Episode 28: Sunday December 27

Drs. Sam Jejurikar, Salvatore Pacella, and Sam Rhee discuss breast reduction (reduction mammoplasty). For patients with very large breasts, having a reduction can feel like — quite literally — having a weight lifted off of their chest. Along with the physical pain, patients may suffer from emotional distress or more significant mental challenges as a result of their large breasts.

The 3 plastic surgeons talk about breast reduction and the factors should be taken into consideration when planning surgery. If you are thinking about breast reduction surgery to improve your live, this episode is a MUST!

Full Transcript (download PDF here)
2020.12.27 S01E28 BREAST REDUCTION TRANSCRIPT
Dr. Sam Rhee: [00:00:00] Welcome to Three Plastic Surgeons and a Microphone with, as always Dr. Sam  Jejurikar whose Instagram handle is @SamJejurikar. He is located in Dallas, Texas. We also have Dr. Salvatore Pacella. From LA Jolla, California. His Instagram handle is @SanDiegoplasticsurgeon. And I am Sam Rhee. I am from Paramus New Jersey and my Instagram handle is @Bergencosmetic. 
As always the show is not a substitute for professional medical advice, diagnosis or treatment. The show is for informational purposes only. Treatments and results may vary based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified health provider.
With any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in this show. And with that, I turn it over to Dr. Sam Jejurikar to talk about one of the most common operations. I think all plastic surgeons do, or, start off doing probably in their practice.
Dr. Sam Jejurikar: [00:01:05] Thank you, Dr. Rhee and good morning to you, Dr. Pacella. 
Dr. Salvatore Pacella: [00:01:08] Good morning. 
Dr. Sam Jejurikar: [00:01:09] so the inspiration for this topic came a few weeks ago when we were reviewing the top plastic surgery procedures done in the U S and breast reduction came up and we realized we hadn't talked to him. And as we were talking, just informed before we, started rolling this podcast, it's clear that every plastic surgeon sees a large number of breast reduction patients.
They're a commonly performed procedure in the U S. they're not that exciting to plastic surgeons just for full disclosure to our viewers, because we do so much about them and there's a few standard ways that people do them, but they're a really important thing. And with that in mind, we thought, we, last week we featured, microsurgical breast reconstruction with Dr. Mike Orseck, which was innovative and different. this is bread and butter plastic surgery, but something that affects a large number of people. to get started, breast reduction is in plastic surgery, probably one of the most commonly performed procedures. And by far, in a way, one of the ones that lead to the greatest number of happy patients, when you look at outcome studies that look at not just cosmetic results, but also functional results, we'll see that breast reduction patients are among the happiest patients in plastic surgery.
Because when I see a patient for a breast augmentation, And that's someone that's unhappy with their appearance and they're getting an implant just to make themselves look better. When I see someone for a breast reduction, there's certainly a cosmetic component, but oftentimes they have severe back pain, neck pain, shoulder pain, lower back pain, which is due to the weight of their breasts.
The, large size of their breasts can actually, cause their bra straps deleted profound pain and even grooving and wounds, which can be uncomfortable. some women with really large breasts can actually get heat rashes in the summertime or even open wounds and just general irritation of the skin.
And then it will see that, the, many of these patients despite, despite having, One two or even three sports bras have a hard time exercising. It's hard for them to find bras. And in many ways they find that their breasts are the focal point of their interactions with other people which can diminish their confidence.
Have you guys experienced similar things when you see these patients, are there other things that we're missing or things that you notice in these patients preoperatively that you think the surgery can help with 
Dr. Salvatore Pacella: [00:03:23] now? Dr. Jejurikar in Dallas. I see that on this list, you did not put weight loss, benefits of breast reduction, surgery, weight loss, the act of doing a breast reduction.
Does it cause the patient to lose weight? It's a common question. I get, I've taken off a bunch of tissue. Of course, it's going to make me lose a few pounds. is that correct? 
Dr. Sam Jejurikar: [00:03:45] Technically. Yes. I think if you are a patient that is overweight and obese, doing a breast reduction will not change that overall States, but let's say we remove two or three pounds of tissue.
Your weight will go down by two or three pounds. 
Dr. Salvatore Pacella: [00:03:58] So that's the key here, right? It's a, it's not a tremendous amount of weight loss. And I think that's a common misconception breast reduction is not a treatment for excess weight. It's really not a ton of weight that we're taking off. 
Dr. Sam Jejurikar: [00:04:11] Exactly. And, the great thing about breast reduction and surgery though, is you can take all of these symptoms that are listed on this slide and make them go away.
And in return you can get smaller perkier breasts and some scars, and the scars are what are oftentimes the, the deterrent of, for patients to actually get the surgery. So what are the scars involved? There's a few different scars that are going to be involved and there's different ways to do a breast reduction.
Every breast reduction is going to have an incision that is around the pigmented, nipple and areola. And, not really quite knowing the social media rules I put in, I put a nipple shield over there, drawing of a nipple smart. I don't want to get censored. Yes. I felt dumb doing that. but every restaurant auction, no matter what's red technique has an incision around the areola.
Why? women that have large breasts tend to have enlargement of the areola. You need to put an incision around it to reduce it. And women with large breasts tend to have it. tend to have nipples that are pointing downward on the breasts in order to raise it, you have to add an incision around that.
In addition, virtually all breast reductions that are, is a technique described, that doesn't use this, but virtually all breast reductions have a vertical scar incision that goes from the bottom of the areola to the bottom of the breasts. So when we talk about short scar breast reductions, what we're really talking about is whether or not it has this final scar and incision across the very bottom of the Infor mammary fold or the crease at the very bottom of the breasts.
and How do you get the sell or how do you make the decision? I find that in my practice about half the patients that I do will have this sort of, we'll have a more limited incision pattern. Half of them will have a broader incision. So in the sort of the more limited incision one, which we call a lollipop incision when we're talking to patients, which, plastic surgeons will refer to as a circumstance vertical.
Incisions are an incision around the areola and a straight line coming down. You'll notice that the surgeon will design something that looks like a key hole. and if you look at this picture in the top left, there are some dotted lines around the periphery, which is essentially where the incision, where the surgeon will make some incisions.
And then the blue is areas where the surgeon will remove skin, like you would peel the skin of an orange and you have breast tissue underneath, essentially the areola slides to the very top of this. And these dotted lines come together to leave you with an incision around the pigments that nipple and areola complex and a straight line coming down.
So for women that are either not that droopy or don't have that much tissue to use, this is oftentimes a nice option. do you find yourselves doing this a lot or is this not very commonly used in your prep?
Go ahead. 
Dr. Sam Rhee: [00:06:48] the lollipop you're referring to the lollipop, right? It's pretty hard to find a lot of patients that fit that for me, I almost always will make a little bit of a T on the bottom, even if it's just an inch or so. And I find that most patients will tolerate that without too much, too much issue.
And I feel like I have a lot more control over the shape of the breast if, it's pretty rare for me to do just a straight lollipop. 
Dr. Salvatore Pacella: [00:07:16] Yeah, I agree. I think, the patients who qualify for this, I think our patients who are in general doing a very small reduction, and, or are fairly petite that needed more of a lift. Type of a reduction as opposed to a volume reduction of size. oftentimes, one thing we didn't cover, but I'm sure we'll get into is insurance coverage for breast reduction. This is, this is a common operation that insurance does usually cover with. If patients can demonstrate neck back and shoulder pain, the big disadvantage of going through insurance is there are oftentimes qualifications that patients need to meet.
Prior to doing a breast reduction. So for example, based on your height and weight, the insurance company will say, we can only, you can take off, you have to take off a max or a minimum amount of volume of say 300 or 400 or 500 grams. And it's very difficult for me to try to take that tissue off through a simple, vertical scar.
Oftentimes have to incorporate a horizontal scar to get the minimum amount of tissue. 
Dr. Sam Jejurikar: [00:08:16] now would be a great time to actually segue into that conversation about insurance. Cause I didn't have a plan at the time to actually talk about that. do you find, both of you guys that the majority of patients that, that you see who want to go through their insurance company are actually able to qualify and achieve the size that they're looking to be post-operatively?
Dr. Salvatore Pacella: [00:08:36] I would think so. Yes. most of the time the patients I see for this are referred from another physician, their primary care doctor, they've demonstrated that they've gone to physical therapy, they've demonstrated significant neck and back pain. and usually, that's been previously documented in the medical record, which I think says a lot to the insurance company.
So in general, most of the patients do qualify for this. I believe. Yeah. 
Dr. Sam Rhee: [00:09:01] I no longer take insurances, but when I did, I found that this a pre-authorization for breast reduction surgery was one of the most onerous processes, at least in New Jersey. For me, most of the insurances were pretty strict about their criteria and they generally included at least three to six months of symptomatic documentation. So it wasn't enough just to have one or two physical therapy sessions. They needed to document over a fairly substantial period of time symptoms and the lack of relief of nonsurgical treatments. and that was really, they were just obstacles, right? Obstacles for patients who clearly had major issues.
Preventing them from getting adequate surgical relief in a timely fashion. that was because it's a financial business and they are looking to try to limit, they know a certain number of patients will give up. And probably pay out of pocket because they didn't want to take the time to do this, to accumulate the documentation and get the documentation.
But it pretty much Sal is right. Everyone requires it. and depending on who your insurance carrier is, it can be quick or it can be long. 
Dr. Sam Jejurikar: [00:10:16] Yeah. My experience has been more like Dr. Rhee's then Dr. Pacellas. I've I don't know about you guys, but I started noticing probably four or five years ago, an increasing number of patients whose insurance policies had carve-outs where breast reductions were just blanket excluded probably 25 to 30% of the patients that would come into the office just had blanket exclusion policies where even if they met the criteria, it would not be covered.
The other thing is, the viewers may not have heard this term, but Dr. Rhee and Dr. Patella will, will know this as well. It's called the Schnur sliding scale. And it's, it's what Dr. Pacella was alluding to earlier, where there is a sliding scale based off of your body surface area, which is determined based off of your weight and based off of your height, the amount of tissue that should come out.
And the way that it was, it came about was from a study done in like the. I think 1992 or 1993, where a plastic surgeon, Paul Schnur, sent out a questionnaire to plastic surgeons. And basically this questionnaire said roughly, or how many breast reductions did you do last year? How many of them did you think were medically necessary?
And then of the ones that were medically necessary? How much did you roughly take out and then he got the patient's height and weight? Very, low response rate. I think, it was under 20% of the surgeons that were pulled actually even responded to it. But off of that, the insurance company created a scale by which they make determinations of whether or not things are medically necessary. And as all of the outcomes, data has subsequently shown relief of symptoms is not correlated to the amount of weight that comes out, but it's a metric that many of the insurance companies are using just to try to make sure they're not doing a cosmetic breast lift instead of a breast reduction, but in some and many of the patients that I actually see who want their symptoms to go away, but they don't necessarily want to be small breasted.
They're not able to really meet the criteria. So 
Dr. Salvatore Pacella: [00:12:08] that's a really interesting, point you make there, Sam. many times in my experience, I will say breast reduction. Regardless of the size that's removed can help significantly with neck back and shoulder pain, even if it's a small amount.
And it's really more of a repositioning the breast on the chest wall, which makes it easier to carry for the weight. The analogy I like to use for patients is, let's see yourself going through an airport and you're carrying a. A briefcase. Okay. It's heavy with a lot of documents. If you're carrying that briefcase by your side next to your thigh, normally like we would do, that's a lot easier to carry than say, if you went the whole way, carrying it out here, It's exactly the same weight. But carrying out here is going to be a little bit more PA is quite a bit more painful and it's going to cause more fatigue. And so when you take the breasts and you're putting them on your abdomen, That's a lot harder to carry than when they're sorting up on top of the chest.
and that's unfortunately something, the insurance companies don't really understand many times. 
Dr. Sam Jejurikar: [00:13:08] Or just like Sam was saying, it's a way to allow them to pay for fewer cases. For sure. 
The other, and by far and away, the most common way to do this operation is to do what plastic surgeons referred to as a wise pattern, what we'll oftentimes describe to our patients is an anchor pattern, which is an incision that goes around the areola. A straight line coming down and a one across the bottom. It says the most common way that's done because it allows the surgeon the most freedom to reshape the breast. The incision around the areola allows us to slide the areola to the ideal position on the breasts.
The vertical incisions allow us to narrow the width of the breast. The one, Across the very bottom. The transverse incision allows us to shorten the length of the breast and also to remove tissue from the bottom portion of the breast easy, easily, which is clearly where people want to get rid of it.
When they're coming in for a breast reduction. the way we all train during our residency. during my residency, every single breast reduction that I saw was done through this type of incision, I think all of us have changed the techniques that we learned in since residency, but just out of curiosity, did you guys see anything that was not this type of breast reduction during your residency?
Dr. Salvatore Pacella: [00:14:20] All we just saw standard inferiorly-based wise pattern, I didn't, it wasn't until my fellowship that I really started changing the way I do things. 
Dr. Sam Rhee: [00:14:30] Exactly same here. 
Dr. Sam Jejurikar: [00:14:32] Same here. All right. 
Dr. Salvatore Pacella: [00:14:34] interestingly enough, Doctores, it was always a wise pattern inferiorly-based pedicle in training, seemed to be so much of a stress inducing procedure many times I just. I don't make it. I don't understand necessarily 
Dr. Sam Jejurikar: [00:14:54] nor do I, a lot of, and a lot of, I'm just going to be totally frank and transparent of yours would appreciate that as opposed to our normal political, guarded way of speaking. We thought a lot of bad breast reductions during residency, where some of the measurements that were being used and some of the design principles just made very little sense  and it's because. I don't know. I'm just going to leave it at that. 
So with that being said, let's look at a case. this is a typical sort of case that I'll see in my practice. Oftentimes, a breast reduction is done as part of a, of a part of a larger body contouring operation. But this was a patient that I saw who had previously had pregnancy.
She was large breasted before her pregnancy and she got bigger and droopier with, with their pregnancy. He was having significant back pain, neck pain and shoulder pain. She would go to the chiropractor with no relief in her symptoms. She wanted to be smaller. she didn't necessarily want to be a B or a C cup, like her insurance company might've wanted, but she definitely wanted it to be smaller about the health of their quality of life and also to help with their pain.
So here are her pictures, so you can see that she has some substantial asymmetry, Hopefully the size of the nipple shields that I put on here. We'll let you know that our Ariel is, have, have enlarged, and she obviously has large breasts. any, any particular way you guys would address this?
Dr. Sam Rhee: [00:16:10] I think one of the things I always want to make sure is okay. sometimes patients just have they're so symptomatic. They will come in somewhat similar to this patient and say, you know what? I just want everything off. I want it all gone. Just make me as small as I possibly can. And I will often have to tell them, listen, if I make you as small as you possibly can, we will lose a great deal of the aesthetic or appearance of your breasts. We have to maintain some sort of shape, some sort of projection and some sort of form. If I took everything off. I usually tell them, you will look like you have a fat man breasts. It will be a low riding mound that has no shape or slope to it. And so I will tell them we can achieve within certain parameters, a reasonable size that will be much better fitted for you, but we can't, I don't want to make you an a cup, that's not the goal here nor that should that be the goal for anybody? I think, 
Dr. Sam Jejurikar: [00:17:15] yeah. I, 
Dr. Salvatore Pacella: [00:17:15] we, patients are often times, they're very, well-educated on the benefits of breast reduction, but sometimes they don't necessarily understand or have been explained the disadvantages of breast reduction so I really. Spend a bit of time talking about some of the issues related to breast reduction, and complications that we can see. you, So I really do, something, I call the four S's. Okay. So there's the number one that the scars, we talked about the scars. They have to be vertical.
They have to be period aerial, or they have to go round. Number two is the sensitivity to the nipple. And depending on the study, you see anywhere from 30 to 50% of patients can experience some changes in nipple sensitivity, unlike say an operation, like a breast augmentation, you're in a cup.
You heal up everybody's happy breast reduction does have some potential issues. The third S is the side. Okay. Side. Boob. What we like to call. Okay. Many patients that are heavier than have bigger breasts. They oftentimes point to this area on the side right here. They say, I want this off.
that's technically not your breast. That's more of the back. Fatty tissue, the back adipose tissue. That's not necessarily taken off or treated with a standard breast reduction. Oftentimes you need some liposuction, which we highly recommend at the same time, because just simply putting a, getting a smaller breasts, if you wear your bra and you don't address the side stuff, that's going to be coming off the side and patients are going to be sorely unhappy.
Then the fourth S is shape. Okay. So unlike a breast augmentation where the. the shape can be perky and perfect. Oftentimes the larger your breast is the more difficult it is to make a perfect shape. And when I counsel patients on is having a potential bottoming out the formity longer term, what a bottoming out deformity is when the breast takes a shape.
That looks a little bit bottom heavy, although it's not big, there's not really a tremendous amount of extra fullness up top. And that's an important thing to understand. I think. I think 
Dr. Sam Rhee: [00:19:18] you mentioned how we did so many bad initial, breast reductions in training and over time, I think a lot about these breast reductions that we did and how we have changed.
All of us have changed a lot in terms of our technique. And we probably have just really applied most of our aesthetic breast knowledge to make these, Better, there's a gray area where you go from mastopexy and breast lift to breast reduction. And the more I treat them, like mastopexies with a large tissue resection, the better off I'm going to be in terms of my aesthetic results.
I know surgeons out there that still do it the same way that they learned 20 years ago, 25 years ago. Obsolete techniques like free nipple grafting, which I think is something that should be shunned, in 99% of patients. and you need to find someone who can really do, a really nice job, regardless of whether, in insurance, out of insurance.
And maybe I'm just saying that cause I'm out of insurance, but you really just have to find the best possible surgeon out there, period. 
Dr. Sam Jejurikar: [00:20:25] I like, I like Pacella's four S's I'm going to probably steal that. I liked that a lot, but, to put together what the, with the boat with both of you were talking about with Sal's, fourth S which was shaping a lot of the really poorly designed breast reductions tend to leave.
It tend to, leave the nipple attached to a lot of tissue and blood vessels coming from the bottom of the breast. What surgeons refer to as an inferior pedicle. And in many of those cases, I have noticed in my own patients and chime in, if you guys feel differently, that when you leave a large amount of tissue attached to the bottom of the brass, you are more likely to see more bottoming out, or more deformity where the breast looks bottom heavy.

Dr. Salvatore Pacella: [00:21:01] that operation is counter-intuitive right. Sam's does, if you think about it, look at this lady. She's got no volume of top. Most of her volume is down below. So you would think that somehow we should be able to take the bottom tissue and move it up to the top. But as standard inferior breast reduction, inferior, pedicle breast reduction, it actually removes tissue from the area where patients are already deficient.
So that's why. It looks pretty bad later on. 
Dr. Sam Rhee: [00:21:30] Do you guys do routinely do inferior pedicles? 
Dr. Salvatore Pacella: [00:21:33] I haven't done. I haven't done an inferior pedicle in 12 years. All superior metal or severe based 
Dr. Sam Jejurikar: [00:21:39] Last inferior pedicle. I do it. I was in Ann Arbor, Michigan. 
Dr. Sam Rhee: [00:21:43] I haven't done. 
Dr. Sam Jejurikar: [00:21:45] 15 years.
No, I do know. I do know some good plastic surgeons that do still believe in the operation. That's not their sole operation, but they do have a few indications for that, which I can buy their rationale. Occasionally I have different ways to handle it, but, ultimately. this patient, the reason why this patient and so many breast reduction patients are coming to see us is they have a lot of weight in their breasts.
They have inadequate support with their own tissue and ligaments. if you don't change anything about their intrinsic support, like there's not even when we make everything smaller and tighter, it doesn't mean that she has tissue that's of the best quality. If you leave it down low, it's going to stretch out to unwell.
It's just the way it is for all of these patients. I'm assuming you guys would probably use a variation of a wise pattern for this operation, which is, again for our viewers and incision around the nipple, a straight line coming down and then a one across the bottom. Am I correct? In that assumption?
Dr. Sam Rhee: [00:22:40] Yes, 
Dr. Salvatore Pacella: [00:22:41] I do.
Dr. Sam Jejurikar: [00:22:41] Then, let's, get to the punch line here. so I, I, anyways, I'll still design the operation, like a keyhole, where we're going to do an incision that's, mainly vertical, but then I'll end up adding, I think, at her about a six centimeter or a six inch rather, incision across the bottom, which is hidden in the crease down here, but fairly typical breast reduction results.
You can see, she's obviously smaller. And she has a better shape, more tissue sitting up high. 
Dr. Sam Rhee: [00:23:07] Yeah, I do the vertical ellipse. I designed that pre-op and then on the table I will design or figure out the inferior incision, the horizontal and how much I need to take out on the table. and then I finally, like the last thing I'll do is set the nipple areolar complex position based on on that. So it's a little bit of a cut as you go, which I picked up from, I think it was Dave Hidalgo in New York while I was there. 
Dr. Sam Jejurikar: [00:23:39] I also did a talk on her. Yeah. I did a tummy tuck on her as well, which enhances the results of the breast reduction. because then the, the breast still stick out further than the tummy, which is desirable.
So I had a ...this week and I don't know if it's just my, My predilection for doing Brazilian butt lifts. But in the last, actually in the last two weeks, I've had three patients introducing me a term I had never heard before, but I think it's applicable. Have you ever heard no. That I know.
Booty-do, you ever heard this? Booty do I got booty-do, 
Dr. Sam Rhee: [00:24:14] that's new booty-do's not one I've heard of 
Dr. Sam Jejurikar: [00:24:17] booty do is when the booty or actually when the tummy sticks out further than the booty do. And so in that situation, You either had to make the tummy small or you got to make the butt bigger. I think the same can be said about the breasts.
Dr. Salvatore Pacella: [00:24:33] So 
Dr. Sam Jejurikar: [00:24:35] that is,
Dr. Salvatore Pacella: [00:24:36] Oh my God. That's hilarious. So that doesn't have Jones from, from urban dictionary, booty do B O T Y D O. When her stomach sticks out more than her booty Duke. 
Dr. Sam Jejurikar: [00:24:51] Yeah. I just learned that patience. I have taught me this with these things, so 
Dr. Sam Rhee: [00:24:58] that at my next consultation, I'll be like, you have booty doo.
Dr. Sam Jejurikar: [00:25:01] There's gotta be right. I was relaying this story in the, or to one of my techs and she looked at me like, yeah, duh. And there was a male equivalent as well, but it's probably not appropriate for the podcast. So 
Dr. Sam Rhee: [00:25:16] you're going to have to tell me that off offline. 
Dr. Sam Jejurikar: [00:25:19] Okay. gentlemen, that's all I know about breast reduction.
Anything you guys want to add? 
Dr. Sam Rhee: [00:25:23] we have a lot of levity when we talk about these things, but obviously, like you said, patients love the operation in terms of their satisfaction. Afterwards. I know patients literally on in recovery feel, a weight's been taken off their shoulders.
They, are very happy with their outcomes. almost everyone is understands what it means to trade. large, heavy. breasts that caused a lot of problems for smaller breasts with scars, which, really helped them a lot, EV every day, like Sal said, I think it is important to tell patients, this is not a form of weight reduction is this is not weight loss.
if a patient is obese beforehand, they're going to be obese afterwards. but for the patients who, are good candidates for this, it is pretty transformative. 
Dr. Sam Jejurikar: [00:26:12] Yeah. Yeah, you are so true. It can change people's lives so much. And, and luckily there's a lot of plastic surgeons that do this operation very well.
Dr. Sam Rhee: [00:26:20] Yes. 
Dr. Sam Jejurikar: [00:26:21] Cello Odie do 
Dr. Salvatore Pacella: [00:26:25] Pacella do 
Dr. Sam Jejurikar: [00:26:25] Well have a great weekend, gentlemen.