Consumer's Guide to Breast Reduction

Breast Reduction Assessment of Value and Outcomes (BRAVO) Study

1. What is breast reduction surgery and how common is it?
2. Who is a candidate for breast reduction surgery?
3. Who is NOT a candidate for breast reduction surgery?
4. Why should I have breast reduction surgery?
5. When is the best time of your life to have the surgery?
6. How much does the surgery cost and will insurance cover it?
7. How do I find a surgeon?
8. What happens at the first consultation?
9. How do I prepare for surgery?

1. What is breast reduction surgery and how common is it?

Breast reduction is a surgical procedure to reduce and reshape large breasts, a condition known as "macromastia".

While there are a number of different operations for breast reduction, these techniques share several characteristics. In each procedure, incisions are made on the lower breast and around the nipple. Extra breast tissue and skin are removed and the incisions are stitched up in a way that minimizes the scarring as much as possible. Also, nipples are repositioned to higher, more youthful positions. The type and amount of scarring vary by technique (see "Are there different types of scars?").

According to the American Society of Plastic Surgeons, 78,169 breast reductions were performed in the U. S. during 1999. Breast reduction surgery is one of the five most commonreconstructive procedures carried out by plastic surgeons each year.

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2. Who is a candidate for breast reduction surgery?

If you have excessive breast size or macromastia (usually bra cup size D or larger), breast reduction surgery can help relieve the physical symptoms caused by the size and weight of your breasts. Breast reduction surgery will change both the size and shape of your breasts. After surgery, your breasts will be in better proportion to the rest of your body.

The American Society of Plastic Surgeons recently conducted a study on the effectiveness of breast reduction surgery. The Breast Reduction—Assessment of Value and Outcomes (BRAVO) Study found that women reporting D cup (or larger) breasts and at least two of the following complaints were good candidates for breast reduction and were likely to experience significant improvements in their symptoms:

1. Upper back pain
2. Neck pain
3. Shoulder pain
4. Breast pain
5. Rashes under the breasts
6. Shoulder grooving due to bra straps
7. Arm pain

Other problems related to excessive breast size may also improve with reduction surgery:

1. Restrictions in physical activities, such as exercise, due to your breast size
2. Self-consciousness about your breast size
3. Breast size that varies significantly from side to side
4. Emotional stress, teasing, and feelings of embarrassment
5. Difficulty finding bras or clothing which fit

In the BRAVO study, most women chose breast reduction to reduce pain. Before breast reduction surgery, many of these patients reported that their pain was equal to that of people with chronic arthritis or heart disease.

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3. Who is NOT a candidate for breast reduction surgery?

You are probably not a candidate for breast reduction surgery if (1) you do not have large breasts (bra cup size D or larger); (2) you do not have pain or other physical symptoms from large breasts; or (3) you are choosing breast reduction surgery for cosmetic reasons("for looks").

You may want to avoid breast reduction surgery if breast-feeding is very important to you. All women of childbearing age who are considering breast reduction surgery should be warned that breast-feeding may not be possible after surgery. Breast reduction surgery should be postponed if your breasts are still growing. Most surgeons recommend waiting until breast development is complete and prefer not to operate on girls in their early to mid-teens. (Exceptions may be made for girls experiencing a rare but very rapid and extreme form of breast growth called "virginal hypertrophy".)

If you are currently gaining or losing weight, you should consider delaying breast reduction until your weight has stabilized. Large changes in body weight following breast reduction may reverse some (or all) of the surgery’s benefits.

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4. Why should I have breast reduction surgery?

In the BRAVO Study (see Question 2), women who had breast reduction surgery had significant improvement in their quality of life. After surgery women reported better physical functioning, less bodily pain, better overall health, and increased energy. Women felt that their emotional and mental health improved and that they functioned better socially. The BRAVO study provides evidence that breast reduction benefits health-related quality of life, pain, physical activity levels, and self-esteem.

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5. When is the best time of your life to have the surgery? (Why wait?)

Generally, a woman’s breasts should be fully developed before reduction is considered. When surgery is performed before your breasts are fully developed, there is a small chance that excessive breast size can recur. For patients in their teens, this risk must be weighed against the potential benefits of breast reduction. Some teenagers having serious problems with rapid and excessive breast growth (a condition called "virginal hypertrophy") may still be candidates for this operation. For these women a hormonal evaluation also may be recommended (to exclude other medical conditions that might require treatment). Particularly if large breast size is causing serious pain or discomfort, surgery may be performed during the teenage years.

Some women wish to wait until they have completed child-bearing, to avoid the possibility of breast-feeding problems caused by the reduction surgery. (Even without breast reduction, a woman’s ability to breast-feed is unpredictable.)Some younger women also choose to postpone reduction surgery because pregnancy, childbirth, and nursing can have unpredictable effects on breast size and shape. However, many women still choose to proceed with breast reduction despite the possibility of future pregnancies.

Each woman must decide for herself if surgery is right for her. She must weigh the pros and cons and have realistic expectations about the results.

If you are currently gaining or losing weight, you may want to postpone breast reduction. Breast size often changes if weight is lost or gained, so surgeons advise that a woman's weight should be stable before proceeding with breast reduction.

While many women have breast reductions in their 20’s and 30’s, older patients also may benefit from breast reduction. It is not uncommon for women age 50 or above to choose to have this surgery. As always, your doctor will evaluate your overall health in determining whether breast reduction is right for you. While some medical problems (such as heart disease or diabetes) may increase the risks of surgery, patients with these conditions may still be acceptable candidates for reduction surgery. Before your operation, make sure that you inform your surgeon about any medical problems that you are experiencing.

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6. How much does the surgery cost and will insurance cover it?

Although total charges vary widely, breast reduction surgery commonly costs between $4200 and $7000. Your doctor's office will give you an estimate of the usual charges. When calculating the cost, remember that there are several separate charges. The surgeon will charge for her/his services (also known as a "professional fee"). Also, you will be billed an additional amount for an anesthesiologist. Hospital charges usually are billed separately from professional fees. Charges for the operating room, hospital room (if you stay overnight following surgery), surgical supplies, and laboratory tests will be made by the hospital.

Most insurance companies and health maintenance organizations (as well as Medicare and Medicaid) provide coverage for breast reduction, but many factors can influence your eligibility. If your doctor can document pain, functional limitations, or other health problems resulting from your breast size, your insurance plan probably will cover the procedure.

A letter of predetermination is usually sent to your insurance company, describing the reasons for the planned operation. Some companies require photos as part of their authorization process. A member of your doctor’s staff will review these steps and any other financial aspects of breast reduction surgery with you.

If you don’t have health plan coverage, doctors usually accept several methods of payment, including checks, cash, and credit cards. Some participate in local or national programs to help you finance the cost of the surgery. Most plastic surgeons expect you to make full payment for the surgical fee before surgery. If you cancel surgery without adequate notice, some doctors may charge a cancellation fee.

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7. How do I find a surgeon?

To find a surgeon, consult your primary care doctor or a local medical center. Almost all board-certified plastic surgeons also belong to the American Society of Plastic Surgeons. (Call 1-888-4-PLASTIC (1-888-475-2784) for referral to a member near you or Find a Plastic Surgeon online.) In picking a plastic surgeon, it is important that they be certified by the American Board of Plastic Surgery (ABPS). Certification means that the surgeon has completed his/her plastic surgery training in an approved institution and has passed a rigorous set of examinations given by the Board.

Always check with your surgeon about his/her hospital affiliation. Does he/she have privileges to perform the procedure at that hospital? You may want to ask your plastic surgeon for patient references. Call these women and ask them about their experiences with breast reduction. The surgeon also may be willing to show pictures of surgical results. Ask to see some of the photographs of patients who underwent similar procedures. Are these outcomes "typical" (or do they represent "best" results)? It’s perfectly acceptable to ask the surgeon about his/her experience with this operation. (For example, "How many breast reductions do you perform each year?) Make sure that you are comfortable with your surgeon and that he/she answers all your questions.

You do not want a plastic surgeon who completed residency training in a specialty other than plastic surgery or who is not certified by the American Board of Plastic Surgery. Not everyone who advertises his/her practice as "plastic surgery" has met these standards. As always, it pays to be a savvy consumer.

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8. What happens at the first consultation?

On your initial office visit, the surgeon will take a medical history and perform a physical examination to determine whether you might benefit from reduction surgery. During your consultation, your plastic surgeon will review any history of previous breast surgery. In addition to breast-related issues, be prepared to discuss your medical history, including any ongoing medical problems, current treatments or past surgeries. Bring a list of your current medications. Any allergies, particularly to medications are important to mention. He/she will examine you, taking measurements and photographs for your record.

The exam also will include evaluation of breast size, shape, skin quality and nipple position, as well as a thorough check for any breast masses or nipple discharge. Women over age 40 may be referred for a mammogram (breast x-ray) prior to surgery. Your surgeon will discuss your preferences for breast size and shape and will address any additional concerns. On your initial surgeon visit, you should receive information about the surgical procedure, including length of surgery, hospitalization, type of anesthesia, recovery time, as well as a list of the risks and benefits of the operation. You may be given these details in a variety of formats such as verbal descriptions, written materials, videotapes, or (even) a web site. However you do it, make sure that you get sufficient information to make an informed choice.

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9. How do I prepare for surgery?

In preparation for surgery, you may be asked to avoid taking aspirin, nonsteroidal anti-inflammatory drugs (Motrin or ibuprofen), vitamin E, fenfluramine, or phentermine at least two weeks before surgery. These substances may interfere with normal blood clotting or with your ability to heal following surgery. It is also advised that you quit smoking if you haven’t already done so, due to potential increases in wound complications and anesthetic risks associated with tobacco use. Women age 35 or older may be required to have a mammogram before surgery. In addition, your doctor may prescribe antibiotics before and after surgery to decrease the risk of infection.

When you arrive at the hospital or surgery center on the day of surgery, you likely will be taken to a "pre-op" area where you will change into a hospital gown. (Yes, they’re ugly and they don’t fit!)An intravenous ("IV") line will be started for fluids and anesthetic drugs. Your plastic surgeon will make preoperative measurements and markings and answer any last-minute questions. You will also need to sign a written permit for the operation. After you arrive in the operating room, the anesthesiologist will give you several drugs through your IV, and you will drift off to sleep. You will remain asleep (unconscious) throughout the surgery. (These procedures usually are not performed under local anesthesia.) Although surgical time varies, breast reduction operation last from two to four hours.