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Breast

Breast Reduction

Medically known as reduction mammaplasty, a breast reduction lifts and reduces the size of the breasts. It is ideal for women whose breasts are too large. Common reasons include feeling self-conscious, back pain, neck pain, shoulder notching (where the bra straps cause an indent on your shoulder), breast sagging, difficulty with exercise, and difficulty finding bras and clothing. It is one of the highest patient satisfaction surgeries I perform.

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Dr. Greenberg specializes in breast reductions using the short scar technique

PLEASE KNOW WHAT TECHNIQUE YOUR SURGEON DOES

Having completed a fellowship in breast surgery after my plastic surgical training at Stanford, and because many of my patients are interested in a female plastic surgeon, this is an area of particular expertise in my practice. The goal is to give you smaller, lighter, firmer breasts with a nice shape. Frequently, the areola size is reduced. Many women notice following the procedure their posture is better, their neck and back pain subsides, and they feel more confident about their bodies. There is no typical patient. Your breasts should be fully developed. Occasionally when a young woman has serious physical discomfort, a breast reduction is done in the mid-teens, with the caveat a second reduction may be needed in the future.

Your breast surgery consultation begins at my office, where I discuss the procedure in detail, review photos of typical results, and examine you to find differences between the size and shape of your breasts. At that visit we discuss types of reduction.  I specialize in the short scar vertical breast lift breast reduction.

Again, this is an area of expertise in my practice.

"When she shared photos of breast reductions she performed I could see the passion she has in her work when she commented on the photos." - K.M., San Francisco
*Individual results may vary
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Breast Reduction Options

Vertical reduction “short scar” technique

The vertical breast reduction is a new technique and is my technique of choice. I like it because it allows me to fully reshape the breast tissue to get good form and projection. Many patients comment they have never been so round and perky. Those internal breast sutures help take tension off the skin, which helps my breast reductions maintain their shape and have better scars than other techniques. It also minimizes the scar, with a “lollipop” scar instead of the traditional anchor scar, so there is no scar under the breast. If your breast extends into your axilla (your armpit area), this portion is fat, and I remove it with liposuction at the time of your lift. I respectfully disagree with colleagues who say someone is “too big” or “too droopy” for using this technique. I have done this technique for over a decade, and I think the results are superior.

 
 

 
 

Other Techniques

INFERIOR PEDICLE/WISE PATTERN “ANCHOR SCAR”
This is still a popular breast reduction technique and has been the workhorse of breast reduction surgery for thirty years. For extremely large reductions, I will still perform this procedure. I do not think it is as long lasting as the vertical lift, it relies on skin tone to do the lift, and the scar is substantially larger, with an “anchor” pattern.

PERIAREOLAR REDUCTION
This scar is just around the areola. It is good for a only for a small reduction/lift. It has issues with the permanent suture, areola widening, and wrinkling of the skin. I tend to use it to do a small repositioning of the areola.

LIPOSUCTION
Is good to reduce the volume of the breast in fatty breasts. Most young women have dense breast tissue, so liposuction is more difficult. For older women who have softer, buttery fat, liposuction would work to decrease volume. Liposuction does not involve any skin excision, so for those with sagging skin, this procedure does not tighten and lift the breast. Be careful with this one. I had a patient who tried this under promises of “half your size” with “no downtime,” who now has rock hard breasts and constant pain.

FREE NIPPLE GRAFT
I like to keep the nipple attached for sensation and ability to breast feed. This is used for extreme breast reductions. The nipple is cut off and used as a free graft. I have never needed to use this technique.

How long do Breast reductions last?

Breast reductions lift and reduce the size of your breasts. I am asked often “how long do breast reductions last?” That is a tricky question, and the answer is it depends.

THE SIZE

Breasts are made up of breast tissue and fat. They respond to weight changes, hormones, menopause, and more.

  • If you gain weight, the fat in the breast will get larger, and your breasts will get bigger.  (Conversely, if you lose weight they may get smaller.)
  • Many women notice a breast size change during menopause. It is unclear if it is weight gain, hormone changes, or both, but my breast doctor who runs a breast center tells me “Most women go up a cup size during menopause.” I can’t find the study on that, but I see a lot of women in my clinic complaining that their breasts have gotten larger.
  • Hormones– birth control, HRT, pregnancy can affect breast size

THE LIFT

Breasts are not a muscle. You cannot “tone” them up. No exercise, cream, or laser will lift your breasts. You need to protect your lift.

  • Wear support 24/7. This means generally an underwire bra during the day and a softer bra at night. Many women have loose skin. You still have breasts. Gravity wants to stretch that.
  • Anything that stretches the breast will cause recurrent drooping- bouncy exercise (so wear very supportive bras if running), weight fluctuations, pregnancies and breast feeding. Yes, sadly this means you cannot go braless now that they are up. If you do, expect your breasts will sag again
  • Your breast tissue can affect your risk of recurrent droop. When the breast has more breast tissue (instead of fat), it tends to hold my internal shaping sutures better, so may hold the shape and lift longer.

Bottom line is that breast reductions improve where you are. The changes seen after a breast reduction may not be permanent. You can gain weight and increase your breast size. You can droop again with time and gravity. Most reductions are still a C+ cup size, and most women who need breast reductions also have issues with the quality of their breast skin. We cannot stop aging and gravity.

You need to actively protect them to keep them the size and height we achieve.

What are symptoms & reasons for a breast reduction?

Breast reduction surgery is NOT just cosmetic. There are many symptoms improved by reducing the weight of the breast and the droopiness of the breast. Studies support this and have shown improvement in neck pain, back pain, kyphosis (the curvature of the back near the neck) and more. I have had patients get improvement in jaw pain (one was able to cancel a jaw surgery as the pain went away after breast reduction), noticeable improvement in breathing, getting off disability for back pain, not needing weekly chiropractor visits, improvement on the soccer team with faster running times, wearing a strapless dress to a wedding with no bra, and more- the stories are endless.

SYMPTOMS WHICH MAY BE DUE TO YOUR LARGE BREASTS 

  • Neck pain
  • Shoulder pain and notching at the shoulders, Shoulder grooves are due to indentations caused by the bra straps trying to hold up the weight and droop of the breasts Study
  • Back pain, particularly in the upper back Study
  • Kyphosis (curvature of the upper spine leading to a rounded back) Study
  • Difficulty wearing bras- this ranges from not being able to find the right size, to it digging into the chest, pain, and other issues.
  • Skin issues– the hanging skin can cause rashes, bacterial or fungal infections, and itching under the breast where the skin folds trap heat and moisture.
  • Numbness and tingling in the shoulders and arms. This may cause numbness going into the hands and fingers.
  • Difficulty exercising. This is due to the weight of the breasts and the floppiness. This may limit participation in sports and other activities. Study
  • Shortness of breath is seen, likely because of the difficulty to expand the lung and diaphragm Study
  • Headaches and migraines, likely due to strain on the neck and shoulders.
  • Difficulty finding clothing, bathing suits, and bras
  • Emotional distress. Many women show low self esteem, depression, and anxiety. They may have unwanted attention and comments due to their breast size. Study  Another study

There was even a study showing after breast reduction, women were more efficient at work. Study

Even if not covered by insurance, you will see many of these benefits. Many of these studies show that any amount of lift and reduction improves symptoms.

Breast ReductionRecovery

Breast reduction surgery is three hours under general anesthesia. You will go home the same day.

Recovery time is one to two weeks. For the first few days you will be on regular pain medication and slowly wean off.  By a week out most patients are off all pain medication and are back to normal daily life.

  • Most desk jobs return to work at a week.
  • Any job which is active (lifting, aerobics instructor, nursing with patient transfers), Dr. Greenberg recommends 2-3 weeks off.
  • You may drive when you are off your pain medication and pain free.
  • Exercise usually around one month out.

Dr. Greenberg performs these procedures at the Menlo Park surgical hospital and the private outpatient plastic surgery center in Palo Alto.

Breast ReductionBefore your surgery

  • Women who have not had children should note breast reduction may interfere with breast feeding ability.
  • If you are actively smoking, you need to stop at least one month before doing surgery. Smoking is a huge risk factor for complications.
  • Lose weight prior to surgery. If you lose weight after, it may loosen your lift.
  • Get a physical. Check your bloodwork. Optimize your nutrition by eating a high protein diet.

breast reduction surgery procedure

I do a vertical short scar breast lift and reduction technique.  The surgery itself usually takes around 3 hours.

The day of surgery you arrive at the surgical center.  The nurse will have you change.  I will see you and do marking on you (yes, just like on the TV shows).  Then anesthesia will see you and start your IV.  All this is done before you go back to the operating room.

Once in the operating room we will hook you up to monitors, put on warming blankets and leg massagers, and the anesthesiologist will start giving you plain oxygen to breathe and medications through your IV.  You will gently fall asleep.  Next thing you know, you are done.

During the surgery I will sit you up.  I will even out asymmetries of the breasts.  I do liposuction of the axilla bra strap area.  When you wake up, you will be wrapped in your garment.  There are no bandages to change.  I like to say you are a “Christmas present,” and no peeking until your appointment.  I tend not to use drains.  In rare cases I will still use a drain (usually if a really fatty breast or a lot of liposuctioned area).

The surgery is under general anesthesia.  I only use board certified MD anesthesiologists.

breast reduction scars

Scars.  It is the achilles heel of breast reductions.  There is no way to move the areola, reshape the tissue, and remove skin without scars.  I love the vertical shorter scar lift because it has a significantly smaller scar.

How do you get a good scar?

  • General basics of scars: treat them well.  I keep them taped usually for the first week.  If the tape is mucky, then remove the tape and wash the incisions and use polysporin.  I then start scar creams at around 10 days out, which you continue until the scars are no longer red, which is usually about 3-6 months.  Use the creams.  I like the liquid silicone because it is favored by the studies I have seen.  (see blogs here).
  • Avoid the scar.  There is a HUGE benefit to not doing the anchor scar.  First, there is less scar.  Second, the scar which traditionally tended to be visible or would keloid or widen was the scar which ran along the inframammary fold (the area where your underwire is).  The vertical lift does not have that scar at all.  So you don’t need to worry about scar showing if you show a little side boob or cleavage. NOTE: you will get bunching and wrinkling of the scar where it ends at the base of the lollipop. This goes away with time.  I have lots of photos of this which I will show you at your consult. 
  • Support.  Tension on scars is bad.  So wear a great sports bra.  Wear it all the time.  Do not let gravity and activity pull on those healing scars.
  • What if you get a bad scar? Thankfully this is rare in my practice.  But if something does not heal well, there are options to be had to improve it.

breast reduction without surgery?

I wish I were magic.

Breast reductions without surgery or scars sound magical. I wish I could do it. It seems like it should be able to work- the breast is made up of breast tissue and fat… So the fat should be able to be removed by liposuction or coolsculpt or kybella or something. Right?

Wrong.

When you have large breasts, you have the issue of breast volume, but you also have the issue of loose skin. The droop. The National Geographic, bungy jumping when you take off your bra, sagging breasts. If you were to remove the fat without reshaping the breast tissue and tightening the skin, then you will be smaller, but also looser and droopier.

The lift is part of the beauty of a breast reduction. There is an old study showing the act of lifting the breast- not removing any volume, just lifting- significantly helped posture, back strain, and neck issues.  The lift makes the breasts cute and perky.  The lift is what will allow you, one golden afternoon, to wear a sundress.  So sadly, there is no non invasive, non surgical, or liposuction only way to fix large breasts.

do you need Mesh or ADM?

Mesh is a man made material which people are using to create “an internal bra.”  ADM is dermis used to do the same. The theory is that your tissue is weak, so we want to support the tissue with an additional layer. Most mesh and ADM are incorporated or replaced by your body’s own tissue.

MOST OF THE TIME THIS IS USED IS WITH THE ANCHOR TECHNIQUE. When you do the anchor scar breast reduction, there are two major flaws: 1. you are leaving all the tissue in the bottom of the breast, which makes the breast bottom heavy, and 2. you are relying on the tightening of the skin to do the lift, and skin tends to stretch and bottom out over time. The vertical lollipop breast reduction I do has tons of internal sutures, it keeps the cleavage breast tissue and “hollows out” the inferior tissue which raises the entire breast, and it does not rely on the skin tone to lift you.

PROs: It can help support the breast tissue. The recent addition of mesh seems to have advanced this as a technique, as the mesh tends to be more supportive over time and is much cheaper than ADM.

CONS: It adds additional cost (even the mesh will add about $1600 – $2000 to your cost), it can be palpable, it is a foreign object which can get infected or encapsulate, and it adds another factor which can go awry.

When would I recommend it? If you have had major weight loss and have incredibly poor skin tone, if you have had an anchor breast reduction or lift before so you must redo that technique, or if you have had a lift or reduction before and failed due to bottoming out, it is a good option.

do you need an implant with a breast reduction?

No. Just no.

This has never made sense to me. When we are doing a reduction and REMOVING tissue, it makes no sense to add volume back in.

PROS: The only pro is it  particularly for the anchor lift which hollows out the breast volume in the upper breast, an implant can add volume in the cleavage area. As I repeat often, this is a major issue with the anchor lift and part of why I do not do that technique.

CONS: How long do you have?

  • Implants can get infected, rupture, turn hard.
  • They for sure will need to be replaced at some point, so you are guaranteeing yourself another surgery.
  • They add cost in the thousands of dollars to your original surgery.
  • When you have any amount of breast tissue over a B cup, your natural tissue will continue to age in a way the implant does not, so your breast tissue will slide off the implant in what we call a waterfall or snoopy deformity. (Sounds cute, doesn’t look cute. See blog HERE)

If your surgeon is recommending a reduction with an implant, see a few more surgeons. If you have terrible tissue quality and want to reinforce your lift, I would much rather see you spend the money on mesh.

cost of breast reduction

What is the cost of a breast reduction?

First let’s talk about cosmetic breast reduction – not insurance coverage.  Here at the heart of the Bay Area in Palo Alto, breast reduction cost likely is in the $17,000-18,000 range, inclusive of surgeon fees, OR fees, anesthesia (MD anesthesiologists do all of our cases), and pathology.

What causes difference in the cost?

Insurance coverage.

Please see my notes above on insurance coverage.  I, your surgeon, do not determine if you are covered.  Every plan is different.  We submit a preauthorization to get some idea if your insurance will help pay.  Even if “covered,” I am out of network, and your copay and deductible varies from plan to plan.  I have had patients who would have saved money doing the breast reduction as a “cosmetic” case, as they had high deductibles and copays.  My fee is constant whether you are insurance or cosmetic, but operating room fees and anesthesia fees tend to be higher for insurance cases.

HSA/FSA

Even if your surgery is not covered by insurance, you may be able to use HSA accounts if you are having issues with neck pain, back pain, shoulder notching, etc.

Breast Reduction Blogs

BREAST REDUCTION – WHAT SIZE DO YOU WANT TO BE?

BREAST REDUCTION- HOW SMALL SHOULD I GO? WHAT DO I REALLY HAVE?

BREAST REDUCTION, THE SCHNUR SCALE, AND INSURANCE COVERAGE.

CAN I GO TO A B WITH A BREAST REDUCTION?

CAN WEIGHT LOSS AFFECT YOUR BREAST REDUCTION?

THE IMPACT OF AGE ON BREAST REDUCTIONS

Breast Reduction Blog

Insurance Coverage

Insurance will sometimes cover the surgery depending on your height, weight, and approximate volume to be removed.

  • Every policy has different coverage.
  • Many now require you to try “correcting” neck and back pain with physical therapy prior to surgery.
  • If you take pain medication, have seen a doctor or chiropractor for neck and back pain, have been treated with antibiotics for rashes under your breast, please bring in letters from those doctors to support your claim.
  • I will take photos and estimate the amount of breast tissue to be removed. The amount insurance requires removed varies with your BMI. The more you weigh, the more they require we remove.  Please see the Schnur scale.

If you are not going down at least 2 cup sizes, about 300g, it is unlikely your surgery will be covered. The fat in your axilla (your armpit area) is not considered breast tissue. The weight of the breast tissue is tricky.  I could operate on two women and drop them both 2 cup sizes- from 34 DD to 34 C.  On one patient I could remove 300g of tissue, on the other I could remove 100g.  Same size change, different weights.  The breast is like a pillow, and when I do a reduction I am compacting your tissue.  For some, the breast lift and compression alone will reduce them in size without any removal of tissue.

Please know I am your advocate.  The decision on coverage comes from the insurance company.  I have been doing breast reductions for almost 20 years.  When I started, most of my reductions were covered by insurance.  Now fewer are.  The short scar technique I use “cuts” out less tissue, as I am using more liposuction.  And the amounts insurance companies require have gone up.  We will review all of this at your consultation.

To those prospective patients who are reading the testimonials on breast reduction surgery, I hope my experience will be helpful.

Like you, I was looking for a surgeon with not only exceptional professional skill, but someone who makes you feel as if you’re her most important patient. I found Dr. Greenberg through my gynecologist, also a former patient of Dr. Greenberg. She was/is everything I had heard. My concerns were paid attention to with a mixture of courtesy, honesty, and humor. Her education is top notch, and is the daughter of a plastic surgeon. After scheduling my surgery, I left the office with the utmost confidence. Her experience and professionalism affords her a unique insight into her patients’ needs.

I’m delighted with the results! Dr. Greenberg, THANK YOU!

Compliments to the staff!

Jill

Anonymous

October 07, 2011

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what is the difference between a reduction and lift?

This is a quick answer.

When doing a breast reduction, we are making your breasts smaller AND doing a breast lift. You do not need to have “two procedures” done- the lift and the reduction are linked.

In my hands, I do the same technique for my breast reductions and breast lifts. This means they both- breast reductions and breast lifts- have the same shorter scar (the lollipop, not the anchor). Same blood supply. Same liposuction of the axilla (bra strap area) if you need it.

This can be confusing, as there are some surgeons who do different techniques for breast lifts vs. breast reductions. There are even surgeons who use different techniques for breast reductions depending on your breast size or degree of droopiness. I am not in that camp- I do the shorter vertical scar breast reduction for all my breast reduction sizes and degrees of sagging.

So what is the difference between a breast lift vs a reduction? The only difference is do I remove breast tissue. If so, it is a “breast reduction.” If I do not cut out breast tissue, it is a “breast lift.”

NOTE: If you have loose breasts, when doing a lift we are compressing your breast tissue. This acts just like a sports bra or a minimizer bra. So when I do a lift, if you have compressible breast tissue, your breasts may look smaller after the lift, even though I did not remove any breast tissue.