Asymmetric breast reduction with vertical plication short scar technique

Breast reduction

Most women ask for a breast reduction because the sheer physical size and weight of their breasts causes significant physical discomfort. This may include back pain, neck pain, headaches (from neck muscle strain), bra straps digging into their shoulders and fat atrophy beneath the bra straps. It may be difficult to exercise and to fit certain types of clothing. There may be skin irritation in the folds beneath the breast. Posture may be affected. Breasts may become particularly large during the menstrual cycle and when breast feeding.

Additionally the breasts may be a source of social embarrassment and unwanted attention. Many women will dress to hide the size of their breasts.

Mr Davis has done many hundreds of breast reductions and finds this surgery very rewarding because of the immediate improvements in quality of life. Most people find it is easier to take a deep breath and the relief from tightly bound bras can be profound. The removal of constant neck, back and shoulder strain is a common comment along with improved posture and ease of doing most physical activities.

Frequently asked questions

General questions

Mr Davis does Breast reduction for a fixed cost. Most standard cases have been done for a total cost of $21,760. Cases that require additional equipment such as liposuction equipment would cost more. For the current fixed cost please either email us or phone us on 0800 268 526

The quoted cost for surgery covers everything including anaesthetist fees, theatre fees, consumables, staying overnight in hospital after surgery, any additional consultations after the first consultation and all the follow up for dressings and checks in the first year after surgery. This cost includes GST.

Several insurance companies do assist with the cost of breast reduction. Usually you would have to have been a member for a certain minimum period and then fulfill certain criteria. You should check with your insurance company first.

Following the consultation I write to the insurance company with the specific examinations finding they request. Almost all cases of significantly large breasts would qualify. Those who simply need a breast lift with no removal of breast tissue do not qualify.

Examples of Mr Davis’ work can be seen at Specific examples of anatomic variations may also be shown during a consultation where appropriate.

It is normal for a breast lift ( called a mastopexy) to be done during breast reduction surgery. This lifts the nipple and areola into a higher position if they have dropped. The areola diameter is narrowed to a standard size (just over 4 cm wide). The areola is centralised over the area of breast prominence where is would typically be in youthful women with smaller breasts.

Everyone 30 years and older should ideally have a mammogram prior to breast reduction surgery. All tissue removed at the time of breast reduction is sent for pathology analysis. I have found early stage breast cancer after breast reduction in women who have recently had a “normal” mammogram. The very earliest stages of cancer may be missed on a mammogram but it is still the best currently available screening test.

I usually only use this technique when performing very significant breast reductions (greater than 1kg per side) when a lot of excess skin needs to be removed.

The Wise pattern is a W-shaped pattern of skin incision that leaves a scar around the nipple and vertically down to the inframammary crease (like the vertical mastopexy) but also leaves a long scar running along the inframammary crease. Essentially the skin is cut out and reshaped like a bra.
There are a number of different ways of reducing the breast gland beneath a Wise pattern scar. The more common types include:

1.    Robbins (inferior pedicle)
2.    Central mound (central pedicle)
3.    McKissock (horizontal pedicle)

The advantage is that the initial result looks very good but the disadvantages are the increased likelihood of bottoming out with time and the longer inframammary crease scar although this should be largely hidden when the arms are by your sides.

During surgery

Where possible, a short scar vertical gland plication is the main technique that I use. This is a technique that evolved in France and across Europe and more recent modifications have been made in Canada. Some of the more famous surgeons names associated with vertical plication techniques are: Claude Lassus, Madeline Le Jour, Daniel Marchac and Elizabeth Hall-Findlay.

The advantages of the vertical techniques are that the bulk of the breast tissue is removed inferiorly, the breast gland tissue itself is modified in shape to produce a cone shape, the breast shape tends to hold itself more securely over time with less “bottoming out than skin tightening techniques and the inframammary crease scar can be minimised or not used at all.

The disadvantages are that the techniques is more complex and there is a learning curve, it is not suitable for massive reductions, an inframammary crease scar is still required after massive weight loss cases, and a skin ripple can be left beneath the breast that in about 10-20% of cases may need to be removed under local anaesthetic three months later if it does not completely flatten. This is at no additional charge for my patients when this is required.

After surgery

Cup size is a ratio between breast and chest circumference. This ratio will change during the menstrual cycle and during weight changes. It will change during pregnancy and breast feeding and may change after menopause. Cup size therefore is not static.

What I find to be more important than cup size is the physical build of the patient and someone with wide hips and broad shoulders should be cautious about having very small breasts and vice versa.

Surgeons cannot guarantee a particular cup size after reduction surgery but it is essential to have a clear idea about a women’s preference. Most women prefer a C-D cup but some have preferences smaller and occasionally larger than this.

The amount of reduction is usually limited by the need to keep the blood supply and nerve supply to the nipple intact.

The shape of breasts will continue to change for at least 6 -9 months after a breast reduction. This aspect is not well discussed in the NZAPS information brochure I give my patients to read about breast reduction surgery. As the internal swelling settles and scar tissue softens, the breasts will drop.

Regardless of the procedure performed, breasts will drop after surgery. I over-elevate the breast gland in anticipation of some drooping in months after surgery. If the breast shape looks perfect after surgery, then I have not elevated it enough!

Scars after surgery run around the nipple areola complex and vertically down to the inframammary crease. In some cases a small scar may be needed in the inframammary crease and this will discussed with you before surgery.

The scars are permanent and will fade over time. They are most noticeable in the first 6-9 months after surgery. I show patients examples of other breast scars in the initial period so that they have a clear idea about what to expect.

Nerves that pass thought the skin surrounding the areola are severed but gradually regenerate over time. The nerves which enter deeply are kept intact however sensory disruption is common in the first few months after surgery. It may take a long time for the sensation to return to near normal and in some cases permanent changes occur.

Studies show that 80% of women regain the sensation that they had before surgery by 12 months after surgery. This means that about 20% of women have some permanent sensory loss.

Some degree of asymmetry before surgery is common and normal. If the difference is obvious then I will try my best to correct this. Perfect symmetry of all aspects of the breast is unlikely. However previously symmetrical breasts should not be markedly asymmetrical following surgery.

Sometimes asymmetry will be caused by by a curved spine, more prominent ribs on one side or shoulders held at different heights.

Breast volume may change over time. This can occur due to changes in weight and hormonal changes such as following breast feeding or menopause.

Although uncommon, repeat breast reduction is possible many years later particularly with weight or hormonal changes.

Very rarely I have patients who have requested breast augmentation following breast reduction many years earlier when they were younger. Remaining breast tissue oftens shrinks (involutes) following breast feeding.

Posture changes gradually get worse over time. Sometimes this is the weight of the breast at the front but many women also hunch their shoulders forward to hide their breasts. Overtime there are permanent changes to the spine and rib cage and it is not uncommon to see a hump at the base of the neck in women wanting to have a breast reduction.

After surgery it is important to practice putting your shoulders back and retraining the core muscle of your back and between your spine so you can stand up straight again (within the limits of permanent bony changes)

The risks

Smoking greatly increases the risk of surgery complications. I want my patients to have the best possible result so please don’t smoke!

The risk of the nipple dying after surgery is very high is active smokers.

A single cigarette will cause the small vessel in the skin to tighten (vasoconstriction) for about 50 minutes. This will affect wound healing. The chance of a hypertrophic scar, wound edge separation and infection is much more likely in active smokers.

Smoking decreases the elastin content of the skin. Over time it will have less elastic recoil. This is most noticeable in the face with visible wrinkles but also affects breast skin.

Atelectasis, or collapse of the small air spaces in the lung, is much more common after an anesthetic in smokers. Ideally smoking should stop a minimum of 6 weeks before surgery and needs to permanently stop to maintain the best results and tissue tone over time.

The main complications after breast reduction include:

  1. Scars
  2. Sensation change
  3. Asymmetry
  4. Breast feeding
  5. Volume changes
  6. Shape change after surgery
  7. Infection
  8. Bleeding.
  9. Death of nipple tissue. This complication is less than 1% but never 0%. It is more common in smokers.

Going forward

Most women who have a breast reduction will not be able to breast feed after surgery without also supplementing with bottle feeding.

Many women with very large breasts can find it very difficult to breast feed before surgery.

Often I will remove between two thirds and three quarters of the bulk of breast tissue when a reduction is done. Of the remaining tissue, only about 20% of it will still be connected to the nipple. Most breast reduction techniques will permanently affect breast feeding because breast ducts will be cut.

This is an important consideration for young women who are yet to have a family but shoudl be balanced against the current physical handicaps of large breast and the possibility that breast feeding will be difficult in any case.

Breast cancer is very common in New Zealand. 1 in 7 women develop breast cancer at some stage during their life. Everyone 30 years and older should ideally have a mammogram prior to breast reduction surgery. This is a requirement by some insurance companies. All tissue removed at the time of breast reduction is sent for tissue analysis. I have found early stage breast cancer after breast reduction in women who have had a “normal” mammogram only weeks earlier. The very earliest stages of cancer may be missed on a mammogram. However currently it is still the best available screening test.

You may have to wait up to a year after surgery before having a further mammogram. If a further xray is required either an ultrasound scan or MRI would be used.