Breast Reduction Risks and Complications

Anyone considering surgery should approach the decision with a healthy amount of respect and caution especially when the surgery is elective (or planned) and is non essential surgery (as aesthetic or cosmetic surgery generally is). All surgical procedures have limitations in terms of achievable outcomes and it is important that your expectations match what is possible through surgery. The choice to go ahead with surgery is always (or should always be) taken after due consideration of the risk benefit balance for the procedure. Although the majority of patients do not experience problems it is important that you fully understand all the potential risks and complications of breast reduction surgery. It is important that you take the time to read over them again prior to your next consultation.

Bleeding:         

It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood which would entail a return trip to theatres. Intra-operative blood transfusion may also be required though this is rare. If a collection of blood accumulates within the breast (a haematoma) that is small enough to not be detected clinically this may result in a spontaneous discharge from the breast at a later date (if this happens it is usually a few weeks following surgery) or the haematoma could become infected forming an abscess which may need to be formally washed out in theatres. Most small haematomas resorb spontaneously, however. Do not take any aspirin or anti-inflammatory medications for ten days before or after surgery, as this may increase the risk of bleeding. Nonprescription “herbs” and dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time following injury to the breast. If blood transfusions are necessary to treat blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Heparin medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets.

Seroma

A seroma can be best thought of a collection of fluid beneath the skin at a surgical site. The composition of a seroma is much the same as that of blood but without the actual blood cells (it contains similar proteins and salts to blood) and is usually the result of lymphatic fluid accumulation (this is the 10% of the fluid that escapes from capillaries within tissues but does not return back to the veins via the small blood vessels but rather by the lymphatic drainage vessels) or by direct production from inflamed tissue (think of the tissues ‘sweating out’ the fluid). If this occurs there is the possibility it will need to be drained (often by simple aspiration with a needle or syringe, though rarely a further operation to may be required). If a seroma were to become infected it could form an abscess which could require further surgery to washout and drain.

Scarring

All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive and of different color than the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be asymmetrical (appear different on the right and left side of the body). There is the possibility of visible marks in the skin from sutures. In some cases scars may require surgical revision or treatment. Scars can appear thick, red and raised all or part of the way along the incision line (a hypertrophic scar) or more rarely can involve tissues beyond the incision itself (and can resemble a badly healed burn), this is known as a keloid scar. Additionally scars can tether to underlying structures or become abnormally pigmented. It is possible that additional treatments may be required for adverse scarring.

Infection

Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary.

Nipple necrosis

Nipples need to be re-sited during breast reduction surgery, and in some women having large breast reductions, this can mean they need to be moved a long way. If there is any problem with the blood supply to the nipple (possibly because the nipples have had to be moved a long way), this may affect the healing and even the survival of the nipples. In the worst-case scenario (which is fortunately very rare) the entire nipple may die. Otherwise, part of the nipple may form a scab, which will eventually heal underneath. If you are unlucky enough for this to happen, you may require revision surgery in the future to address poor scarring or to reconstruct a new nipple for you.

Nipple asymmetry

The shape, size and position of the nipple on the breast may differ following surgery. Although every effort is made to ensure symmetry differential healing between the breasts and scar formation will have an impact on the appearance of the nipples on each side.

Change in Nipple and Skin Sensation      

You may experience a diminished (or loss) of sensitivity of the nipples and the skin of your breast. Because the surgery itself involves moving the nipple and separating it from the rest of the breast tissue the nerves supplying the nipple may be cut. Partial or permanent loss of nipple sensation can occur after a breast reduction in one or both nipples. If you are having free nipple grafts as part of your breast reduction procedure your nipples will lose sensation. Changes in sensation may affect sexual response or the ability to breast feed a baby.

Delayed Healing

Wound disruption or delayed wound healing is possible. Some areas of the breast skin or nipple region may not heal normally and may take a long time to heal. Areas of skin or nipple tissue may die. This may require frequent dressing changes or further surgery to remove the non-healed tissue. Individuals who have decreased blood supply to breast tissue from past surgery or radiation therapy may be at increased risk for delayed wound healing and poor surgical outcome. Smokers have a greater risk of skin loss and wound healing complications.

Skin Contour Irregularities

Contour and shape irregularities may occur after reduction mammoplasty. Visible and palpable wrinkling may occur. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility when there is excessive redundant skin. This may improve with time, or it can be surgically corrected.

Skin Discoloration / Swelling       

Some bruising and swelling normally occurs following a reduction mammoplasty. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods of time and, in rare situations, may be permanent. Additionally, these areas may have exaggerated responses to hot or cold temperatures.

Firmness

Excessive firmness of the breast can occur after surgery due to internal scarring or fat necrosis. The occurrence of this is not predictable. If an area of fat necrosis or scarring appears, this may require biopsy or additional surgical treatment.

Fat Necrosis                 

Fatty tissue found deep in the skin might die. This may produce areas of firmness within the skin or the underlying breast tissue. Fat necrosis may also result in discharge of liquid from the surgical incision due to fat liquefaction. Additional surgery to remove areas of fat necrosis may be necessary.  If an area of fat necrosis were to become infected it would require further treatment with antibiotics or surgery. There is the possibility of contour irregularities in the skin that may result from fat necrosis.

Skin necrosis

If the blood supply to the skin is insufficient following surgery (which can be for a variety of reasons) the skin, particularly at the incision site, can necrose (die). If this happens the skin will form an eschar (scab) which may need to be removed surgically. Dressings are likely to be required for a period of time and further surgery may be needed.

Surgical plan

Although a pre operative plan will have been discussed prior to the operation, there are multiple ways of undertaking an individual procedure. Each technique has been developed to achieve the same end result (though may result in differing scar patterns). It may sometimes be necessary to alter the initial plan discussed with you at the time of operation due to anatomic considerations that become apparent during the course of the surgery.

Damage to Deeper Structures    

There is the potential for injury to deeper structures including nerves, blood vessels, muscles, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according to the type of procedure being performed. Injury to deeper structures may be temporary or permanent.

Nerve injury

Sensory nerves that supply the breast, nipple and chest wall can be damaged in breast reduction surgery. This can result in altered sensation, loss of sensation (numbness) or (rarely) pain if a sensory nerve is injured. If there is change or loss of sensation or movement this is usually temporary and recovers by itself, however the loss, alteration in sensation or pain can be permanent and may require further surgery.

Pain                 

You will have pain following surgery. The intensity and duration of the pain varies from individual to individual following breast reduction surgery. Very infrequently chronic pain due to nerve damage or nerve entrapment in scar tissue may arise following breast reduction surgery (neuropathic pain).

Sutures

Most operations involve the routine use of deeply placed sutures (stitches) within and beneath the skin. Such sutures are usually designed to be dissolving however in some individuals they make take longer to dissolve than intended or may provoke a reaction from the body. In such instances they may form small pockets of inflammation (stitch granulomas or abscesses) which resemble an infection but are in fact due to the underlying stitch. Similarly, the stitch may poke through the skin and become uncomfortable. In such cases the stitches will require removal.

Allergic Reactions         

In rare cases, local allergies to tape, suture material and glues, blood products, topical preparations or injected agents have been reported. Serious systemic reactions including shock (anaphylaxis) may occur to drugs used during surgery and prescription medications. Allergic reactions may require additional treatment.

Deep vein thrombosis, cardiac and pulmonary complications

Any procedure requiring general anaesthesia and immobilization for a period of time increases the risk of the formation of blood clots in the legs. Such clots can dislodge and move to the lungs, causing shortness of breath and strain on the heart. Such clots can potentially be fatal. Air travel, inactivity and other factors (medications such as the oral contraceptive pill or increased tendency to form clots) can increase the risk of clot formation. It is important you tell Mr. MacQuillan of any previous history of swollen legs or blood clots prior to surgery. If you experience shortness of breath, chest pains or feel palpitations (abnormal heart beats) following your surgery it is important you seek medical advice immediately.

Blood Transfusion                    

If blood transfusions are needed to treat blood loss, there is a risk of blood-related infections such as hepatitis and HIV (AIDS). Heparin medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets.

Considerations for the time around the operation:

  • Clothing to wear to hospital – we recommend you wear a button or zip top for ease and comfort (such as a tracksuit top). You may find your arms and shoulders feel a little stiff after surgery.
  • Keeping your skin clean – we recommend regular washing before and after surgery with tea tree wash.
  • Good supporting spats bra – a good bra is essential after breast surgery. We suggest lipoelastic bras, which you can purchase from the clinic or a post surgical bra from the Marks & Spencer range. They offer good support and stretchy ops, meaning that they can accommodate your breasts during any post-operative swelling you may experience, and in addition, a cup size does not have to be decided on. They are also front fastening, which makes things easier after surgery. We would also suggest you purchase two bras, so one can be in the wash whilst wearing the other one. It is important to ensure that the bra fits comfortably around your chest.
  • Wear the sports bra for 6-weeks day and night unless otherwise advised.
  • Sleep for a few days with an extra pillow after surgery – this should help swelling to reduce.
  • Locking after your dressings – your wounds will be dressed in brown tape which stays on for two weeks. You can shower with the dressings on, but please have your back to the shower hose, so he tapes dent come off. It is essential that the dressings are dry prior to getting dressed – dab of excess water with a towel, then use a hair dryer on a cold setting to dry the tapes.
  • Post-operative follow-up – you will have a check up with the nurse one week after surgery, and then a further appointment for the removal of tapes at 2-weeks and trimming of any stitch ends. Later follow-up will be arranged subsequently.
  • Take things easy & slowly after surgery. Gentle pottering about, no heavy lifting or jumping up and down for first 2-3 weeks.
  • Driving can be started at 2-3 weeks.
  • After 6 weeks you can get back to normal exercise.
  • Scar management – this will be discussed with you at your 2-week post-operative appointment. Regular moisturizing and massage of your scars is important, and silicone gel can help ensure your scars settle down as quickly as possible.

Further Reading about Breast Reduction with Consultant Plastic Surgeon Anthony MacQuillan