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Dr. Kuruvilla (00:11):
Hi everybody. Welcome back to Behind the Double Doors. My name is Dr. Shannon Kuruvilla and I'm a plastic surgeon at Basu Aesthetics and Plastic Surgery. Today I'm really excited to be talking about breast reduction and everything that goes into patient selection, the surgical technique and recovery. So there are two kind of main reasons that might contribute to breast hypertrophy or very large breasts. So genetics, usually just how much glandular tissue you have, how that glandular tissue responds to hormones in your body. And then the other side of what makes up the breast tissue is fat. So if you're somebody who holds onto fat in your breasts or you're going through a period of weight gain, you might develop larger breasts. So usually when a patient's coming to me complaining of large breasts, curious about a breast reduction, interested in what relief that might look like for them, there's three main ones.
(01:02):
So it's usually back pain that just hasn't gotten better with physical therapy, strength training exercises, shoulder grooving. So the bra is kind of causing grooves in the shoulders because the weight of the breasts are pulling down on them and then rashes underneath. So anytime you have skin touching skin, it can create a lot of moisture and it can breed fungal infections similar to a diaper rash. Those are the main ones. And then just general discomfort, like fitting into clothes, having trouble exercising, or aesthetic reasons too. They don't feel like it fits their body. They feel like it's disproportional up top. Those are sort of the most common complaints I hear. I think it does affect self-confidence, body image significantly, particularly for younger patients. And then I think as we mature and are less bothered, either less bothered by teasing or just it doesn't happen as we age as much, it more is like a discomfort thing and maybe frustration not being able to fit in clothes or feeling like your shirt fits everywhere else really well.
(02:08):
But the breasts maybe are the first thing somebody notices when they see you. I think it's kind of always in the back of their mind. Usually it's very clear to me that a patient has been thinking about a breast reduction when I see them for a consult because they've basically already picked the procedure for themselves and they've had it in their mind. They know that this is going to treat their problem. They are ready to accept scar burden for that better form, that better comfort. They're just very motivated. They have already kind of decided that they're going to have the surgery and it's just a matter of with whom and when. When patients come in, a couple misconceptions that are pretty common that I hear that I will address with them is A the concern that we remove your nipple and then either throw it away or try to put it back on leading to poor scarring. That we do not do.
(03:00):
And then the second one is that I'm going to make them either too small or flat chested and it's not going to fit their body. And then I guess kind of the counter side to that is are you going to make me small enough? Am I still going to have symptoms? So I guess one is what I do with the nipple and areola, and then two is usually a size concern, whether they're still going to feel like they're too big or they're going to be flat chested. In my training when we are addressing the breast, there's three components we're always thinking about and wondering how to address those surgically. One is the breast footprint, so where the breast sits on your body. So some people are very low breasted, some people are naturally very high breasted. So kind of just that area on your chest wall that your breast is covering.
(03:47):
The second one is the gland, so the tissue or the parenchyma, so that's the glandular tissue, the fat, everything that's kind of deep to the skin. And then the third one is the skin envelope. So the skin, all three of those things contribute to your breast shape and your breast form. A breast lift and a breast reduction both involve treating that skin envelope. So removing the extra skin to get the nipple and areola lifted to a more youthful appearance is what we say, or youthful location. And then removing extra skin also to help reshape that footprint and kind of reshape the breast. That happens for both procedures. And the goals are just slightly different for both. So the goal for a breast lift is you like the size of your breasts, you like how your breast looks when you're wearing a bra and a form fitted t-shirt and you like that size, but once you remove that, the skin falls, the nipple hangs low.
(04:44):
And so we are just addressing skin. A breast reduction, the goal is symptomatic relief. So we're removing volume, but once you remove volume, you also have to remove enough skin to help lift the breast. How long does a breast reduction take? And that very much depends on how large of a reduction that I'm performing. I would say on average anywhere between four to six hours, six being very, very, very large breasts. Both of those are safe to perform in our state licensed ambulatory surgical center. So you come in to our ambulatory surgical center, I do the surgery, you recover. Usually you're up and walking 15 to 20 minutes after the surgery and you do go home. I will call you to check on you that evening to make sure everything is going well. You're feeling fine, no questions. We check on you the next day.
(05:32):
But yes, very much safe to do as an outpatient procedure with a breast reduction. Your typical scar pattern will involve a scar around your areola. So a lot of times people's breasts have stretched the areola, so the areola is large and if we're reducing the size of the breast, you also want to reduce the size of the areola to have that proportional result. So a scar around the outside of it, it usually hides pretty well because it is at an area of pigmentary changes in the
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body, so it kind of hides along the outside of that darker pigmented skin and then an incision or scar going straight down from there. So that lollipop type scar. Sometimes the breast reduction can be completed with just that scar more often than not though I also will include a scar hidden in the crease of the breast. So people will call that the inverted T or the anchor and the scar in the crease hides obviously pretty well in the crease.
(06:25):
And the reason I do that is I feel like I can much better reshape the breast. It just gives me an extra vector of pull basically to remove tissue and drape the skin In discussing the scar burden with patients, it is a delicate topic because I don't like putting scars in visible places. I know patients don't want a scar that's visible that they either see every single day or when they're intimate with somebody. But a breast reduction surgery, you very much have to be willing to accept that scar for better form, and that is a preceptive plastic surgery in general. Unfortunately, there is no scarless surgery yet, but there are things that I do technique wise and post-surgery to optimize the appearance of that scar. I do a multilayered closure, so it's all about offloading tension on the skin. I do sutures within the breast tissue itself to help optimize the strength of the repositioning of the glandular tissue and also just to offload of the skin after surgery.
(07:27):
We are aggressive with scar massage, silicone taping or silicone gel, and then also if necessary, we will do erbium to treat pigment of scars or microneedling to treat texture of scars. Dr. Basu and I tell all my patients what you do after surgeries, as important as what I do during surgery, there's a reason behind asking you not to do any heavy lifting, any steno activity, I don't want any increased swelling putting strain on those scars. You're going to swell and the swelling is going to take up to six to eight weeks to go down. So it's hard. I think patients have gone through the trauma of a surgery and the pain afterwards and they want the result immediately. I want that for myself and most things in life, and it very much is a waiting game to see that final result. So I'm with them every step of the way.
(08:16):
It's a lot of reassurance and counseling, but they end up being very happy that they did it. Most patients who have a breast reduction honestly are more overwhelmed by the relief that they feel in their back and their discomfort than by the actual surgical pain. So it's very common that my patients don't need to take any of their pain pills. We still provide it with them just in case they need. So from a pain perspective, it seems to be a very well-tolerated procedure. The first 24 hours you are feeling that swelling, you're still feeling a little bit out of it from the anesthesia. Usually you feel up to getting back to a desk job by day two, the swelling. Some patients will describe as similar in sensation to engorgement. If you've ever breastfed a child, it's just that similar feeling like you're just kind of swollen.
(09:04):
It feels tight. If everything goes well in surgery, there's no concerns. I will usually see you at the one week mark, and that's kind of when your swelling has peaked, so you'll be very swollen up top. Some patients are like, did you even reduce me? These are still pretty large press. And then after that seven day mark, the swelling will gradually decrease, and I find that usually by six weeks it's 85% gone. Scars. I do a waterproof tape called silk tape. It's wonderful in terms of offloading tension to the skin that stays on for three weeks. So after I see you at your one week, I'll see you at your three week appointment to assess the scars and see how they're healing. And then I see you again at your clearance appointment. So sometimes I do leave drains in my breast reductions, and that is just because everybody is going to send fluid into a surgical field, into an injury that I've created, you're going to send fluid there.
(10:00):
And if I am at all worried about how much fluid you're going to make, I have a low threshold actually to place a drain just because I want something to remove that fluid and not have it build up behind your scars and threaten your scars either from your incisions from opening or make your scars wider. The drain usually stays in for about a week. Depending on the state you're in you might be able to have your breast reduction covered by insurance. There is very specific physical exam findings that has to be documented to help get it authorized by the insurance companies. So if somebody is experiencing pain after surgery, it's important for us to know what's causing the pain. So I often am talking to the patient, is it unilateral? Is it on one side versus the other? Is one side significantly more swollen?
(10:45):
Are you having more bruising on one side? So these are things that I'm making sure there's not an immediate postoperative complication like a blood collection, a hematoma, if I've ruled that out. I do multimodal pain medicine, so I talk to 'em about taking Tylenol around the clock, Advil around the or Motrin, ibuprofen around the clock if you are able to. I do prescribe a narcotic for breakthrough pain, and then I also prescribe something called gabapentin that treats more of like a nerve pain. So there's lots of nerves in the breast. They get angry at me when I do surgery on them. So if patients are having more of a neuropathic type pain, I'll usually push them more towards the gabapentin. And then things that help reduce swelling because swelling is really uncomfortable. So do I need to adjust your bra? Can we do some form of compression, kind of like around the upper part of your breasts?
(11:34):
Those are the main ways that I treat it. We can offer an adjunct in surgery of a long acting numbing medicine to the area that lasts for like three days or so after surgery. I haven't
found that to be necessary for these patients yet, but it's an option. So in counseling patients for potential complications after a breast reduction, I always talk about a hematoma or a blood collection. I am dividing blood vessels during surgery. I take my time and make sure that I cauterize them or tie them off if necessary. I irrigate multiple times. I make sure that your blood pressure is well controlled during the surgery. These are all things that I do from a surgical technique to try to minimize hematoma. However, I have no control over what patients do when they go home. So it's usually any sudden increase in blood pressure that can cause hematoma cause either a clot to break off or just a vessel to start bleeding.
(12:27):
Heavy lifting is a big one. Straining if you're going to the restroom, if you're nauseous, and then if your blood pressure gets really high. So if you're somebody who has high blood pressure, making sure that it's well controlled before surgery and after surgery, we do a really good job of helping you manage postoperative nausea to prevent you from swelling and having that val Salva kind of response when you're nauseous or dry heaving. And then we are broken records when we are talking to you about activity restrictions. So when are patients able to get out of our super cute postoperative compression bra, is at that six week clearance appointment. So I ask you not to use any underwire bras until then. And that's also when a majority of the swelling has gone down and it's kind of safe to say you're at your new size. So I would hate for you to go and buy a bra based off of your three weeks swollen breasts and then have it be too large later on once the swelling goes down.
(13:28):
So up until that six weeks, I do ask you to wear a compressive bra at the three week mark if you're really tired of ours and you can find something more comfortable on Amazon that just provides some compression, that's totally fine. Is there a typical time somebody has a breast reduction procedure? And I'll answer that from two perspectives. One certain time in the year and then certain time in life. So certain time of the year, I'm asking you not to swim. So I think from a recovery standpoint, a lot of patients when they're having bigger surgeries prefer to have it in the fall. Winter months, you're not outside, you're not trying to go swimming. It's just kind of easier to lay low and nest and just recover. So that tends to be more common. But I mean, if you're confident that you're going to not miss the pool for six weeks and I'm totally comfortable with performing it during the summer, it's a great option for teachers and other people who might have off during the summer.
(14:20):
And then in terms of a different certain time of life. So there are two main sequelae of a breast reduction that I have to counsel my patients on, and the biggest one is the propensity for breastfeeding. If you are somebody who has not had children yet, you potentially see that in your future you might consider either breastfeeding or pumping. I'm removing glandular tissue. There's a theoretical risk that I will reduce your breastfeeding potential. I tell patients that usually after breast reduction surgery, about a third of patients can breastfeed no problem. A third of patients will have to supplement with formula and a third of patients will not be able to breastfeed. But that actually mirrors the general population of people who have had breast reduction and who have not. So how much the surgery affects that potential is really hard to say, but I think it's important for patients to understand that that is a possibility and I wouldn't want them to regret having this surgery in the future and always wondering if that was something they were super passionate about.
(15:22):
I would say I like patients to be within their ideal weight. No huge plans for significant future weight loss or weight gain, and that's just for a risk of recurrence or your skin sagging or just the balance between how much tissue you have and how much skin you have being thrown off. That is a risk that happened with pregnancy. So anybody who hasn't had kids yet, and they might have kids in the future, I tell them there's a chance you want a revision in the future. I don't know what your body's going to do after your breasts are going to get larger with pregnancy. They will stay larger if you decide to express milk. And I cannot predict how your skin will retract back when that is all done. Those are the two main things for when in life just they have to be, have that in mind.
(16:06):
Usually they're so motivated that they accept that risk and they're ready. But I will do it at any point for patients. Obviously if you're under 18, you need a parental consent. But I also have treated women well into their middle age who have large breasts and they're just tired of it. The most important thing that I am considering when performing my breast reductions or booking a revision is how am I going to affect the blood supply to the nipple? Because when I'm removing tissue everywhere else, I'm removing those blood supplies. So there's four main known blood supplies to the nipple of the breast. One comes in superiorly, laterally, medially, kind of from the breastbone and then inferiorly. And you can choose to base your breast reduction on any one of those. That is really important to consider when you're seeing a patient who's interested in a revision.
(17:01):
So I like to know what pedicle that patient had performed when they had their breast reduction. And ideally I do that same pedicle just so I'm keeping things consistent. So you can go to our Instagram @BasuPlasticSurgery to see our before and afters of patients who have given consent to social media. You can go to our website to see even a larger volume of patients. Patients are a little bit more comfortable to provide consent for their photos, to be on the gallery on our website than social media, and make sure that you're looking at a breast reduction patient, not a breast lift. Make sure it's not a patient who has had a breast lift with an augmentation. I also tell patients to kind of see if they can tease out one or two that have their same body habitus and kind of have similar size breasts, and that can be a reasonable result to expect.
(17:54):
Some patients want me to make them as small as possible. Some patients want just a little bit of a reduction. So understand that the results you're seeing are all based off of what those patients wishes were and something it might be possible to make you a little bit smaller, a little bit, leave you a little bit bigger if that's something you wanted. So that was a crash course on breast reduction. I hope that that was informational for everybody and maybe left you with a fewer questions than you started out with. However, I'm sure there are still more questions as this procedure relates to your anatomy and your body. So if that is the case, please don't hesitate to reach out. I'd love to meet with you. Thanks for listening.
Announcer (18:40):
Basu Plastic Surgery is located in Northwest Houston in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram follow Dr. Basu and the team @BasuPlasticSurgery. That's BASU Plastic Surgery. Behind the Double Doors is a production of The Axis, T-H-E-A-X-I-S.io