Breast Reduction: Reducing, Lifting and Reshaping

Breast reduction is usually undertaken for medical rather than purely aesthetic reasons: pain in the back, neck and shoulders, grooving from bra straps, chronic skin irritation in the inframammary fold, and difficulty with physical activity. The operation reduces volume, but reducing volume is not in itself the objective. The breast that remains has to be lifted and reshaped, otherwise the result is a smaller breast of the same shape.

Volume and shape are separate

The same weight of tissue can be removed from two breasts and produce entirely different results, depending on what is done with the tissue that remains. In a large, ptotic breast the tissue has settled downward and laterally and the skin envelope has stretched. Removing tissue reduces volume; it does not concentrate the remaining tissue or support it. This is accepted thinking in breast surgery rather than an approach unique to this practice.

The approach I use: multilevel reduction

The approach I work by was developed with Dr. Amiram Borenstein and published in a retrospective series of 338 reductions. The principle is to build the structure of the breast from the bottom upward: after tissue is removed, the remaining tissue is mobilised inward and sutured to itself to form supporting pillars, the lateral pillar is secured to the pectoralis fascia, and the structure is supported from the chest wall rather than suspended from the skin. The skin is closed last, over a structure that already holds its shape.

The imbrication step is what actually changes the shape: thin dermal flaps are raised on either side of the vertical limb and horizontal sutures are placed at the tissue edges above the pillars. As they are tightened the breast narrows and projection increases. Tension on the skin at closure is correspondingly lower, which bears on both the scar and the durability of the result.

Scars

The scar in this approach runs around the areola and vertically down to the inframammary fold, without the long horizontal scar characteristic of the Wise pattern. It improves considerably over twelve to eighteen months. The extent of reduction and the shape of the breast determine whether a horizontal component can be avoided entirely.

Breastfeeding and sensation

The approach preserves the continuity of tissue between the nipple and the breast parenchyma, and so preserves the breastfeeding mechanism and nipple sensation as far as possible. No reduction technique can guarantee future breastfeeding, and a patient planning pregnancy should raise this explicitly at consultation.

Pathological examination

Breast tissue removed at surgery is sent for pathological examination in every case. This is routine practice and not an indication of any particular concern.

Recovery

The operation is performed under general anaesthetic, lasts two to four hours, and is performed as day surgery. Patients are discharged the same day, and I do not use drains routinely.

Recovery is easier than after breast augmentation. The reason lies in what is done during the operation: there is no manipulation of or injury to the pectoralis muscle and its fascia, where pain receptors are most dense, and no stretching or expansion of the tissues of the kind an implant requires. Most patients operated on before the weekend are driving and managing ordinary daily activity, including desk work, within a few days. Strenuous exercise resumes gradually after roughly four to six weeks, and the final shape settles at three to six months.

Patients after weight loss

In a breast following significant weight loss, including loss driven by GLP-1 medication, the tissue is deflated and the skin envelope remains wide. Planning differs, and the operation is often closer to a lift and reshaping than to a reduction. About surgery after weight loss →