken in order not to be overly aggressive. Other factors which may increase the risk of this complication include:
While an inevitability of surgery, the issue is not whether you will have a scar, but rather the quality of your scar. The goal is for you to have a well-healed, faint or fair scar with time. In order to prevent the unsightly scar that so many people are worried about, Dr. Rahban takes steps to minimize it.
Dr. Rahban believes in a 50-50 rule. Fifty percent of scar healing has to do with the technique of your surgeon’s closure, or how well the incised tissues are brought back together. The other fifty percent is the patient’s biology. Because a patient has little control over her biology, there is a lot of emphasis placed on your surgeon and his closure technique. While many surgeons place their emphasis on post-operative scar management, there is very little science that any of these modalities actually work. Therefore, Dr. Rahban focuses on an unusually fastidious closure technique to ensure that all tissues heal with minimal scarring.
Please refer to his timeline on wound management for more information.
This is a very rare complication. Despite this, we take action to minimize the risk as much as possible. This primarily includes having the patient stop all medications that promote bleeding at least two weeks in advance, such as anti-inflammatories, aspirin and supplements.
Also quite rare, infection is thoroughly combatted before, during and after surgery. The night before surgery, we have patients wash themselves with an antiseptic soap. We give patients antibiotics directly prior to surgery, as well as after surgery. Additionally, Dr. Rahban has very strict post-operative instructions regarding wound management that he believes reduces the risk of infection.
Patients may complain of what’s known as a boxy or square breast due to poor markings. While a breast reduction is absolutely about a reduction of volume, it is also about maintaining an aesthetic breast shape. If a surgeon makes inaccurate markings, the resultant volume may be fine while the new breast shape is unsatisfactory.
If a surgeon over reduces the breast tissue relative to your anatomy and breast diameter, it can leave you with a flat and unattractive breast.
The loss of sensation to the nipple has nothing to do with the incision used in the breast reduction. The majority of the sensation to the nipple comes from the fourth intercostal nerve located near the armpit within the breast pocket. Most loss of sensation is due to picking too large an implant and therefore damaging the nerve when the pocket for the implant is created. This is mostly inapplicable when undergoing breast reduction, but it is still a risk.
With both types of breast reduction incisions, some degree of breast tissue is incised, thereby cutting breast milk ducts. Therefore, some degree of breast milk reduction can be anticipated. Unfortunately the degree of reduction is difficult to predict prior to surgery. Many patients are still able to breastfeed after a breast reduction.
“There are several things you must look out for when doing breast reduction.
- You want to make sure that when everything is done, that your breasts are symmetrical. Many patients start out with one breast larger than the other, but the goal at the end is that they match.
- You want to make sure your breasts are not over-reduced. Often I see patients who are coming to me for breast augmentation after having a reduction. That is a preventable problem.
- You want to make sure your breasts don’t bottom out over time. Often, patients will complain that many years later, their breasts are sagging worse than they were before the reduction.
- You want to make sure that the incisions are short and they don’t extend into your armpit or into your cleavage. That is a very difficult problem to correct and you will never be able to make the scars go away.
- Closure is everything. It is critical that the incisions be closed well, because breast reduction surgeries are notorious for making thick and wide scars. I don’t allow anyone to close your incisions but myself. No tech, no other doctor. Therefore I can assure you that you will have a natural and beautiful result.”
There is no standard cost for a breast reduction as there are many unique variables. Below is a list of the elements that will determine the cost of your procedure so you understand what exactly you are paying for.
Below are specific questions to ask your surgeon during your consultation. Each of these will allow you to understand his or her approach and thus make an informed decision. To print these questions so you can ask your surgeon, see link below to download a copy take with you to your consultation.
The superiomedial pedicle technique preserves the most crucial breast tissue located in the upper pole or upper chest. The most common aesthetic complaint among women with large, sagging breasts is the lack of breast tissue in their upper chest with excess in their lower chest. The superiomedial pedicle technique utilizes this upper tissue to preserve the blood supply to the nipple, whereas the inferior pedicle technique removes the upper tissue, with preservation of the blood supply from the bottom.
Cautionary note: Make sure that your breasts are not over-reduced in an effort to meet insurance guidelines. Many insurance companies have strict volume reduction requirements in order for you to qualify. Some doctors may remove too much breast tissue in an effort to meet these requirements, leaving patients with breasts that are now too small.
Often, patients will tell their surgeon that they would like to be a small C, and to their dismay, when the swelling settles and 6 months have gone by, their breasts look wide and flat, not small and round like an attractive breast. This is the result of over-reduction.
In many cases, breast reductions are considered solely from a size perspective and aren’t approached with the same aesthetic consideration as other cosmetic procedures. Doctors may feel that a patient with smaller breasts will be happy irrespective of the shape, as the primary goal is reduction in volume. However, without proper markings, patients may find their breasts are boxy or misshapen after breast reduction surgery.
Some physicians feel they can do the markings during the surgery. This may lead to incisions that are longer than necessary, leading to one of the most common complications, which is a visible scar within the cleavage and the axilla or armpit. Doctors who try to do their markings on the table don’t have the benefit of a standing patient to guide them.
In the operating room, patients’ arms should be safely secured on arm boards, allowing them to be safely sat up during surgery. One of the main methods to ensure accuracy and attractive outcomes is sitting the patient up multiple times throughout the surgery. While this may take extra time for a physician, this critical step allows for him to see the progression of his breast reduction and create symmetry.
Every patient goes through a thorough pre-operative process. This begins with a pre-op visit two weeks prior to surgery. This is similar to a second consult. During this time, you will go over the details of your surgery with Dr. Rahban, and you will get a second opportunity to ask questions and go over your procedure, thus ensuring a complete understanding.
After a breast reduction, Dr. Rahban schedules a total of five follow-up appointments. Most plastic surgeons schedule two follow-ups, during which time you may not even see the doctor. During every follow-up appointment, Dr. Rabhan sees his patients personally.
