Why Breast Reduction After Weight Loss Is Really a Breast Lift

Dr. Gardner (00:00):
I did a buttock lift with auto augmentation. I did a fleur de lis tummy tuck and breast reduction lift and thigh lift. She looks fantastic and she's wearing a bikini on the beach.

Kirstin (00:12):
Woo-hoo. Yeah, girl.

Dr. Gardner (00:14):
So don't let a little scar get in the way of you enjoying your life.

Announcer (00:21):
You're listening to Alabama the Beautiful.

Kirstin (00:24):
I'm Kirstin Jarvis and I'm here with Alabama Cosmetic Surgeons, Dr. James Koehler and Dr. Vincent Gardner. Hey, Dr. Koehler and Dr. Gardner.

Dr. Gardner (00:32):
Hey Kirstin.

Dr. Koehler (00:32):
Hey Kirstin.

Kirstin (00:34):
All right. Today we're going to be talking about the breast reduction that isn't a reduction. You have a 19-year-old with back pain and a woman who's lost a hundred pounds and they get told the same thing, that they need a breast reduction. They're not having the same operation and one of them usually needs a little volume put back.

Dr. Gardner (00:55):
Correct. So I agree completely. Those are two different scenarios and they're very different. Let's start with the 19-year-old. A younger patient who probably has very large, heavy, pendulous breasts and their typical complaint is neck pain, back pain, shoulder grooving, general discomfort. If they are sports oriented, they like to jog, they like to run, be outdoors. Sometimes it's very difficult with very large breasts to contain them. They'll wear two or three bras. They'll wear Spanx type garments. They're hot, they're sweaty. A lot of times they will have rash from rubbing underneath their breasts and they're just generally uncomfortable. So that's scenario number one. And I would offer that patient a breast reduction because most of the time they're going to feel better, the neck pain, the back pain, they get improvement and they just feel better with breasts that fit them better. And so we offer them a reduction.

(02:02):
And typically that involves with obviously bringing the nipples back up to a more favorable location and reducing essentially the lower pole. We're getting rid of the lower half or the lower pole of the breast. And those patients are generally very happy. If you look at, take RealSelf, for example, if you look at the thumbs up or the worth it rating on RealSelf, one of the highest ratings is going to be a breast reduction. Now let's look at the other scenarios where you have somebody who's lost 100, maybe 150 pounds and they have really droopy, saggy, deflated breast, and that is a completely different animal. They do benefit from a reduction, but the reduction is more of a lift. Now almost every lift involves removal of some breast tissue, hence the reduction. Whereas in the first scenario, we're removing a large amount of breast tissue, a true reduction.

(03:03):
But the second scenario, we are still removing the lower pole of the breast. We're generally going to remove more skin with that. And again, depending on the nipple position, we'll have to reposition it back to a more favorable location. Those patients by and large are going to be very volume depleted to begin with. And once we remove the skin and the breast tissue, they're going to be further or more volume depleted. And most of those patients, I would argue, probably are going to want an augmentation. They're going to want to put their volume back. And some people would opt to do that at the same time. If they're a large reduction in somebody who's lost a lot of weight, it's probably better to stage those to get the shape right, get the nipple back where it belongs, let them heal up from that and then come back and let them size so the sizing is more accurate.

(04:01):
And then they can choose what amount of volume that they want back and we can do their chest wall measurements and find an implant that's going to suit their needs. And so both scenarios end up with very happy patients. They're just completely different.

Kirstin (04:19):
Is there a difference in what a breast looks like after massive weight loss compared to any other person who comes in for a reduction?

Dr. Gardner (04:28):
They're a little bit hard to compare, but let's do it anyway. So a lot of times somebody with massive weight loss may have a lot of stretch marks. Now again, let's go back to the first scenario. You can still have a lot of stretch marks in somebody who grows quickly and they can stretch the skin, but it's a little bit different in somebody who stretched out their skin by weighing an extra 80, 100 or plus pounds. And so they're different, but they can both involve skin stretching. The quality of the skin in the massive weight loss patient tends to be much worse, thinner tissue overall, and it's just stretched out and it doesn't do well. Plus it's not always, but a lot of times maybe a little bit older as well. So yeah, it's just completely different skin. It responds differently and so we tend to treat it a little differently.

Kirstin (05:23):
Does it matter how the weight came off through surgery or GLP-1s or diet and exercise?

Dr. Gardner (05:31):
So that's a common question. And I would tell you that in my experience, patients that lose weight slower tend to do better. Having said that, we also need to look at the operation that they had. Say that they had a bariatric procedure. One of them, the Roux-en-Y gastric bypass is by definition a state of protein calorie malnutrition. And so those patients, the quality of their skin I would argue is not as good. And I would also, in my experience, tell you that patients that lose weight a lot more slowly, their skin tends to retract a little bit better and they probably have better quality skin.

Kirstin (06:15):
Okay. When does someone need an implant on top of a lift or reduction and how do you make that call?

Dr. Gardner (06:23):
Well, so what I would tell a patient is that if they came in and they said, "Well, I don't know if I want an implant." And what if they say they just want a lift? I would tell them that even just by removing skin and repositioning their nipple, their breast will be smaller. Even if we don't remove a significant amount of breast tissue, say we don't remove any, say we just remove skin, I would tell them that their breast will be smaller. And so you will have patients that'll come in and they'll say, "Hey, I want my breast to be about the same size. I don't want to buy new bras and I just want to lift." Okay. Well, right there I'm going to tell them, "I can't guarantee you a cup size. I'm not going to guarantee that you won't need extra volume." And so a lot of times we don't know where they're going to end up. They're going to have swelling with the procedure. So sometimes that is a little bit hard to gauge because they come in post-op and for the first couple of months they like the size of their breast. And then as the swelling slowly subsides over three to six months, suddenly their breast is smaller and they may decide that they want to come back and add volume.

(07:29):
So obviously that's a very personal thing and they're going to have to decide. And someone will come in and they'll tell you right off the bat said, "Hey, I like being the size that I am and I know my breasts are going to be smaller after the reduction and I'm going to go ahead and plan and we're going to put an implant back in." And I just did one of those recently where she knew from the very beginning and we set hers up as a staged procedure because we did a large volume reduction and she still had a fair amount of breast tissue and I think we ended up putting her on a 400 CC implant in and she's going to look fantastic. She is going to have her volume back probably be a similar cup size, but a much different shape.

Kirstin (08:10):
Okay. I'm not going to show you what I'm talking about, but I hope that we all know what I'm talking about when I say the roll that runs from the breast around to the back, the little fat roll. What do you do about that?

Dr. Gardner (08:23):
Yeah, so that's a great question. We see that commonly. A lot of times it's with patients that have extra weight, but it's called the Tail of Spence and it is breast tissue that it can extend out into the axilla. That and the other one that I will tell you and I'm going to try to show you is there's always this area right here of extra fatty tissue and a little bit of extra skin. And that I call it an anterior bra roll and I don't know, other people call it different things. And then I would call the breast tissue that extends under the armpit into the axilla, I would call that axillary breast tissue. But liposuction can be really a great tool to reshape the lateral breast as well as to minimize and try to improve that anterior bra roll area. So those are two areas that we will commonly liposuction when we're doing a reduction/and or lift. And honestly, sometimes you can also do that even with just a straight augmentation. It just depends on how much of that axillary tissue that they have.

Kirstin (09:36):
When we're talking about a reduction in massive weight loss patients, are their scars any different than anyone else or are they in a different place or are they longer? How is scarring?

Dr. Gardner (09:49):
Again, it depends on the volume that they have. We make scars as long as we need to, to get the shape that we want and to try to make the puckering lay down flat. And so sometimes we'll have to extend that incision laterally if we're removing a large amount of tissue. And somebody who's a massive weight loss patient who might also need a back lift, but let's say they have that extra tissue, those kind of back rolls, but they don't want a scar going all the way around. Well, you have to end the incision somewhere. So a lot of times you're going to have to talk to the patient about that and say, "Hey, we can try to make this lay down flat, remove as much tissue as we can. We might end up with a little bit of pucker." And I sometimes will talk to them about extending it and doing a back lift at the same time.

(10:38):
They may not be interested in that. And that's typically going to be a massive weight loss patient. But in that scenario, we're going to make the incisions long enough to where we need to try to reduce or minimize puckering and to get rid of the extra skin.

Kirstin (10:53):
So when we're talking about these massive weight loss patients, a lot of times they need multiple procedures or would like to have multiple procedures. Are breasts normally something that you would combine with something else like arms or tummy? Okay.

Dr. Gardner (11:07):
Absolutely. Breast and arms can work well together. Again, depends on the length of the procedure when we plan it. Obviously we want to keep it in a safe amount of time. The other thing that we might do is we might do the arm incision and then actually connect it to the breast, the lateral breast incision and remove extra skin underneath the arm. I call that a lateral chest lift. Some people call it a torsoplasty, but it works well, especially in somebody who's a massive weight loss patient and they have a lot of extra skin. And that might also prevent them from needing a circumferential back lift incision. So in the right patient, it can be a nice procedure to help get rid of extra skin and maybe have them forego a back lift.

Kirstin (11:56):
Okay. We're going to talk about being ready and what has to be true before people proceed with surgery. How stable does someone's weight need to be before you'll operate?

Dr. Gardner (12:11):
Good question. Not a one size fits all answer. Used to, when I was doing bariatric surgery, we told patients you need to be stable for a year before we would send you to somebody to consider skin removal because we would tell them that you don't want to have surgery and then lose another 50 pounds. Same scenario, you don't want to have surgery and gain 50 pounds. So I tend to feel very comfortable as long as somebody is within maybe 10 to 15 pounds of their ideal body weight, or not their ideal body weight, I shouldn't say that, of their goal weight. Because typically ideal body weight, we base that based on BMI, based on their height, and not everybody fits into that category and not everybody's going to be happy with that. So I say, or at least in my mind, I want them to be within 10 to 15 pounds of their own individual goal weight.

(13:10):
Because again, I do think if you gain or lose significant weight after, you're going to potentially alter your results and they know that going in. Having said that, it's rare that I see a patient that does gain a lot of weight after these type surgeries because they've worked so hard to lose the weight. And once they get their skin removal, they're so happy in their new body that they're reluctant and they work hard. So most of them have also changed their lifestyle, so they're going to do well.

Kirstin (13:40):
For those patients, do you recommend any additional protein or different nutrition than you would any other patient?

Dr. Gardner (13:48):
No, but that's a good conversation that we have to have because the key to doing well after any surgery is good protein intake. And when I was doing bariatric surgery, our goal was 60 grams of protein after a Roux-en-Y gastric bypass procedure. And so you're trying to fit a lot of protein into a pouch the size of a small egg, and patients struggled to get 60 grams of protein in 24 hours. And so I'd like for them to get 90 to 100 or even more. I have had scenarios where patients didn't heal well. I've had incisions pop open and the only explanation that I could come up with was that their protein, when you talk to them, they would tell you, and it's usually not the patient, it's their spouse that would say, "Oh, they don't eat very much protein." Because the patient sometimes will tell you, oh yeah, yeah, yeah, I'm getting plenty of protein.

(14:43):
But a lot of times I think that that's really the reason when we have sometimes post-op infections and wound healing problems that it may not be that they're getting enough protein.

Kirstin (14:57):
Okay. How common is separation at the T junction and what happens if it opens up?

Dr. Gardner (15:04):
So T junction separation, what's a T junction? A T junction is where you have, let's say you've got a horizontal incision and then a vertical incision. And what happens is you've got essentially three incisions coming together and you can have lateral tension, which is most common, and you can have that at the base of a fleur-de-lis abdominoplasty incision. You can have it at the upper junction of an open book tummy tuck, or more commonly, it's going to be at the breast lift reduction junction. And so a lot of times you can have some issues there because of lateral tension. And so again, I kind of go back to, I like to tape incisions for six to eight weeks and the taping, what it does is it allows you to transfer a lot of tension and keep it off of the T junction and put it on the surrounding skin.

(16:03):
And if you can spread that tension out over a longer area, you're going to get reduced tension and better wound healing. So yes, that can happen. It's usually not an issue in the sense that we don't have to take the implants out. It's more of a nuisance and it just takes time to heal and it's frustrating and it prolongs people from being able to get back into the swimming pool, that sort of thing. So it's generally a frustration, but it's usually not something that's an issue long term. The other issue that we can run into is that it sometimes doesn't scar as well, and so we may end up coming back down the road and doing a small little revision under local in the office.

Kirstin (16:48):
Does the skin keep relaxing or does any of this need redone down the road typically?

Dr. Gardner (16:56):
Great question. I would argue that the massive weight loss skin is always subject to continuing to stretch out to some degree. The other thing that we've talked about before is that you'll have a patient where they look fantastic in the OR. We stretch them very tight. We bend the bed up doing a tummy tuck about 30 degrees to try to really pull them tight. And then six months after surgery, they have a little bit of laxity that comes back. That's not a problem with the operation per se. It's more of an issue of, hey, you've got skin that's unfortunately been stretched out and just like a balloon, you stretch it out multiple times and it's never going to come back to that original shape. So I tell all of those patients that they could have some issues with some relaxation and stretching of that skin, and there's always risk of having to go back and take a little more, do what we call revision.

(18:00):
And again, it's not that we didn't take enough the first time, it's just that that skin quality is not as good, more subject to stretching out and maybe needing a revision down the road.

Kirstin (18:13):
For a woman who's lost the weight and feels like her chest is the last thing standing between her and being finished, what would you tell that person?

Dr. Gardner (18:24):
Again, I would just say that the post-bariatric or I should call them that, the massive weight loss patients, in my opinion, are some of the happiest patients. They're transformed and just like the patient you're describing, they see themselves, they have saggy deflated breasts. They don't feel comfortable intimately with their partner. They don't like what they see in the mirror when they get out of the shower. And if you can correct that, not make it perfect, but make them see the way they want to feel, give them the volume back, give them some shape, then they're going to be really happy. And again, I've always said this, massive weight loss patients, in my opinion, are very forgiving of scars if they get the shape that they want. I have a patient that just sent me some photos a couple days ago of her at the beach.

(19:16):
I did a buttock lift with auto augmentation. I did a fleur-de-lis tummy tuck and breast reduction lift and thigh lift. She looks fantastic and she's wearing a bikini on the beach.

Kirstin (19:29):
Woo-hoo. Yeah, girl.

Dr. Gardner (19:30):
So don't let a little scar get in the way of you enjoying your life.

Kirstin (19:36):
Amen. Okay. I love it. Love to hear it. Do you have a burning question for Dr. Koehler or Dr. Gardner or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler and Dr. Gardner.

Dr. Koehler (19:54):
Thanks, Kristin.

Dr. Gardner (19:55):
Thank you.

Kirstin (19:57):
Get back to making Alabama Beautiful.

Announcer (20:01):
Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @easternshorecosmeticsurgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.