BREAST REDUCTION Breast hypertrophy (over-sized breasts) can occur from a variety of causes such as weight gain, inherited predisposition, or following pregnancy or the use of birth control pills. Besides being unsightly, these heavy breasts may be painful and require heavy supportive bras. Often sensual feelings to the nipples are nonexistent or when the nipples are stimulated the sensations are unpleasant. Cutting of the shoulders from the strained bra straps and back pain have been the result of hypertrophic breast. A breast reduction is an alternative for women with these symptoms. In regards to patients with moderate to small sized breast, surgery can be performed in the office surgical unit. Patients are given local anesthesia preceded by intravenous sedation, which essentially negates any feeling of the local anesthetic injections. Patients recover briefly in the recovery area and are sent home. For patients with larger sized breasts, surgery must be performed under general anesthesia in the hospital surgical unit or the Surgicenter. The surgery takes four hours, which is the same amount of time as when performed in the office surgical unit. A keyhole type of incision is made to move the nipple-areola complex to a more superior position and in turn allow for removal of excess tissue. Following removal of the tissue, the nipple-areola complex is moved to a superior position, either preserved on a pedicle of breast tissue, which runs in a vertical fashion or as a free graft. If the nipple must be moved a great distance, it is taken as a free skin graft and placed in the correct position on the reconstructed breast. Thus the breast is reconstructed into a new breast mound, which is more normal in position and more aesthetically pleasing. Patients may even be discharged the day of surgery if anesthesia has been uneventful and they are up for going home. Other times, patients are discharged a day or two after the operation. Discharge depends on their sensitivity to general anesthesia and the amount of drainage they may or may not have from their drains inserted at the time of surgery. Many of the side effects of surgery are obvious to you. You will have scars that will essentially be involved around the new nipple site and underneath the crease of the breast extending out into the axillary or armpit area. You will also have a vertical scar communicating from this horizontal scar underneath the breast crease to the nipple. These scars tend to fade with time but occasionally they can remain thick and reddened for some time. If these changes persist, the scars are excised as in a scar revision. In addition to outside scarring, there can be scarring on the inside of the breast which could involve some nerves that go to the nipple and breast area. This discomfort, caused by the strangulation of nerves to the breast by scar tissue, usually subsides with time and occurs rarely. When it persists, cortisone injections to the nerve site may be required. In rarer cases, reoperation for excision of the scar tissue around the nerves may be necessary. Depending upon the amount of breast tissue removed and whether the nipple is moved on a pedicle or replanted as a skin graft, there is a loss of nipple sensation. A grafted nipple has no feeling at all. There is also the chance of infection. In any operative procedure even a scratch on the skin can cause a local wound infection. However, in the case of the breasts, the breast tissue may also become involved. Use of prophylactic antibiotics may help the statistical incidence of this problem. Should it continue to occur, appropriate antibiotics as cultured for the organism involved are necessitated. In some cases patients may require hospitalization for appropriate antibiotic treatment and wound care. This again is a seldom seen problem but is something which must be considered. Nicotine decreases blood supply to the skin. For this reason, we demand patients refrain from chewing Nicoret gum or smoking two weeks prior to surgery and one week after surgery. Hand in hand with infection is the problem of compromised blood supply with the operative maneuver. A poor blood supply can cause death of breast and skin tissue, even inclusive of the transplanted nipple. In this rare event, patients will require revision of their wounds and sometimes even consideration of skin grafts. The nipple-areola complex, should it be lost, will likewise require reconstruction using grafts from the groin area. Again, the incidence of loss of nipple and the nipple-areola complexes is extremely rare. As with any operation, there is a chance of bleeding. Severe bleeding demands return to the operating room to evacuate any hematomas (accumulations of blood). Because of the possibility of bleeding and accumulation of body fluids, drains are often placed at the time of surgery. We ask that patients not take Vitamin E or aspirin products prior to surgery as they decrease the blood’s ability to clot. Another consideration is the effect of the reduced breasts with pregnancy. Breastfeeding is impaired significantly with the interruption of the breast tissue and the placement of the nipple in a new position. A pregnancy in itself can increase breast size and in turn cause engorgement of the breasts, essentially regrowing previously excised breast tissue from the reduction. Similar increases in the breast size can occur with weight gain. For that reason, patients for whom it is applicable should refrain from pregnancy as well as weight gain in order to preserve an ideal breast contour. Also, patients should lose weight to their baseline minimum prior to surgery in order to potentiate the best results. Another factor to be considered is that the breast tissue submitted will undergo permanent pathological evaluation. Depending upon the amount of breast tissue, this evaluation can take several days. If the evaluation reveals a breast cancer in the specimen, that breast will require definitive mastectomy. Discussions regarding the mastectomy will be made at that time. In brief, a mastectomy can be performed with an immediate breast reconstruction using either local flaps and/or flaps of skin and muscle from the back area. Underlying these flaps, a silicone implant is placed to reconstruct a breast mound. In cases where there is a high index of suspicion or strong family history or concern on the part of the patient, we will obtain mammograms preoperatively. It is preferable that patients scheduled for major operative procedures contribute their own blood prior to their operation. Preferable two units of blood are contributed over two to four weeks. These units are stored fresh for up to 30 days but can be frozen for up to five years. Iron therapy is recommended for ten days prior to auto-donation and continued up to and after the time of surgery. Designated units from close family donors can also be arranged in the event of a patient being unable to donate for themselves. I would recommend that you review the points in this letter with a loved one who might also accompany you on your next visit as a neutral third part and add further objectivity to your decision making process. For purposes of insurance coverage, we will be sending a letter of preauthorization to your carrier or carriers with appropriate photographs and a letter of explanation regarding your surgery. We will attempt to expedite authorization but this varies with the various agencies involved. Medicare will not pre-authorize any surgeries, but, in those patients with photographic and operative specimen verification, there has been no problem with payment. Please feel free to ask questions on any of the points raised in this letter of Dr. Kennedy or any member of his staff.
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