Women with very large, pendulous breasts (macromastia) may experience a variety of medical and other problems caused by the excessive weight of their breasts. These include neck, shoulder, and/or back pain; painful shoulder indentations and grooving related to bra straps; skin hyperpigmentation related to bra strap irritation; skin rashes in the folds beneath the breasts; slouched posture and skeletal deformities; occipital headaches; upper extremity paresthesias; restriction of physical activities; and difficulty finding clothes that fit properly. Unusually large, disproportionate breasts can make a woman or a teenage girl feel extremely self-conscious. For these women, a breast reduction (reduction mammoplasty) may be the solution.
Breast reduction is usually performed for relief of physical symptoms rather than simply for cosmetic improvement. Most women who have the surgery are troubled by very large, sagging breasts that restrict their activities and cause them physical discomfort. Breast reduction is intended to improve a woman’s comfort and daily function by reducing breast size and eliminating the weight that causes muscular spasm and poor posturing of the neck, shoulders, and back. The goal is to give a woman smaller, more shapely breasts that are in proportion with the rest of her body. The major focus of this procedure is to reduce the volume of the breast while lifting the nipple-areolar complex, reducing the breast skin envelope, and reshaping the breast. The procedure removes fat, glandular tissue, and skin from the breasts, making them smaller, lighter, and firmer; it also reduces the size of the nipple-areolar complex. In most cases, breast reduction should not be performed until a woman’s breasts are fully developed; however, it can be performed earlier if excessively large breasts are causing serious physical discomfort.
According to The American Society for Aesthetic Plastic Surgery National Data Bank Statistics, 103,077 patients had breast reduction surgery performed in 2015.
Techniques for breast reduction vary depending upon the size of the breast, the degree of ptosis, and the amount of skin laxity and excess. When the extent of reduction required is modest the operation often resembles a mastopexy more than a reduction. Small reductions can be performed using a peri-areolar, vertical, or inverted-T technique. Moderate sized reductions can be performed with a superior or inferior pedicle, a short-scar, a vertical, or an inverted-T technique. Larger reductions are usually best performed with an inverted-T technique, and an inferior or McKissok pedicle work well when greater vertical transpositions of the nipple-areolar complex are required to correct significant breast ptosis. Rarely, a free nipple graft method is need for the largest of reductions and/or when there is a substantial degree of nipple ptosis.
The Wise-pattern, inverted-T scar procedure is the most commonly performed breast reduction. This procedure produces an anchor-shaped scar that encircles the areola, extends vertically downward, and follows the natural curve of the crease beneath the breast. It is usually based upon an inferior pedicle of breast tissue designed to maintain nipple-areolar complex perfusion, and which may allow for the preservation of sensation and the ability to breast-feed. Breast tissue is removed medially, superiorly and laterally to the nipple-areolar complex, which remains attached to breast tissue in the central and inferior pole of the breast. The areola is reduced in size and shifted to a higher position. To accommodate the new shape and size of the breast, the skin envelope must also be reduced. The remaining skin, that was formally located above the nipple-areolar complex, is redraped around the inferior pedicle to reshape the breast. In vast majority of surgeries, the nipple-areolar complex remains attached to the breast tissue. However, if the breasts are extremely large or pendulous, the nipple-areolar complex may have to be completely removed and grafted into a higher position; this will result in a loss of sensation in the nipple and areolar tissue. Liposuction may be used with reduction surgery to improve the lateral breast and chest wall contour.
The vertical procedure has gained popularity to reduce scar length. It is based upon a superior pedicle where tissue is removed from the lower pole of the breast, using a circumvertical skin resection, without any internal shaping.
Criteria For Medical Necessity For Breast Reduction Surgery
If you experience any neck, back, or shoulder pain, bra strap grooves, poor posture, decreased activity or other functional problems that are related to large breasts then breast reduction surgery may be covered under your insurance. Insurance coverage depends upon specific terms of each policy, and individual patient factors/symptoms However, evermore frequently, breast reduction is an exclusion in many insurance policies.
Patients seeking insurance coverage for breast reduction for symptomatic breast enlargement must have their physician(s) obtain written preauthorization of medical necessity from the insurance company. Insurance policies vary tremendously in their extents of coverage, requirements, documentation, and exclusions: Most have specific requirements for minimum amounts of breast tissue to be removed; Some require overweight women to lose weight prior to surgery; Still others may require an orthopedic evaluation of back pain, or a trial of physical therapy and anti-inflammatory medication prior to authorization of surgery; And, many policies specifically exclude breast reduction surgery, even if medically indicated. Some of these requirements may seem unfair or not make sense from a medical standpoint, but if these specific provisions are written into a patient’s insurance policy, they must be followed if insurance coverage is expected. As all policies differ, it is important to check with your insurance company for the specific documentation you are required to file when seeking a medical necessity determination.
Many insurance companies are now requiring that some or all of the following criteria, or other similar criteria, be met in order to be considered allowable for coverage for breast reduction.
- The patient has significant symptoms, documented in their medical records, which interfere with activities of daily living, including:
- Pain in the upper back, neck, and shoulders which is of long-standing duration and increasing in intensity, and/or
- Peristent, non-seasonal submammary skin rash/inflammation/irritation (intertrigo) which is unresponsive to local hygiene and topical anti-infective therapy, and/or
- Ulnar nerve paresthesia resulting in pain and/or numbness in the arms and/or hands.
- The physical exam documents:
- Significant shoulder grooving or skin ulceration, and
- Obvious breast hypertrophy and
- Sternal notch-to-nipple distance > 28cm for women > 5’2” tall, or > 25cm for women < 5’2″ tall, and
- Physical exam findings consistent with symptoms related to mammary hypertrophy.
- Failure of a comprehensive conservative treatment measure, including:
- A minimum of 6 weeks of physical therapy for the back, neck, and/or shoulder pain including a maintenance home exercise program, and
- Appropriate support bra with weight distributing straps, and
- Anti-inflammatory medication, unless contraindicated, and
- Symptomatic measures, including application of heat and cold and
- Appropriate local hygiene and topical medication for intertrigo.
- Documented Body Mass Index (BMI) < 30, which is below the level considered “obese” according to the guidelines of the National Institutes of Health (NIH) – National Heart, Lung, and Blood Institute (NHLBI) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obese Adults.
Breast reduction is considered “cosmetic” for those individuals who are asymptomatic or do not meet the criteria for medical necessity set forth by their insurance company—we will be happy to provide you with a price quotation. For more information regarding breast reduction please contact us at 414-443-0033.
Breast Reduction Before & After Photos
Post Operative Instructions and Information for Breast Reduction
- Our office will request authorization from your insurance company to determine if benefits covering breast reduction surgery are available to you. It is recommended that insurance approval be received prior to scheduling surgery.
- Breast reduction is performed under a general anesthetic, and can be performed as a day surgery or with an overnight hospital stay depending upon your insurance requirements.
- Drains may be placed beneath the breast to reduce post-operative fluid accumulation. These drains are usually removed the day after surgery.
- Patients will receive instructions regarding incision care, and how you may bathe. Gauze dressings should be changed as needed until incision drainage subsides. After the drainage has ceased there is no need for gauze bandages unless they improve comfort.
- Patients wear a support bra or other support wrap for two weeks following surgery; then a supportive sports bra or other comfortable bra may be worn. Avoid under wire bras for 2-3 months following surgery.
- Patients should wear a comfortable support bra, sports bra, tube top, or other wrap for 6 weeks following surgery; then a supportive sports bra or other comfortable bra may be worn. Avoid under wire bras for 2-3 months following surgery.
- Patients return to the doctor’s office at 1-2 weeks, and approximately 1 and 3 months, after surgery.
- The majority of sutures are dissolvable, but a few sutures may need to be removed 1-2 weeks after surgery.
- Bruising resolves within 2 weeks. Initially the breasts are quite swollen and tight. Swelling will usually subside over about 8 weeks, but may take 3 months or longer in some cases.
- Avoid any strenuous activities for at least 2 weeks after surgery. Your doctor will instruct you when to begin a gradual return to activities. Patients should avoid stretching their arms over head or backward for 2-3 weeks after surgery. Patients are generally return to an unrestricted activity level by 4-6 weeks after surgery.
- Patients should wait until 6 weeks following the operation before buying bras that are intended to fit well.
- Lubrication and massage of the scar lines can begin 3 weeks following surgery. Scars will soften, flatten, and fade over 6-12 months.
- Avoid exposing the breast scars to the sunlight or other ultraviolet light for 6 – 12 months after surgery.
- Plan on remaining off work for 2-3 weeks after surgery.