Large breasts, medically known as macromastia, is associated with a range of musculoskeletal symptoms involving back, shoulder, and neck pain. The weight of the breasts eventually causes grooving of the skin across the shoulder from the straps of a bra which is weighted down. While insurance companies often insist on conservative treatment measures such as weight loss and physical therapy before approving surgery, only actual breast reduction surgery can truly alleviate the associated medical symptoms.
In my Indianapolis plastic surgery practice, breast reduction is a highly successful procedure that in every patient provides an immediate and long-term relief of painful back, shoulder, and neck issues. Having performed many breast reductions, I am convinced that the relief comes as much from the breasts being repositioned back up higher on the chest wall as it does from the amount of breast tissue and weight removed. A frequent question from some patients is whether the breasts are lifted up at the same time as they are reduced. The answer to that is…..absolutely! The design of a breast reduction (it is a very geometric operation) is such that a lift and reduction is performed at the same time. Like making a cone out of a flat piece of a paper, a wedge of skin and breast tissue is removed from below and the breast is brought together with the nipple being moved higher. (it is not quite this simple but this is a good way to think about it) This forces the remaining breast tissue higher up on one’s chest. While initially after surgery the breasts will look too full up on top (and the bottom of the breasts will look cut off or too flat), within weeks the breasts will round themselves out better. I never make a breast reduction look perfectly round at the end of the operation. If so, the breasts will bottom out later and no fullness on top will remain. You must factor in to the design of a breast reduction how the breasts will change after surgery to end up with a good-looking result.
All of this comes at a price….so to speak….and the price is the trade-off of extensive breast scarring. When I say, extensive breast scarring, I do not mean that the scars will look bad. I do mean that the amount (length) of the breast scars will be extensive. Fortunately, half of the breast scar lies along the lower breast fold where they are not seen. The visible remainder runs around the nipple and then vertically down to meet the lower breast fold. While I have performed very few breast scar revisions, patients need to have a good appreciation of the scarring to be certain that this is an acceptable trade-off.
Breast reduction is a very well accepted and successful surgery. The breasts can be reduced to almost any size that a patient prefers and one that is a better match to their body frame.
Dr. Barry Eppley

Indianapolis, Indiana

Breast reduction surgery, also known as reduction mammoplasty, was performed on over 175,000 patients in 2006 (over 20,000 were in men but that is a very different topic that breast reduction in a female and will not be covered here) It is a frequently sought-out procedure by many large-breasted women, young and old, for one very good reason…it is tremendously effective at reducing or eliminating the back, shoulder, and neck pain that comes from carrying such weight around on their chests and upper stomachs. This explains why the scars that result from the surgery, while not always ideal from a plastic surgeon’s viewpoint, seem to be a good trade-off for the vastg majority of patients who undergo the procedure.

Breast reduction is one of the few plastic surgery procedures that can still get consistently covered by medical insurance….if the patient qualifies. Qualifications include large breasts given one’s height and weight, evidence of problems with the breasts such as shoulder grooves and skin rashes under the breasts, and evidence that conservative treatment methods such as physical therapy, chiropractic treatments, or pain medications have not worked.

So if you qualify, how does a breast reduction operation work? A breast reduction is done by a precise cut-out pattern that is based on one single concept…….remove breast tissue, tighten skin, and…..keep the nipple alive! If it weren’t for the nipple, a breast reductiuon operation could be done twice as fast and could be reduced to any size, no matter how small. But that circle of pinkish-colored tissue changes how the whole procedure must be done.

The nipple is keep alive by making sure that enough blood supply gets to it from below both during and after surgery.. This means the nipple is never removed (there is a variation of a breast reduction procedure known as breast reduction with free nipple grafting…but that is not what we are talking about…and is rarely sued today) This means that a central core or central pedicle of breast tissue undeneath the nipple must be maintained for the blood supply to get through. So, as the breast tissue is being removed, the central pedicle gets smaller and smaller but canc only be reduced so much. How much can never be precisely known during surgery so it is an art to know how far to push the limited of breast tissue removal from the central pedicle. My rule of thumb is….I would rather leave a little too much and have a live nipple after surgery….than remove too much and have a smaller breast with with a dead nipple. While we as plastic surgeons do well at reconstructing nipples, a reconstructed nipple is never as good as your original one! Therefore, I tell patients I will not likely go less than 2 cup sizes smaller than where we start for safety’s sake of the nipple. This often is disconcerting to hear for some patients but the improvement that one gets ina breast reduction, in my opinion, is as much due to the skin tightening and lifting the breast back up on the chest wall as it is due to the actual amount of breast tissue removed. (All breast reductions…..are a breast lift too!)

The skin cut-out pattern is the precise design part of the operation. The skin cut-out is based on a simple principle that most grade-school children know……how to make a cone out of a piece of paper! By simply cutting a wedge out of paper and bringing the edges of the paper together….you have a cone! While this conceptual image is not precisely accurate (it is more like a keyhole rather than a simple wedge), you get the picture.

So, breast reduction surgery is……locate the new position of the nipple and mark the skin cut-out pattern (prior to surgery), make the skin cut-out, keep the nipple attached to the breast tissue, remove breast tissue from all sides getting closer to the nipple, and bring the keyhole together. Finally, pick your new spot for the nipple on the cone and bring it through.

Doesn’t sound simple…and it isn’t. The breast reduction operation is a mixture of precise design, art of shaping, and a lot of sewing. And to make matters more difficult…..there are two breasts and you have to match them. It is a lot of work, but very rewarding as those women who undergo it have almost instantaneous relief of much of their pain…and get to go out and finally buy new bras!

Dr Barry Eppley

Indianapolis, Indiana