History: The patient is a (XX)-year-old woman who I am seeing in consultation today. She reports that she is no stranger to surgery and has had three breast surgeries and is now looking to have a fourth. The first operation that she had was a breast augmentation. She says she thinks she really needed to have a breast lift but she was scared of the scars, so she just had a breast augmentation, which left her way too big. This was in (XXXX). The same surgeon then replaced her implant with a smaller implant and gave her a lift in (XXXX), and then, in (XXXX), she had again a smaller sized implant and a lift performed one more time.
She still feels too big. She cannot buy shirts that button down the front. She feels like everybody stares at her when she is in a bathing suit, and she does live on a lake and spends a lot of time in a bathing suit. She is looking at what options she has. Before the first surgery, she said she was a D or a big C. She currently wears a DD or DDD bra. She is unable to find bathing suits.
She wants to have a smaller, more narrow breast and complains of having a lot of breast tissue she feels against her arms. She does report having a weight gain of 10 pounds this winter. She currently has 200 cc smooth, round gel implants. The patient has a negative family history of breast cancer and has no personal history of breast disease.
Her most recent mammogram was six months ago and it was negative. She is G3, P3, and has children aged 5, 6, and 7. She breast-fed all of them. She does report her breasts increased in size after the birth of her children. The patient’s other significant medical history is significant for an abdominoplasty, rhinoplasty, a DCR on the left eye, and a left forehead lift.
Medications: She takes no medicines.
Allergies: She has no known drug allergies.
Social History: She is a nonsmoker, occasional drinker, non drug user. She has a supportive husband and works as a stay-at-home mother.
Examination: The examination reveals that the patient is 5 feet 3 inches tall. She weighs 134 pounds. Examination of the breasts revealed macromastia bilaterally with grade II breast ptosis. Wise pattern scars are present bilaterally. The right nipple sits a little bit higher than the left, and the left breast is slightly longer than the right. No masses are palpable on examination. Nipple sensation is intact, but according to the patient, not very sensitive. She has no nipple discharge. The breast tissue itself is fibrocystic. There is a loose skin envelope present with stretch marks noted.
Assessment: Macromastia. Could benefit from the removal of 200 cc breast implant with mastopexy.
Plan: We discussed with the patient that as she feels that she is too large, our recommendation would be to remove her breast implant and do a breast lift. She does have a fair amount of her own breast tissue that is present. She would probably drop two cup sizes, if she had the breast implant removed and a lift performed; this being based on the notion that 100 cc is equivalent to a cup in a standard sized woman with a standard sized breast. We drew for her a Wise pattern mastopexy and implant removal. This would give her scars around the nipple-areolar complex down vertically to the crease and in the crease itself. We would try to make her breasts the same as much as possible, but we could not guarantee symmetry nor could we guarantee a bra cup size.
Regarding the lateral fullness that she feels, this is, we believe, from her breast tissue and not from her implant. This could be improved slightly from narrowing of the breasts but could not be guaranteed to be completely resolved, as she does have natural breast tissue, which has natural movement. We discussed the risks of sensory changes, nipple necrosis, and permanent scars.
We also discussed that the shape of her breasts will be different without an implant. We showed her pictures of patients that have augmented breasts and patients with natural breasts who have undergone surgery, and we pointed out the main difference is the lack of superior fullness with a natural breast. This is a normal natural breast appearance to have most of the fullness at the bottom of the breast, but something that she would need to get used to.
From our standpoint, it does not do her any good to have this breast implant as she feels too large. We also do not feel it would be the right choice to do a breast reduction and leave an implant behind as to us this is counterintuitive and fraught with higher risk of complications in our opinion. The patient and I discussed that she always could have a breast implant placed again, if for some reason she was dissatisfied with this, but I think that this would be better for her in terms of being able to find bras that fit, clothes that fit, and be more proportional.
I also believe that this would give her the least maintenance required going forward because with an implant, she still will need to do some maintenance procedures in the future. The patient and I discussed that this is an operation that would take about three hours to perform under anesthesia. A drain may or may not be used, which would be removed the next day.
We discussed the risks of pain, infection, bleeding, damage to the neighboring structures, need for further operation, DVT, PE, as well as the other risks previously discussed. The patient also asked a lot about some submental fullness. I suggest she just treat that with weight loss. We also discussed that she should be at her goal weight prior to undergoing breast reduction, and if she were to gain weight or undergo menopause, it is possible her breast could increase in size again. While I cannot guarantee her that this operation will fulfill all of her goals, it would make her have a smaller breast more proportional for her, which I think is something that she would feel good with. The patient will meet with (XX) today to discuss scheduling.