Breast Reduction

Most surgeons performing Breast Reduction or mammoplasty remove excess fat, glandular tissue and skin, lifting and reducing the areola and breast using t-shaped incisions. South Florida breast reduction specialist Dr. Mendieta will attempt to limit scaring by taking a graduated approach during surgery. He starts with the least amount of scaring and progressively adjust the breast until the desired shape, size and lift are reached. In rare cases this may be a scar that only goes around the areola, the majority of cases will have a lollipop or L shaped pattern. Rarely, does it involve a full anchor or T shaped scar. However when he performs a Reduction, his main goal is to give you a nice perky and lifted breast. He uses a variety of techniques to reshape the gland; from as simple as a suture suspension technique to placing the gland under a strip of muscle (both these techniques give tremendous upper pole fullness, the appearance is almost as if you have implants). Dr. Mendieta learned many of these techniques in Brazil and Europe that minimizes scarring, restores the breast to a more youthful appearance. What procedure is best for you will depend on your anatomy. To learn about all the options you can tour our web site. To learn what procedure is best for you please contact us.

Women needing breast reduction suffer from several symptoms including chronic back and neck pain, to inner arm numbness from nerve compression, to skin infection or irritation underneath the breast. The medical condition is real, very bothersome, and not makes women self conscious.

III. Breast reductions procedures:

(a) Circumareolar breast reductions with minimal scaring.

(b) Vertical or t-shaped scar breast reductions.

(c) No-scar breast reduction through liposuction of the breast.

Please click below for general information on breast reductions procedures.

• Who needs breast reduction surgery.
• What are my different options with breast reduction surgery - what type of scars will I have?
• How to prepare for the surgery.
• The surgery.
• Recovery period after your breast reduction surgery.
• Your new look.
• Complications and risks.

Although in today's society many women are trying to augment their breast, there is a group of women who already have large pendulous breasts. These women may suffer from a variety of medical symptoms that are directly related to the size of their breasts. The symptoms can vary from chronic back and neck pain, to shoulder strap marks from the bra, inner arm numbness from nerve compression or chronic inner arm irritation from the breast and clothing rubbing up against each other, to skin infection or irritation underneath the breast from moisture and constant friction. Whatever the symptoms, the medical condition is real, very bothersome, and not to mention it can make many women or teenagers extremely self conscious. The treatment for this is to remove excess fat, glandular tissue and skin, while at the same time lifting the areola and breast and reducing the size of the areola. The procedure is called a breast reduction or reduction mammoplasty. Most surgeons reduce and lift the breast using extensive t-shaped incisions, leaving very obvious, visible scars. Although these scars are sometimes unavoidable, Dr. Mendieta also uses techniques that originated in Brazil and Europe that minimizes scarring, restoring the breast to a more natural, rounded and youthful appearance while regaining lost cleavage.

Breast reduction surgery is sometimes covered by some insurance companies if it's medically necessary. However each company has its own criteria for what they will cover or not cover and more than likely require that a certain amount of breast tissue be removed. Check your policy for your particular case.

Who needs a breast reduction?

Heavy breasts can lead to physical discomfort, a variety of medical problems, shoulder indentations due to tight bra straps, and extreme self-consciousness.

Breast reductions are for women that are unhappy with their current breast size and desire smaller breast. The reasons for seeking the reduction are vast; it could be because of medical reasons, limitations to physical activities (like running, swimming, horse back ridding, etc,) to look better in clothing or simply because they want smaller breasts. Even though the procedure may involve extensive scars, it is this procedure that has the highest patient satisfaction in plastic surgery. The operation creates such a relief of the constant discomfort and medical symptoms that patients are very happy they had the operation.

Many patients ask the difference between a breast lift and a breast reduction, the main difference is that in a lift you don't remove any breast tissue; you are simply reshaping the breast. However, the extent of scarring is usually the same.

What are my different options with breast reduction surgery - what type of scars will I have?

The most important part of this evaluation will be your consultation. It is at this time that the breast size and shape, degree of droopiness (ptosis), and the skin quality will be evaluated. These three elements are the most important factors that will determine the extent of scaring you will require. In order to understand your options better, it is important to understand the history of breast reductions and the different philosophies that have evolved over the years.

Breast reduction techniques have been developed following three major principals:

1. What is done to the skin (The extent of scaring)

2. What is done to the breast gland itself?

3. Where is the blood supply to the nipple coming from? Inferior, superior, lateral, medial or central.

In the traditional way of thinking we felt that the only way you could reshape the gland was to tighten and pull the skin in order to create support, contour and shape. The skin was like a brazier. This philosophy would encourage most of us to use the traditional anchor T-shaped scar because it was through this type of incision that we could remove breast tissue and manipulate the skin to contour and reshape the breast. The Brazilians and Europeans challenged this thinking because they felt that the skin was very elastic and like any elastic structure it could stretch. (i.e., much like when you gain or lose weight the skin stretches). Therefore, if we depended on the skin to maintain shape, it may not last since the skin would eventually stretch and create early recurrence of the ptosis. It was their feeling that most of the reshaping and glandular removal should be done independent of the skin, once the correct breast shape was attained then the skin was merely used as a cover for the work done. This way, we don't depend on an elastic structure to maintain shape, and we would have a longer lasting and better result. With this new philosophy, we no longer needed the big scars, since the skin was only being used as a cover, and any excess skin, we felt, would retract and mold to the contour of the new breast. (Much like your skin molds to your body when you loose or gain weight). This is how the limited scar techniques evolved and have become more of our focus today. We began to focus on limiting the extent of the scars and began to concentrate more on reshaping the gland itself after removing the necessary amount of breast tissue.

It is important to note that not all surgeons subscribe to this philosophy, and therefore they may not believe or are not comfortable with the limited scar techniques. While this limited scar techniques worked great in small to medium breast, it fell short on, medium to large breast, and in patients with very poor skin quality. The reason why, was because, these women with very droopy or large breast just had too much skin, and in women with poor skin quality, the skin had lost its ability to retract. Although the skin did retract somewhat in both of these scenarios, it was just too much to ask for and the skin would then wrinkle and overhang. Therefore, in these patients we needed to make longer scars in order to remove the excess skin that exist, otherwise the breast would look too wrinkled and with poor shape.

The final component has to do with preserving the blood supply to the nipple. This becomes more of a technical issue for the surgeons and would not be part of your decision making process. Your main concern will be the extent of the scar and not how the operation is done. But to give you an idea, the nipple has to maintain its blood supply or it will die. The blood supply and that part of the breast that has that blood supply is called a pedicle. When performing a breast reduction one has to decide where that pedicle that maintains the nipple alive can come from. If it comes from the lower part of the breast it is called an inferior pedicle, the upper part of the breast it is called a superior pedicle, the lateral part of the breast it is called a lateral pedicle, the medial part of the breast it is called a medial pedicle, and finally the center part of the breast it is called a central pedicle. Once the pedicle is created then one can safely remove the rest of the breast gland, perform the breast reduction, shape the gland and still preserve the nipple intact. Like I said this will be your surgeon's preference. Where this becomes an issue, is if you are having another breast procedure and you had a previous reduction, then it is important to know what technique and what pedicle was used. This way we don't cut the circulation to the nipple in the second procedure.

The moral of the story is that not everyone is a candidate for the limited scar techniques and we need to evaluate your skin quality, amount of droopiness (ptosis) and size of your breast in order to make recommendations.

Although we have certain guidelines to help us evaluate the degree of droopiness, there is still some room for interpretations as to the skin quality and size of the breast. Also the surgeon's philosophy, expertise, training, and preference will influence his decision as to what is best in your case. Given all these variables, it now perhaps makes more sense as to why you may hear so many different suggestions from different surgeons as to the best option for you.

In terms of scaring there is the circumareolar scar, (scar is only around the areola), the vertical scar reduction, (the scar is around the areola and a vertical scar on the breast), The L- shaped scar reduction (scar around the areola, a vertical scar on the breast and a horizontal scar that only extends to the outer part of the breast), and the traditional anchor or inverted T-shaped scar.

Preparing for your surgery.

Every plastic surgeon has his own ritual and recommendations. Depending on your age and family history, we may require you to have a mammogram (breast x-ray) before surgery (Especially, if you are over the age of 35 or have a family history of breast cancer). You will also receive specific instructions on how to prepare for surgery, including guidelines on eating and drinking, medications and certain vitamins to avoid before surgery, as well as post operative care sheets. We have found it helpful for patients to do the following things that you will need before your surgery:

• Ice packs or frozen peas (you will need these for the next 48 hours),
• You will need to purchase a Sports bra, which you will wear for about 2 weeks for comfort.
• The night before your surgery you can take a Valium 10 mg this will make you sleep like a baby. Also the night before surgery we recommend taking a zantac 300 mg, this will sometimes help with preventing nausea after your surgery.
• Don't eat or drink anything after midnight (when you brush your teeth in the morning don't drink the water).
• The morning of surgery wear something very loose that is easy to take off and on, don't wear any jewelry, you can shower but don't place any creams, lotions, deodorants or perfumes.
• Arrange for someone to drop you off and pick you up after surgery. Arrange for someone to stay with you for a couple of nights.
• You will have tape around your incision site, which will be removed when your sutures are removed at about day 5-7. Don't worry you will be able to shower the day following surgery; it is ok for the tape to get wet.
• The following day you will come to the office for a follow up visit and massage.

Where your surgery will be performed.

Breast reduction is a procedure that is most commonly performed in patients that are in good to excellent health, and therefore it can be done in either office based surgical centers, ambulatory surgical centers, or hospitals. Most of our breast reductions are in our own office based surgical center; this affords a very relaxed atmosphere with more patient privacy and comfort. The exceptions obviously would be if the patient has any major medical problems or the patient desire it to be done in the hospital.

Types of anesthesia.

The operation can be performed in various ways, either under local with IV sedation, nerve blocks with sedation or General anesthesia. It is Dr. Mendieta's preference to use General anesthesia since it is extremely safe and the operation is only about 2- 3 hours.

The surgery.

Vertical or t-shaped scar breast reductions.

A new technique that can be used in all sizes of breast, in almost every patient, and it appears to maintain a longer lasting result is one that was described by a Brazilian surgeon named Dr. Ruth Graf, and pioneered in the United States by Dr. Thomas Biggs. In this procedure part of the breast gland is tunneled underneath the pectoralis muscle and therefore the superior pole fullness is maintained because part of the gland is maintained in its position by the muscle. The results have been excellent to date, giving the breast an appearance almost as if you had implants. The length of the scar will depend on how big and how droopy your breasts are. There are only a handful of surgeons performing this technique, but to date we have had excellent results. Dr Mendieta has modified this technique even further by also incorporating a technique described by Dr. Dennis Hammond to further increase the superior pole fullness.

Techniques for breast reduction vary, but the most common procedure involves an anchor-shaped incision that circles the areola, extends downward, and follows the natural curve of the crease beneath the breast. The following description is not performed by many surgeons.



Incisions outline the area of skin, breast tissue, and fat to be removed and the new position for the nipple.

In the vertical or T-Shaped incision, the breast is separated from the skin, excess glandular tissue and fat are then removed. The gland is re-shaped and re-contoured. Part of the remaining breast gland is then tunneled underneath the pectoralis muscle. This allows more superior breast fullness that is longer lasting. The nipple and areola are placed in to there new position. Using a tailor tack method the amount of skin to be resected is determined. First we start with a circumareolar closure; if the wrinkling is too severe and the results will be compromised a vertical skin excision is added. If the amount of excess skin is still too great, an L- shaped excision is done. If the skin remains excessive, then a full T-Shaped incision is done. Liposuction may be used to remove excess fat from the armpit area.

In most cases, the nipples remain attached to their blood vessels and nerves. However, if the breasts are very large or pendulous, the nipples and areolas may have to be completely removed and grafted into a higher position. (This will result in a loss of sensation in the nipple and areolas tissue.) This is extremely rare, and is very seldomly done. This type of procedure is performed more common on a patient who has very large pendulous breasts and may be a smoker or a diabetic.



Skin formerly located above the nipple is brought down and together to reshape the breast. Sutures close the incisions, giving the breast it's new contour.

Stitches are usually located around the areola, in a vertical line extending downward, and along the lower crease of the breast. In some cases, techniques can be used that eliminate the vertical part of the scar.

And occasionally, when only fat needs to be removed, liposuction alone can be used to reduce breast size, leaving minimal scars.



Scars around the areola, below it, and in the crease under the breast are permanent, but can be easily concealed by clothing.

Recovery period after your breast reduction surgery.

Remarkably this operation is not very painful, your breasts will be bruised, swollen, and uncomfortable for a day or two, but the pain shouldn't be severe. Any discomfort you do feel can be relieved with medications. Expect to have some wrinkling around the areola especially if the minimal scar breast lift is performed, this should improve and will take about 3 months.

Although you will be up and walking the next day, most patient are able to return to work in about one week, some patients recuperate remarkably well and have been able to return earlier, however the average is about a week. In order to resume any exercise programs or any heavy lifting, it may take 3-4 weeks, depending on how well you heal as an individual, the average is about one month. After surgery, you'll wear an elastic bandage or a surgical bra over gauze dressings.

Within a few days, a soft support bra will replace the bandages or surgical bra. You'll need to wear this bra around the clock for three to four weeks. The stitches will be removed after 7-10 days.

If your breast skin is very dry following surgery, you can apply a moisturizer several times a day. Be careful to keep the moisturizer away from the suture areas.

There are some creams that can be used to help with healing (i.e. Scar guard, silicone, vitamin E, etc); these you can start using after the sutures are removed.

You can expect some loss of feeling in your nipples and breast skin, caused by the swelling after surgery. This numbness usually fades as the swelling subsides over the next six weeks or so. In some patients, however, it may last a year or more, and occasionally it may be permanent.

Your new look.

At first the upper part of your breast may seem very high and very full and, it can have a funny appearance, this occurs because your breast is swollen and it will take about 2-3 months for the breast to settle and take its nice natural shape. You may also notice that one breast is higher or larger than the other, this is quite normal since one side may swell more than the other, (if you notice your before pictures you will see that your breast were not symmetrical to begin with). It will take about 3 months for you to become accustomed to your new look and not notice the differences as much. You may experience wrinkling around the areola and this will improve over time, it may take up to 3 months. Most patients are very happy immediately after their surgery. It is those patients that have unrealistic expectations and are not willing to wait for the healing process that become dissatisfied and anxious. Remember it takes about 3 months for all the swelling to go away and the breast to settle into their new positions.

We will make every effort to make your scars as inconspicuous as possible. Still, it's important to remember that breast reduction scars are extensive and permanent. They often remain lumpy and red for months, and then gradually become less obvious, sometimes eventually fading to thin white lines. Fortunately, the scars can usually be placed so that you can wear even low-cut tops.

You should also keep in mind that a breast lift won't keep you firm forever - the effects of gravity, pregnancy, aging, and weight fluctuations will eventually take their toll again.



Risks and complications after a breast reduction operation.

Any surgery always has a possibility of complications or a reaction to the anesthesia. Even though these complications are rare we need to mention them so you have a full understanding.

A breast lift is not a simple operation, but it is normally safe when performed by a qualified plastic surgeon.

• Infection - This is very uncommon after a breast reduction, but if it were to occur it would happen around day 7-10 after your surgery. This is usually resolved with antibiotics.
• Hematoma - This is a collection of blood, this is very uncommon as well, and if it were to occur it usually happens within the first 24 hours. You would notice one breast much larger and tender than the other and it would require a re-operation to control whatever might be bleeding or oozing.
• Wound Breakdown - This occurs more commonly in smoker. This is when a separation of the healing tissues occurs creating an open wound. This may occur, but if it does it is just a matter of letting the body heal itself. It will resolve without any problems, however it may require a scar revision at a later date after all the tissue has healed.
• Scaring - This is perhaps the biggest issue in breast reduction. We try to leave as small as scar as possible however the extent of scaring will depend on the size of your breast, the amount of lift needed and your skin quality. Breast reduction does leave noticeable, permanent scars, although they'll be covered by your bra or bathing suit. If you are a poor healer you can develop wide scars, hypertrophy scars or keloid scars. There are a few things that may help with healing like silicone patches, steroid injections, vitamin E, and pressure. The type of scars you develop will depend on your healing process. (Poor healing and wider scars are more common in smokers.)
• Areolar loss - This is perhaps the rarest of complications but the most dreaded. It is extremely rare. This happens when there is not enough blood supply to the nipple and areola and it necrosis, or dies. It is a particular concern in patients that have had previous major breast surgeries, especially with smokers and women that have extremely large breast. As stated this is extremely rare and very unlikely.
• Loss of breast - feeding ability - This is possible whenever any breast surgery is performed, however it is very rare with breast reductions since the breast ducts are usually left intact.
• Cancer - There is no higher incidence of breast cancer in patients that have a breast reduction. We recommend obtaining a mammogram before your breast lift or reduction, especially if you are over the age of 35 or have a family history of breast cancer.
• Skin discoloration - Although rare, after a breast lift you may see some skin discoloration of the breast itself and sometimes even the areola.
• Stretch marks - This is not really a concern with breast lifts or Breast reductions, since we are not increasing the volume of the breast. If anything we are reducing the volume. Stretch marks can be seen when you are combining a breast lift with a breast augmentation.
• Recurrence of ptosis - This is a very common problem, after several years the breast may begin to droop again. Although it will not be to the extent it was before surgery, what you will notice is that you loose some of the superior pole fullness. This is why some of the newer techniques focus on maintaining more fullness superior by glandular reshaping.
• Asymmetry - One breast may appear larger of different than the other. This is not really a complication but a fact of life. Each half of the body is very different than the other; therefore you can never have exactly the same breast. Expect some asymmetry in your breast and areolas.
• Fat necrosis - If some of the breast fatty tissue does not receive enough blood supply then that part of the breast will develop an internal necrosis or tissue death. When this occurs in the fat it is called fat necrosis. This is very rare in breast reductions. If it occurs, the body may reabsorb the tissue but you will go through a period of feeling hard lumps in the breast. Sometimes they don't disappear and we need to remove them.
• Nipple position, different size areolas - Because the breast is never symmetrical, you will always have one breast that is different from the other. At first this difference will be very noticeable since your breast is swollen. Once the swelling subsides, then you wont notice the difference as much but it will always be present (no one has symmetrical breast). The procedure can also leave you with unevenly positioned nipples and different size areolas. If the difference is too great sometimes you can improve the difference with a scar revision surgery, but they will never be exactly alike.
• Re-Growth of the breast - This is rare but sometimes even though we have made the breast smaller, they can increase in size after the surgery. This is especially true if you gain weight or become pregnant.

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