Breast Reduction

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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Breast reduction with breast lift is routinely performed together because they share the same incision sites.


In essence, breast reduction creates a smaller “cup size” to address symptoms associated with enlarged breasts such as painful bra strap grooves, rounded shoulders, postural problems, neck and back pain, and spinal curvature.


breast reduction with breast lift


Breast lift, meanwhile, corrects the appearance of pendulous breasts by removing a small amount of loose skin and lifting and transposing the soft tissue.


Despite having different goals, the two breast surgeries are routinely combined because they share the same incision sites—around the nipple, within the submammary fold, and perpendicularly between the nipple and the breast fold. Furthermore, both involve removing a certain amount of loose skin from the lower breast pole.


(Note: Breast reduction almost always incorporates breast lift, although this is not always the case in breast lift unless the patient specifically requests for a smaller cup size. It is important to note that overlarge, heavy breasts are generally pendulous in appearance, according to California Surgical Institute website.)


When breast reduction is medically warranted, i.e., performed to improve the patient’s quality of life, health insurance coverage is possible. However, most issuers require trying first non-surgical treatments such as weight loss and therapy (in an attempt to improve posture and possibly reduce discomfort caused by overlarge breasts) before they cover its cost.


Breast lift, on the other hand, is always considered a cosmetic, elective procedure and thus precluding any chance of insurance coverage.


Whether performed separately or together, the results of these surgeries are expected to last a lifetime, provided that the patient maintains a healthy weight and avoids pregnancy in the future. For this reason, women of childbearing age and teenagers may have to postpone these procedures.


However, performing breast reduction with breast lift (or even without it) could be a good option for patients as young as 15 if their hugely disproportionately breasts are causing pain. This is particularly true for normal weight women who have tried non-surgical treatments to no avail.


But there is one caveat when breast reduction and/or breast lift is performed “sooner than ideal”—there is an increased risk of tissue regrowth, which may warrant some type of revision surgery down the road.

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The ideal breast size for reduction surgery is primarily anchored to the patient’s level of comfort. It is important to note that a good number of patients seek the procedure to remove a huge weight off their back and ultimately improve their quality of life, as suggested by celebrity Beverly Hills plastic surgeon Dr. Tarick Smiley.


In addition to back pain relief, many patients also seek the surgery to improve their posture, correct their rounded shoulders, and eliminate chronic headaches.


ideal breast size for reduction

Before and After Photos of a Breast Reduction Surgery Patient


Aside from delivering the most comfortable breast size, other goals should include creating an optimal shape, hiding the surgical stigmata as much as possible (i.e., scars are placed at the border of areola and within the submammary fold), and minimizing risk of tissue regrowth.


Tissue regrowth may occur after significant weight gain and pregnancy, so it is in the best interest of patients that these factors are ruled out before the surgery is attempted. For this reason, women of childbearing age and those whose weight is not yet stable are advised to postpone the procedure.


The truth is, it is quite difficult to guarantee a cup size after a breast reduction surgery. First and foremost, cup size is not an accurate measurement as each bra company has its different interpretation.


The patient’s body largely determines the ideal breast size for reduction. For this reason petite women may want to have a slightly smaller size, while large-framed patients may have to choose a fuller, heavier breast if their goal is to preserve a more natural look and better proportion.


But if there is a high probability that tissue regrowth will occur, a scenario that may happen when breast reduction is performed in patients in their mid or late teens, they may have to choose a size that is smaller than their initial plan.


Some patients also choose to have a breast size smaller to their liking so their health insurance will cover the surgery’s cost (for instance, some companies require at least 500 grams of removed breast tissue per side in order to qualify for coverage).


While breast reduction is best reserved for women whose breasts have fully “stabilized” and they are done having children, teenagers whose overlarge breasts cause them undue discomfort can opt for it.


Dr. Smiley says that there are no limitations on how small the breasts can be made, although significant reduction is tied to increased risk of numbness or other sensation-related problems and poor scarring.

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