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Elective Breast Surgery

Basics

Description

- There is no known increased cancer risk with cosmetic breast surgery. - Patients should be aware that any breast surgery will change breast tissue and increase the challenge to examine and diagnose pathology of the breast. - Surgical risks - Includes reactions to anesthesia, bleeding, and infections

  • How a woman views her breast size can have strong emotional and psychological impact on her self-image.
  • Common elective surgery for women include: Augmentation mammoplasty to enhance breast size and reduction mammoplasty to reduce breast size. Breast lifts (mastopexy) can raise and reshape breast by removing loose skin.
  • Breast enlargement is commonly a same-day surgery.Surgery lasts an average of 1 ½-3 hours.Costs $4,000-$8,000
  • Breast reduction is a more complicated surgery but often is same-day surgery.Surgery lasts an average of 3-4 hours.May require hospitalization post-opTemporary drains may be placed.Costs $6,000-$12,000
  • Health insurance does not cover breast augmentation or breast lifts.
  • Some health insurance companies cover breast reduction if considered medically necessary and if a minimum of 500 g of breast tissue can be removed per breast.
  • Patients undergoing reduction mammoplasty often find significant improvement in their quality of life with the reduction or elimination of preoperative complaints such as back pain.
  • Pregnancy-associated breast changes will affect the look of both implanted and reduced breasts.
  • Breastfeeding is commonly affected by cosmetic breast surgery because of rearrangement of breast ducts and/or reduction of nipple sensation.
  • Women may wish to undergo breast augmentation or reduction surgery after pregnancy and breastfeeding is no longer desired.

Risk Factors

  • There is no known increased cancer risk with cosmetic breast surgery.
  • Patients should be aware that any breast surgery will change breast tissue and increase the challenge to examine and diagnose pathology of the breast.
  • Surgical risksIncludes reactions to anesthesia, bleeding, and infections
  • Other risksImplants have never been proven to increase the risk of cancer, connective tissue, or autoimmune disease.An implant can last up to 20 years before there is deflation or leaking. Replacement requires additional surgery.All breast implants will have scar tissue formed around them called a capsule. The capsule can cause contracture, deformity, and pain.The Baker Scale is a descriptive measure of the severity of capsular formation around the breast implant.Class I is minimal.Class IV is severe and requires surgical correction.Implants do not typically feel nodular; therefore, if nodules are found on breast exam, they should be evaluated as per standard of care for suspicious breast masses.Implants may decrease visualization of breast tumors with mammography.
  • Elective breast surgery may impair nipple sensation, affecting breastfeeding and sexual pleasure.

Diagnosis

History

  • Prior to surgery, a woman should discuss with her primary care provider and surgeon the reasons why she wishes to have the surgery.
  • Providers should explore how realistic are the woman's postoperative expectations.
  • To assist a patient with her surgical options, surgeons should provide preoperative and postoperative photos of previous patients.
  • Signs and symptoms:Large breasts (macromastia, breast hypertrophy/hyperplasia) have numerous associated physical problems including:Headache, neck pain, back pain, shoulder pain (including from bra strap grooves), skin irritationWomen with large breasts may also face psychological and social stresses including inability to participate in exercise and other social functions.

Physical Exam

  • Basic preoperative exam including a thorough breast exam
  • Any abnormality identified must be evaluated prior to elective breast surgery.

Tests

Imaging

  • Preoperative mammography is recommended for women ≥30 years to obtain a baseline.
  • Any abnormality on mammogram must be evaluated prior to elective breast surgery.

Treatment

Surgery

  • Augmentation surgeryAn implant is a silicone pouch filled with saline.Silicone-filled implants have recently been reapproved by the FDA for use in cosmetic breast surgery.An incision for the breast implant is made under the breast, around the areola, through the umbilicus, or in the axilla.The implant can be placed either submuscular (behind the pectoral muscle) or subglandular (between the breast tissue and the muscle). The submuscular approach is more common.
  • Breast lifts only remove excess skin.The incision is around the areola.
  • Reduction surgeryThere are a variety of surgical approaches for reduction surgery, typically preserving the nipple-areolar complex.Incisions are typically are around the entire areola and in the lower breast.

Ongoing Care

Follow-Up Recommendations

  • The patient should expect some postoperative pain, swelling, and bruising.
  • Reduction surgery typically requires the patient to have a drain in place for several days.
  • Patients should avoid vigorous postoperative activity for 4-6 weeks.
  • Over time the augmented breast will soften; however, it will never feel as soft as the natural breast.
  • Patients may choose to massage the augmented breast to enhance softening and recover sensation.

Additional Reading

1Chadbourne E, Zhang S, Gordon M. Clinical outcomes in reduction mammoplasty: A systematic review and meta-analysis of published studies. Mayo Clin Proc. 2001;76:503-510. [View Abstract]2Freund R. Cosmetic breast surgery. New York, NY: Marlowe & Company, 2004.3Love S. Dr., Cambridge UK Perseus Publishing, 2000.4Ruot-Worley J. Augmentation mammoplasty: Implications for the primer care provider. J Am Acad Nurse Pract. 2001;13:304-309. [View Abstract]5Sarwer D, Nordmann J, Herbert J. Cosmetic breast augmentation surgery: A critical review. J Wom Health Gend Base Med. 2000;9:843-855. [View Abstract]6Smith M, Kent K. Breast concerns and lifestyles of women. Clin Obstet Gynecol. 2002;45:1129-1139. [View Abstract]7Stoppard M. The breast book. New York, NY: DK Publishing, 1996.

Codes

ICD9

  • 611.1 Hypertrophy of breast
  • 611.82 Hypoplasia of breast

ICD10

  • N62 Hypertrophy of breast
  • N64.82 Hypoplasia of breast

SNOMED

  • 4754008 gynecomastia (disorder)
  • 8915006 congenital hypoplasia of breast (disorder)

Clinical Pearls

  • Augmentation mammoplasty enhances breast size.
  • Reduction mammoplasty reduces breast size.
  • Reduction surgery is a more complicated surgery than augmentation.
  • Any breast surgery will change breast tissue and increase the challenge to examine and diagnose breast pathology in the future.
  • Elective breast surgery may impair nipple sensation, affecting breastfeeding and sexual pleasure.