Gigantomastia, macromastia (pathologically large breasts)
Unnaturally large breasts represent a significant health risk; their considerable weight overloads the spine and back. The patient complains about significant pain in the area of neck, back, shoulders and upper limbs. The breasts itself are rather sensitive and even painful. The weight of mammary gland deforms the shape of breasts and therefore the breast reduction surgery (removal of the mammary gland and breast-lift) brings not only a physical relieve but also mental well-being.
Ideal size: 200-350 ml
Mild hypertrophy (tissue proliferation): 400-600 ml
Moderate hypertrophy: 600-800 ml
Marked hypertrophy: 800-1000 ml
Macromastia: 1000-1500 ml
Gigantomastia: over 1500 ml
These values are classification criteria for reference only. If a woman has subjective problems related to the excessive volume of breasts, the surgery is indicated. The causes include hormonal misbalance which appears in adolescence or at childbirth or lactation but also a considerable increase of weight and metabolic problems related to the thyroid disorder. The research confirms that some hormones influence the hypertrophy of galactophore (estrogen, growth hormone, FSH) and other hormones causes the hypertrophy of the gland (prolactine, estrogen, progesterone). Macromastia may be bilateral or unilateral. The latter is the result of primary growth stagnancy in one of the mammary glands.
What is a breast reduction surgery?
Breast reduction is an operation which removes the excessive volume of mammary tissue. This operation can include other treatment, for example breast-lift.
Are you a suitable candidate for breast reduction?
You have to be healthy and with a good balance of mind and with realistic expectations concerning the operation and the final size of your breasts. Breast reduction is requested by women of all ages. Girls up to 20 years of age are not recommended for the therapy as their breasts are still expected to grow and the re-operation might be necessary. Girls suffering from a higher sensitivity to normal estrogen level from their young age have a significant breast volume already at the age of 20 and are operated as early. In these women a re-operation is envisaged in the future.
Before the breast reduction surgery
If your breasts are too large to correspond with your body proportions and their weight causes health problems as dorsal pain or headaches, we can recommend you to undergo this operation. During the first consultation, the doctor shall talk to you about your expectations and reasons for breast reduction. First of all, he should understand your idea about the final size of your breasts. The doctor will consider the condition and elasticity of your skin and check your general health state to prevent possible complications during the operation and hereafter. The pre-operation examination considers the height and weight of the woman, chest shape and breast position (ptosis, height of inframammary fold and intermammary cleft). If you have reached certain age, you shall probably undergo a mammogram (breasts x-ray). Sometimes another two mammograms are made during the healing process. The surgeon co-operates with your gynecologist and also sends you for comprehensive pre-operation internal examination.
You should organize your transport home after the operation and assistance for one or two days, if you need it.
You will probably be asked whether you take any medication containing acetylsalicylic acid (Aspirin, Acylpyrin, Alnagon, Mironal etc.). These medicaments can cause increased bleeding during the operation and thereafter.
In the sitting woman with upper limbs along her body the surgeon marks the position where to move the nipples and areolas. This position is the intersection of the inframammary fold and a line directed through the center of clavicle. The position is approximately in the middle of the arm; perhaps slightly higher in younger women. The areola is approximately 10-12 cm from the center of the chest and approximately 20-22 cm from the suprasternal notch. The average areola is 40 x 40 mm in size.
The operational breast reduction requires general anesthesia, it means you shall sleep during the whole operation.
You will be probably reminded not to eat, drink and smoke during approximately 6 hours before the total anesthesia. You may stay overnight in the hospital.
The most suitable time for operation is the 1st week after menstruation when there is relatively less blood in the breast and the tissues are less influenced by hormones and do not retain water. Patients who take hormonal contraceptives are recommended to discontinue the pill and plan the procedure after a pause of at least 1-3 months. If the patient breastfed she is recommended a pause of at least half or one year since the last breastfeeding.
The operation lasts for 2 – 3 hours.
The treatment consists in removing the excessive volume of the mammary tissue.
The classical incision is done near the areola, then vertically to the sulcus under the breast and continues in this line. The excessive tissue is removed and the breast is stretched. The most important step, which differentiates the particular techniques, is the transfer of the nipple and areola to the correct position. It uses the suspensions of the complex.
Vertical double-pedicle technique: The surgeon performs incision from the place marked for the areola to make a strip which includes the areola. The strip ends in the inframammary fold and the surgeon separates it from the deep structures of the gland. Then the lateral tissue of the breast is reduced and the areola transferred by frilling the upper part of the pedicle. This technique maintains the nerve and vascular supply of the areola and nipple from the upper and lower vascular and nerve branches. This technique is not suitable for large reductions.
Upper pedicle technique: Two parallel incisions are performed from the place marked for the future nipple-areola complex. The areola is separated from the lower part of the breast by a circular incision. In this stage the areola is attached only by the upper pedicle which is separated from the body of the gland. The breast is further incised downwards to the inframammary fold and in this fold. The surgeon removes sufficient amount of the gland and sutures the lower part of the breast. Then the upper pedicle is frilled and the areola area is gently sutured. The final scar is anchor-shaped.
Lower pyramid pedicle technique: The pedicle is attached by a large base in the inframammary fold and narrows upwards to the nipple. The pedicle forms a pyramid. The large base ensures very good blood circulation and nerve supply. This technique is suitable for young women as it does not restrict breastfeeding function. The surgeon removes excess tissue and skin above the pedicle.
Exceptionally, the nipple-areola complex is transferred as a free graft; however there is a danger of graft rejection and interruption of nerve and vascular supply. The treatment includes adjusting the areola, which is usually moved and made smaller as well. That is why your breast shall look younger. At the end of the operation, your breasts will be covered with a sterile gauze.
Large part of breasts modeling can be performed with a new method “single scar”. It is a surgical procedure that respects anatomy of the body. The mammary gland is basically not damaged – the procedure is performed on its surface and partially below it, so it is possible to breast feed without problems after the surgery. Another advantage of this technique is very low risk of areola’s sensitivity reduction after the surgery. Although the main advantage still remains less amount of scars that stays after the surgery. Nevertheless it is necessary to count with a scar around areola and downward along the breast. If we choose this surgical procedure we can save 2x15 cm of scars in the inframammary fold.
After the breast operation
You will probably feel a little pain during first hours after the operation; this pain can be effectively reduced by medication. Your breasts will be covered with sterile gauze and it is necessary to rest during the first days after the operation.
The bandage will be removed after few days and replaced with a surgical breast supporter. This bra must be worn exactly according to the recommendation of the doctor. You can start to alternate this operational bra with a normal solid bra after 14 days. You shall probably stay in the hospital one day after the operation. Healing is a highly individual long term process. It may be supported by a biostimulation laser or with various creams and gels; we recommend DermatixSiGel (applied twice a day, the treatment starts when stitches are removed), silicone strips (to strengthen and moisturize the scar). The healing process may be also supported by Wobenzym. Some clinics offer the patients these products within the post-operative treatment.
Your breasts will be swollen and with bruises during the first days, the bruises start to disappear quickly. Some swelling can last even few weeks.
The stitches are usually removed in 15 – 20 days after the operation, according to the material.
You can go back to work after one week, but if your job includes heavy physical activity, it is recommended to start working few days later.
You should not practice sports and other physical activities for one months.
Your nipples will be more sensitive for some time after the operation. Do not touch them as long as the contact is not pleasant.
It is necessary to protect the scars from sunshine for 6 months.
First the scars shall be punched out and sharp red, after some time they start to fade and turn flat.
Do not forget that the scars never vanish completely. The doctor can recommend medical aids to quicken their disappearing. The final size of scars depends on the ability of your body to heal them.
For 2 months there can be skin folds in the lower parts of your breasts, which later disappear.
Areola after reduction
The complications may be divided into non-specific which can occur after any operation. These are mainly bleeding and inflammatory complications. Also blood clots are dangerous in the post-operative stage. This complication may be prevented by an early mobilization (it is suitable to start walking slowly after the operation). The specific complications typical for the concrete surgery include the danger of nipple and areola necrosis, or the change in pigmentation. We are often afraid of post-operative asymmetry. The patients are most often disturbed by the change in skin sensitivity. It is a natural condition after the operation and it should adjust within 3 months. In this time period the scars should become softer. In people with inclination to keloid scars (rigid punched out scars) every cosmetic surgery is contraindicated. As the tissue is scarred after the operation, the diagnostics of breast tumor is more difficult in the future. The lactiferous duct may be disturbed by the surgery and breastfeeding may be rather complicated. Cysts (globular formations filled with fluid or air) often forms in the operated area.
The operation is considered as reduction mastoplasty, provided more than 500 grams is removed from the glandular body. A health insurance company shall pay for the surgery if you have a recommendation by neurologist, orthopedist or psychiatrist. A plastic surgeon shall decide if it is gigantomastia and if you should undergo particular examinations. Upon the examination results the surgeon requests in writing the auditing physician of the insurance company to refund the treatment. Make sure if the clinic you have chosen has a contract with your health insurance company. Not every clinic has concluded the contract and there are also clinics which have contracts only with some insurance companies. The insurance company also refunds reduction of an asymmetric breast. In this case the asymmetry must be large. If you decided to fill the smaller breast with implants, the insurance company would refund only the surgery but you would have to pay for the implants.
How long shall the result of the breast reduction surgery last?
This operation has lasting results. It is however not possible to prevent the influence of time and gravitation and the beasts can drop slightly.
To reach the best results, it is necessary to follow all recommendations of your doctor.
How to choose the right plastic surgeon
As breast reduction is a substantial surgery which in case of success may boost your self-confidence and vice versa; the choice of a surgeon is a rather discussed topic. There are no 100% sure instructions not to put a foot wrong. Even with the best surgeon you cannot be sure of a surgery without complications. However there are few suggestions to make the choice.
Find out where in your surroundings breast reductions are performed.
If you have the chance, ask the clients of the particular clinic about their satisfaction. This method however cannot assure that if they were satisfied you shall be as well, but it is certain evidence.
Do not economize and undergo initial consultations with more surgeons and make the choice according to your own intuition and good feeling. Own experience is priceless.
Do not be afraid to ask the surgeon during the initial consultation what kind of education he/she has, if he/she is attested (examined by an expert committee) for plastic surgery, what kinds of surgeries he/she performs most often and how many breast reduction surgeries he/she performs annually.
This text has been created with kind assistance of Tomas Dolezal, M.D.