Breast reductions are a surgery I commonly perform.  It is great –not just from the lift and cosmetic perspective– it is great from a health perspective.  I have seen dramatic changes in neck pain, back pain, posture, and better body image.  Any woman who takes off her bra and watches her breasts plummet to her waist, can’t jog because of the bounce, or has deep digs in her shoulders from her bra knows of what I speak.

This study is out of Maryland, led by Dr. Shermak at Johns Hopkins.  In the introduction it states, “Despite the fact that complications after breast reduction surgery occur at a relatively high rate of 14-52%, breast reduction is one of the more commonly performed procedures in plastic surgery. ” 

She goes on to state, well known factors impair outcomes in breast reduction surgery:

• BMI (obese or greater)
• resection of 1000g
• smoking

But what about age?  So they did a study of 2156 breast reductions.  They looked at the different types of reductions: inferior pedicle / Wise pattern, superior pedicle with nipple graft, vertical lift (the one I do), and liposuction alone. 

What is considered a complication?  They included symptomatic scars, minor wounds requiring dressings, fat necrosis, infection, and seroma. 

Age groups were younger than 40, 40-50, and older than 50. 

So.  What did they find? 

•  Age over 50 is a “significant factor” impairing outcome, particularly with regard to infection and wound healing problems.
• Even 40-50 showed a trend toward complications

Why?

• They postulate due to lower estrogen levels.  They found women on hormone replacement therapy or birth control pills fared better, and those with ovaries removed did worse with regard to reoperation for postoperative wounds.
• Other theories include: decreased growth factors, diminished cell proliferation.

Of note: This conflicts with a study of Roehl et al who found complications were more common in the 30-39 year old group.  This paper postulates maybe the younger women in that study were different- high BMI, larger reductions- which made them get a breast reduction at a younger age.  They said in this study they controlled for factors affecting the outcome, so they could single out age alone.

So take home message?

Don’t wait to do the reduction.  If you are done with kids and breast feeding, and still have those hormones going, this study indicates it is better to do the surgery now. 

We have to fight much more to get this coverage than we did in the past.  If you have seen any of the following, please try to get a letter of support for your breast reduction.  Insurance companies want to see your reduction is “medically necessary.”  Back pain, shoulder pain, disc issues, disability from work are all supportive to prove medical necessity.

• Physical therapy for neck and back pain
• Chiropractor
• Orthopedic surgeon
• Xrays (or MRI, CT scan) which show disc issues or degenerative changes in the neck or upper chest
• Disability
• Primary medical doctor issuing pain medication (for neck and back pain) or antibiotics (for rashes)

Please alert these caregivers ahead of time and have them write a letter of medical necessity for your breast reduction.  Get copies of the readings of any pertinent Xrays or other tests to show changes.  Bring these letters with you to your appointment.  It is more effective for me to submit your case for review as a packet which includes all of the information, along with my letter and your photos.

Also see my blog on insurance coverage.

Frequent massages and yoga are usually not supportive. Sorry! But they are lovely to have.

Some doctors are all about fancy lasers and technology and will tell their patients about how their way is better.  I get wanting to believe new technology can somehow make our old boring suture and cutting surgery better.  It does seem kind of wild the surgery I do today is not radically different than what my father practiced 40 years ago.

A study in the October 2011 PRS (Plastic Surgery Journal) looked at harmonic scalpel versus electrocautery (also known commonly as a Bovie) in breast reduction surgery.

Trial:

• Randomized controlled trial
• 31 matched pair patients.  One randomized blinded side to the harmonic scalpel, the other to the bovie
• They looked at operating time, drainage volume, and postoperative pain.

Findings?

The Harmonic Scalpel was equivalent to the Bovie.  So to answer the question in my blog title, the answer is no.  The harmonic scalpel does not give you an advantage in breast reduction surgery, but it did increase the cost, as the harmonic scalpel is $$.

Yes, yes, I know for many of my large breasted patients they want them off. Gone.  You are done with the whole breast thing.  I get that.  But there are two basic reasons you can’t or shouldn’t go super small.

1. Technically, the breast reduction is usually done with a breast pedicle.  In English, this means the blood supply to your nipple areola is coming from a chunk of breast tissue.  You don’t fully cut off the nipple and areola (phew!).  It stays attached to the underlying breast tissue. 

The droopier you are, the bigger and longer the pedicle.  You can’t make the pedicle too small- you need to keep the blood supply adequate, so your nipple and areola live. 

2. Aesthetically.  I find cup sizes are hard to talk about.  Getting slightly deep here (we are in California …) What is a B cup? A C cup?  When you say “B” and I say “B” are we picturing the same thing?  We know a 36 C versus a 34 C is not the same amount of breast tissue.  In fact, a 32D can look quite normal.

When you talk about size, it is hard to distinguish exactly what size you are currently and what size you want to get to.  A B cup is a pretty small breast.  I think the basic consideration is to think about proportion.  When you have been large breasted your entire life, you are used to the proportion it gives.  Your belly never has looked large because your breasts are larger. 

You may really want to be small in the chest.  I am happy to get you as close to where you want as safely possible.  Things to help you think:

• Find photos of the “ideal” size you like. 
• Look at your body.  Imagine your breasts are small. 
• Strap down your breasts in a really tight bra and imagine they are gone.  Do you like how you look? 

My advice is always to err too large, not too small.  We can always remove a little with lipo after.  It is hard to add some back.

“I found Dr. Greenberg after several months of searching. I was unhappy with the size of my breasts implants and wanted to make a change. After interviewing five or six women surgeons, I made my decision and decided to run with Dr. Greenberg.

From the first appointment and initial impression, I knew that Dr. Greenberg and her staff was top notch. Not only did I feel extremely comfortable talking to Dr. Greenberg, my husband felt the exact same way. We both came in numerous times and pestered her with more and more questions about this and that and what if and you know, all the apprehensions related to breast reduction. Every time, Dr. Greenberg answered every question we had in terms that we non doctors understand and spent considerable amounts of time with us on each visit. She was extremely knowledgeable and patient with us. Came down the day of surgery, she greeted us with a big smile, drew some lines on me, made me feel very relaxed and reassured me that I was going to be a very happy girl when I woke up, sore but still, very happy.

Post surgery, she was 100 % correct, I could not have been happier. She created my new look exactly the way I envisioned and I could not be happier with the results. Her work is amazing! Very little down time too, maybe a month and that was it. I was back to the gym and loving my new look. It has been 4 months since the surgery, and I have very little scaring or pain. Dr. Greenberg’s expertise and ability to actually create what she told me she would create amazed me.

Her work is beautiful and I can honestly say that, my new figure has changed my life and am the happiest I have ever been. I will highly recommend Dr. Greenberg for years to come. Dr. Greenberg does awesome work!”

RM, Breast lift and implant removal patient, Burlingame, CA

Now in the filtered review section on Yelp

A study was published in the general surgery literature.  It was a good study on 12,600+ patients in Sweden looking at smoking (and obesity) effect on surgery.  Sweden has nationalized health care, so they are able to study many things well.  The surgery was an inguinal hernia surgery- small potatoes relative to a lot of what I do as a plastic surgeon.  An inguinal hernia is a tiny incision, tiny location, usually an hour surgery, and not a flap.

Findings?

34%

Current smokers had a 34% increased risk of a complication relative to nonsmokers.

We doctors talk talk talk about the negative effects of smoking.  But when I talk about this to my patients before surgery, it is for a real reason.  Your risk of an issue goes up if you are a smoker.  The risk of infection, poor wound healing (and therefore poor scar), wound breakdown, tissue and skin loss, and others.  I won’t do certain surgeries on current smokers because the risks are too high.  Breast lifts, breast reductions, tummy tucks, and facelifts are all very dependent on blood supply.  I specifically address this in my consent.  I had one patient at her preop become very agitated – turns out she was a closet smoker, denied it to me, but when she had to sign the consent form and saw in black and white clearly spelled out what smoking does, she knew she couldn’t do the surgery.

How much smoking is ok?
None.

• A history of smoking, even remote, will affect your ability to heal, though some of the ill effects do reverse with time.
• Smoking just on weekends, the “oh I don’t really smoke… oh you know… sometimes I do socially… when I have a few drinks…”  is not okay.
• Smoking things other than tobacco is not ok either.

What happens?
Increased infection, poor healing, tissue loss.

Can you give me some good news?

Stopping smoking can reverse some of the bad effects of smoking.  If I know you are an ex smoker, I do things more conservatively to try to avoid issues. Honesty is the best practice here.  I am not your mom.  I am not here to lecture you on the yellow teeth, expense, aging of your skin, etc.  I am your surgeon.  I am here to work with you to get the best surgical outcome we can.

Hernia. 2007 Apr;11(2):117-23. Epub 2006 Dec 6.
The effect of tobacco consumption and body mass index on complications and hospital stay after inguinal hernia surgery.

“She Changed my Life for the Better! A Skilled Caring Surgeon – Palo Alto, CA”

Recommends Dr. Greenberg:

“She changed my life for the better! Dr. G is an extremely skilled, compassionate surgeon.

I had been through 2 breast augmentation and reduction surgeries. One was performed by a well known on TV beverly hills plastic surgeon who is a supposed known expert, who left me disappointed, disfigured and never even saw me after the surgery even though I tried to schedule with him.

I have to say since my first appt with Dr. G, she knew what I had gone through and understood me thoroughly and took the time to understand my needs and she gave me very comprehensive advice. I thought I needed a smaller implant but she suggested I had enough breast tissue to remove implants and she was correct.

I have never even in my twenties had perky nice figured breasts. She uses a technique that leaves minimal scarring and s sure to uplift the breast. Now, I take off my bra and have to stare awhile in the mirror because I can’t believe the nice well shaped perky breasts in the mirror are mine. I look at them for the first time admiring them adoringly.

Although I have always had a positive outlook and disposition, I cannot explain how Dr. G’s skillful work has given me my life back. I can wear pretty shirts that close and do not pop open, my breasts have a beautiful uplift and I can exercise and even jog again. Life is definitely better.

Dr. G has studied different techniques and explains why she uses the technique she does and explained to me exaxtly what to expect after. This experience was so vastly different than the other two I had. I would recommend my sister, my mother, a friend to Dr. G because I trust her fully and know that as a woman she cares about women, their health and has the skill to help women become the best they can be. She would never push a procedure on anybody and explains clearly before the outcomes that can be expected.

As far as caring for her patients, she took the time on her way home from her vacation for a follow up visit with me after the holidays as my home is 2 hours away from her office. I cannot sing her praises enough. In short, yes, I highly recommend her. From California.”

M, Breast implant removal, capsulectomy and short scar vertical breast lift, Sacramento, CA

I do a ton of breast surgery.  I have 3 kids.  I am a huge fan of breastfeeding.  How can I advise my patients about breast surgery and the relationship to breastfeeding?   I know a lot from being in practice for over a decade, and I read a lot of studies.  Every piece of information helps in the decision making.

There are women who are going to have a hard time breastfeeding.  Some of these women have had breast surgery, others did not.  Is there some way to predict who is whom?  Who will have a harder time?

A study came out in Birth, Sept 1990 looking at the influence of different factors on your ability to breastfeed a baby.  The study followed 319 women who were pregnant with their first baby who intended to breastfeed.  These women were evaluated in their last trimester for their initial measurements.  They looked at:

• surgical incisions
• size
• symmetry
• nipple protuberance (do you have inverted nipples?)
• and the woman’s estimate of their breast increase during the pregnancy

At two visits after the first 2 weeks postpartum (all were term babies), the infants were weighed and the moms estimated how big their breasts got when their milk came in.  Breastfeeding was evaluated and help was given when there were problems, looking particularly at how to maximize the amount of milk made.

“Sufficient” milk production related to an average weight gain daily of 28.5g between visits.  If they had to supplement with formula this was noted as well. 

What was related?                                                              

• 85% of mothers had sufficient lactation
• 15% had insufficient lactation, despite intervention
• 7% had some kind of breast surgery prior to their first pregnancy.  If a periareolar incision was used, these women had a 5x rate of lactation insufficiency compared to those without any surgery.
• Insufficient lactation was significantly associated with minimal prenatal breast enlargement
• Insufficient lactation was significantly associated with minimal postpartum breast enlargement when the milk came in
• Inverted nipples were more likely to have lactation insufficiency (not statistically significant)

So. How can you anticipate?  If you have inverted nipples, or prior breast surgery with an incision in the periareolar area, you may have decreased milk production.  15% of women in this study had insufficient milk production, and many did not have any prior surgery or inverted nipples.  If your breasts get much larger with pregnancy and when your milk comes in, signs are good you will produce enough milk. 

What I have seen in my plastic surgery practice here in Palo Alto, where there is positive peer pressure to breastfeed, is prior surgery does not mean you can’t breastfeed.  What I found in practice and these studies is your milk production may be lower.  But any breast milk is good for you, your baby, and your bond.

Let me start first with an email I received from a patient,  ”I just want let you know that I have had no problem breastfeeding.  I am grateful that nothing was damaged during my breast lift surgery.  Nice job to you!!  We had a beautiful girl.  I was worried about breastfeeding but it is going great.  I have a ton of milk supply on both breasts.   I just wanted to let you know. “

All breast surgery affects the breast.  Seems like a simple concept, but we forget it sometimes.  A 20 year old woman who wants a breast reduction may be more focused on getting her breasts smaller and somewhere above her waist, not the bonding and nutrition she may give with breastfeeding 10 years down the road when she decides to have kids. 

So I discuss it. 

Any woman who has not had children and wants to do any surgery of the breast needs to consider the effect surgery will have on the breast and your ability to breastfeed.  Thankfully, for most women, they are able to make milk.  The studies show there may be a decreased amount of milk, but I have had many patients who have had breast augmentation or breast reductions and lifts who have successfully gone on to breastfeed.

If you are a decade away from thinking about kids or you have a lot of issues with your breasts (backpain, droop, asymmetry, etc), then know there are techniques which help maximize your future ability to breastfeed.  If you are on the verge of having kids, wait to do the surgery.   It will totally preserve your ability to breastfeed among other advantages: