Basics
Description
- 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-op
- Temporary 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 risks
- Includes reactions to anesthesia, bleeding, and infections
- Other risks
- Implants 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 irritation
- Women 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 surgery
- An 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 surgery
- There 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.