Breast Reduction

Major breast reduction surgery is a technically complex procedure since the goal is not just to downsize the breast in order to provide immediate relief from neck and back pain, constant skin irritation, and other physical symptoms. Most patients are also concerned about getting a perkier, natural-looking breast contour.


However, the more breast tissue and skin excised during surgery, the more difficult it is to achieve a good shape and projection. Furthermore, the risk of poor healing and other complications increases as well, says leading Los Angeles plastic surgeon Dr. Tarick Smiley.


Nonetheless, great results from major breast reduction surgeries can be achieved with meticulous dissection and deep understanding of the anatomy, he says in his recent Snapchat posts.


He has shown a female patient with hugely disproportionate breasts that hung too low, drooping over her tummy area.

major breast reduction

Aside from the disproportionate appearance, prior to surgery the patient also complained that her overlarge breasts were causing “rounded” and painful shoulder, back pain, skin breakdown, and discomfort when doing exercise and other physical activities.


(Note: Because a good number of breast reduction patients have physical symptoms, it is not surprising that the surgery has one of the highest patient satisfaction rates among plastic surgery procedures. According to a 2012 survey released by the American Society of Plastic Surgeons, about 90 percent of patients rated their results “good” or “very good.”)


Dr. Smiley says major breast reduction requires the standard or anchor technique, which is named after the shape of its resulting scar. It uses an incision around the areola, which goes down the midline, and then across the bottom of the breast.


A modified form of breast reduction eliminates the horizontal incision across the bottom of the breast; hence, the resulting scar resembles a lollipop. This technique is referred to as lollipop or vertical reduction, says the celebrity plastic surgeon.


The patient required the anchor breast reduction technique, which has allowed for the removal of more than 600 grams of breast tissue on each side.


Meanwhile, the lollipop breast lift only suits patients who require smaller reductions, between 300 and 500 grams of breast tissue on each side.


One of the main issues with major breast reduction is the scar appearance, particularly the vertical scar because of its more obvious location (the scars around the areola and within the submammary fold are more discreet). But with meticulous wound suturing technique, Dr. Smiley says most patients can expect “almost invisible” or “very faded” scar after 6-18 months.


He highlights the importance of closing the incisions in several layers, while just allowing the skin to “kiss each other” instead of closing their edges with stitches. The idea is to eliminate tension on skin, which promotes favorable scars and good healing, he says.

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Breast reduction to fix asymmetry is a highly complex procedure. Contrary to popular belief, the lopsidedness is not only caused by the size disparity between the two sides; several factors also come into play like the nipple size and position, difference in the projection of each breast—even the shape of the chest wall may also contribute to the condition.


Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says every woman has uneven breasts; however, it only becomes problematic when the lopsided appearance prevents someone from wearing a swimwear without feeling too conscious, or tries to hide it by changing the way she dresses (e.g., using pad only on one side).


breast reduction to fix asymmetry


Dr. Smiley says that no patient should expect perfect symmetry after breast reduction or any other forms of breast enhancement surgery, although a good surgeon will make every effort to make each breast quite similar to each other.


The celebrity plastic surgeon says that breast reduction to fix asymmetry may involve just the larger breast—reshaping and reducing its size to make it more symmetric with the other side.


However, one caveat of leaving the other breast “untouched” is that it will not behave the same way as the surgically enhanced side, warns Dr. Smiley.


To achieve a good level of symmetry that can persist long term (both sides will “mature” and “behave” quite similar), Dr. Smiley says that breast reduction or any form of breast surgery should ideally involve both sides.


With breast reduction, whether or not there is a notable size difference between the two breasts, Dr. Smiley says the vast majority of patients will also require some type of mastopexy, or breast lift in layman’s term.


Breast lift and breast reduction share the same incision sites and thus additional scars are not an issue.


Breast lift not just repositions the downward pointing nipple; it also raises and reshapes the breast tissue with the use of internal sutures, explains Dr. Smiley.


To further improve symmetry, Dr. Smiley says he uses a device that resembles a cookie cutter to delineate the new smaller areola. He also ensures that the scar goes precisely at the dark-light skin junction so it blends well into the background.

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Drastic breast reduction surgery is performed not solely for aesthetic reasons, but to improve the patient’s quality of life, said leading Beverly Hills plastic surgeon Dr. Tarick Smiley.


Dr. Smiley has recently demonstrated drastic breast reduction surgery on his Snapchat account. The female patient shown in the video complained about the chronic back pain, postural problem, and shoulder discomfort due to the extra weight of her large, pendulous breasts.


drastic breast reduction

The left photo shows the result of drastic breast reduction surgery.

In the video, Dr. Smiley has explained the challenges of drastic breast reduction, particularly relating to increased bleeding and loss of nipple sensation. However, the risks can be avoided or at least minimized with meticulous dissection and deep understanding of the breast anatomy, he added.


Dr. Smiley said that large, pendulous breasts have longer blood supply originating from the muscle and therefore there is an increased risk of excessive bleeding and nipple areola loss.


“Nipple areola loss occurs when its skin literally dies,” he said, adding that one way to avoid this complication is to perform free nipple graft in which it is removed entirely from its stalk (main blood supply) and later grafted back into its place after eliminating some of the breast tissue and skin to reduce the “cup size.”

drastic breast reduction

The right breast looks significantly smaller and perkier versus the “untreated” left side.


But even the free nipple graft has its own caveat, Dr. Smiley has warned.


“We try to avoid the free nipple graft because it typically causes loss of sensation in the areola. Hence, we only decide if this is warranted during the operation and I will try to avoid it as much as possible,” he said.


During the operation, Dr. Smiley decided not to perform the free nipple graft; hence the areolar complex has remained attached to its stalk or main blood supply. Nonetheless, he was able to lift the drooping nipple by 20 cm from its previous location.


He also reduced the areola so it will look proportionate to the new, smaller breast size.


Meanwhile, Dr. Smiley has ensured that the scar goes precisely around the areola’s border and parallel to the breast fold for optimal scar concealment.


And while the vertical scar between the nipple area and the breast fold is in a more obvious location, Dr. Smiley said it is expected to fade into the background after 6-12 months.

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Breast lift for large sagging breasts faces unique challenges, which must be recognized and assessed well in advance of the surgery to achieve impressive results, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.


One major caveat of breast lift for large sagging breast is the susceptibility to drooping recurrence because of the sheer weight of the breasts. Nonetheless, this perceived challenge could be offset by several techniques, which have been explained below by Dr. Smiley:


breast lift for large sagging breasts

  • Achieve one’s optimal health


Dr. Smiley only performs breast lift on patients who are near their ideal weight, which they are able to maintain for at least of six months. Not only it ensures more precise tissue resection and thus more predictable long-term results, women of normal weight are also less likely to experience healing problems, infection, and unacceptable scarring compared to obese patients.


Obesity—along with diabetes, blood disorder, and other serious medical conditions—is closely linked to increased risk of complications after any type of surgery.


  • Simultaneous breast reduction


If the saggy breasts are hugely disproportionate in relation to the patient’s [thinner] frame, she may ask for a simultaneous breast reduction, which not just improves “body proportions” but also makes the breast less susceptible to the effects of gravity and aging.


It is important to note that breast reduction and breast lift share the same incision sites; hence, additional scarring is not an issue.


  • Anchor breast lift


Modified breast lift techniques—i.e., they result in fewer scars and possibly shorter recovery—give patients more options. Nonetheless, women with large sagging breasts can achieve no or very little improvement from them.


The anchor breast lift remains the best option for women with large sagging breasts; this is particularly true for someone needing a simultaneous breast reduction.


During an anchor breast lift, doctors create keyhole-shaped incision above the nipple area and then an anchor incision pattern that goes from the right to the left side of the lower breast pole. The goal is to remove some of the excess skin and elevate the breast tissue with the use of internal sutures.


The resulting scars go around the areola’s perimeter (perfectly blends at the dark-light skin junction), vertically between the areola and the submammary fold, and parallel to the fold.

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Combining tummy tuck and breast reduction is one of the most popular mommy makeover surgeries. While this has been a routine procedure, theoretically it results in increased bleeding and higher surgical trauma, and ultimately higher risk of complications.


To minimize risk of complications from multiple surgeries, the consensus is to complete combo surgeries in less than 6-7 hours. For this reason, some patients may need a team of surgeons operating simultaneously to limit the operative time.


combining tummy tuck and breast reduction

Furthermore, combining tummy tuck and breast reduction entails a strict patient selection process. The idea is to rule out any medical condition that can increase the risk of complications, particularly relating to wound healing and infection.


Hypertension, blood disorder, heart problem, obesity, and diabetes are just some of the roster of medical conditions that make any elective plastic surgery, particularly when it involves multiple procedures, imprudent.


If tummy tuck and breast reduction surgery is expected to take “too long,” or the patient has a medical condition that makes “combo surgery” inadvisable, the consensus is to have them separately. Nonetheless, procedures done in series also have their downsides such as multiple recovery periods and higher cost (i.e., the patient will pay for anesthesia and OR fees each time).


Increased bleeding is one of the caveats with combining tummy tuck and breast reduction or any other type of combo surgeries. Nevertheless, new techniques can minimize such risk. For instance, leading Beverly Hills plastic surgeon Dr. Tarick Smiley may elect the use of epinephrine injection before creating incisions.


Epinephrine is a drug that constricts the blood vessels thereby reducing the amount of bleeding. This is particularly helpful in tummy tuck, breast reduction, body lift for massive weight loss, and liposuction.


Furthermore, epinephrine can prolong or rather “spread” the numbing effects of local anesthesia, hence the patient could rely less on oral narcotic pain meds, which are linked to constipation, nausea, and lethargy.


The amount of postop pain is another issue with combining tummy tuck and breast reduction. But with proper pain management system, e.g., pain pumps or Exparel injection, most patients will find the initial healing stage (5-7 days) not too unpleasant.


Exparel injection is particularly ideal in combo surgeries. This is injected into the fascia and muscle right before the incision is closed with sutures.


Dr. Smiley says the numbing effects of Exparel can last up to four days without “disrupting” the normal functions of the body as their effects are limited to the surgical site. This is not the case with oral narcotic pain meds, which are known to cause nausea and vomiting.

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Cosmetic breast surgery that combines two or more procedures has become a common routine nowadays. In some situations, this is even a more preferable approach than having two separate surgeries in order to produce more natural results.


Today, the most common “combo” procedures are breast augmentation with lift, and breast reduction with lift, according to the California Surgical Institute website.


cosmetic breast surgery

Breast augmentation with lift prevents a specific deformity called Snoopy due to its close resemblance to the profile of the classic cartoon dog.


When implants are used in sagging breasts without a simultaneous breast lift, their bottom edge might become visible beneath the lax skin, and thus there will be an appearance of two pairs of submammary fold.


But with a simultaneous breast lift, the implants will not “herniate” as the internal support and the actual breast tissues are reinforced with sutures. In addition, the south-pointing or low-lying nipple area is positioned higher to further achieve a proportionate result.


Breast lift is also commonly incorporated with breast reduction, a procedure that produces a smaller “cup size,” which in turn can provide instant relief from back pain, rounded shoulders, postural problems, and other ill effects of overlarge, heavy breasts.


Large breasts are susceptible to the effects of gravity (i.e., causing their skin to lose their elasticity), thus it always makes sense to incorporate some type of breast lift during the surgery.


Meanwhile, breast lift does not always entail a simultaneous breast reduction unless the patient specifically requests for a smaller cup size as well.


Cosmetic breast surgery involving combination procedures aim to produce a more natural-looking and youthful appearance—i.e., conical shaped, 45:55 breast ratio (i.e., most of the volume should be in the lower pole), proportionate nipple diameter relative to the breast size, and “ample” distance between the areola and the submammary fold.


A slight lateral bulge is also deemed ideal, although all efforts are made to prevent it from becoming excessive and thus giving an illusion that the breasts are too wide apart.


Also, it is ideal to produce a ski-slope appearance in the upper pole. In fact, one study has suggested that the ideal breast profile should have a 45:55 ratio, with the areolar complex serving as the delineating mark between the lower and upper breast poles.


Of course, good symmetry between the left and right breasts must be achieved during cosmetic breast surgery. For this reason, some patients may need different sized implants, or require more tissue removal or additional elevation on one side.

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