Posted on February 26, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
The trend of the week this week: questions to me, the plastic surgeon, about “how can I avoid you?” How can I do what I want without surgery?
I get it.
Surgery is a big deal. It is scars, and surgery with its risks, and recovery, and paying money. So I get it.
So. Back to the question: Can I do a breast reduction without surgery? Breast size is related to a bunch of things. And breast size and composition (breast tissue versus fat) changes over time. Two things come to mind which will reduce your breast size without surgery:
1. Lose weight. Particularly if you are overweight, losing weight will reduce the size of your breast.
2. Breast feeding. It doesnt’ happen for everyone. Some women stay the same size, and some swear they are larger afterwards, but the general trend I see is loss of volume after breast feeding, particularly the longer and more children you have.
But size isn’t everything with the breast.
When women come to me with large breasts they have two issues. 1. size (obvious) 2. droop. The skin is an important factor. One of the issues we have with liposuction of the breast is the younger large breasted women who have good skin tone (who’s skin will shrink if the breast is made smalller) tend to have dense breast tissue with little fat, which is not amenable to liposuction. The older women with the softer, buttery fat who would liposuction easily are droopy, so when you remove the volume, they just droop more.
So, as breasts get smaller, they flatten and droop. I fix this constantly in women in their 40s seeking a mommy makeover. If you want to go smaller AND reshape, lift, and firm up the tissue, you need a surgery. Welcome to my short scar vertical breast lift.
So it is just the size you don’t like? Or do you also not like the bungy jump when you take off your bra? If you want to lift and firm, you need surgery. Sorry.
Posted on February 4, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction, interesting & new
Ahhh. Marketing.
Do I sound like a broken record or what? I am just so dismayed by all of the hype and spin out there. It seems like everyone is trying to make a catchy new phrase for their surgery which will change the world, defy gravity, have no scars, and no downtime.
Bottom line still is when it sounds “too good to be true” it is.
I recently got an inquiry about the laser bra. Why don’t I do it, it only takes one hour to do, it keeps its lift better, etc etc. In general, good plastic surgery techniques get accepted by the general board certified plastic surgeon population over time. The hype and marketing things do not.
Lasers sound cool. They sound more modern, high tech, and less invasive. But there is a great deal of deception about lasers. When I was in residency and the CO2 laser came out, we all jumped on board. Now 15 years into plastic surgery, with a gazillion different lasers out there, I don’t use lasers at all. There are many types of lasers. Some address redness, some pigment, some promote collagen in the skin, some sandblast off the top layers. The one used in the laser bra is the CO2.
The CO2 laser does tighten the skin. I used to use it for resurfacing facial skin. I stopped using it due to issues with depigmentation, redness, and potential for scar. If you are using it on skin which subsequently is buried, those are not problems. The biggest thing with lasers is the amount of “tightening” is not much. Some people imagine lasers are like putting a wool sweater in the dryer. Oh. If that were only the case. We 40 somethings would jump in and laser every inch of us. But alas, lasers are more like an “iron”- they help remove fine light wrinkles only.
The laser bra involves lasering the top layer of skin, and then using that skin, tacked down to underlying tissue, as an internal “bra.” Sounds fantastic. Who wouldn’t want an internal bra to lift you?
But the laser bra will not “hold” the lift any better over time than traditional surgery. Traditional breast lifts already use the skin as an internal bra- we just deepithelialize it, not laser it. Regardless of what you do, skin stretches. Skin droops. This is deceptive marketing. I am saddened by the claims.
- “The Laser Bra surgeon can keep the breasts lifted in a natural, beautiful position.” Nothing can “keep” breasts lifted. They will droop again over time.
- The time claims of surgery are skewed. Normal breast reductions do NOT take 5 hours- in most hands it takes 2 1/2 to 3 hours.
- Finally, many of the photos involve augmentations. Implants will always help “lift” the breasts and give fullness in the cleavage area- and that has nothing to do with what reduction or lift technique you use.
I have done many different kinds of lifts over the years. The breast is made up of breast tissue and fat. In general
- the more breast tissue, less fat
- the smaller the breast
- the better you support the breast (ie good bras)
- the less you stress the breast (pregnancy, breastfeeding, jogging)
the better and longer your lift will last.
I find in my hands the best lift is the vertical lift. I do a lot of internal suturing. Why? It takes tension off the skin and shapes the breast better. Hmmm. Maybe I should make a catchy new term. “The hammock”? “The cone”? “The anti-gravity-little-scar-secret-special-exclusive-breast reduction-by-Dr. Greenberg” technique?
I think I will stick with being a good surgeon and leave marketing to others. There are many good breast surgeons to choose from. Meet a few. Look at photos. And beware of the gimmicks. When someone sounds like they are selling you a rainbow, they usually are.
Posted on December 28, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
Ah. The chicken and egg dilemma. 
Many women with large breasts are overweight.
Many overweight women have large breasts.
When you are overweight insurance will tell you your breasts are large because you are fat. Lose the weight and your breasts will get smaller. This is true. Especially as you age, breasts get fattier. Even women who when younger had “breasts which did not change with weight,” will see breast size change with weight change when they are older.
So. You are overweight and have large breasts. What to do?
Back to the chicken and egg dilemma…
If you are overweight you need to work out to lose weight. If you have large breasts, it is difficult to do the aforementioned exercise to lose weight because you can’t run, do aerobics, or do anything else which is bouncy. (Who can find a bra? Must you wear two bras?) Yes, yes. It is not impossible. You can work out with less bouncy things like swimming and biking. And yes, you can lose weight by watching what you eat. But it is more difficult.
Why try to lose weight before breast reduction?
The reasons are multiple:
1. Breasts are about proportion to your body. I don’t know what size to make you if I don’t know what size your body will be.
2. A breast reduction lifts the breast. If you lose weight after your reduction you will loosen up your lift. (This is not good. It will make you droop.)
3. If I make your breasts a perfect size and you lose weight, your breasts will get smaller. Again, it is all about proportion to your body.
4. If you are healthier, you will heal better and faster. There are higher surgical risk and complication rates when overweight, especially if your BMI puts you in the obese category.
So. Get working out. Double bra it and get moving. I love breast reductions and lifts. I think they can be life (and back pain) changing surgery.
Posted on November 18, 2009 in Breast, breast augmentation, breast implant, breast reduction
I got a question from a 5’3” woman who got 690cc implants. “I did not want to go that big but unfortunately my doctor put in these huge implants.” She now wants to downsize but does not want a lift.
Eek.
I was so sad to read this. A 690 implant is a huge implant in any woman, but particularly in a petite one. A large implant like this will thin your skin and cause your breast to droop. Will she need to do a formal breast lift?
1. The longer your implant is in
2. the older you are
3. the less bounce-back your skin has (have you had pregnancies? Breastfed?)
4. the droopier you are currently (do you pass the pencil test?)
the more you will need a lift.
Volume lifts the breast. Some women come in after pregnancy or aging and have droopy breasts. The amount of droop varies, and the droopier you are, the more likely you need to do a formal breast lift. Breast lifts have scars. I do the short scar vertical technique; many doctors still do the longer “anchor” scar (eek. even here in the Bay Area the anchor is still the most popular lift.). No plastic surgeon likes to put scars on the breast. If we can achieve what you want with a simple augmentation, we like to.
So a young woman comes in, is droopy, and wants to be bigger. How much volume do you add? How big of an implant do you use? Eventually every woman can “lift” her breast by adding volume, but in many cases the amount of volume you need is obscene. Some doctors want to avoid the scar of a lift at any cost, so they will put in a huge implant. Size is important. Every day when you get dressed, try to jog, meet new people, drop your kids off at school you will be that size. Are you comfortable?
I see many of these women. I have patients, particularly those who were droopy at a younger age, where the doctor told them, “Honey, I’ll take care of you.” These women did not participate in choosing the volume of their implant (which is crazy to me). They come to me a few years out, wearing jackets or vests to hide their large breasts. They are DD, DDD on top of a tiny frame. And they are unhappy. Most women in Northern California do not want to be as large. Those from the Bay Area and Palo Alto tend to be athletic women. My common surgery to fix their issues is to downsize the implant and do a breast lift. I always wish I would have met them first. I would have had an honest talk with them: size, scar, and perkiness. I could have saved them years of discomfort, achieved what they wanted in their first surgery, and they would have a better result. The years of being too large thins the skin and causes the breasts to droop more- irreversible changes.
So I have not met this woman. I have not seen her tissue, what it looks like, how droopy she is. But this is a big big implant. She should definitely take it out ASAP. The longer it is in, the more irreversible thinning and damage to her tissue. As far as the lift goes, I don’t know what she looked like before the implant. I don’t know if this doctor put in the obscene implant size to try to avoid a lift. From the sound of things though, to get this woman into the land of women who can jog, have people talk to their face, or buy a shirt which can still button, she will need a lift. Which is probably what she needed in the first place.
Posted on November 4, 2009 in Body, Breast, breast reduction, liposuction
I heard the term “moobs” the other day. It conjured up images of men with breasts, the man boob, the “manssiere” (love Seinfeld with the bra for men). So I did what all people do these days to find out information. I googled the term. If you look in the urban dictionary, you will see it defined:
Moobs: A combination of the words “man” and “boobs.” This is what happens when fat gathers in a male’s chest area, and gives him the appearance of having breasts.
Usually seen in overweight males, but can strangely also occur in men who are not really overweight
or my favorite
Moobs: Floppy, Jell-O like protrusions in the male chest area. Usually sported by fat, overweight men or men who attempted sex change. Can be used as a form of communication when jiggled properly
I’m curious about how the moob can be used as a form of communication when jiggled, but that sounds like a whole other blog.
As with all things medicine, we have a technical term for man boobs. We call it gynecomastia. “gyne” female. “mastia” breast.
True gynecomastia is breast tissue in men. It is composed of fat, breast glandular tissue, usually an enlarged areola, and extra skin. When you feel the chest, you will often feel a firm disc of breast tissue behind the areola. These chests do not look like an overweight guy with extra on the chest: usually the areola is enlarged and there is ptosis (droopiess) of the skin. To treat true gynecomastia, we combine liposuction (usually ultrasonic to help break up the fibrous fat and tighten the skin) and direct excision of breast tissue. If needed, this is accompanied by a reduction in the areola and tightening of the skin, though I usually try to steer toward the smallest scars possible. The goal of surgery is to get you to feel comfortable taking your shirt off in public. Scars on the chest aren’t so good for that.
Most cases I see though are not really gynecomastia. Most are due to fat with little or no breast gland component, which you may hear referred to as “pseudogynecomastia” or “lipomastia”. These are most of the “man boobs” or “moobs” you see in photos. The good news is breasts made of fat are easier to treat. In these patients there is less droopiness of the skin, and the areola is normal sized. These chests tend to respond well to simple ultrasonic liposuction.
Adolescent gynecomastia is common and usually temporary. Regardless of age, if you have a case of gyecomastia which is persistent, you need to also look at other causes such as steroids, liver failure, tumors, genetic disorders, marijuana use, and some medications.
Most of my male liposuction patients have liposuction done to their chest. Liposuction is for areas of fat resistant to diet and exercise, a pocket of fat, just like the “love handles” or “abdomen”. Sometimes men in great shape with low body fat percentage preferentially gain fat in the chest. I find many of my patients will not bring it up, but I consider it part of my standard operation for liposuction in men.
Do you need a moob job? As with all things, I encourage patients to fix things they can without surgery. Look for underlying causes. If you are overweight, lose weight. There is much advice from others on what to do: I I have seen sites on cardio, special exercises and diets, herbal supplements, and even a site with the newest male bra. One site has the secret key to burning fat on just the chest. (It is only $50 for the step by step guide, and shhh, you can’t share the secret!) But as I find with a lot of cosmetic surgery, many people try to sell you a rainbow. Most patients I see have moobs of mostly fat, so lose weight. Tone up. And if the fat persists, get liposuction to improve it.
Posted on October 10, 2009 in Breast, breast reduction, interesting & new, liposuction
Large pendulous breasts suck. They give you neck pain, shoulder pain, rashes under your breasts. You hunch over due to the weight and droopiness. Forget about jogging. Oh, and the lovely feeling of the breast sticking to your skin on a warm summer night. But the scars of a breast reduction aren’t so nice either, particularly the large anchor style scar of the inferior pedicle technique. (Please do see my lollipop, shorter scar on my vertical breast reduction.)
So you hear about a breast reduction by liposuction with no scar, easier recovery, and can reduce my breast size by 30-50%? Sounds fantastic! Great! Sign me up!
I saw a woman recently for a breast reduction. She presented to me with chronic pain and large, pendulous breasts which were rock hard. She is a smart woman But even she, who is a doctor, was pulled in by the media, hype, flashy office, promise of no scar and quick recovery.
I have to be honest. I went to our national meeting and saw beautiful results of breast reduction by liposuction. I left the meeting and thought, I should look into that. The next day I met my patient. I have never in my decade of private practice seen a breast like hers. It was droopy, hard, painful. She relates to me her story. “I researched the procedure and talked to a few plastic surgeons. I work a lot, and couldn’t take weeks of downtime. I wanted to do something where I would heal quickly. They had a hard time getting the fat out of me. Afterwards, I am bigger than I was before. I have chronic pain throughout the breast every day. I wish I could go back in time.”
Liposuction of the breast has issues.
1. It does not lift. A major benefit of a traditional breast reduction is the lift you get. Most women want the reshaping, firming, and lifting as much as they want the reduction in size. Some surgeons advocate when you remove tissue, the weight of the breast is lighter, so the skin will lift. In younger patients with good skin tone, this may be true. But this leads to the second issue…
2. Breasts, particularly young breasts, have a lot of breast tissue. Breast tissue is dense, firm, and won’t reduce with liposuction. Liposuction can only remove fat. So for many 18 year olds with large breasts, liposuction is not an option as a significant portion of their breast is not fat. Older women (read 60s, 70s, 80s) breasts are mostly fat. But then the liposuction will not correct the drooping, just reduce the size.
3. The lift is important. What bothers large breasted women is neck pain, back pain, poor posture. A study came out of Sweden (where they have nationalized healthcare and it is easier to study such things) showing the act of LIFT improved symptoms. In other words, even if the breasts were not reduced, the pure act of lifting them improved symptoms.
4. What happens to breast tissue when you liposuction? Particularly ultrasonic or laser liposuction? We always worry when we do anything to the breast about
- cancer. could this increase the rate of cancer?
- imaging to look for cancer. could this obscure cancers? give us calcifications?
5. Pathology. Whenever I remove any breast tissue, I always send it to pathology. Rate of breast cancer in women is 1 in 6. When liposuction is done, the tissue is sheared, you have no idea where it came from in the breast, and it usually is not even sent to pathology.
So. I do a lot of liposuction. I have written a chapter in a major plastic surgery 7 volume set on liposuction. I am a fan. But when it comes to the breast, I am timid. The issues I listed are real. And after having met my patient, who is a 50 year old woman with rock hard, scarred, abnormal, painful breasts, I have to wonder if the scar is so bad.
Posted on October 7, 2009 in Body, Breast, Mommy Makeover / Body post baby, Skin / Nonsurgical, breast reduction, scars & scar care, tummy tuck
No plastic surgeon can do surgery without a scar.
I know. Shocking the “doctors” on shows like Nip Tuck and every soap opera out there can fix a major accident with not a single scar, but real doctors cannot. In the real world, anytime you cut through the skin there will be a scar.
Our goal is to make that scar as fine, hair lined, tiny, well placed, and invisible as possible. But even a scar which will be a good scar (and fade to nothingness) starts as a scar you can see. I show scars when they are new. Most of the photos on my website are of scars at 6-8 weeks. On some surgeries, like eyelifts or breast augmentations, these scars are almost invisible quickly. Why? Breast augs and eyelifts have small scars, which are hidden and under no tension.
The common surgeries I do with larger scars are breast lifts and breast reductions (both of which I use a shorter, lollipop scar) and tummy tucks. You may be thinking, good heavens woman, why would you show those scars?!? Why are you not like the other plastic surgeons who only show scars at a year when they have faded or have every tummy tuck scar hidden under underwear? I could be cheeky and say, I am not like other plastic surgeons. But the true answer is you pay a price for surgery. I feel strongly you need to know that price, or I guess I should say potential price. I expect most of my patients will have scars which fade well. I don’t have many issues with ugly raised scars, keloids, etc. But I do have some patients who don’t scar well….usually it is a part of the scar…and for their surgery that patient paid a bigger price.
When you lift your breasts so they don’t hang to your knees after breast feeding three kids, the price you pay for cute perkier breasts is a scar. Many years ago I converted from the inferior pedicle technique, where we had a large anchor scar (where it is like the lollipop WITH an additional scar running the entire length and position of an underwire) to the vertical technique. Why? It shapes and holds better, and it is a smaller scar on the skin. If you are trying to limit a scar, why not go all the way and do the cute little donut lift where the scar only goes around the areola? (Excellent question from my educated Bay Area crowd…) That procedure is fraught with issues, and the scar though smaller frequently wrinkles, elevates, and bunches. A larger flat hairline scar is less noticable than a smaller wrinkly one.
Tummy tucks are a great operation to tighten the muscles and get rid of the loose, stretch-marked, muffin top skin, but the price you pay is a scar. Again, particularly in my fair skinned patients, I expect the final scar will be a hairline almost invisible scar. But what if it isn’t? My Bay Area patient base is very well educated. We had our children at older ages, so many of us got used to having a fit, healthy, tighter body. The changes after pregnancy can be tough. When you were hit hard by pregnancy, to get your muscles and skin tight again with a tummy tuck, you need to be okay with the scar. I find the patients who focus on the other changes- the flatter tummy, waist definition, tight skin, no stretch marks, smaller size- will be happy. The patients who are really bothered by the scar have a lower “price” they are willing to pay. I advise these patients to take a black sharpie marker and draw the scar on their belly. Wear underwear, your swimsuit, low rider jeans. If you had a tummy tuck and you were one of the few who did not heal well, would you be okay?
Here may be a place where being a female plastic surgeon who has had kids, pregnancies, and (eek) looser belly muscles and (sigh) looser skin, here may be a place where I am different in how I advise my patients. I watched my body change. I knew it was coming. I wanted these children more than anything. But my body will never be the same. Every person has what price they are willing to pay for perkier-lifted-firmer breasts or a flatter-tighter-waist-defined belly. What amount of risk? sensory change? scar? I can sense when I have a patient who has a low price they are willing to pay. They need a surgery to go perfectly and scarlessly or they will regret it. For these patients I advise them what you have now sucks, but it is G-d given. You earned it with your kids. Do you want to do this?
So I show scars. I show them when they are new and red and visible. The patients who can see these and go forward will be happy. The ones who can’t are usually the ones who had too low of a price and should stick with what they have.
Posted on September 15, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
Insurance coverage has gotten more difficult over the years. When I started my practice, most of my reductions were covered by insurance. Now most are not. I believe the act of lifting and reducing the breast helps with neck and back pain, posture, ease of dressing, and ability to exercise. You can check with your insurance to see if “reduction mammaplasty” is a covered surgery with your plan. All plans are different, even within the same insurance company. If you have seen other doctors such as a back doctor, physical therapist, or chiropractor for neck and back pain, a letter from them supporting a medical benefit in your breast reduction is helpful. A minimum reduction of at least two breast cup sizes is necessary. With current recommendations, a 5′6″ woman who weighs 140 pounds needs a reduction of 370-400 grams per breast to be covered. If she weighs 160, she would need about 450 grams per breast. Liposuctioned fat cannot be applied to this total. In the office I can show you with sizers the approximate amount. For some of my patients, the “minimum” needed to be removed is almost a mastectomy.
Please read below for a sample of an insurance letter to understand what we face now. We are happy to help the process with photos, letters, and the coding. I am your advocate.
“Reduction Mammaplasty for symptomatic breast hypertrophy or hypermastia may be considered medically necessary when the documentation provided shows that the member meets all criteria of our medical policy.”
- Clinical documentation of pain in the upper back, neck, and shoulders which is long standing in duration and increasing in intensity, and is not related to other musculoskeletal causes (eg poor posture, acute strain, post traumatic conditions, poor lifting techniques. or over use)
- Clinical documentation of ulnar nerve paresthesia or compression, which results in pain and/or numbness in the arms and hands.
- Physical exam documenting hypertrophy.
- Clinical documentation showing failure of a minimum of 6 weeks of physical therapy for back, neck or shoulder pain including a maintenance home exercise program.
- Clinical documentation showing failure in the use of an appropriate support bra with weight distributing straps.
- Clinical documentation showing failure in the use of anti-inflammatory agents, unless medically contraindicated.
- Clinical documentation showing failure in the use of symptomatic measures, including the application of heat and cold.
- Documentation of the patients body surface area based on the Schnur Sliding Scale, where the patient’s breast weight per breast is estimated at greater than the 22nd percent line, consisting of breast tissue, not fatty tissue to be removed.
(Dr. Greenberg note: You can see the Schnur Sliding scale at http://www.bcbst.com/mpmanual/The_Schnur_Sliding_Scale_chart.htm and the body surface area calculator at http://www.bcbst.com/providers/calculator.asp )
