Breast Resizing: Going Smaller

Big breasts can get uncomfortable, or you might just want to say bye to your implants...

A breast reduction or explantation of breast implants can be done cosmetically or with insurance. We talk about what factors to consider, and the journey from pre-operative testing to recovery. It can get confusing if you've been recommended a breast implant at the same time as a breast reduction! Knowledge is power so learn more below.

As always, if you don't know what to do, call us at Pulsar Health to book an appointment, so that we can help you to figure out what might work best for you.

Breasts can of course be too large, either for comfort or for aesthetics. European women tend to prefer a smaller breast aesthetic than American women. Breast size can increase with hormonal shifts such as with nursing, and not go back to a comfortable size. Breast implants can have their "season" in your life, and it may be time to take them out for aesthetic or other reasons, called a "breast explantation". Sometimes, the recommendation is made to have an implant at the same time as a breast reduction, which can be confusing. All this and more are discussed below... 

Q: What's the difference between a cosmetic breast reduction and an insurance-paid breast reduction?

A: Macromastia, the medical terms for large breasts, can sometimes be treated using insurance if it is a covered benefit, and if it is causing chronic pain, shoulder grooving, rashes etc... not affected by weight reduction. When it is covered, oftentimes there is a requirement to remove a minimum amount of breast tissue, which can make the breasts quite small, so this should be borne in mind in deciding between an insurance versus cosmetic reduction. In cosmetic breast reduction, you can choose how much to keep / remove and don't need to meet the many requirements of insurance-paid breast reductions.

Q: Do the breasts get lifted in a breast reduction, and what types of scars are needed?

A: Breast reduction has the side benefit of lifting the breast. Depending on the amount of breast tissue removed, it can affect the ability to breast feed. Typically, an "anchor-shaped incision" is required to get enough of a breast lift if there is excessive skin or ptosis (lowered position of nipple) of the breast, which results in 3 scars that together look like an anchor: 

1. movement of the nipple areolar complex (NAC) needs an incision around the NAC
2. vertical incision down from the NAC to the fold under the breast, called the inframammary fold (IMF)
3. final incision along the IMF

These incisions typically heal well over the course of a few weeks to a few months. Sensation of the NAC after surgery can vary. Sometimes, there may be delayed wound healing where multiple incisions meet. Scars can thicken (hypertrophic scars) or even grow outside the area of the incision (keloid scars). This is treated with steroids, lasers, or if necessary surgical excision. Having said that, almost everyone who has had a breast reduction has loved having it, with relief of back / neck pain and an easier time getting clothes to fit well.

If you require revision of a breast reduction done somewhere outside of Pulsar Health, be sure to bring your operative note from that surgery, because the way the surgery was done affects the blood flow to the nipple areolar complex (NAC). If there isn't enough blood flowing to the NAC, parts or the whole of it can die. This is also why we do not do elective breast reduction surgeries on people who smoke or have significant nicotine exposure, as it impairs the blood supply needed for healing. We usually recommend three to six months of no smoking in order to minimize the effects of prior nicotine exposure. Sometimes the breasts are so large that a free nipple graft is the only way to "salvage" your nipple, but this does lose sensation to the nipple area, and is rarely needed in breast reductions.

Q: Why would I be told me to get an implant when I get my breasts reduced?

A: At Pulsar Health, we try to avoid placing implants when reducing breasts, as the goal is to move the breast tissue into a more attractive position without having to use other materials. During the surgery, an improved cleavage is created by repositioning breast tissue and tightening the skin. This is usually fabulous initially, but the cleavage does reduce over time as the breast tissue settles and falls, with some stretching of the remaining skin happening as the body adjusts after surgery. If a prominent cleavage is wanted, the use of a small implant in that area can have a longer-term effect of structural support for keeping the cleavage better defined. This does come with all the benefits and complications of a breast implant. Alternatively, fat can be added to the cleavage at a separate procedure after the reduction, to augment the cleavage without an implant. Fat grafting may require repeating, and like any procedure has benefits and risks. Feel free to book a consultation with us to discuss this in more detail.

Q: What are breast explants?

A: Breast explantation is removal of a breast implant and the fibrous capsule that naturally forms around it. Sometimes insurance will cover this procedure if there are functional issues such as pain, rupture or some other complications such as breast implant associated illness (see Breast resizing: going bigger section for risks of breast implants), depending on your insurance plan. When we remove the implant and capsule, at Pulsar Health we take great care in removing as much of the capsule as safely possible, which makes the surgery longer, but gives you the best long-term result. This is typically done under general anesthesia. You should consider doing a breast lift (mastopexy), at the same time or afterwards, to address loose tissue following removal of the implant. Insurance normally does not cover mastopexy procedures or replacement implants unless there is a personal history of breast cancer. Please see the website section on Breast reshaping for more information on mastopexies.

Q: Do I need any special tests before breast surgery?

A: Prior to any breast surgery, we like to obtain imaging of the breasts with a screening mammogram, or for younger denser breasts, an ultrasound to make sure there is nothing else going on. Also, all nicotine exposure including smoking and vaping must be stopped for three months before and two months after breast reduction surgery. On the day of surgery, you will have a urine pregnancy test. Young healthy people don't usually need any blood tests, but if you have heavy periods or medical problems, we may need to check your labs.

Q: What should I expect after breast surgery?

A: Following surgery, you will have dressings on that stay there until they are changed out at the office. We will guide you on what to do afterwards. Drains are usually placed for explantation surgeries but not most breast reductions at Pulsar Health. Antibiotics should be taken regularly after the surgery, but pain or nausea medications only as needed. Everyone has a different pain tolerance level, but most people do not need pain medication after a few days. We do recommend that you avoid sleeping on your front for at least a couple of weeks. 

At Pulsar Health, we will guide you on your post-op journey. The size of the breasts is initially quite a bit larger than it will be due to swelling, and the breasts will "drop" anywhere from a couple of weeks to about three months, stretching out the lower tissue, so we compensate for that at the surgery to prepare for the drop. We recommend that you have a stable weight and continue to avoid nicotine for at least six weeks after the surgery. Underwire bras can be worn after adequate healing. You can walk straight away, but more vigorous exercise should wait two to four weeks.

Recovery from anesthesia usually takes a few days. At Pulsar Health we do most breast reduction and explantation surgeries under general anesthesia, but we have done selective breast reduction surgeries awake as well as some breast lift procedures.