The Facts About Breast Surgery

Women get breast surgery for myriad reasons: to relieve pain and improve comfort, to boost confidence or as an integral element in fighting cancer. Three of the most common procedures are breast reduction, breast reconstruction and breast augmentation.

All elective breast surgeries are performed by board-certified plastic surgeons in an accredited office-based surgical facility, ambulatory one or hospital. A medical evaluation, lab tests and imaging are performed before surgery, and patients may be asked to stop taking certain medications, such as aspirin and ibuprofen.

A short hospital stay may be required depending on the type and extent of the procedure (most often with reconstruction). All three procedures usually require anesthesia, so patients should arrange for a friend or family member to drive them to and from the surgery and stay with them for the first night.

Breast reduction

Breast reduction (reduction mammoplasty) involves the removal of excess breast tissue (fat, glandular tissue and skin) to create a more proportionate breast size and shape. There are multiple reasons a woman may choose to undergo the procedure, such as wanting to alleviate pain or discomfort caused by large breasts, to feel more comfortable in her body or to correct asymmetries, such as those caused by having breastfed or the natural aging process.

Having disproportionately large breasts (macromastia) can cause physical and emotional stress. Excess weight on the chest can strain back, neck and shoulder muscles. It can be difficult to engage in physical activities or to fit comfortably into clothing, and skin underneath breasts and where bra straps dig into shoulders can become irritated.

During the surgical procedure, a circular incision is made around the areola (the dark circle around the nipple). The nipple (still attached to its blood supply and nerve) is either repositioned or removed and transplanted higher on the breast. The areola may be reduced in size. Next, the tissue beneath is reduced and the breast lifted to create a proportionate, smaller shape. Incisions are closed and sutures placed.

Breast reconstruction

Breast reconstruction can be a life-restoring option for cancer patients who have undergone a mastectomy or lumpectomy. It can also be used to correct a congenital malformation. It may include one or multiple procedures and be performed in conjunction with breast cancer surgery or at a later time. Implant-based reconstruction uses a product to form the mound of the breast, while flap reconstruction (autologous reconstruction) utilizes a flap of tissue from another part of the patient’s body.

About 40 percent of women who have a mastectomy or lumpectomy opt for breast reconstruction. Some women feel it boosts their self-confidence and comfort and erases or lessens physical reminders of cancer, easing the emotional burden. A breast lift, reduction or augmentation may be utilized for the healthy breast to help achieve a symmetrical result.

During an implant reconstruction, the surgeon places the implant either behind the pectoral muscle or in front of it, using a dermal matrix that the body later replaces with collagen. Many women require a tissue expander beforehand to stretch the skin to accommodate it, in which case the reconstruction is performed in a series of procedures.

First, the balloon-like expander is placed under the pectoral muscle. Over several months, the expander is injected with saline or carbon dioxide to slowly expand the skin. Once the tissue has stretched sufficiently, the expander is replaced with the implant.

Flap reconstruction is a more extensive procedure than implant reconstruction. Options include using a TRAM, DIEP or SIEA flap from the abdomen or a flap from the buttock (gluteal flap), inner thigh (TUG flap) or latissimus dorsi back muscle.

The type of reconstruction performed on a cancer patient depends on multiple factors, including the current breast shape, the kind of procedure the patient underwent, other treatments (such as radiation) and body type. The flap is removed from the donor site, then transferred, shaped and attached to the breast.

For women who were not candidates for nipple-sparing mastectomy, breast reconstruction may also include nipple reconstruction and use tattooing to define the areola around the nipple.

Breast augmentation

About 400,000 American women annually opt for breast implants, either to increase breast size, lift, fullness or roundness, or to boost breast volume after weight loss. Breast augmentation can also be achieved through fat transfer from another part of the body.

Women who choose breast augmentation often do so to boost self-confidence and self-image or improve breast symmetry or balance between hips and breasts.

Several types of products can be used. Saline implants, filled with sterile saltwater, create uniform firmness and roundness. Structured saline implants have an additional inner structure to improve the natural feel.

Silicone breast implants feel more natural and don’t collapse like saline implants if they sustain a leak. They also require more follow-up because, unlike saline, silicone can’t be reabsorbed and expelled by the body if there is a leak.

There are also form-stable implants (known as gummy bear implants) that maintain shape even if the implant breaks, but this product requires a longer incision and can rotate under the skin, resulting in an odd shape. Round implants mitigate rotation problems and create a fuller appearance.

Smooth breast implants are the softest option and move with the implant pocket, allowing for the most natural look, though they can cause visibly noticeable rippling under the skin. Textured implants are designed to create scar tissue, linking the implant to the breast pocket and reducing the likelihood of it moving around.

During implant augmentation, an incision is made under the fold of the breast, in the armpit or around the areola to reduce scarring. The implant is inserted into the breast pocket, either under or on top of the pectoral (chest) muscle. Incisions are closed and the skin sutured.

Potential complications of breast surgery

Any breast surgery could have complications including pain; infection; scarring; skin discoloration or pigmentation changes; bruising, swelling or bleeding (hematoma); allergic reaction; blood clots; fluid accumulation; damage to nerves, blood vessels or muscles; deep vein thrombosis; heart or lung complications; necrosis (death) of breast tissue; and possible need for revision surgery.

Results may also be disappointing, with possible breast asymmetry, irregularities in breast contour or shape and changes in nipple or breast tissue sensation. Breast surgery can also complicate future breast diagnostic procedures or compromise a woman’s ability to breastfeed.

Gaining or losing weight or becoming pregnant after a breast surgery may change results, as can hormonal factors and gravity. Women who smoke or are in poor health or immunocompromised are at higher risk of complications and are not good candidates.

Additional risks of breast reconstruction and breast implants include chronic pain; partial or complete loss of the flap; increased breast firmness; implant leak or rupture; increased risk of implant-associated anaplastic large cell lymphoma (BIA-ALCL); “breast illness” symptoms including brain fog, rashes or muscle and joint pain.

Aftercare

Dressings and bandages are applied to incisions, and a support bra or elastic bandage can be worn to minimize swelling and support new breasts during healing. Patients might go home with drains to collect fluid. The surgeon will explain how to care for the incisions (such as keeping dressings dry and intact), what drugs to take (pain medications, antibiotics) and concerning signs to watch for.

Patients can get back to most normal activities in two weeks. Heavy lifting and strenuous exercise (including sex) should be avoided for three to six weeks or more. Patients should sleep on their back for the first few weeks.

Concerning side effects such as shortness of breath, heart palpitations or chest pain are rare but require immediate medical care. It’s essential all after-care and follow-up care instructions are followed to reduce risk of complications and ensure the best possible outcome.

If you’re planning to have any breast surgery, take good care of yourself before and after. Eat a well-balanced diet high in fruits, vegetables, whole grains and legumes. Get plenty of protein to support the healing process. Minimize processed foods, salt, sugar and caffeine, and don’t drink or smoke. Stay hydrated and prioritize rest and relaxation. Good sleep is essential.

Seeing and enjoying the results of the procedure are an exciting part of the process, but don’t rush it. If you have any concerns during the healing process, reach out to your surgeon right away.