Breast Surgery & Procedures

 

Breast Lift - Mastopexy

 

Procedure:

Raise and reshape sagging breast by removing excess skin and repositioning remaining tissue and nipples. (Can be combined with augmentation surgery*).

 

LENGTH:

2 to 2.5 hours.

 

ANESTHESIA:

General anesthesia usually outpatient surgery.

 

SIDE EFFECTS:

Temporary bruising, swelling, discomfort, numbness, dry breast skin. Permanent scars.

 

RISKS:

Thick, wide scars; skin loss; infection. Unevenly positioned nipples. Permanent loss of feeling in nipples or breast.

 

EXERCISE:

Resume 1/3 intensity at 3 weeks. Low impact activities at 1/3 duration of exercise, repetitions, amount of weight and pulse rate. 2/3 intensity at 6 weeks. Full intensity including high impact (running, horse back riding, high impact aerobics) at 8 weeks.

 

FADING & SCAR IMPROVEMENT:

6 to 24 months.

 

SWELLING:

Moderate/Significant 4 weeks, Subtle/Mild 2 to 3 months, all of which are dependent upon extent of procedure(s).

 

DURATION of RESULTS:

Variable. Breast size may fluctuate with hormonal shifts, weight changes, and pregnancy.

 

OFFICE VISITS:

1st 5 to 7 days / 2nd Visit 10 to 14 days. Anticipated office visits: 4 to 5 the first 3 months then yearly.

 

GARMENT WORN:

Support as needed for 6 weeks.

 

PAIN MEDS:

Ibuprofen or Narcotics as needed.

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More Information About Breast Reduction

— Reduction of Breast Size with Breast Lifting and Reshaping

The operation to reduce the size of the female breast has been refined significantly following its widespread introduction in the 1950’s. The term reduction mammoplasty refers to surgical procedures which reduce the size and weight of excessively large breasts. Breast reduction surgery alleviates many of the following complaints of women suffering from mammary hypertrophy (excessively large breasts):

• Shoulder grooving from the weight borne by the bra strap causing pain and disfigurement,

• Back pain, neck pain, and general discomfort from the weight of the breasts,

• Rashes under the breasts from moisture accumulation especially in warmer weather,

• Limitations with certain activities such as aerobics or sports making physical fitness and weight loss difficult,

• Social embarrassment resulting in shyness, loss of confidence, and avoidance of certain social activities that require revealing clothing (swimming, hot tub, etc),

• Difficulty finding clothing that fits appropriately without the need for alteration. In addition to the information contained here, during your consultation and examination, we will review specific factors which pertain to your individual case. (As you review this information, please write questions in the margins that we can address during your consultation.)

Mastopexy procedures (breast lifts) are designed for women whose breasts have begun to sag due to the effects of gravity and aging, or after pregnancy and breast feeding. The degree of breast ptosis (sagging of the breast) ranges from mild (slight loss of nipple height with bottoming out of the breast tissue) to severe (extreme stretch marks with the nipple pointing to the floor), with different procedures used to correct the various degrees of sagging. In general, mild cases can be corrected with minimal scars while severe cases often require additional incisions.

The female breast is composed of two main components: A skin envelope, and the breast tissue within that envelope. When the glandular tissue of the breast is extremely large, the effect of weight and gravity over a number of years stretches the skin envelope. As the envelope stretches, the breast sags and elongates, and the nipple areola complex moves downward relative to the initial position of the breast mound. Excessive enlargement of the breasts may be due to many factors including genetic predisposition and hormonal influences.

In reduction mammoplasty, three separate components of the breasts are modified in order to improve excessive size: 1) The total amount of glandular tissue within the skin envelope is reduced, 2) The skin envelope itself is reduced and tailored to a smaller size to fit the reduced glandular tissue, 3) The nipple areola complex is repositioned and moved upward to be centered on the new breast mound.

In mastopexy procedures (repositioning of the breast mound without significant reduction), the amount of glandular tissue is not significantly altered, but the breast mound is repositioned back up on the chest wall. The nipple areola complex is repositioned upward on the new breast mound as in reduction mammoplasty. Hence, the primary difference between reduction mammoplasty and mastopexy is that mastopexy involves repositioning without reduction of the size of the breast. The specific type of surgical procedure best suited to reduction or repositioning of your breasts depends upon several factors. The specific size and shape of your breast, the size and shape of your frame and torso, as well as your desires regarding the amount of reduction or repositioning, and the limitations of specific surgical procedures are all important. At your consultation, after examining you, I will discuss in much more detail the type of procedure I feel best indicated for correction of your specific deformity.

With both mastopexy (lifting) and reduction mammoplasty (reduction in size and repositioning), it is necessary to make incisions in the lower part of the breasts in order to reduce the skin envelope and to reposition the nipple areola complex. These incisions are made and closed very carefully, but nevertheless, any surgical incision must result in a scar. In every case, I attempt to minimize the amount of scar necessary to achieve the desired result, and certainly to maximize the QUALITY of the scar.

Nevertheless, in considering either mastopexy or reduction mammoplasty, it is important for you to recognize that these scars will be present and are necessary to achieve correction in the size and position of your breasts.

The specific appearance of scars is variable according to your own healing characteristics. Scars require approximately one year to totally mature for their best appearance. Initially, the scar is a very faint line, which then becomes reddened and slightly raised and stays that way for a period of two to three months. As the redness fades, the firmness also subsides for about one year. The scar is then mature, faded in color, inconspicuous and soft. When closing any of the incisions, I turn the skin edges slightly upward or everted, and you will notice a very slight ridge along the incision for a period of weeks. If skin edges are not everted at the time of closure, scar contracture, which occurs over a period of 3 months, can result in a depressed scar which is more visible and less desirable. When the edges have been turned upward slightly, as healing occurs, the scar flattens and becomes less visible.

The length and specific location of scars depend on the specific type of surgical procedure necessary to correct your breast size and shape, and I will discuss this in detail with you during your consultation. In general, scars are placed in the fold beneath the breast within bra and bathing suit lines in order to minimize visibility. Since most of the stretching of the breast skin envelope occurs in the lower half, it is in this area that most of the envelope reduction is carried out.

In order to achieve the desired result, at the time of your operation it is necessary to tighten the lower portion of the skin envelope significantly, since in the first few months following your operation, the lower portion will again stretch slightly due to the weight and downward pressure of the tissue left in the breast. Although this effect is minimal, it causes some change in the shape of the breast in the first few months following your operation. Initially, the lower half of the breast from the nipple to the fold beneath the breast will be quite tight and slightly flatter than its final contour, which will be more rounded when the skin stretches. As the breast tissue settles downward slightly, the position of the nipple areola complex will rise slightly and point more upward on the breast mound. Hence, AT THE TIME OF YOUR OPERATION, IT IS NECESSARY TO FLATTEN THE LOWER PORTION OF THE BREASTS SLIGHTLY AND POSITION THE NIPPLE AREOLA COMPLEX SO THAT IT IS POINTING VERY SLIGHTLY DOWNWARD.

In the first 2-6 months following your operation, the lower pole skin will stretch, and the nipple areola complex will rise slightly to give the final more pleasing contour of the corrected breast.

If your breasts are extremely large, you will notice some difference in your balance and posture immediately following your procedure. Although these sensations may be significant in the first day or two, you will readily adapt to the reduced breasts and be significantly more comfortable.

In order to reposition the nipple areola complex, it must be PARTIALLY detached from the surrounding breast tissue, leaving a bridge of tissue to provide blood supply to the nipple and areola. The amount of detachment necessary depends on the size of the breast and the distance the nipple must be moved in order to be centered on the new breast mound. In mobilizing or separating the nipple areola complex, it may be necessary to detach both some of the nerves to the nipple as well as some of the milk ducts. If this is necessary, there may be some reduction in the sensitivity of the nipple areola complex, as well as reduction in the ability to nurse. In the newer types of procedures we are currently using, reduction in nipple sensation as well as reduction in the ability to nurse are significantly less than in previous years, but nevertheless may occur. In mastopexy (repositioning without reduction), reduction in sensation and ability to nurse are usually not as significant as in reduction mammoplasty. After examining your breasts, I will discuss in more detail with you to what degree I think these limitations will apply to your case.

THE SIZE AND SHAPE OF THE BREASTS VARY SIGNIFICANTLY FROM ONE SIDE TO THE OTHER IN MOST WOMEN. The difference in size is frequently 10-20%, and the specific shape of the breast is determined by the shape and size of the skin envelope. With both reduction mammoplasty and mastopexy, I attempt to equalize the size and shape of your breasts as much as possible. Due to limitations of your tissues, as well as the healing and stretching properties which occur following the operation, there will be slight differences in the size, shape and nipple position in the two breasts following surgery, just as there were before surgery. These differences are usually minimal, and within the range of normal breast asymmetries.

In general, breast reduction and mastopexy are performed under a light general anesthetic. I believe (as do our board certified anesthesia colleagues) that this is a better and safer approach than local anesthesia alone or local anesthesia under sedation with intravenous drugs.

Breast reduction and mastopexy can sometimes be combined with other surgical procedures, usually producing slightly greater, but nevertheless acceptable risks. For example, breast lifting is often combined with breast augmentation. A decision in this regard must be strictly individualized, depending on the type of other surgical procedure being performed as well as other medical and surgical factors.

The purpose of all types of cosmetic surgery is to improve your appearance as much as possible. This change will hopefully improve your quality of life by improving your self image in a very positive way. By addressing and improving those specific areas which detract from your appearance, leaving the positive aspects of your appearance undisturbed, this type of surgery results in an overall improvement in your appearance. Cosmetic surgical procedures are not magic. They are detailed procedures designed to improve specific aspects of your appearance. They can do no more than that. Whether you are happy with the results of cosmetic surgery will depend largely on how well you communicate to us which specific aspects of your appearance you are unhappy with and how well we communicate to you what a surgical procedure can and cannot do toward alleviating the problem. Plastic surgery does not perform miracles. A combination of art and science, plastic surgery is not an exact science. Some of the factors involved in producing the result (such as your healing characteristics) are not totally within your or our control, and therefore, it is impossible to warrant or guarantee the results of your surgery.

After talking with you and examining you, I will make every effort to clearly and precisely give an opinion about whether a specific surgical procedure can significantly improve your areas of concern with a high degree of reliability and a minimal level of risk. All cosmetic surgical procedures involve some trade-offs. I will try to outline these clearly for you and answer any questions you might have. The final decision regarding having the surgery is yours, and I encourage you to consider it carefully and deliberately.

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AT YOUR INITIAL CONSULTATION VISIT:

When I visit with you in the office, we will review your past medical history, as well as your desires regarding either reduction or mastopexy. Age is not a limiting factor in determining who can have either procedure, as long as your general health is good. We will review extensively the information contained here, as well as more specific information with respect to your specific needs. I will examine your breasts in order to make recommendations about the appropriate procedures, as well as to insure that no clinical abnormality exists before surgery.

In this consultation, I would expect you to be frank in discussing your expectations with me. Do not hesitate to ask any questions that you may have. I will be equally frank with you, explaining the factors that could influence the procedure and the results.

I cannot make the decision for you regarding whether to undergo surgery or not. I can only advise you regarding the surgical options and anticipated outcomes I would expect for you based upon your individual anatomy, desires, and realistic expectations. I will define goals in a surgical plan at this initial consultation. Follow up appointments will include time to ask further questions or review the procedure so that you are comfortable with its nature and implications. I will educate you and define the operative scenarios and choices available to you, but you must make the final decision regarding the surgical procedure.

When a decision is made to proceed with surgery, preoperative photographs will be taken. These photographs are essential to the planning, execution, and follow-up of your procedure. If you are a candidate for breast reduction, the photographs are often required by insurance companies for pre-approval of the procedure. They are taken with you in the standing position (the position in which you are most often seen). You are lying down during the procedure and we refer to these photographs frequently, as your tissues appear very differently than when you are standing.

Our staff will discuss the fees for the surgical procedure, and estimated fees for the cost of the operating room and anesthesia. If the size and weight of your breasts is causing significant functional impairment, some health insurance policies may cover a portion of your surgical and hospital costs. Mastopexy, or repositioning of the breasts without significant reduction in the size, is considered a cosmetic procedure and is not usually covered by health insurance. After our consultation, I will be happy to write your insurance company, and our staff will communicate with them regarding the degree of coverage of the specific procedure planned in order to assist you with financial planning for your surgery. Our staff will discuss the fees for the surgical procedure, and estimated fees for the cost of the operating room and anesthesia. Fees for cosmetic surgery are payable prior to surgery, and include the cost of the surgery, and postoperative follow up care. A surgical assistant’s fee may be charged, if a second surgeon assists me during your operation. Tissue removed during surgery is required to be sent to pathology and you may receive a bill for this service.

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BEFORE YOUR REDUCTION MAMMOPLASTY OR MASTOPEXY:

Our nurse and office manager will make all arrangements regarding scheduling of your surgery and will give you specific instructions as well as reconfirm these with you by telephone and/or letter. Since both of our schedules must be coordinated with the surgical facility and anesthesia schedules, please allow our personnel a reasonable amount of time to make these arrangements. They will make every attempt to accommodate your requests.

Good general health is mandatory for a problem free and predictable recovery from any surgical procedure. Wellness and good general health result from proper diet, regular exercise and appropriately timed medical evaluations focused on preventative medicine. Good nutrition, vitamin and herbal supplements, as well as adherence to holistic health principles are important concepts in maintaining wellness. Certain supplements, although generally beneficial, may have adverse effects during surgery. Please advise us about all your medications and supplements, so we may advise you regarding their safety in regard to your surgical procedure.

We believe that good nutrition is an important component to excellent surgical outcomes. Multiple studies show that most Americans aren’t getting the recommended daily intake of necessary vitamins and minerals, much less the optimal amount. These sub optimal levels of nutrients have been linked with major diseases from heart disease to cancer.

We use a three phase healing program with nutritional supplements to help you recover more quickly and with less downtime. We have you start this a week or so ahead of time to ensure that you are boosting your body’s immune system and removing anything that could interfere with anesthesia or increasing bleeding. Immediately following surgery we give you nutrients that help reduce pain and inflammation and detoxify the anesthesia and other medications. The third phase has additional healing nutrients to support your recovery.

Routine laboratory tests including blood counts and blood chemistries, a pregnancy test when applicable, and an electrocardiogram if you are over 50 years old, will be performed prior to surgery. These tests are performed routinely to screen for any abnormalities which might complicate your anesthesia or surgery. A recent mammogram may also be required to complete your preoperative evaluation.

Do not take any aspirin or any drug containing aspirin for at least two weeks prior to your surgery. Aspirin may retard platelet function, a blood component that is important to normal blood clotting mechanisms. There are many drugs which contain aspirin. Before taking any drug, check the label carefully to assure that it contains no aspirin.

Nicotine causes constriction of blood vessels, and can impair circulation to tissues following any surgical procedure, especially those of the skin. Smoking should be discontinued prior to the procedure for a minimum of 2 weeks. You should cease smoking for a minimum of 4 weeks following your procedure.

Do not eat or drink anything 8 hours prior to surgery. Safety in the administration of anesthesia or sedation requires that your stomach be absolutely empty for this interval of time before surgery.

You may shower or bathe normally the evening prior to surgery. Additional antiseptic cleansing of the skin areas will be carried out by our nurses immediately prior to your surgery.

You should wear loose fitting, comfortable clothing the day of surgery. A loose fitting shirt with buttons in front is preferable to any type of clothing which must be put on over the head. Please be sure that you have all of your questions answered prior to going into the surgical facility. I prefer that you make an additional appointment in the office if necessary to answer questions regarding your surgery. On the day of surgery, I will visit with you briefly immediately prior to surgery.

Arrange for someone to drive you home at the appropriate time following your procedure, and arrange for someone to stay with you the night of surgery.

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THE DAY OF SURGERY:

In most instances, these procedures are performed using general anesthesia. Occasionally, mastopexy may be satisfactorily performed using local anesthesia with heavy sedation so that you have absolutely no recall of events of the surgery.

During your surgery, incisions are made according to the markings made prior to surgery, the skin envelope and glandular tissues are appropriately reduced, the breast mound repositioned, the nipple areola complex repositioned, and all incisions carefully closed. Depending on the extent of the procedure and anticipated fluid drainage following your operation, small silicone rubber drains may be placed at the time of operation. These are very small tubes, which will exit through the corner of your incision and will be removed during your first dressing change following surgery. You will have a compressive dressing for several days after surgery, which will be replaced with light gauze dressings and a post-operative bra for comfort.

Following your operation, you will remain in the recovery room for approximately one hour, and then be transferred back to your room (if in-patient). I will speak briefly with your family or friends immediately following surgery.

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Postoperative Healing:

Postoperative healing requires some mandatory down time as part of the surgical recovery process. Post surgical healing requires the body to repair the surgical wound (whether in the skin, fat, muscle or bone) with scar tissue. The bruise and tissue fluid in the wound are gradually replaced by stronger scar or fibrous tissue over a period of 6-8 weeks. Until the time that the healing area is strong enough to maintain tissue integrity, the wound is held together by the sutures (stitches) placed at the time of surgery. Too much wound tension (stress) before the strength of the healing tissue is satisfactory, can cause disruption of the incision. I place sutures very precisely to account for these healing characteristics to maximize your postoperative activity, comfort, and safety. However, your inherent healing characteristics significantly dictate these parameters. Stretching, movement, massage, and return to normal activities of daily living in the early postoperative recovery allow for the optimal return to your full normal life style.

After the initial burst of high energy healing and the bulking up of scar tissue, the wound enters a maturation phase, and the scar tissue becomes thinner, less red, and stronger. The maturing and stabilization of scar tissue occurs over a period of 6 to12 months. Long-term changes tend to be more subtle, slower, and less evident than short-term changes that occur in the first 6 to 8 weeks.

There are no absolute parameters regarding return to postoperative activities and one must adjust for variation in pain tolerance, invasiveness of surgery and healing variations.

In general, you cannot speed up the healing process, only slow it down by too much activity too soon. Overexertion can lengthen the period of time for pain to decrease, swelling and bruising to resolve, and the final surgical results to be evident. Healing occurs for up to one (1) year, sometimes longer. The latter changes tend to be subtle and gradual, and therefore not nearly as dramatic as in the initial 6 to 8 weeks.

Please be patient with your own healing. Any change in your appearance affects your perception of self-image and requires an adjustment period of days to weeks. It is normal to have mild feelings of doubt or a low mood during this period in the first 1 to 3 weeks following surgery. These feelings are then rapidly replaced by positive feelings as healing progresses and you adjust to your improved appearance.

As I discussed with you preoperatively, there may be areas on the skin of the breast or nipple, which seem to have decreased sensation following surgery. This is normal and as swelling subsides, and skin nerves re grow, some of this sensation will return.

Please contact me if any of the following occur: Marked increase in swelling in either breast, marked increase in discomfort in either breast, marked increase in redness or bruising in either breast, or a temperature above 101 degrees taken orally.

At your convenience, please call my office for an appointment to see me the first week following surgery if this has not already been done. Should you have any additional questions or should any problems at all arise, please contact my office.

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LIMITATIONS, RISKS, POSSIBLE COMPLICATIONS OF REDUCTION MAMMOPLASTY AND/OR MASTOPEXY:

Risks and untoward complications with either reduction mammoplasty or mastopexy are rare, and I mention them not to frighten or alarm you, but only to completely inform you prior to your decision regarding surgery. If any of these concern you greatly, please discuss them with me during your consultation.

Whenever anesthetic drugs are administered, either for general anesthesia or sedation accompanying local anesthesia, unpredictable and untoward reaction to a drug may occur, and it can rarely be life threatening. I perform your surgery in an atmosphere totally equipped in every aspect to handle any type of problem with appropriate equipment and backup medical personnel immediately available.

Separation of the glandular tissue from the skin envelope, removal of glandular tissue (in reduction mammoplasty), tailoring of the skin envelope to reposition the breast, and repositioning the nipple areola complex all require severing some skin nerves to the skin and/or nipple. In addition, these maneuvers require the repositioned tissues to acquire blood supply from a more distant source. With current procedures, loss of nipple sensation and/or insufficient blood supply to the skin are greatly reduced, but nevertheless may occur.

Sensation may be decreased in the skin and/or nipple areola area, and may be totally absent in the nipple in 5-10% of patients. If sensation to the skin or nipple is decreased, it usually returns over a period of weeks or months as the nerves to these areas re grow.

If there is inadequate blood supply to the skin, this usually occurs either in the fold beneath the breast or in the nipple areola area (areas most distant from blood supply). Decreased blood supply can cause blister formations with crusting and subsequent superficial or even deeper tissue loss. Actual tissue loss occurs in less than 3% of cases. It is treated conservatively in most cases by allowing a crust or scab to form over the area, continuing normal activity, and allowing the wound to heal beneath the crust. In these situations (less than 3% of cases) subsequent scar revision may be necessary. In extremely rare cases, an additional skin graft or other operative procedures may be necessary.

Repositioning the nipple areola complex in many cases requires severance of milk ducts draining into the nipple. In some, but not all cases, this may subsequently affect your ability to nurse.

Asymmetry (difference in size and shape) of breasts which is always present to some degree preoperatively will also persist to some degree postoperatively. Scars present are usually located in the fold beneath the breast, around the areola, and from the lower edge of the areola down to the fold beneath the breast. As discussed above, the appearance of these scars improve with time, with the actual extent of scarring depending upon your individual healing mechanisms.

Significant bleeding in the breasts following operation occurs in 2-3% of cases and may require re operation or surgical drainage. A small amount of drainage from the incisions for 2-3 days is normal.

Infection is an extremely rare problem, particularly with the administration of antibiotics prior to and following your operation, but may rarely occur and require operative drainage of the infected area.

The approximate figures listed above concerning the occurrence of the various complications are based on statistics obtained from large series of patients published in the plastic surgical professional literature by Board Certified Plastic and Reconstructive Surgeons. All of them are extremely unusual, but may occur occasionally despite the most vigorous standards of medical practice.

 

CONCLUSION:

Reduction mammoplasty and mastopexy are highly reliable, extremely rewarding procedures in selected patients for reducing and/or repositioning the breast. In properly selected patients, these procedures significantly reduce the weight and hence symptoms occurring from excessively large, heavy, pendulous breasts. In addition, they improve the appearance of the breasts, often allowing you to wear clothing without a bra if you desire. Most patients experience a very positive improvement in self-image, comfort, and greater flexibility in choosing clothing styles.

As you review the information here, please write questions in the margins, so that we may answer in more depth and detail specific questions you may have during your office consultation.

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