The End to End Process

Dr Burt's Goal
"My aim is to provide my patients and referring doctors with the best possible standard of care. Part of that commitment is providing you with the most current, quality information available about conditions that concern you. The following information has been collated in order to fully inform you about you breast reduction and to arm you with the information to further explore and manage your own health. I hope this information will form the platform for active discussion about your concerns when we meet."

Introduction.

Your breasts are unique. Breast size, shape and characteristics are infinitely variable. Every woman has some difference in the size and shape of her breasts. The characteristics of your breasts change with life events (particularly puberty, pregnancy, breast feeding, and menopause) all marked by changes in size, shape, and the differences between your breasts. These changes are normal but can be distressing in situations were changes are excessive or where they lead to
obvious asymmetry.

Am I a good candidate for breast reduction?
Large breasts are a significant source of medical problems. Back pain, neck pain, breathing problems and skin problems may all occur. The weight of breasts commonly lead to shoulder pain either directly or as a consequence of bra straps cutting into shoulder tissues as the day progresses. Finding appropriate clothing (particularly bathers, and bras) can be all but impossible in many instances, which is a social, and workplace disadvantage. Active pursuits (sports, swimming, walking, jogging) are often prevented. A combination of these factors is usually what leads women to enquire about breast reduction surgery.

About breast reduction
Breast reduction (reduction mammoplasty) removes fat and glandular tissue from the breasts making them smaller and, therefore, lighter. Because the breasts are made smaller the excess skin is also removed. Changing the skin envelope can be important in reshaping the breasts. In most cases the nipple and surrounding tissue (the areola) needs to be repositioned and, if it is stretched, it is reduced in size in proportion to the new breast size. The goal is to achieve balance; breasts of size and shape in proportion to the rest of your body. See our video page for more information.

Will breast reduction be right for me?
Most women who decide to have breast reduction surgery are motivated by physical problems rather than cosmetic concerns. Most of these women have large, sagging breasts that cause back and neck pain or other physical symptoms as well as preventing them from participating in preferred activities. Where possible, it is usually better to wait until your breasts are fully developed. In extreme circumstances, where serious symptoms are present, breast reduction may be indicated at an earlier age.

Breast Feeding.
In general breast reduction is not recommended for women who intend to breast-feed and, where possible, it is optimal to delay a breast reduction until you have completed your family. This is not always possible. Many women have breast reduction performed prior to commencing their family but must accept that they may have no capacity to breast-feed.

Don't rush your decision.
As with all purely elective surgical procedures, women considering breast reduction must be take considerable and effort to understand the procedure, the limitations and risks associated with the procedure, and have realistic goals and expectations of the results. Investigating breast reduction should be an active process. The more information you gather and the greater your understanding of the process, the more likely you are to arrive at the correct decision for you. You are also more likely
to have realistic expectations and be happier with the results.

Who should be especially cautious about considering breast reduction?
You may decide against considering breast reduction if:

  • You have a strong family history of breast cancer
  • You have a history of forming bad scars (hypertrophic or keloid scars)

At your initial consultation visit
When we meet we will discuss your symptoms, how long they have been present, and what difficulties the symptoms present. We will discuss your past medical history, history of breast changes at puberty, pregnancy, during breast feeding and after completing breast feeding as appropriate, including variation in cup size with each of these stages. We will discuss in detail any history of breast disease (cysts, lumps, infections). I will enquire about your family history of breast disease (mother, sisters, maternal grandmother).

We will review in specific detail the problems you are having with your breasts I will examine both your breasts and axillae (armpits). I will feel for the presence of any lumps or cysts. I will measure your height, weight, chest size, and hip size, which we will use to discuss breast proportion. I will measure the size and position of the nipple/areola comparing sides for symmetry. I will examination you for evidence of differences in breast size, which is almost universally present. I will measure the distance from the fold beneath your breasts to the nipple on both sides and the distance between your nipples.

We then will have the opportunity to sit down and discuss in detail your requirements, the current state of your breasts, what the future may bring, the limitations of breast reduction and trade offs which may be required as well as the possible complications which can occur. We will look at photographs to illustrate proposed surgery, postoperative recovery and results. Why we don't have images on our website.

What are my options?
No treatment: The decision to proceed to breast reduction is purely elective. You should feel no pressure to decide to have a breast reduction simply because you have consulted a surgeon. Equally, in most cases, the result of surgery will not be significantly altered if you decide to delay your decision (even if you delay many years).

Surgery: Your breast reduction procedure will be individually planned and formulated for you. There are many different techniques available each of which has a place in helping individual women. All techniques remove fat and glandular tissue from your breasts. When a significant amount of tissue is removed or the nipple has to be repositioned skin will also need to be removed. This requires incisions to be made on your breasts and, therefore, permanent scars will be present.

Liposuction alone can be considered for breast reduction in some cases. The drawback of liposuction as a standalone procedure is that it may not provide the repositioning of the nipple and the reshaping of the breast which is desired.Where possible limited incision procedures may be used (this normally still involves an incision around the nipple and a vertical incision). Some women with particularly large breasts also require an incision placed in the fold under
the breast to remove the excess, stretched, skin from underneath the breast.

When a decision is made to proceed to surgery we will prepare a written estimate of costs involved and I will discuss this with you. Both Medicare, and your private insurance, will contribute to covering these costs. Photographs of your breast will be taken prior to any surgery. (Only for our records)

Before your breast reduction
My staff will make arrangements for the scheduling of your surgery. You will be given specific instructions and we will confirm these in writing and on the telephone.

Where possible we would like you to avoid taking aspirin or any medications containing aspirin for two weeks prior to your surgery. Aspirin and related medications contain substances that can create a bleeding tendency at the time of surgery. We will provide you with a list of common names of medications containing aspirin. If you require painkillers over this period we suggest paracetamol or, if necessary, paracetamol with codeine.

If you have been a smoker it is essential that you cease smoking a minimum of three to four weeks before your procedure and not recommence smoking for a month or more following surgery. Your body's ability to heal is severely hampered by smoking and the risk of complications due to impaired healing in people who are smoking is unacceptably high. It is not in your best interests to proceed with breast reduction while you are smoking it is far better to wait until you can stop.

You need to arrange someone to drive you home at the appropriate time following surgery and arrange for someone to stay with the night following discharge from hospital. DO NOT EAT OR DRINK ANYTHING FOR SIX HOURS PRIOR TO SURGERY. The safety of your anaesthetic requires that your stomach is empty for this period prior to surgery. Notify us of the medications you are taking prior to surgery. Bring comfortable loose fitting clothing that you do not need to put over your head.

Your Breast reduction
Your breast reduction will be performed under general anaesthesia. We will discuss this at your consultation. Your specialist anaesthetist will meet you prior to your procedure and will discuss the specific anaesthesia plan with you at that time. Immediately before your surgery, I will measure your breasts and mark your skin with a marking pen the planned procedure. This is done whilst you sit upright on the edge of a bed. This is necessary because once you are asleep and lying down your breasts naturally fall to each side and the desired shape of your breasts cannot be assessed and marked in the lying position.

Once you are asleep and we are certain that you will feel no pain a solution of local anaesthetic is injected into the breast tissue. This also assures us that you have no pain during the procedure, reduces the amount of other medication you receive which may cause nausea after surgery, and reduces bleeding during the procedure. All the preparation having been carefully completed the incisions are made and removal of tissue is performed.  All tissue removed is weighed and stored separately (left and right breasts). At the completion of the procedure all breast tissue is sent to the pathology doctors to be examined under the microscope. At the completion of the procedure the incision lines are dressed with thin flexible dressing material. For the large majority of women drain tubes are not required. You will wake up in the recovery room. You will be drowsy initially and slowly wake over thirty minutes or so.The majority of women stay in hospital overnight following surgery. If it is your wish you can consider a day procedure.

After your breast reduction
Breast reduction is not usually a very painful procedure and the local anaesthesia placed into the breast tissue during the operation will keep you comfortable for some hours. After this medications are given to reduce any pain. You will feel tight, perhaps bruised and uncomfortable in your breasts, which you would expect. You will start with fluids after surgery and if you have no difficulty progress to your normal diet within hours after surgery.The morning following surgery I will see you early in the morning. The nursing staff will help you shower.

Postop Garments.
Within the first few days you will commence wearing a soft, supportive,"crop top" progressing to a "sports" bra (no under wire). This will increase your comfort and supports your new breast shape. You will not need to purchase post opbras prior to the procedure.

Setting up at home for your return.
Prior to having your procedure you should arrange things at home for your return. You will need to set up a relaxing, comfortable position; lying propped up in bed at night and a similar setup on the couch, or in a comfy chair for during the day. You will be well enough to go for regular walks during the immediate postoperative period. This is extremely important even if only inside the house or short distances. You may be unable to sleep on your side if this is your normal preference for several days post surgery.

Postop medications.
Your prescriptions for medications will be discharged from hospital with appropriate antibiotics and pain killers. Activity levels immediately after surgery.

The first three to five days following surgery you will feel drained, swollen and uncomfortable (but not in pain). You will be able to supervise around home but will not be feeling up to participating much. Following this you will progressively feel more able to do things around home. Bruising around your breasts becomes obvious during this time. This is normal and will slowly resolve over two weeks or so. You will also notice numbness in the skin of your breasts which is also normal this may take many weeks or months to improve. Numbness around the nipple is also to be expected. Some women have poor nipple sensation prior to surgery and this will be unchanged. It is normal to experience decreased nipple sensation following surgery, it will often take six weeks or so to improve. In a small number of people permanent loss of nipple sensation can occur. Equally in rare cases increased (oversensitive) nipple sensation can occur.

Driving.
You will not be able to drive your car following surgery until your incisions are healed and you feel comfortable. This takes seven to ten days in most cases. We will give you guidance in this area.

Work.
Most women return to work within two weeks of surgery but this will vary according to the physical demands of your employment.

Post op visits.
We will keep in close contact with you following your procedure to reassure you and answer any questions you may have. Your first office visit will typically be two to five days after the procedure. We will see you as frequently as necessary after this.

When will the results of surgery be obvious?
You will see dramatic changes in your breasts immediately you awake from surgery. There will be considerable swelling however, and it will take some time for your breasts to feel soft and approach their new long-term appearance. In fact, there will continue to be subtle change in your breasts for twelve to eighteen months following surgery.

Permanent Scars. Permanent scars are part of this procedure whichever technique is chosen. Scars can be anticipated to be red, lumpy and itchy for six to twelve weeks. In most cases scars will soften and fade to become paler than the surrounding skin but this process can takes up to 18-24 months. Extensive information and tuition will be given to you about caring for your scars. What are the limitations, risks and potential complications of breast reduction?The following information is provided to fully inform you about breast reduction.The information is not intended to scare you. Serious complications following breast reduction are uncommon. Your experience is likely to be a
positive one. Haematoma, collection of blood and fluid within the breast occasionally occurs in the first few hours after surgery. If this occurs we return to the theatre and remove this fluid.Infection is uncommon but sometimes occurs. If you have ever had irritation or infection in the fold under your breasts you will understand this is a potential site for bacteria to accumulate.

We give you antibiotics during your procedure to minimise this risk. Delayed healing is sometimes a problem when it occurs it usually occurs where the new breast fold is created beneath your breast.Loss of nipple sensation and sensation in the skin of your breasts occurs commonly in the first few weeks following the procedure. It will slowly improve over weeks or months in most cases .In rare cases permanent loss of nipple sensation can occur. Rarely oversensitivity of the nipple can occur.


Scars. Breast reduction involves extensive incisions all of which heal by formation of scars. In most cases the scars settle with time to be acceptable to the patient. A small number of women form bad scars (either hypertrophic or keloid). If you or other members of your family have any history of forming bad scars breast reduction may not be an operation for you. Think very carefully about how you feel about scars on your breasts and around your nipples. If you are distressed by this thought you should think long and hard before proceeding to breast reduction. Asymmetry. It is normal for your breasts to be slightly different in size. This is universal prior to surgery and slight variation in breast size is normal after surgery.

Breast lumps. Sometimes lumps appear in fat tissue of your breasts (fat necrosis) following breast reduction. This represents part of the spectrum of healing of breast tissue. These often resolve by themselves over some months following surgery. Sometimes these lumps are painful and you may require pain medication to treat the pain.

Breast cancer and breast screening. All women over forty should consider having regular mammography (every two years) to find early-unsuspected breast cancers. The Australian government (through Breastscreen) provides this service to all women over fifty years. Very rarely an unsuspected breast cancer may be found in the tissue removed during breast reduction. All tissue removed at surgery is stored separately for each side (right and left breast) and is sent to a pathologist
specialising in breast tissue for examination. If you are forty or over will request you have a mammogram prior to planning surgery and all patients will be requested to have a mammogram twelve months after surgery to establish a new baseline for ongoing breast screening in line with the Australian breast screening program.

Breastfeeding post surgery. ALL women undergoing breast reduction must do so understanding that they may have no capacity to breast feed. In some cases following breast reduction women are able to lactate (produce milk). The amount of milk is usually not sufficient to fully feed a newborn child and additional formula feeds maybe required. From an emotional viewpoint suckling is important to mother and baby and in most cases this will be possible if you this is your choice at the time. Long term results. Your breasts will continue change as you progress through life. Your breasts will enlarge again in the event of further pregnancy, they will change in size and shape with significant changes in your weight and as you get older they will show all the changes of aging.

What's next?
Breast reduction is a commonly performed procedure both in Australia and around the world. Breast reduction can be a most beneficial operative procedure when performed for the relief of physical symptoms (back, neck and shoulder pain), to enable a woman to enjoy exercise and activity and to overcome self-consciousness of overly large breasts.

There are several treatment options available. Each of these may be appropriate in an individual patient. Achieving the optimal outcome in the management of your needs requires a thorough understanding and communication regarding your situation. Together then, we can devise the appropriate course of management to best suit your needs.Please review this information carefully and write down any questions you may have. I look forward to covering this information in more detail at the time of your consultation.

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