#13: Everything You Need To Know About Breast Reduction

This week Dr. Barrett does another solo episode delivering answers to the most asked questions about breast reduction. Tune in and get answers to the top questions we're asked about this impactful procedure.

You are listening to The Natural Plastic Surgeon Podcast. I'm Dr. Daniel Barrett, Board-Certified Plastic and Reconstructive Surgeon located right here in Beverly Hills. I specialize in cosmetic surgery of the face, nose, breast and body. This podcast is dedicated to those deciding if plastic surgery is right for them and revealing all the latest beauty secrets. New episodes premiering every Monday at 10 am. Let’s get started.

On this episode of The Natural Plastic Surgeon…

Dr. Barrett: A lot, a lot of my patients they frequently have neck pain from the bras. Or shoulder pain or back pain--upper back pain--is...and because of their breasts are just so heavy. They're not able to do exercise. They’re not able to run or jog without triple sports bras.

Dr. Barrett: Natural-looking is key. You want the breast to look like a teardrop shape. And again the vertical breast reduction helps achieve that. But also you want to minimize the scarring. So even though the lollipop vertical breast reduction is a better way to go, you still have some scarring around the areola. You want to make sure that your nipples and your areola match the size of the breast. And you also want to make sure you manage your scarring and your, your healing afterwards. So I tape all my patients, their incisions….


Hey everyone this Dr. Barrett, we've got a special episode for you today. This is everything you need to know about breast reduction. A lot of you know that I had a recent patient who's an influencer, Nicol Concilio, who recently had a breast reduction. And we answered a lot of questions on that episode, which we can link to in the show notes for you, so you can go check it out. But I wanted to, kind of, dive into all of the other questions, and all of the other aspects about breast reduction that I think are really valuable to people that are thinking about getting breast reduction procedure.


Okay, so first of all, what is breast reduction surgery? Breast reduction surgery is a surgery whereby we remove breast tissue, either through direct excision, or liposuction to reduce the volume and the weight of the breast. There's a lot of different techniques that this can, that can be used to make this happen. And I, I want to, kind of, touch base on those really quickly.

The first one is a, is the most common one that's done. It's called the anchor pattern or Wise-pattern, where they have an incision around the areola, a line going down and then a horizontal line going across the bottom. That's called the anchor pattern or Wise-pattern breast reduction. It’s the most traditional, most commonly-used technique for breast reduction. It certainly works. However, the, the appearance of the breast can be kind of flat and boxy. Because of the, and those additional scars can be unsightly, especially the horizontal component, which I think are unnecessary.


There's also a free nipple graft or amputation-style breast reduction technique. These are really, for really, really large women who have greater than 26 centimeters distance from their nipple to the inframammary fold. That's where we actually take the nipple off, amputate the breasts and then put it back on. And that's, that's rather than dramatic and most people don't typically do that.


The third option is a lollipop or vertical breast reduction. And this is a technique designed, created by Dr. Elizabeth Hall-Findlay. She's got a practice up in Canada. You should definitely check out her website. She described this technique whereby she doesn't try to hold the whole breast up with the skin, right? That's what the Wise-pattern tries to do with that anchor, it tries to hold it all together with the skin. Because, guess what? We know this from facelifts--that when you do a facelift and you try to hold everything up with skin, it relaxes in about a year. And then you lose the whole result.

So what she does, what she designed instead is to do internal suturing to hold the breast up, incisions around the areola and a single line going down. And then to address the lateral fullness and the medial fullness, you use liposuction instead of making big incisions to chase out the extra breast tissue. Okay, so this is the technique that I actually went and learned from her to use and I think is the best way to do breast reduction. Or breast lifts, rather…actually, breast lift or reduction to get that more three-dimensional, perky breast that doesn't drop over a year or two year’s time, because it's not using the skin to hold the breast up. You’re using internal pillar sutures to make it all stay up and high.

There's more to it than that, you can really get a deep dive into about the surgical procedure. You can actually check out some of my videos on how I actually do that. So you can see how we remove the tissue on the bottom and we keep the fullness up on the top. And that's kind of the key for the vertical breast reduction.


All right, so who's a good candidate for breast reduction? Well, you know, if you have very large breasts and they're bothering you, okay, so and they're causing pain. So a lot, a lot of my patients they frequently have neck pain from the bras. Or shoulder pain or back pain--upper back pain--is...and because of their breasts are just so heavy. They're not able to do exercise. They’re not able to run or jog without triple sports bras. You don't have to live like that. So you can, you know, this operation is a great operation for you. Or you're getting skin rashes underneath, in the fold underneath the breast, frequently, that could be a sign that you might need a breast reduction.


Now, it's actually one of the cosmetic surgery, one of the procedures in the cosmetic surgery realm that insurance actually covers. Now there's some requirements for that. You have to check with your insurance plan but, typically, if you have about 500 grams or more of tissue that needs to be removed and you're having physical symptoms and complaints that have failed diet, exercise and weight loss, you might be able to get your insurance to cover it, okay? But you have to get pre-authorized to do that. You have to make sure that your, your insurance accepts certain physicians...that you're considering coming here, out of network coverages and stuff like that.

That is you know, the, the candidates and I will say that my breast augmentation--I'm sorry--my breast reduction patients are my happiest patients. Because we're, we’re both alleviating a functional problem, and creating a nice cosmetic appearance for the breast for our patients. So there's, it's a double win. We’re killing two birds with one stone, you're getting reduction of all those, the weight problem, the neck pain, the shoulder pain, the rash problem and you're making them look a lot nicer and matching the person's body.

A breast reduction is not for someone that has excessive weight. Okay, so if you need, breast reduction for people that have tried diet, and exercise and weight loss, and their breasts don't change any size. You, you know who you are, you were, you were 13-years-old, and you had really large excessive breast growth, and the rest of your body is completely normal size. That is a typical breast reduction candidate.


So where do you start with your breast reduction research? Well, it all starts with the type of reduction. And I would say find a surgeon who does a vertical breast reduction. I think that's the best, the most advanced, the latest, superior breast reduction technique. Find someone who does a lot of them. Make sure that they're board-certified, check their reviews, check their before and after photos. That's your checklist. Go through all of those.

Then go meet with the doctor, make sure it's a good fit. You want to make sure that you can get the size that you want because...do you want to be DD, D, C, a B? Do you want nothing at all? Okay, you have to be clear in terms of what your goals are. Find some photos that actually match what you're looking for in terms of your expected size or what you want, what you see for yourself once you're all set and healed, okay?


How do I get natural-looking breast reduction results? Natural-looking is key. You want the breast to look like a teardrop shape. And again the vertical breast reduction helps achieve that. But also you want to minimize the scarring. So even though the lollipop vertical breast reduction is a better way to go, you still have some scarring around the areola. You want to make sure that your nipples and your areola match the size of the breast. And you also want to make sure you manage your scarring and your, your healing afterwards. So I tape all my patients--their incisions--for once a week, for six weeks. And that tape forms like an external cast.


So if you were to break your arm, you would need a cast on your bone, for your arm, for six weeks for, in order for it to heal. The same is true for your skin. So that's why we tape the incisions for six weeks. So we don't get any micro-movements when you're taking a breath or moving that cause a little slight disruption in that healing environment so that those skin cells can reach out and connect with the other skin cell that was previously moved from the surgery, okay?


How do I determine size? Well, that's done in the operating room. So we, we get photos from you in terms of what your goals are and goals, goal size photos. And then we start with a conservative amount of reduction. Because once you take the tissue you can't put it back. So we do piece-by-piece, we weigh it. We check the other side piece-by-piece. Then we perform our liposuction. We try to do tailor tacking, make sure we have good symmetries. Because most people, one breast is bigger than the other. And you have to try and adjust for that to give yourself a little more symmetry. I think you do, you don't want to just take the same amount off of each breast. Unless you have perfectly symmetrical breasts, which is very rare.


Do I need implants with my breast reduction? This is something that some surgeons actually do, they'll put a breast implant in for upper pole fullness. And then they'll do the breast reduction. So it's, it’s like, it's like you're adding volume, but then you're taking it away. I, I think it's probably not applicable for most of the situations that it's actually used in. It'd be very rare to actually do a breast reduction and augmentation at the same time in my book.

I think if you do the appropriate breast lift and reduction at the same time, you don't necessarily need an implant. Because how does that make sense? You're actually taking breast tissue, but then you're adding an implant in? So you're adding and then taking away? I feel like you just need to make up your mind--which way you want to go? So that's why, I, I'm not ruling it out completely. There’s some situations where it might make sense. But majority of the time you just need to choose the right reduction technique, and then you avoid some of the implant complications that can happen. You gotta get an implant replaced every ten years, you could have capsular contracture, you can have implant rupture--all kinds of things. And when you have this beautiful breast tissue, yes, it's way too much, but you have this beautiful breast tissue, you want to get that up and the right position, then you don't need an implant. You got all God's gift right there on your chest.


All right, will it affect nipple sensation? Possibly. So the rate of that we don't really know. It's, like, a little less than 5% of loss of nipple sensation. I think if you're very careful with your dissection and your surgical technique, and you understand the anatomy where the nerves come through, you can greatly reduce your loss of nipple sensation. A lot of times you get temporary numbness with the time of surgery, which generally starts to come back around six months.

However, nipple sensation, if you're one of those people, that nipple sensation is the most important thing to you in the world, then don't do breast surgery, okay? Because there's always a chance that you can lose that. So it's always a, surgery’s a risks and benefits. There's no perfect operation. I can't wave a magic wand and make your breasts look smaller. I wish I could, without any surgical complications. And, and so yes, I am trying to minimize those complications for you. But they still exist. So you have to weigh those. It's important to understand them and weigh the relative risk.


Can I breastfeed after a breast reduction? So, so here are the, the statistics on breast reduction and the ability to breastfeed afterwards. There's a 40%, the, there's various papers that talk different amounts of percentages. But the consensus is about 40% of women who get breast reduction surgery have difficulty, serious, significant difficulty breastfeeding. Okay, so if breastfeeding is the most important thing to you in the world, it is very important, but if it's the most important thing to you in the world, do not get breast reduction surgery or wait till you have children.

However, if this is a very functional thing for you, and very limiting, then go get the surgery, okay? There's still a chance that you could still breastfeed, but if you're having back pain, you're not going to be a good mother and, you know, to your children if you're counting living in this pain and they’re, they're causing irritation to you, and they're only gonna get bigger during pregnancy.

So when I do my breasts reduction operation, I'm really trying to minimize the amount of removal of the glandular tissue compared to the total glandular tissue connection to the areola and nipple complex, right? So if you think about it as a pyramid, trying to take a little wedge of that pyramid, but leaving all of the other parts of that pyramid intact, so that there's still a glandular nipple connection for my patients to breastfeed if they choose to do so, or if they choose to plan to have kids. What I don't like to mess around with, in terms of operations and the potential for breastfeeding later, is nipple surgeries. I don't like to do nipple reductions, or inverted nipple repair on women who want to breastfeed afterwards. Okay, because the nipple is a top of that pyramid. That's where everything goes, right? You can take a little bit of the corner of the pyramid, but if you take the top of that pyramid, you're going to really significantly disrupt your ability to breastfeed.


Should I wear a bra after surgery? This is where I differ from a lot of other plastic surgeons. I don't put you in a compressive bra after surgery. Main reason why is because we've just disrupted the blood supply to that pyramid, right? By taking out a big chunk of that, of that breast tissue. So if we compress that whole breast afterwards with a very tight surgical bra, you're more likely to get nipple necrosis and that's the number one fear of breast reduction surgery is getting nipple necrosis.

Just imagine if you fell asleep on your arm, right, you're cutting off the blood supply to your hand, it goes numb. Now, if your hand just had surgery on it, you could have wound healing problems. Let's say, you're doing the same thing when you're putting on a tight surgical bra. So yeah, that's a traditional thing that a lot of surgeons typically always use. And people always ask me, like, you know, how come you don't do that? Well, I get much less rates of nipple necrosis--actually, virtually none--much less rates of incisional necrosis, which can also happen on the, on the base of the incision.


Recovery. Breast reduction procedure is actually a pretty speedy recovery. Patients wake up, they feel instantly better. Everyone. They always feel instantly better. They feel like a weight has been lifted off their chest. Yes, there's a little bit of soreness. But it's not like a breast augmentation procedure where we're actually messing with the muscle. We're only messing with the glandular breast tissue on top. Yes, there's some incisional pain, and there's some breast pain, but there's very little, like, deep pain that could keep you up at night time. Okay?

So that's why breast reduction recovery is pretty quick. I have a specific protocol I start all my patients on. First two weeks, all you're doing is walking. Second two weeks, you can do exercise, cardio, get your heart rate up. And then week four, yes, you heard this, right, you can go jogging, okay? You can actually go running with a sports bra, as long as you have some support. And then week six, you can do upper body exercises.

So I, kind of, I believe in accelerated recovery using your body as your guide. I really, I can't stand when people are sedentary for the entire six weeks when they're healing because you just get way out of shape. You're not healing, you're not, it's not healthy for you. Okay, so I always like lots of movement after all my surgeries, and there's no exception when it comes to breast reduction.


Has anyone had a crazy reaction to the surgery? No, I don't think anybody's had a crazy reaction. I think everybody has done extremely well. Nobody, none of my patients have had significant pain when they wake up. Anesthesia is extremely safe. You're more likely to be struck by lightning in your lifetime than to have a significant problem from anesthesia.

We do do a general anesthesia because, yes, parts of, some people try to do breast reduction under local but it's, it's just way more comfortable. You take a nap. I do inject a lot of numbing medicine throughout the whole breast. I even actually tumesce it with a tumescent solution. Because even though your mind is asleep with general anesthesia, your body has sensation and it can feel trauma. All right? So that trauma goes to the spinal cord and the spinal cord has a primitive memory as well. So I try to minimize that by injecting lots of numbing medicine for at the time of surgery.  So you're really not getting a whole lot of trauma on your body. And so your recovery is much faster. That's why a lot of my patients are really back at work in three or four days after breast reduction.


What is the procedure like? Well, the, the main part of breast reduction, that's the most important, in terms of the procedure, is the markings. We spend a lot of time, when you show up the day of your surgery, we spend a lot of time doing the markings. And about 15 to 20 minutes doing the markings. And I want to make sure they're symmetrical. I want to make sure that we have the measurements very precisely because you want to measure twice, cut once.

Once we get to the operating room, it's actually very easy. You just come and you lie on the table, you relax, you get some nice medication and off you go, you're asleep. You, the, the worst thing is getting an IV. And it's a tiny little needle and they anesthetize the whole area. And once the IV is in, you're good to go.

So once you are asleep, then we actually prep the area. Make sure it's nice and clean. And we go over our markings again and make sure that they didn't get disturbed with the prep. The prep is a cleaning solution to make sure it's completely sterile. And then we inject all of that numbing medicine--we spend about 15 minutes injecting the numbing medicine, the tumescent solution. We make our incisions, we remove the tissue that we need to remove. And we weight it as we take it out, and we compare to the desired size photos, okay? So as we're taking that tissue out, we're, kind of, looking and, kind of, you know, taking piece-by-piece. We’re really trying to sculpt the breast and making sure that you're getting the size that you want.

And then we do our final touches with the liposuction. And a lot of times I go into the axilla so we don't have any bra fat that, kind of, hangs over. And then we close it up. We close it in five layers. The breast has five layers. We do those internal pillar sutures, we check the nipple, make sure there's no liability issues. We close it in five layers and then we tape it and, and that's it. We put some gentle gauze on it if there's any oozing and it oozes for the first 24 hours, but no surgical bra.


We talked about recovery. And how about people that are coming from out of town? If you're coming out of town for a breast reduction procedure, I would recommend you stay out here for two weeks. Or come back, stay out for the first couple days, get the first layer sutures out and then come back for a second visit at week two. We can have you just do one follow up visit but, generally speaking, I like to, like to see you at least twice after the operation and then we can do follow-ups via Telemedicine or Skype, so that we can make sure that you're healing well and doing everything you're supposed to be doing.


Here's another question. I have two children.  How will they sur…how will the surgery affect my care for them? Well, if you have very young children, you don't want to be picking them up for the first six weeks. Obviously your incisions, they're being held together by sutures--a lot of internal sutures--and you want to make sure that you're protecting that area so it has at least good six weeks to, kind of, heal and form a very tight closure.

So that's it for our breast reduction Q&A you guys. And I hope that was very helpful for you to learn about breast reduction procedure. I have a whole website if you want to learn more information, it's called ReductionsByBarrett.com. Or you can check out my main website, DrDanielBarrett.com and check, check out my breast reductions there. Again, final advice, make sure you do your research, find a board-certified plastic surgeon who does a lot of breast reductions and look for that vertical breast reduction technique. It'll make a huge difference in terms of your quality of your results.

If you have any questions, feel free to shoot me an email or leave your comments, questions, feedback right here on my YouTube page, or here on the podcast.

Thank you so much.

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Here’s the link to the episode discussed in this podcast: Influencer Nicol Concilio Gets a Breast Reduction!