written by DR MICHAEL MIROSHNIK FRACS

PLASTIC & COSMETIC SURGEON

www.drmiroshnik.com.au

Throughout time, large breasts have been considered a strong sign of femininity and fertility. They highlighted a woman’s ability to nurture and were applauded by artists, religious factions and the public alike. However, women with excessively large breasts can find them both aesthetically and physically detrimental. Indeed, as anyone with very large breasts can tell you, there reaches a point when shape changes as well as sag make the breasts less attractive than they could be. Moreover, the extra weight involved is associated with physical ailments such as shoulder, neck and back pain, bad posture, hygiene issues, irritating bra strap marks and in severe cases even breathing difficulties.  Large breasts can also quite easily dominate a woman’s appearance and silhouette, making her look unbalanced and disproportionate.  

The idea of breast reduction surgery has been around for a long time, much longer in fact, than that of enlargement! In 1669 in England, some 340 years ago, Dr William Durston both described and performed what was probably the first true surgical reduction of the female breast in the western world. Since that time, breast reduction surgery has flourished- evolving from simple debulking procedures to sophisticated reshaping surgery with relatively small scars. The last 15 years in particular, have shown some of the most dramatic changes.

It is important to realise that with the removal of breast tissue and redundant skin, the breast circumference itself is changed and so it is usually necessary in the same procedure to lift the breast as well as reshape it in order to achieve aesthetically balanced and beautiful results.  In addition, as the nipple and areola (the pigmented area around the nipple) are being repositioned to suit the newly created breast, they are usually also reduced or reshaped to make them more attractive. For these reasons; breast reduction, breast lifting and nipple/areolar reshaping are three topics that are often dealt with together when assessing someone who is considering this type of surgery.

As breast reduction surgery does not rely on any implantable material, it is completely up to the surgical technique of the plastic surgeon to produce a well shaped breast and the operations themselves are generally more complicated, taking longer than standard breast augmentation surgery.

There are many ways to classify the operations available for a plastic surgeon to use, but for the purposes of this article, we will use the simplest way, which is to classify them in terms of the pattern of skin excision.

Vertical Pattern Breast Reduction/Lift

(Also known as Short Scar or Lollipop pattern breast reduction surgery)

This operation has revolutionised breast reduction and breast lifting and is by far and away my preferred technique for most women seeking this type of surgery. The scar resembles the shape of a ‘lollipop’ as it runs around the nipple/areolar and then has a vertical extension straight down the middle of the breast.

Although first used by surgeons in the 1960s, it wasn’t until recent times that the technique has undergone great refinements and hence flourished around the world.

Although the skin pattern is essentially a ‘lollipop’, what the surgeon does once inside the breast tissue has many variations. These surgical variations differ in not only from where tissue is removed but also in what is done to the nipple/areolar unit. One of the recent more popular internal procedures, the superior-medial pedicle technique, involves rotating the nipple 90 degrees. This clever manoeuvre not only lifts it and the breast around it, but also effectively ‘cones’ the breast tissue to give it a very pleasing and youthful appearance. It works very well particularly in breasts that require more nipple projection and lack overall shape.

The amount of breast tissue that is actually removed, lifted and reshaped can be intraoperatively tailored to each individual’s requirements. In some, who prefer to maintain volume, the amount of tissue removed is quite minimal and the emphasis of the operation becomes one of lifting as well as perhaps breast and nipple/areola reshaping. In others, the emphasis is indeed in volume reduction and in these cases large amounts of tissue can be removed to make a dramatic difference in appearance and cup size.

Anchor-Shaped Pattern Breast Reduction/Lift

(Also known as Inverted ‘T’, Traditional or Wise pattern breast reduction surgery)

This operation is the ‘tried and tested’ workhorse of breast reduction surgery. It is still the most commonly practiced breast reduction pattern in the world. The scar, however, is much longer than that of the vertical technique resembling an inverted ‘T’ or an ‘anchor’. It runs around the nipple/areola, extends vertically downwards (like the vertical pattern) but then joins with another scar which horizontally follows the entire lower curvature of the breast, running along the breast crease. 

The anchor pattern was popularised in the early 1950s and has changed little since that time. As with the vertical reduction, various internal techniques can be used by the surgeon to reposition the nipple. A common procedure to achieve this when combined with the anchor pattern is the inferior pedicle technique where the nipple is lifted straight up to its new position, without any rotation.

Very large volumes of breast tissue can be removed by the anchor-pattern breast reduction as it allows for the excision of more skin than the vertical pattern. By excising skin in both vertical and horizontal directions, the skin envelope at the end of the surgery always matches the breast tissue underneath it. This is an advantage when women require drastic reductions in cup size or have large quantities of loose and redundant skin that need to be removed at the same time.

Male Breast Reduction

A completely different subset of patients to consider are males. In these instances, for various physiological and pathological reasons, men who usually have very little breast tissue, develop feminisation of their breasts- a condition known as ‘gynaecomastia’. This can not only be painful and bothersome but, understandably, cause a great deal of psychological distress to those afflicted.

After ruling out medical causes for this condition, the surgical treatment of gynaecomastia usually involves a combination of liposuction and direct surgical excision. Surgical incisions are skilfully hidden around the areolar edges so that they are extremely difficult to see.

Breast Liposuction

Although an uncommon way of treating large breasts alone, liposuction is a very useful adjunct to any of the previously described procedures. In fact, it is almost mandatory in the male breast reduction and used quite frequently in most short-scar, vertical techniques for the female. In this regard, I often use it for removing any excess breast tissue that goes up towards the armpit region.  

 
As with other plastic & cosmetic surgery, most important decisions concerning technical choices are made in the preoperative consultation and it is important to emphasise this fact to patients. An operation that is great for one person may be inappropriate for others as people’s needs as well as physical forms vary so much in our society.

Breast reduction & lifting surgery often requires at least an overnight stay in hospital and the use of drains. These drains are removed prior to discharge. Also, as the operation is commonly done not just for cosmetic but for physical reasons, the surgical costs are usually rebatable by most health funds.

Case Examples

All by Dr Michael Miroshnik

www.drmiroshnik.com.au

Case 1 (Below): 33yo female, children, vertical (short-scar) breast reduction and lift with nipple repositioning and reshaping. Approximately 650g of tissue was removed from each breast, F cup -> D cup bra

www.drmiroshnik.com.au

www.drmiroshnik.com.au