The Life Changing Magic of Breast Reduction

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:08):
Hey Dr. Koehler.

Dr. Koehler (00:10):
Hey Kirstin.

Kirstin (00:11):
Do you know what we're talking about today?

Dr. Koehler (00:14):
No, please tell me.

Kirstin (00:15):
Breast reductions.

Dr. Koehler (00:17):
Alright, good.

Kirstin (00:18):
We love them around here. Okay. Is there a typical age or story for your usual patient that comes in requesting a breast reduction?

Dr. Koehler (00:27):
Well, I don't know if there's a usual story. I mean, there's definitely some usual concerns. The concerns are these women have breasts that are quite large, much larger than average, to the point where they sort of have common complaints like neck pain from having to hold them up with a bra, strap marks that dig in even after they take off their bra, you can still see the marks from their bra for hours or maybe it doesn't even go away after years of having heavy breasts, rashes up underneath the breasts. Sometimes it's a cosmetic concern. People are like, I feel like my eyes are up here and people are looking down here and it can make them self-conscious. So sometimes it's not necessarily they have symptoms, but they just feel that their breasts are too large and they don't like how they feel with their breast being that large.

(01:18):
And we see that across many ages. So I mean, one time had a girl on my schedule that was 14 years old, I believe, for a consult for breast reduction. I was like, okay, who put this on my schedule? 14-year-old for a breast reduction? And then I saw the 14-year-old and I was like, my goodness. I mean, they were huge, massive breasts. So that's not the typical, I mean obviously we typically are seeing people probably in the ages of 18 and up, but sometimes even younger patients, but it's not an age thing. I mean, it's obviously a developmental thing and sometimes it can be weight related too, which just so you know, obviously the breast tissue is composed of gland and fat. And you can just sort of find out from talking to women, some women will tell you, well, when I gain or lose weight, my breasts don't change at all. And other women are like, oh my gosh, that's the first place I lose, or the first place I gain. So it's different for every woman, but definitely weight gain can play a role in the size of the breast.

Kirstin (02:20):
Are there issues or anything that would prevent somebody from being able to have a breast reduction?

Dr. Koehler (02:26):
I mean, if there's health issues that prevent them from having surgery, sure. There's not things that prevent, I guess, from doing it as much as there can be things that we discuss that maybe will make people think twice about going ahead with it. For instance, there's going to be permanent scars, and the scars are typically an incision around the nipple, vertically underneath the nipple, and then horizontally in the crease of the breast. Those are the typical incisions for breast reduction. And those scars are permanent. So if a person says, well, look, I just really don't want to have those scars. Well then they may not be a good candidate. Another question that sometimes comes up is, particularly in younger patients, women who've not had children, that then they go, well, what if I do this, can I breastfeed? And it's a difficult question. It's been looked at.

(03:16):
And there was one particular paper that I often quote to people where they matched the groups based on their body mass index. So there were several groups that were looked at. One group had no surgery at all, and the other two groups had breast reductions, but different techniques of breast reduction, and we'll get into the details of that. But then they looked at these women, their ability to be able to breastfeed, and really in the end, even the women that had surgery, their difference in being able to breastfeed was not significantly different than those women that had had no surgery at all. So most doctors will say though, to their patients, like, look, we are cutting the gland of the breast. And depending on the technique, yes, it absolutely could inhibit your ability to be able to breastfeed. If you do a what's called a free nipple graft where we cut the nipple off completely and then remove the breast tissue and skin graft it on, which is not a common technique that we use here, but that's done for really, really, really large breasts, those women are not going to be able to breastfeed.

(04:20):
So anyhow, yeah, that's a discussion that we would have. It wouldn't necessarily prevent you from having the surgery, but it might make you think twice about should I do this now? And if I'm having one, planning on having kids, maybe I'll finish having kids. Because if it's important to you to breastfeed, obviously not having surgery, it doesn't guarantee that you still may not be able to breastfeed even if you haven't had surgery. But if you want your best chances, I mean that's probably going to be the best opportunity.

Kirstin (04:45):
So walk me through a breast reduction. How does it work?

Dr. Koehler (04:49):
Well, basically what we're doing, so when your breasts are really large, they're typically sagging below the crease of your breast. And oftentimes on these women with really, really large breasts, the nipple is well below the crease of the breast, sometimes it's even just pointing straight down. I mean, there's just a lot of weight there. And so the way the surgery is done is that, and there's different techniques and so I'm kind of speaking in general terms, but the basics of the procedure are your nipple is typically not cut off, it stays attached to breast tissue, but we're going to relocate the nipple to the place where it should be in an ideal situation. And then all of that heavy breast tissue on the underside of the breast, all of that heavy, heavy breast tissue is going to be removed. And in doing so, now you're not going to have that breast tissue sagging below the crease of the breast and the breast tissue itself is going to be perkier.

(05:47):
So it's lifted. And I will just say this, all breast reductions are breast lifts, it's the same operation. The difference between a breast lift and a breast reduction is primarily on the amount of breast tissue that's removed. With breast lifts, we're just removing a little bit of sagging tissue and we're really just relocating the nipple. And a lot of times we're doing an implant at the same time. But with a breast reduction, the sole purpose is to remove as much tissue as needed to get to the patient's size that's desired. And yes, the breast is in a more lifted position, but one thing that we talk to all patients about when they get a breast lift, there is a misconception that when you get a breast lift that that's somehow providing more fullness to the top part of the breast. And I always say like a breast lift, we should get rid of that term because mentally patients perceive that their breasts are going to sit higher on their chest, and that's just not what happens. I always say they should call it like a nipple relocation procedure or a de-sagging procedure, cuz that happens, we relocate the nipple and remove sagging breast tissue. And our breast reduction is the exact same except for we don't just relocate the nipple and remove sagging skin underneath, we are also removing the heavy weight of breast tissue to get them to the size they want. So they're kind of the same but different.

Kirstin (07:12):
So you technically get a free breast lift with your reduction.

Dr. Koehler (07:16):
Sure, yeah, there you go. Yeah.

Kirstin (07:17):
Okay. So you touched a little bit on scars. Will you maybe tell us what the scars would look like for a reduction? I know you said around the nipple kind of vertical a little bit and then in the crease.

Dr. Koehler (07:29):
Yeah, that's the typical scars. People call it an anchor incision. So the incision is completely around the nipple, so around the nipple vertically to the crease of the breast and then horizontally in the crease of the breast. So that's the typical anchor incision. Sometimes we can get away without the horizontal, and so you just have the incision around the nipple and vertical. But I'd say most significant breast reductions, at least for me, most of those patients are going to be getting that horizontal incision as well. And the scars are going to heal and they're going to look good, but it takes sometimes up to a year for 'em to look really good.

Kirstin (08:03):
I always feel like breast scars usually heal very well in your, I mean, they've reduced down to nothing.

Dr. Koehler (08:11):
Yeah. There's always a scar, but I mean I think they do generally heal well, but everything, I mean, part of it is the patient and we can't control that. But we do a meticulous job of the closure. We use best suture that's out there. We do a lot of things that we tell people to do before and after surgery to help minimize their scars. So there's things that can be done. And I'd say the vast majority of people, their scars end up appealing very well. But they have to understand there is a scar and it is permanent. And I'll share a story. This happened to me years and years ago. It's, it's probably been close to, it's been about 10 years ago, but I had a lady came in for a consult and she'd had a breast reduction done somewhere else, and she was just so distraught.

(08:51):
She called him her Franken boobies, she was not happy the result, and I hadn't seen her yet. And I said, okay, well we'll let you get changed. I came back in with my nurse to do the exam, and I looked at these and I was expecting some terrible scars, and they look great. I was like, these breasts look really good. I don't know who did them, but they did a great job and this is the scarring that I would expect to see. And in fact, these look good, I would want these on my website. They look great. And anyhow, I guess the reason that moment sticks out in my head is because here's this lady that's got a really good result, and it wasn't even my result. So it's not me going, oh, I did a great job. She's upset, she's crazy or whatever. She had a good result and she didn't perceive it that way.

(09:42):
And so obviously there was a disconnect in the consultation process and the whole way that this went down because obviously she didn't expect the position of the scars and the nature of the scars, and she got her breasts to the size she wanted, but she just didn't, I don't think she understood it fully. So I don't know, obviously I don't have the other side of that story, but just to the point of this is that look at lots of pictures of breast reductions, and if you look at those and you go, I couldn't deal with those scars, then this procedure is not for you.

Kirstin (10:14):
When it comes to areolas, do you, or can you reduce the size of the areola if the patient's not happy?

Dr. Koehler (10:22):
Almost always the areola size is being reduced because women with large breasts, the areolas typically get stretched out. And so we kind of have some average sizes that we use. We use it just for an average size breast, which is what we're typically going for women, we're looking in B or C cup type of range typically for breast reductions. And we just use typical sized areolas for breasts of that size. And so in most cases that is going smaller, well always it's going smaller. But I do want to make a point about the size of the breast, how much we can reduce them, since we kind of asked about reducing areola. Probably when it comes to breast reduction surgery, the one, I want to say a complaint, I don't even call it a complaint, but the concern that patients have a lot of times after they've had the surgery is sometimes patients wish they could have got their breasts smaller than we were able to achieve.

(11:25):
And I think that's an important thing to discuss ahead of time and with your surgeon is like, how realistically, how small can you get me? Typically we try to get people as proportioned as possible. And I will say sometimes I'll have patients go, I want to be a B cup when I'm done. And I'm like, B Cup is not going to even look good on your body. If you're overweight and your breasts are really big and heavy and we get 'em down to a B cup, I don't know that that's even going to look good. But aside from that, sometimes it's just technically not possible to get them to that size without doing a technique that I wouldn't say it's just not my preferred technique. And what I mean by that is if we do some of the traditional breast reduction techniques, we're removing breast tissue, but we do have to leave some breast tissue behind and the blood vessels that supply that tissue, otherwise there won't be circulation to the nipple and the nipple will not survive and the nipple will die.

(12:20):
And so you can't remove, it's not just like keep removing, you have to stop at some point because otherwise you're not going to have good circulation to that pedicle that supplies the nipple. And there is a way around that, and that's called the free nipple graft. And I mentioned it earlier in our podcast, and that's where you cut the nipple off at the beginning of the procedure, store it in moist gauze on the back table. You go ahead and you take all the breast tissue out and you close everything up, and then you just take that nipple and skin graft it on at the end. And it can look okay, but that guarantees you that you're going to lose all nipple projection, so your nipple will be completely flat. You definitely will not regain sensation to the nipple because we've cut it off, and you're not going to be able to breastfeed because the ducts have been cut. And so sometimes to get people to the size they want, if we have to do a technique like that, there's other consequences. So those are just some things that when you have your discussion with your surgeon to keep in mind.

Kirstin (13:20):
How long does a typical breast reduction take?

Dr. Koehler (13:24):
The surgery itself depends on how much breast tissue we're having to remove. Sometimes we're doing additional liposuction along the lateral thorax. So sometimes patients, it's not just fullness in the breast, but it's fullness along the side. So if we have to do additional liposuction, if we have to do a large amount of tissue reduction, it can take a little bit longer. So I don't know, I'd say anywhere from two to three hours might be typical, but it could be shorter or longer depending on the circumstances.

Kirstin (13:51):
Do you send patients home the same day?

Dr. Koehler (13:53):
Yes, we do. And we typically do not put drains in, which is something else I'd say for many, many years, drains were pretty routine for this type of a surgery, but some of the things that we're doing now to make it less blood loss, and we just found that we don't typically need to use drains. And so although on occasions we will put a drain in, it's not a routine thing for us. So it's very comfortable.

Kirstin (14:20):
Tell me what recovery looks like.

Dr. Koehler (14:23):
Well, when you wake up, it's not even going to be painful at all because we've done injected local anesthesia. It's going to be comfortable. You're not going to have any pain. The pain associated with breast reduction, although there is discomfort from the incisions that we talked about, there's going to be some incisional pain, but it's really, it's surprisingly not terribly uncomfortable. Now, if we do liposuction along the sides, I think those patients will be uncomfortable. Liposuction tends to be a little more, but if we didn't do any liposuction, just did a breast reduction, it's typically not a painful procedure. And in fact, for those women that come in with the symptoms that say, oh, I've got neck pain and strap marks and all this kind of stuff, there's almost a sense of an immediate relief in recovery room or certainly by the next day because that weight has been lifted off of their chest and it's like it's a relief.

(15:15):
And I guess sometimes we have patients that come in and they want this covered by insurance, and we should maybe discuss that a little bit. So this is one of the rare, not rare, but one of the fewer cosmetic type procedures that also falls into the category of, well, could my insurance cover it because I'm having actual medical symptoms related to this problem. And so it's not an easy yes or no answer that it could or couldn't be covered. And there's a lot of things that come into play, but if it could be covered, it is going to be based off of how much breast tissue is going to be removed. So if there's not lots of breast tissue that's going to be removed, the insurance company's not going to pay for it because it's got to be a significant weight to come off to where we're like, okay, that's enough that you're going to have that relief that I just mentioned about after surgery.

(16:09):
When you wake up, you'll be, oh my gosh, I feel so much lighter because they've taken three pounds, two pounds off of each breast. It's a lot of weight that sometimes will come off, but if there's not going to be enough tissue removed, insurance is not going to cover it. And even if you do have all of those symptoms, you still have to get it preauthorized through the insurance because sometimes insurance will come back and go, Hey, your BMI is this, we're not even going to consider surgery until you actually lose weight first because we feel like part of your symptoms are related to weight. So there can be a lot of other things. Now the last thing is I do all cosmetic surgery, so I don't do any insurance. So sometimes people say, well, if this will be covered by my insurance, can you file it for me or can I file it through my insurance?

(17:00):
And in the past, the answer was pretty simple. It was like, yeah, well, we can do your surgery and then we can give you the codes and do all this stuff and you can send it off and we can try to get it covered, what would be covered. It may only cover the facility or the anesthesia, and they may not cover my surgeon's fee because I'm out of network. But it's different now, now because it all has to be preauthorized and all that kind of stuff. I mean, if we go through us, there's a good chance that you're not going to have it covered. So if you're wanting to go through insurance, just make sure you call your insurance carrier check and see that your doctor is a provider for your insurance and that, because if they're out of network, they still, insurance may still cover it, but not to the full amount. So find people that are covered on your plan and go and have consultations with them unless you decide you're like, look, I'm okay to pay out of pocket. I want to do that. And we have people that do that. They come see us, cuz they just want us to do the reduction.

Kirstin (17:54):
As far as helping patients with their recovery, are there certain medications that you prescribe or certain garments that you recommend wearing or certain pillows or anything like that that help make recovery more comfortable?

Dr. Koehler (18:07):
I mean, not specifically. I mean, yeah, there's definitely some supplements and medications that we give for patients to get them through. We certainly encourage people to have a high protein diet. They need to, that now is not the time to try to be losing weight. You need to be eating healthy so that your body can heal. So there's some nutritional supplements and things like that that we'll sometimes recommend, but mainly if you're just eating healthy, you're going to be fine. There's medicines that we can recommend to help with bruising, although bruising is not a complication, it's just something that may take time to resolve. And if you don't want to have bruising, there's things we can do to improve on that. But no, there's not, you know, like a good supportive bra we send you home with one, and then we usually, even after a week, we're like, okay, you can now try to find something that fits you specifically. We have these sort of one size fits nobody type bras, and everybody likes their bras a certain way. So going and finding something that's comfortable, you can go do that afterwards.

Kirstin (19:04):
What about going to the gym or working out?

Dr. Koehler (19:07):
Typically six weeks. Now you can start walking two, three weeks after surgery, right after surgery really. But to go for longer walks, want to wait a couple of weeks before you go and do that. We really just don't want you getting working up to a sweat, getting your heart rate way up. I mean, you just had surgery. I understand for people that want to be active and get back to their regular activities, that's great, but you don't want to cause a complication that's going to set you back further. So just give it a few weeks. And my typical advice, you've heard me say this before, but for these people that are really go to the gym and they're very concerned about getting back to the gym, I just tell people, change your focus. For the next six weeks, nutrition is your focus and you just eat clean and eat healthy and don't worry about the gym. Make the nutrition your focus, and then at six weeks you're fine to do whatever you like. Now I also qualify that with listen to your body. So if you know it hurts, you got aches or pains, then that's your body saying, I'm not ready. And you just have to modify accordingly. But you're not going to wreck what I did at six weeks. You're good to go.

Kirstin (20:12):
I like that advice. Change your focus.

Dr. Koehler (20:14):
Yeah, I mean, I think it's just, we've heard it a million times from trainers and other people. It's like, oh, the nutrition is so important. That's a big part. And I get the high that people get from doing exercise, and I'm not saying, like I want people to get back to exercise. I think it's great, it's important, it's healthy, but in these healing times, don't just say, oh, I can't do anything. You can do something you just can't work out, change the focus and still do something good for your body.

Kirstin (20:41):
I love it. All right. You kind of answered all these questions without me asking them, so is there anything else you want to add about breast reductions?

Dr. Koehler (20:50):
We shouldn't do them.

Kirstin (20:51):
Always bigger, never smaller.

Dr. Koehler (20:53):
No, it's like one time we were doing a breast reduction and this anesthesia provider was sitting back and he kind of shaking his head, what's the problem? He said, oh, it's like cutting down a fine oak tree.

Kirstin (21:09):
I love it.

Dr. Koehler (21:11):
So no, I mean it's a great surgery, helps a lot of people. And I think the important thing to realize when it comes to feeling good about your body is like this isn't a one size fits all scenario. I mean, there's some women that love to have larger breasts and there's a lot of women that it impairs their ability to do the things they want to do. They're active, they want smaller breasts and they feel more comfortable in their own body with smaller breasts. So it's what makes you feel good and understanding what you're getting into.

Kirstin (21:45):
My best friend had a reduction about a year ago, a little over a year ago. She's this teeny tiny five foot five, 120 pound girl, but she's always had double D breasts, if not larger than that. They're unproportionate to her body and her frame. And so she did a reduction. She was like, I want to be tiny, give me an A or a B, and she has a small B, and she's so happy her life has changed. She's like, I've never been able to not wear a bra since I was 12 years old. I've always worn a bra. And she's like, now she can go out without a bra. She can wear bathing suits that are adorable and cute, and she feels so good in her body. It's great.

Dr. Koehler (22:26):
Yeah, that's good. Yeah. I will say you sometimes hear some stories the opposite though, right? I've had patients that come in to see me for breast augmentation that have had previous breast reductions. And they got their breasts smaller, and then they realized, boy, I kind of don't like the way I feel and look with these.

Kirstin (22:45):
I miss my boobs.

Dr. Koehler (22:46):
They miss their boobs. So I mean, I get that, but that's why you go into this whole process trying to educate yourself, know what you're getting into. Surgery is not a move it here, oh no, move it back. I mean, some of the decisions you make are not easily reversed. So just go in with good information.

Kirstin (23:08):
Okay, that sounds great.

Dr. Koehler (23:11):
All right. I think, is that all Kirstin?

Kirstin (23:13):
That's all. Until next time.

Dr. Koehler (23:16):
All looking forward to it.

Kirstin (23:17):
Do you have a burning question for Dr. Koehler or me? You could leave us a voicemail on our podcast website at Alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks Dr. Koehler.

Dr. Koehler (23:29):
Thanks, Kristin.

Kirstin (23:30):
Go back to making Alabama beautiful.

Dr. Koehler (23:32):
Thank you.

Announcer (23:32):
Got a question for Dr. Koheler? Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and 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, theaxis.io.