|
What Is Removed During
Breast Reduction Surgery?
The breasts become enlarged with the presence of fat and glandular tissue.
When a patient is of average weight, or very thin but has large, pendulous
breasts, the culprit is usually redundant glandular tissue. When a
patient has a high body fat percentage, the breasts usually become heavy
from the increase in size of the fat cells. What is removed depends
entirely upon the make up of the breasts and the desired end size.
Obviously if the patient has a small body fat percentage (in thinner
patients) but still desires breast reduction, the removal consists mostly
of glandular tissue and skin if the correction is great or a lift is
needed. If the patient has a high body fat percentage, a significant
amount of fat can be removed without removal of the glandular tissue
unless there is redundant breast tissue present. Skin will also be
removed and give a lifting effect.
So, remember, the key
properties removed from the breast are glandular tissue, fat cells and
redundant skin.
Special Cases & Rare
Occurrences
Other indications for breast reduction may include instances of gigantomastia.
Gigantomastia can occur during puberty (virginal hyperplasia) or during
pregnancy. With pregnancy-related cases, incidence of occurrence is
usually 1:100,000, or 1 in 100,000 pregnant women. This may include
both breasts (bilateral) but can occur in only one (unilateral), resulting
in significant asymmetry. In the average woman, breast weight is
usually approximately 200 g. In patients with gigantomastia, the
breasts may weigh in anywhere from 4,000 g to 7,000 g or more (total).
Rashes, ulcerations, infections and other skin anomalies are common under
and around the breasts in patients
who are afflicted with gigantomastia. In more advanced cases,
incidents of necrosis and hemorrhaging are possible. The cause of
gigantomastia is currently unknown, however, it is hypothesized that
estrogen may be a significant factor in triggering the disorder.
Biopsies have shown hyperplasia of the stroma and epithelium5
of the breasts contributing to the enlarged and painful state of the
patient's mammae. Secondary complications arise from the enlargement
of the breasts and can attribute to additional problems which must be
treated as well. If the cause of the problem, the enlarged breast or
breasts, is not taken care of, the secondary complications will more than
likely continue to occur.
"Enlargement of the
breast during puberty and gestational periods is a normal expected
physiological process. Massive diffuse enlargement of the breast during
the gestational period is a rare condition and referred to as
gigantomastia, as suggested by Strombeck1 in
1964. Gigantomastia was first described by Palmuth2
in the German literature in 1648 and by Simpson3
in the English literature in 1920. The subject was elegantly reviewed by
Beischer et al.4 in 1989, where they
described three cases and reviewed 17 cases in the literature."
(Emergency Mastectomy in Gigantomastia of Pregnancy*)
Patients stricken with
gigantomastia have significantly improved their lives and health after
breast reduction. Another plus is that most insurance companies
will cover all costs of this surgery in those who are afflicted with both
macromastia and gigantomastia.
Your
Consultation Appointment
Once you have researched several surgeons, you will make consultation
appointments. The consultation appointment is ultimately designed
to interview the surgeon and discuss, in his/her opinion, what your
options are. Not all surgeons are going to offer the same
techniques, have the same opinions, nor have the same aesthetic
preferences. It is usually best to get at least 3 opinions.
At this
appointment you should bring a list of questions you have prepared to ask
the surgeon, photos of what you like or do not like, and discuss any
concerns you may have.
Communication is crucial in reaching one's goals. You must be able
to voice your desires to your surgeon if he/she is to understand what your
desired results may be. Discuss your goals with your surgeon so that
you may reach an understanding with what can realistically be achieved.
The physical examination will include
determining the laxity of the skin and weight of the breasts. The size of the scar
is dependent upon the amount of skin that you will need to have removed. I realize you may be uncomfortable
doing this in front of a stranger, but to be blunt, let it all hang out.
The surgeon needs to see what he is working with.
How
The Breast Reduction Surgery Is Performed
Breast
Reduction surgery
usually takes about 2 to 4 hours to perform depending upon the
technique, degree of ptosis (sag), and the skill of the surgeon.
Your surgery may take longer if other procedures are being performed in
conjunction with your breast reduction, such as abdominoplasty or non
breast-related procedures.
Surgical
Markings
You will be marked for surgery. These markings will indicate
where the incisions will be, depict the center of the sternum,
etc. These markings are made with a permanent Sharpie-type
marker specifically made for surgery. Many surgeons use single
use, individually wrapped surgical pens. Some surgeons draw your
markings in the examination room, some in the O.R. and still others on
the operating room table.
There are many variations
so the markings to the right may appear different than your own.
The markings will remain on the skin after you are scrubbed with
Betadine solution. |
 |
I.V
Insertion
You may or may not have already been hooked up to the saline IV drip and
are awaiting the O.R. to be prepared for your surgery. Other
surgeons wheel you into the O.R. and insert your IV then. If you had been given an oral
sedative or valium prior you usually could care less what they are sticking in
you. If you haven't been given a sedative, the initial first few
minutes until you are anesthetized may be stressful.
Having an IV inserted feels sort of
like blood being drawn, but for a shorter period of time. It's the
initial placement of the IV catheter that may sting a bit. Some
patients get it in the crook of the elbow, some the hand. I dislike
the ones in the hand as it's a nasty place for a bruise to be, at least
with the arm you can hide it, it all depends upon your veins
though. So if your veins are not very prominent this can be a
problem.
After the needle is injected into the
vein, it is pulled out and a little Teflon tube is left in your vein. This
intravenous tube is called a catheter. However many people consider
the whole access system a catheter. Let's call the access system a 'catheter
hub' for simplicity. This hub usually contains the catheter, a needle,
a flashback chamber and tubing connected with a luer lock. The hub
acts as an injection port and is taped to your skin to keep it from
getting knocked
out. Medications can be injected into the body via this port or be
connected the tubing to allow automatic infusion of drugs and intravenous
fluids with a computerized drip system. In short, the
IV is for a saline drip to keep you hydrated and also acts as a vascular doorway
for medications, many times including anesthesia.
You may or may not receive
some medications to help you relax or feel sleepy at this time. This
can help with pre-operative anxiety if you were not given an oral
medication to do so.
Monitoring Equipment
Regardless of the order and manner in which they insert your IV, after you
are placed on the operating table they will talk to you for a minute or
two and hook you up to the heart monitoring and oximeter machines, possibly
wrapping your legs with compression cuffs and other final
preparations. Your vital signs will be monitored, including your
blood pressure, body temperature, pulse rate/heart beat, and your
breathing rate -- all very important factors to determine if you
are okay while under anesthesia. The O.R. staff will also check your
blood pressure. You have more than likely had your blood pressure
taken before with the use of a cuff which inflates firmly around your
arm. You will also have an oximeter clip (or strip) placed on either
your finger, your earlobe, or possibly on your big toe. The oximeter
machine monitors the oxygen/carbon dioxide saturation in your blood --
this is very important.
You may also
have intermittent pneumatic compression sleeves placed on your legs to
decrease the risk of Deep Venous Thrombosis (DVT) and subsequent pulmonary
thromboembolism. Heavier patients may especially benefit from
this. These devices are inflatable sleeves for your legs which are
either thigh high or knee high that inflate and deflate to keep
circulation optimal. You may also have heat lamps or heated
blankets, depending upon the surgeon, your temperature, etc.
Your vital statistics must be determined as stable before going any
further.
Anesthesia Types
Used In Breast Reduction Surgery
If you and your surgeon have
chosen an IV Liquid Sedative, they will
either manually insert medications with a hypodermic into a Y site or injection
port along the length of the silicone tubing connected to your catheter hub/IV
or more than likely your anesthesiologist will attach a bag of
anesthetic or use a computer-controlled drip system. The computer system
automatically infuses a few drops of anesthetic every few seconds into a drip
chamber where it mixes with the saline. The drip crate can also be
controlled via the roller clamp. Flow regulators can also regulate the
flow rate.
When the
anesthesiologist releases the
roller clamp the mixture starts heading towards your body. The effects of the anesthesia are felt
soon after injection or opening the roller clamp -- a few seconds in fact.
It
feels like heat going into you veins then creeping up your arm; then it jumps from your shoulder to a metallic-like taste under your
tongue and then you are blissfully anesthetized.
If you have
chosen Gaseous-state anesthesia (Twilight, Gaseous General)
Your
mouth and nose will be covered with a mask and you will usually be told to
count back from 100. You will usually remember getting only to about
96 before falling fast asleep. Then, the anesthesiologist will more
than likely intubate you. Intubation usually involves an
endotracheal tube down your throat to deliver gaseous anesthesia to your
lungs. However, some surgeons give you a little IV sedation and then
intubate you and switch over to gaseous sedation. Both of these
maneuvers eliminate the horrible experience of having a tube shoved down
your throat while you are awake.
Another option
is with the use of a laryngeal mask airway (or LMA). This is a lot
like the older intubation for General but
there is a shorter tube and a little balloon the size of your two thumbs at he
end. The tube holds your tongue down and of the way so it does not obstruct your
breathing and the balloon inflates and bocks fluid from entering your
windpipe either from saliva or stomach acid and makes a seal so the gas can
be delivered to your lungs. It is basically like a diaphragm for your
windpipe. With the
older intubation you have the pleasure of having a tube down your throat but you
don't usually remember it going in. You may wake up with a raw throat with
either but it is usually less so with the LMA.
You may
wake up with an irrigated and dry throat regardless because canned or
cylinder air (scubadiving tanks as well) is d-r-y. There is no moisture in these
tanks. It is your turbinate structure (three little fleshy flaps in your sinuses)
inside your nasal structure that mostly warms and humidifies the air which you breathe.
When you have to humidify your air, your body needs more moisture. The
saline drip will assist in this as well.
Another
option is with silicone tubing which is placed in the nose, however this
is rarely used as surgeons and anesthesiologists prefer that the windpipe
be protected and the tongue firmly held down. Be sure to ask your
surgeon which method he will be using if you are interested.
Regardless of which method, the gaseous anesthetic is mixed with oxygen
and this is how you will breathe during your surgery.
Surgical
Methods
The O.R. staff will then scrub your torso (and other areas if you are
having other procedures) with a 7.5% Betadine Surgical Scrub. The
O.R. staff will then rinse off the area with sterile gauze soaked in
saline and then paint your surgical area with the 10.% Betadine Solution
which resembles a brownish, iron-colored liquid. This will sterilize
the area by killing surface bacteria, fungi, protozoa, viruses and
yeasts. A common bacteria found on the skin is the naturally occurring
Staphylococcus aureus, or simply Staph) and decrease your risks of
an infection.
There are several
methods or techniques and these are highly dependent upon your needs as a
patient and the surgeon's preference or training. Some surgeons will
use a pedicle, or pedicle flap, to decrease your chances of nipple loss.
ped·i·cle
pronounciation: 'pe-di-kal;
noun; Latin pediculus, from diminutive of ped-, pes circa 1626
a flap
which is left attached to the original site by a narrow base of tissue to
provide a blood supply during grafting; 2: the part of a skin or tissue graft left attached to the original site
during the preliminary stages of union.-- called also pedicle graft -- Merriam-Webster Medical
Dictionary
These Pedicle
Methods are:
-
horizontal
pedicle method: where the nipple is kept on a horizontal pedicle.
-
lateralizing
or B method: where the nipple is kept on an oblique pedicle.
-
periareolar
method: where the nipple is kept on a central pedicle.
-
vertical
pedicle method: where the nipple is kept on a vertical pedicle.
The new
position of the nipple may be marked with a surgical marker but it is kept
on the pedicle of tissue so the blood supply is uninterrupted. The
areola/nipple is surgically moved to a new position then the skin envelope
(your breast) in nipped and tucked and otherwise reconstructed around the
lesser tissue. The incision is usually around the areola and down to
the underneath lobe of the breast, like a lollipop and sometimes an anchor
shape. If your breasts aren't too large and do not need major
reduction then ultrasonic liposuction (UAL) may be an option for you.
Just know that burns are possible with UAL breast reduction.
Other
Pedicle Methods
 |
 |
|
Central
De-epithelialized Pedicle - Le Jour (Vertical) &
Anchor
The Central Pedicle reduction technique was first introduced by
Hester et al in 1985. |
Superior
De-epithelialized Pedicle - Le Jour (Vertical) &
Anchor |
|
|
 |
 |
| Inferior De-epithelialized Pedicle - Le Jour &
Anchor |
Lateral De-epithelialized Pedicle - Le Jour & Anchor |
|
|
 |
|
| Medial De-epithelialized Pedicle - Le Jour &
Anchor |
|
In these procedures the new areola size will be determined
and the incision made. The incision will not be made all the way
though and only be de-epithelialized. This way, a pedicle is formed
and blood circulation of the areola complex is maintained during the
operation. Incisions are also made where tissue will be
removed. These cuts are usually all the way through (see diagrams)
until the breast fat is visible. The pedicle is still attached to
the areola complex as
depicted by the dark maroon tissue in the diagrams.
After the predetermined
incisions are made the excess skin is removed from the breast. The skin
underneath the breast (the incision line) is drawn together and sutured,
lifting the breast to a new higher position. The areolae and nipples are
"removed" (if applicable) to reposition at a higher placement
for the rejuvenated breast. The sutures will remain in this anchor fashion and around the areolae until about 10 days,
depending upon the heaviness of the breast and if implants were utilized
for augmentation.
With the
reduction using Lollipop (or
keyhole) Mastopexy incisions, the incisions are around the areolae and nipple area
and in a straight line down from underneath the areola to the natural
crease of the breast. It is like the Standard Mastopexy but a little less
tissue (in the shape of a triangle) as well as excess tissue around the
areolae is removed. This is generally for breasts which have a medium
amount of ptosis (sag). The incision edges are drawn together as in
a Standard Mastopexy and sutured together. The nipple and areolae
complex is moved up as well.
Additionally,
some reductions are performed using the Benelli technique with or
without the addition of permanent sutures.
Usually before closure the
operating room staff performs an instrument and gauze check. After you are
stitched up and your surgical bras placed over your newly reduced breasts, you will be woken up slowly where you will feel very groggy and the
pain may or may not start to set in as of yet. More than likely it
will not as the breasts are injected with a Lidocaine and epinephrine
mixture that is designed to constrict your blood vessels and
capillaries for less chance of bleeding as well has numb the area of
course for comfort. The Lidocaine also prohibits the body from
realizing it is being injured, hence disrupting autonomic responses such
as swelling,
increased heart rate, etc.
Coming Out
Of Anesthesia
The
transition period can be very rough for some patients. You may
experience sickness, dizziness, crying, depression, anxiety,
haziness, etc. It is generally like drinking a lot of alcohol and
feeling "drunk" but with even less control over your
body's movements at first. You may also be cold and shaking and
this is usually from the anesthesia. This will pass. Your throat
may be sore if you chose to have General anesthesia via
intubation.
The Recovery Room
You will be taken
to the recovery room, which is usually located right off of the operating
room, and placed in a recliner, hospital bed or gurney and placed somewhat
upright to help with swelling and drainage. Your saline drip will
more than likely still be in and you will usually still be hooked up to
the monitors so that your recovery can be properly tracked. If you do feel
sick or are in pain, alert the recovery nurse. He or she will give you a
pain reliever and possibly some sickness relief medication or a few sips
of cool water to ease your stomach.
If you chose
Light Sleep Sedation or Local with IV (basically the same thing) you
should be allowed to go home pretty soon (2-3 hours, depending). If
you chose General they will want to keep you around for a bit longer,
plus you may get a little sick. They give you medication to remedy this
but it may or may not work for you. You may have to urinate directly after
surgery due to the amount of saline, In fact the surgeon may insist that
you do before releasing you.
The Drive
Home
You MUST have
someone to drive you home and care for you for the first 48 hours - I
needed care for about 72 hours. This person will need to help you to the
bathroom, dressing, eating, etc.
Risks
& Complications of Breast Reduction
Although risks are to
be expected with any surgery, the more severe the surgery, especially
with tissue removal, the more the increase of possible complications.
Reduction mammaplasty is not an exception.
General
Risks & Complications
First and foremost there could be
an allergic reaction to the anesthetic. General is
considered to be more risky yet any anesthetic could bring on a
negative reaction.
Please
read our anesthesia section for a full disclosure of the inherent
risks of undergoing anesthesia. Negative reactions to
medications may also be an issue so watch for sudden rashes,
difficulty breathing, increased or decreased heart rate, hives,
wheezing, anxiety, fainting, dizziness, nausea, vomiting, etc.
For more information, see our anesthesia
section.
Medications which may
commonly cause an allergic reaction include anticonvulsants, barbiturates,
penicillin or other antibiotics, Novocain, Xylocaine, sulfa drugs,
and some pain medications.
Loss
of Sensitivity or Numbness
Loss of sensitivity is common, although temporary. Nerve
endings are severed during this surgery, so you must be patient
until they regenerate and sensations begin to return. This
can tale several months, however permanent sensation loss in the
areola (nipple) area or breasts, in general, can and may
happen.
Scarring
Irregularities
While scars are going to be a reality, there is also a risk of
hypertrophic scar tissue, keloids or inner scar tissue. If you
smoke or have a history of abnormal collagen formation or scarring,
you may have irregular scarring. A
regimen of Steri-Strips directly post-op, switching over to scar gels
and Silicone Gel Sheeting after suture removal.
Wound
Separation
The separation of the wound edges may be an issue in some cases.
If this occurs, keep the area very clean and contact your surgeon
immediately. Revision surgeries are not always necessary but can
be in some cases. Wet bandages can keep wound edges moist and encourage
collagenation and wound binding. If this is not the case, an
additional surgery to either excise the wound edges or score thee
edges and resuture the incision is possible. Regardless of the
method needed to close the wounds, the healing process will take
longer for a patient with separation than it would with a patient with
normal wound healing.
Asymmetry
There may be asymmetry. Although your surgeon will attempt to
make your breasts as even in volume and height as possible, the body
is not made of modeling clay. The body also heals differently
from patient to patient. However, this does not in anyway excuse
a surgeon from doing poor work. Please be sure to view as many
before and after photographs as you can during your initial consultation.
Hyperpigmentations
Or Permanent Bruising
Permanent hyper-pigmentation (permanent dark spots) from the bruising
are a risk. Hyperpigmentation should subside in a matter of a
few weeks but may stay for longer than expected. Do not get
discouraged as there are treatments for this rare complication.
Intense Pulsed Light treatments can break up the residual blood in the
bruise and allow it to be resorbed by the body. Simple
applications or warm compresses after you're healed can assist in the
dilation of the blood vessels and the resorption of the blood.
Blood
Loss
Intraoperative and post-operative blood loss is a rare complications
which will require immediate medical attention. In very rare
cases, blood transfusions may be necessary. Your surgeon will
instruct that you cease taking any anti-coagulants which may include
aspirin and aspirin-containing medications, vitamin E, garlic tablets
and more. Please see our
Medication
& Supplement List for further information and be sure to
disclose each and every medication you may be taking or have taken in
the weeks before
surgery.
Hematoma
& Seroma
Any sudden
change in contour, or color should be reported immediately. A
hematoma is a collection of
clotting or clotted blood in a body cavity which can cause pain, scar
tissue, infection and more. A seroma is a collection of the
watery portion of the blood in a body cavity or space. A seroma
can also cause pain and scar tissue.
Fat
& Tissue Necrosis
There are more risks with this operation due to the fat and its
surrounding tissues becoming necrotic (dead tissue). If the fat
becomes necrotic from lack of blood supply, the fat tends to turn
orange-ish clear and drain from the incision, however it can spread
and worsen. If the tissue becomes necrotic, immediate treatment
is necessary! You must have the tissue removed before it
spreads, a major infection develops, or possibly causes gangrene.
Necrosis
of the breast tissue, breast envelope and or incision line is very
rare but there are increased risks in those with compromised wound
healing abilities, history of smoking, circulatory problems, and
diabetes. The chances of necrosis are also increased after
radioactive/chemotherapy treatment, or have temperatetherapy or
cryotherapy post-operatively.
If
anything happens regarding tissue necrosis or compromised vascularity
please research Hyperbaric Oxygen Therapy (HBOT)
it could save your breasts AND your life.
Infection
Infections usually show symptoms within the first few days. Some
possible infections and a more common one being Staphylococcus, or
simply Staph. A more severe one is Methyl Resistant
Staphylococcus aureus, or MRSA. This strain is a Methycillin-resistant
bug, but is not considered a "super bug" and is usually
sensitive to at east 3 types of antibiotics. In itself it is
very rare, much less with BA.
Be
sure your thoroughly wash the breast and torso area with an
anti-bacterial soap such as Hibiclens or Anti-bacterial Dial for a few
days before surgery. Patients
are often told to wash their bodies thoroughly with these
anti-bacterial soaps up to three days beforehand although some
surgeons require that you do so only the night before and the morning
of. This precaution may assist in ridding the immediate area of
Staph which naturally occurs on the skin. Your surgeon or the OR
staff will also scrub you with a Betadine solution as well,
right before your incision is made.
Signs of
infection usually include redness, severe swelling, discharge, foul
smell, severe pain which develops several days after your surgery and
does not improve, intense heat of the area, a fever over 100.5º F.
Burns
From Ultrasound-assisted Liposuction
With the ultrasonic technique, patients have been known to receive
actual burns from the ultrasonic technique. The fat is actually
melted within the body by 'exciting' the fat molecules with high
frequency radio waves and is suctioned out.
Pulmonary
Thromboemboli
Another risk of breast reduction is pulmonary Thromboemboli, although
not as high of a risk as it is with liposuction-assisted reductions or
when liposuction is performed in combination with breast reduction.
A thromboebolus is a blood clot and this blood clot can break free and
travel to the lungs resulting in pulmonary Thromboemboli. This
can put a patient into adult breathing distress and subsequently into
cardiac arrest or coma -- leading to the loss of oxygen rich blood to
the brain. Pulmonary Thromboemboli can happen within three (3)
weeks of the surgery but will most likely show symptoms of shortness
of breath and fatigue within the first 72 hours. However,
pulmonary Thromboemboli can occur suddenly, without warning.
Most patients with P.E. collapse and begin rapid deterioration after
attempting to climb a flight of stairs.
General
Dissatisfaction
Also, there are the risks of the results just not
living up to what you expected. Scars will be a definite issue and
you must take this into account beforehand. They will also appear
worse before they get better so prepare yourself. Patience and scar
products can help.
Having too much tissue removed may leave you with smaller
breasts than you would like. Be sure that you communicate your
desired post-operative cup size to your surgeon. However, if insurance is
to cover the operation, a certain amount of tissue must be removed to
qualify. Ask your surgeon how much tissue is required and double
check with your insurance. Regardless, balance may the last thing on
your mind before surgery, as long as your back stops hurting and your bras
stop digging into your shoulders. Think about the long term.
How Patients
Rate This Procedure
References
*Emergency Mastectomy in Gigantomastia of Pregnancy: A
case Report & Literature Review; S. El Boghdadly, FRCS(Eng), FACS; J.
Pitkanen, MB ChB, DTMH; M. Hassonah, FRCOG; M. Al Saghier, MBBS
(1) Strombeck JO. Macromastia in women and its surgical
treatment, a clinical study based on 1064 cases. Acta Chir Scand 1964;(suppl.):341.
(2) Palmuth T. Observations medicuarum centinae tres
posthumae. Braunschweig 1648;Cent II, Obs 89.
(3) Simpson BS. Notes on a case of diffuse hypertrophy of
the breasts. Edinburgh Med 1920;24:176-9.
(4) Beischer NA, Hueston J, Pepperell RJ. Massive
hypertrophy of the breasts in pregnancy: report of 3 cases and review of
the literature. Never think you have seen everything. Obst Gynecol Survey
1989;44:234-43.
(5) Giant Breast Tumors; Mohammed B. Hawary, FRCSC;
Eufemiano Cardoso, MD; Sultan Mahmud, MD; Jamal Hassanain, MD
|
