Breast reduction is one of the more popular and common procedures performed by plastic surgeons. Although breast reduction surgery is considered routine, all surgical procedures involve risk. The risks of surgery are decreased and recovery enhanced when the surgery is performed by a fully qualified experienced Plastic and Reconstructive Surgeon in an accredited surgical facility with an experienced surgical team. A/Prof Damian Marucci is an Associate Professor of Surgery at the University of Sydney and has performed hundreds of breast reductions over the past 20 years.

Here are some of the specific potential complications of breast reduction surgery

• Allergies

Surgery involves the use of various medicines, sutures and dressings – and there is always the small risk of allergies to any of these items. Some allergies can result in a rash or itchiness, other allergies can provoke a more generalised reaction involving changes in blood pressure, generalised swelling or problems with breathing (anaphylaxis).

• Anaesthetic risks

Breast reduction surgery is performed under general anaesthesia. This means that the patient is completely asleep. The anaesthetist will put a tube in the patient’s mouth and monitor the heart, lungs and breathing carefully during the surgery. Even though the patient is completely asleep, A/Prof Marucci will put local anaesthetic into all the wounds to make sure that everything is nice and numb for many hours after the operation is finished. Any anaesthetic puts strain on the heart and lungs. There are risks of breathing issues, low blood pressure, reactions to the anaesthetic drugs and a sore throat from the breathing tube. Some patients have nausea and vomiting after general anaesthesia. The anaesthetist can give special strong medication to counter this if needed. Even though there are many things that can go wrong during an anaesthetic, general anaesthesia for breast reduction surgery is safest when performed in an accredited surgical facility with a properly trained and qualified anaesthetist.

• Bleeding

The breast has a very good blood supply. Although this helps with wound healing, it also means there is a small risk of bleeding during or after surgery. During surgery, A/Prof Marucci will carefully control the bleeding from any major blood vessels encountered. It is rare for there to be significant bleeding, such that the blood pressure would be affected or that a blood transfusion would be required. Sometimes blood vessels can open up and start bleeding after the surgery causing a collection of blood or a “haematoma”. Haematomas can cause swelling, bruising and, if not drained, may result in significant blood loss. Patients who develop a post operative haematoma usually need to go back to the operating theatre to have the bleeding controlled under general anaesthesia. The wounds are normally washed out and then put back together again in the same way as was done originally. It might mean an extra night in hospital or more bruising than there otherwise would have been.

• Blood clots

There is a risk of blood clots developing in the legs during and after a general anaesthetic. Blood clots in the legs (Deep Venous Thrombosis – DVT) can sometimes break off and travel to the lungs (Pulmonary Embolus). If this happens, it can cause severe problems with breathing and blood pressure, even leading to death in severe cases. A/Prof Marucci and his team take DVT/PE extremely seriously, so a number of steps are taken to limit the risk of these complications. Compression stocking are applied to patients before surgery and special pneumatic calf compressors are used to massage the calf area during anaesthesia. Patients are given an injection of blood thinners in the hours after surgery to help prevent DVT. Finally, patients are encouraged to get out of bed after surgery and gentle walk around to get the circulation moving

• Breast Asymmetry

No woman has completely symmetrical breasts – breasts are “sisters” more than “twins”. The goal of breast reduction surgery is to decrease the weight of the breast and lift the breast tissue up onto the chest wall where they belong – and doing it all with as much symmetry as possible. Despite the goal of perfect symmetry, it is common for their to be some minor asymmetries. Sometimes scars can be more prominent of one side or the other, sometimes there can be differences in the volume of the breast or the shape, size and position of the areolars. Asymmetries may be minor and need no treatment. Sometimes the asymmetries are more significant and require revisional surgery.

• Breast Contour and Shape Irregularities

The ideal breast shape has a rounded lower pole when viewed from in front and side. The projection of the breast when viewed from the side should gradually increase with the maximal point being where the nipple is sited. Breast reduction involves surgically reshaping the tissues of the breast and holding them in a new position using dissolving sutures underneath the skin. Sometimes this can cause irregularities of the shape of the breasts. Sometimes, there can be anomalies of breast contour, away from the rounded ideal described above. Most contour irregularities tend to improve with time, however sometimes revisional surgery may be required. Revisional surgery may involves liposuction to remove tissue some areas or fat grafting to add tissue to other areas. Sometimes a more comprehensive revision is needed to address major anomalies.

• Changes in Sensation of the Nipple and Breast Skin

The goal of breast reduction surgery is to decrease the weight of the breasts and to move the nipple and breast tissue higher on the chest wall, while keeping the nerve supple to the skin and nipple intact. All surgery involves cutting through tissues, and it is common for there to be some numbness of the skin of the breasts after the surgery. The nerves normally grow back over a period of months. There can be “electric” shooting pain as the nerve find their way back to the skin. The nipple receives its nerve supply through the breast tissue. There may be some numbness of the nipple in the weeks after surgery, but this usually improves over time. Rarely, there can be permanent numbness of the nipple. This is especially a risk when large amounts of breast tissue need to be removed as part of the surgical procedure.

• Damage to deeper structures, such as nerves, blood vessels, muscles and lungs

With surgery on any area of the body, there is the risk of damaging anatomical structures in the area. Nerves provide sensation to the skin of the breast and areola. It is common for there to be some numbness of the skin after surgery, but the sensation tends to come back to normal after a few weeks. The nerve supply to the areolar comes up through the breast tissue, and so is at particular risk during breast reduction surgery. A/Prof Marucci designs his breast reductions to maximise the nerve supply to the nipple. Even still, some patients do have some numbness after surgery which may last for a few months. Rarely, the numbness of the nipple can be permanent.

Damage to blood vessels is a common aspect of most surgical procedures. Bleeding is usually controlled using electrocautery or clips. Sometimes damage to blood vessels doesn’t become apparent until hours after surgery, in which case the patient might need to return to the operating theatre to stop bleeding. Rarely, bleeding can be severe and a blood transfusion is required or medicines needed to keep the blood pressure in a normal range

Chest wall muscles, ribs and the lungs are situated underneath the breast tissue. It is rare for any of them to be damaged during breast reduction surgery. Occasionally, the lungs are damaged by a local anaesthetic needle that has gone too deep. This may cause a collapsed lung – but that would be very rare.

• Deep vein thrombosis, cardiac and pulmonary complications

During general anaesthesia, the body remains still. The act of surgery on the body can result in the blood being more prone to clot. This combination means that there is an increased risk of blood clots forming in the veins of the legs during any surgical procedure, including breast reduction surgery. This is called a Deep Venous Thrombosis (DVT). These blood clots have the potential to break off and travel to the lungs, where they can interfere with lung function. This is called a pulmonary embolus (PE). A pulmonary embolus can make a patient extremely unwell – and can be fatal, if the clot is large enough.

Any general anaesthetic puts strain on the heart and lungs. There is a risk of a heart attack, abnormal heart rhythm, lung collapse or low blood oxygen level with any general anaesthetic. The risk of these complications in healthy patients undergoing breast reduction is very small.

• Excessive Firmness of the Breasts

Breast reduction surgery involves removing excess breast tissue and reshaping the tissuethat is left behind. Dissolving sutures are used to hold the new breast shape as an “internal bra”. The resulting scars will hopefully hold the breast in its new improved configuration. This may be at the expense of increased firmness of the breast tissue. This firmness usually resolves with time as the sutures dissolve and the scars soften.

• Fat necrosis (death of fat tissue within the breast)

The breast is made up of glandular tissue and fat. Breast reduction surgery involves removing some breast tissue and repositioning the remaining breast tissue. Sometimes the blood flow to areas of fat and gland can be affected. Sometimes fat tissue can be crushed within sutures used to reshape the breast. If either of these things occur, it can result in the death of globules of fat. This is called “fat necrosis”. This can result in inflammation of the affected area of breast tissue, with redness, heat and swelling. It can cause lumpiness. It may be associated with infection. Most commonly fat necrosis can just be monitored and patients treated with tablet antibiotics. Sometimes fat necrosis can result in lumpiness which requires further surgery once everything has settled.

• Fluid accumulation

Blood and fluid can sometimes collect under neath the skin following surgery. Often, the body is able to resorb this fluid over a period of time. Sometimes, the body can’t and the fluid collection persists as a “seroma”. A seroma may cause lumpiness, discharge out of the wound or else become infected. Fluid collections may need to be drained, sometimes with a needle but sometimes in surgery. Antibiotics may be needed. The cosmetic result might be affected.

• Infection

Infection can occur after any surgical procedure, and breast reduction surgery is no different. Although serious infections are rare, there is the potential for infections to occur either in the skin, deeper inside the wound, in the bladder (Urinary Tract Infection – UTI) or the lungs (pneumonia). Infections are usually treated with antibiotics. It is rare that surgery is required for an infection, unless it is associated with fat necrosis or seroma (see above).

• Pain

Breast reduction surgery is performed under general anaesthesia so that patients don’t feel any pain during the procedure. A/Prof Marucci puts lots of local anaesthetic into the wound during the procedure some that patients will have many hours of numbness in the wound after the operation has been completed. In addition to this, patients will be given strong painkillers after the surgery when the local anaesthesia wears off. Initially the painkillers may be given through a drip although patients are usually sent home with tablet painkillers. Although all of these steps are taken to prevent discomfort, patients may still experience pain after surgery. Different patients cope with the discomfort of recovery differently. Some patients require painkillers for a few days, whereas others continue to experience pain for weeks or even months after surgery. A/Prof Marucci and his team do not want you to have pain. Pain can prolong your recovery, increase the risk of complications and affect your ability to resume your normal life.

• Poor wound healing

Poor wound healing can occur after surgery. Poor wound healing is more likely to occur in patients who have diminished immunity (eg diabetics or patients on steroid medications). Any condition that decreases blood flow to the wound can affect wound healing (eg smokers). Local factors, like wound infection, can also contribute to poor wound healing. Poor wound healing can require prolonged dressings and cause unfavourable scarring (see below)

• Possibility of revisional surgery

The goal is to perform one operation. Sometimes more than one procedure is required. For example, if there were to be unexpected bleeding after surgery, repeat surgery may be urgently required to control it. Another situation might be where there was significant asymmetry after surgery requiring correction. These revisional procedures may be major or minor. They may involve further expense and may require further time off work, recovery and will entail the usual risks of surgery and anaesthesia.

• Potential inability to breast feed

Breast reduction surgery involves removing breast tissue in order to decrease the weight of the breasts. However, breast tissue is left behind in order to keep the skin and nipple alive. Although the breast tissue that remains underneath the nipple means that patients can usually breast feed after breast reduction surgery, this is not always the case. Studies have demonstrated that breast feeding success after breast reduction surgery depends on the surgical technique used. Success rates of 75-100% have been reported with techniques that preserve a significant column of breast tissue underneath the nipple, down to the chest wall. On the rare occasions that a patient requires a free nipple graft (only used for massive breast reductions), breast feeding would not be possible.

• Potential loss of skin/ tissue of breast where incisions meet each other

Breast reduction surgery involves reshaping both the skin and breast tissue, then holding everything in position with sutures. There are typically two points of the closure there is a “T-junction” of wound closure (basically where the wound closure looks like a “T” at the bottom of the nipple or an upside down “T” where the scar in the fold meets the scar going down the front of the breast). There is an increased risk of wound healing problems at these T-junctions than elsewhere on the breast. When a wound breakdown does occur, it usually leads to a small raw area or sore, less than the size of a fingernail, that can simple managed with daily showers, Vaseline and gauze. These usually heal on their own. Rarely, a more major breakdown may require more involved dressings. Very rarely, revisional surgery is required. As noted before, revisional surgery may involve further expense and may require further time off work, recovery and will entail the usual risks of surgery and anaesthesia.

• Potential partial or total loss of the nipple and areola

This is a rare but devastating potential risk of breast reduction surgery. The goal of surgery is to remove excess breast tissue, while leaving enough breast tissue behind so that the nipple and areolar have an adequate blood supply. If the blood supply to the nipple and areolar is damaged during surgery, usually because too much tissue is taken from behind the areolar, it can result in partial or full loss of the nipple or areolar. Thankfully, using careful surgical technique, this complication is very rare. If the nipple or areolar were to be affected, this would result in scarring. A nipple reconstruction, involving flaps, grafts and tattoos, may be required.

• Skin discolouration, pigmentation changes, swelling and bruising

Any surgery can result in swelling and bruising. This usually subsides over a period of a few weeks, although the final result can take months. Different people’s skin responds to surgery differently, and sometimes there may be skin discolouration or pigmentary changes that may takes months to resolve. Rarely these changes are permanent.

• Unfavourable Scarring

Whenever a cut is made into the skin, a scar is formed. The idea of plastic surgery is to make any scars of surgery as thin, small and as neat as possible. Different people scar differently, however, and sometimes there can be disappointing scars. Scars can stretch, be indented, be raised or be red/purple for a prolonged period. Sometimes there is a lump at the very end of the scar, called a “dog ear”, which usually settles on its own over months, but sometimes requires revisional surgery. Some patients may develop “pathological scarring” – this is where the wounds have not healed in a normal way. One example of this is a “hypertrophic scar”, where the scar has stretched. Another, more serious example, is a “keloid scar”. A keloid scar is one where the scar tissue has continued to grow, even though the wound has healed. Keloid scars can be unsightly, itchy, painful and very firm to touch. There is no cure for a keloid scar, although controlling it may require a combination of steroid injection, silicone sheeting, massage, occasionally further surgery and (very rarely in severe recurrent cases) radiotherapy.