The Life Changing Magic of Breast Reduction

Dr. Houssock (00:04):
You are listening to another episode of Perfectly Imperfect. Hi Val.

Val (00:10):
Hi Dr. Houssock. How are you?

Dr. Houssock (00:12):
I'm wonderful. Welcome to the Perfectly Imperfect podcast.

Val (00:15):
Thanks for having me. I am really excited about this topic.

Dr. Houssock (00:19):
I feel like we say that every time and people don't believe us, but it's the truth. We are excited.

Val (00:25):
This is also my favorite surgery that we do.

Dr. Houssock (00:29):
What are we talking about today?

Val (00:31):
Breast reductions.

Dr. Houssock (00:33):
Yes, so gosh, good, good topic. So very often people confuse breast reduction with breast reconstruction, and so very often patients think that it will be an insurance-based procedure. And so sometimes they don't even think about us first. So today we're going to kind of talk about that and why it may be us, it may not be us, but ultimately we love this procedure, it's true. And Val, and I would say that it's probably one of the most functional surgeries we do, meaning that patients legitimately wake up more comfortable than how they were when they went to sleep.

Val (01:14):
100%. I love walking into recovery and they're with Alina and they're sitting up and I ask 'em how they're feeling and they're like, I already feel like a weight's lifted off my shoulders. And a lot of times actually get tearful, but just because they've been living like this for so long and they already feel a difference and it's very rewarding. That's why I love this surgery.

Dr. Houssock (01:34):
So breast reduction patients will come in and they will talk to us about how they are just tired of carrying breasts around this big breasts around. And sometimes I feel like they're almost, I won't say embarrassed, but they feel like they need to legitimize it.

Val (01:55):
Definitely.

Dr. Houssock (01:56):
Like, I've always had big breasts and I'm just tired of them and I'm just tired of wearing them. They hurt and they're difficult to work with, my outfits don't fit, and they feel like they need to justify it. And that is completely different than our patient population who comes in smaller and says, I just want to be bigger. I want to fit an outfit, whatever. There's just something funny about feeling like if God has blessed you with a big breast that you are, it's just terrible that you want to make them smaller. And I always think that's funny.

(02:29):
It really is kind of like everyone, and oftentimes they'll say, yeah, my husband loves them, but I'm sick of 'em. And so long story short, there's no real right or natural breast size.

Val (02:42):
So true.

Dr. Houssock (02:44):
Some women want to be big, some women want to be small, some women want kind of in the middle, and that's what we're here for. So first of all, we aren't judging anyone. We don't care If you want to be bigger, you could have a double D or a triple D and now want to be bigger and whatever. If we could do it for you, baby, we're going to do it for you. So we don't mind that. But I will say that the patient population that comes in and has been big breasted or has developed big breasts over their lifetime are coming in. Yes, because they want to look a certain way, but most of the time it's symptoms, right?

Val (03:20):
Yeah. They just functionally they want to improve that.

Dr. Houssock (03:24):
What do they talk to you about when you talk to them pre-op? What kind of things do they complain about or are excited about when it comes to having a reduction?

Val (03:31):
Definitely fitting better in their clothes for sure, and just improving their posture, helping with back pain, neck pain, being able to be more active. A lot of them say that their breasts hinder that because they're in the way, but I will say it's just mostly just feeling more comfortable in their own body. That's the biggest thing is what I hear them say and that they're just excited to, I feel like these patients have the best mindset going into surgery too, because they're like, I'm going to come out of this feeling more like myself, for sure.

Dr. Houssock (04:04):
Yeah, and it's so interesting because it allows patients to do activities that they may be really being having to put off because of it. And it transcends age groups. I've done patients as young as a minor. I've done a breast reduction in someone who's under 18, and I've done breast reductions in women in their sixties. And the reason why there is that huge wide gap is because some women are born with big breasts and they've had big breasts since they were that young, and some women have had them for their whole life and then are tired of it and want to get them taken care of later in life. But then there are patients who just developed them through pregnancy or weight gain or whatever it is. And so there's no age group. Now, I will tell you that in some ways I think that the younger population are the ones that might be more affected and why we talk about, yes, it's okay to do a minor when it comes to a breast reduction, it is ethically okay to do a breast reduction on someone that young.

(05:08):
And the reason for that is in the right patient, somebody who is mature, they come with their guardian and they understand the risks of having a breast reduction, but also at this point in their life, they're not participating in certain things. The women who I've done who have been in minors under 18 will not work out. They do not go to the gym. They will not even go to gym class. They can't, they're very embarrassed. They cover themselves at school. They feel very insecure because of their large breasts. And so in the right situation, a minor can be appropriately treated with a breast reduction. Now that patient population specifically or really the you get it, you get it done. The higher risk that unfortunately the breasts can return, you can still develop more breast tissue. You're also at that age going to go through a lot of different changes in life.

(06:10):
And so through pregnancy delivery, weight gain, really, quite frankly, puberty and then eventually through menopause, your breasts are going to change. And so we always counsel the younger patients that there is a very high risk that they'll be back to get this done. Again, this is not necessarily a one and done, we just have to know that the older you get the lower risk, you'll need it again, but it still can happen late in life. More recently, I've had a significant amount of women who have been in their forties and fifties who then just recently in perimenopause started developing large breasts.

(06:52):
So I mean it could be anybody. And then that really, it gets even more complicated because what is the breast tissue? Is it dense breast tissue? You would expect when patients are younger or is some people will gain weight and when they gain weight, they gain it in their breast. And so it's fattier tissue and it all can be reduced, but your tissue could be from many different factors. It's not just hormones. It can be from weight gain, it can be from a lot of different things. So depending on that will depend on your risk in my mind of whether it will come back. If you've got a lot of dense breast tissue, I mean hormones are hormones, you can certainly redevelop breast tissue. If it's fat and you are healthy and you don't put on a lot of significant extra weight, then there's probably less likelihood that your breast will come back to that level.

(07:43):
And so when we talk about that function, we are talking about the volume, but that volume can be very weighty and heavy, but also where that heaviness is sitting on your body can also ergonomically affect how your breasts feel. So if your breasts are sitting high on your chest, generally speaking, that is where our body is meant to carry our breasts. And so if they're sitting up in the right position, they can be heavy, but it's not as cumbersome as those who have overtime dropped. And when the weight is now sitting at the lower rib cage, the effect on the back is pretty significant where you can feel where it's being pregnant, having that forward kind of feel all the time on your back. So yes, they can be heavy and sit high, but there is something even more definitively uncomfortable about a breast that's sitting low. So when we do that breast reduction, people say, is it a lift or is it a reduction? Well, it's both because if you are going to put your breasts back in the right position, not only are you taking weight off, you're also making them feel more ergonomically appropriate.

Val (08:56):
When you do the lift part, are you also relocating the nipples as well too?

Dr. Houssock (09:01):
Yeah, I mean, nine times out of 10 when you measure from right where your collarbone is down to the nipple, there's a certain number that that should be at, that's an average. It's somewhere between 19 and 21 centimeters of a length. And so there's a lot of different ways that as a surgeon, we determine where your nipple should be, the inframammary fold, that little crease technically speaking, that's underneath there is where your nipple should be about equal to that. But long story short, some of it's just art and we look at you, but yes, there is a difference in where your nipple should be most of the time. So we do move the nipple. People think that we pull it off and stick it back on. Now, that is a thing that's called a free nipple graft. And I will tell you that we are taught in training that there is a certain breast that might require that, but I have been in practice for almost eight years now, and I have not had to do that. So I would say most of the time, nine times out of 10, the nipple stays attached to your body, but when I reconstruct it and bring everything back up and remove some breast tissue, the nipple stays attached to you and attached to your blood supply. So while we do lift it up, it's never left your body.

Val (10:13):
Right now we're just making a new opening for it. Like a new window.

Dr. Houssock (10:16):
Yes, a new window, a new window.

Val (10:19):
Cuz we reconstructed the house, so then we open up a little opening to let it come through.

Dr. Houssock (10:24):
Yeah, exactly. So that's the big thing. And how much we take, it depends. Val and I are in the OR together, and we talk about this all the time. We talk to patients, patients will say, well, what size will I be? Right Val?

Val (10:39):
All the time.

Dr. Houssock (10:40):
All the time.

Val (10:41):
And with this it's like, yes, we want to make you a small as possible, but it's also got to be safe because you take too much, then you're disrupting the blood supply.

Dr. Houssock (10:49):
Correct.

Val (10:50):
And so that patients don't realize that, yeah, we can definitely make you small, but we need to leave some back. That way your nipples are going to live and everything's going to recover well.

Dr. Houssock (11:02):
Yeah. And really that's where our consults, none of our consults here are quick. We really take our time. And when it comes to what you're looking for, it's hard because I can't tell you exactly what you'll be, but I always say, what are you looking for? And some women say, listen, I've always been big breasted and my frame will hold a breast, so I don't want to be too small. And so that helps me because then I know, all right, well we're still looking for a nice full breast, and that's great and that's fine. And then we'll have a population who will say, actually, I want you to get me as small as I can, and so we'll take whatever we can, but also respecting that blood supply for the nipple, like Val said. And so pictures help us, the conversation in consultation helps us, but ultimately we never can promise you a cup size, right, Val?

Val (11:51):
No. It's really too hard to determine exactly what cup size you're going to be, and you also need to leave some back so that way that the breast has a shape to it too.

Dr. Houssock (12:01):
Right, exactly.

Val (12:02):
So having that upper poll fullness to give them some cleavage and give them more of a perky look if they're looking for that, of course. But it's really, you just can't go to town and take everything completely.

Dr. Houssock (12:14):
Totally, totally. And so that kind of goes back to taking everything totally, or how much to take. And that kind of goes back to this idea of this being functional, but also

Val (12:24):
Absolutely.

Dr. Houssock (12:24):
patients will ask if there's an assumption that maybe insurance will cover it. So that's tough because the answer to that when people ask I always say is maybe, so Val and I have been in practice long enough to know that there's a certain size that if you have macromastia, you have massive breast, there is a chance insurance might cover it, but not necessarily, right. It's really based on your BMI and every insurance company has their own algorithm and each algorithm is based on your weight and the weight that is taken off in surgery, meaning that they want pathology to weigh your breast tissue that has been removed and they have a certain minimum that must be is required to be taken off of you based on your BMI to determine whether or not they will cover it.

(13:13):
And what's very difficult about that algorithm is that even if the surgeon knows what the amount is, we can't promise you that we can take that amount off and give you the look that you're looking for. You may require more extensive removal to get covered than you aesthetically want. And so it's not a straightforward answer. And so while Val and I work in a practice that does not take insurance, I always encourage if patients are hoping for that, they can always see one of my colleagues who does take insurance and see what their thoughts are. But I will tell you, unfortunately, the vast majority of breast reductions that we see would not beed under insurance.

Val (13:54):
Yeah, absolutely.

Dr. Houssock (13:56):
And what I normally tell patients is, if you want to come to us and you want, you're interested in potentially being covered, the way that you would work in an aesthetic practice is we would do your procedure and then you could submit to your insurance and they may or may not refund you or some of the surgical fee, and there's just no way to know.

Val (14:19):
Also, adding to that, you also want to check with your insurance company to see what their out-of-network benefits are because you really want to let the insurance company know I'm considering an out-of-network surgeon, what are my benefits? What's the paperwork you're looking for and all that. So definitely always double check your out-of-network benefits before.

Dr. Houssock (14:40):
And even that little tidbit is more than most of us know here in the practice. So I'll be completely honest with you that because we do not deal with insurance, we don't have the capacity to help you with all of that. So the best we can do for you is we can provide you with your operative note, any of your information that you have that we can provide that for you. But we don't work hand in hand with insurance companies. So while I do unfortunately think that most will not be covered, I always encourage if you're interested in making sure that that's not the case, because who wouldn't want to make sure that you couldn't potentially get something like that covered with another surgeon? You can always get another opinion, and I have people who I'm happy to send you to and it's no hard feelings, believe me, I understand that these are expensive procedures and if you have the potential of getting it covered, you should. So that is always an option. And I always also will tell you, if I think you're on the border, I'll let you know. If I'm like, girl, you're not going to be covered, you don't have enough, I'll let you know that too. We'll be honest about that.

Val (15:46):
Absolutely.

Dr. Houssock (15:46):
So ultimately you have the reduction and then what happens? Talk to everybody about what we tell them for their aftercare.

Val (15:55):
So for aftercare, we definitely like to keep you in your surgical bra for at least 48 hours. And then after that, that's when they can take their first shower. The biggest thing really is no aerobic activity and heavy lifting for at least four to six weeks. If you're healing well, looking good, Dr. Houssock might clear you at that four week mark, but most of the time it's somewhere up to six weeks. Also, depending on how much breast tissue we took off too. So if you had a pretty extensive breast reduction, that also can hinder recovery time as well too. But the biggest thing you know is wearing that surgical bra just to get that compression and also that support. It feels good having it after that way they're in place. And it could really help with swelling and discomfort as well too. So that surgical bra is going to be your best friend and it's really all about time and letting your body heal.

(16:44):
And I always tell my patients overall, the majority of healing is the first four to six weeks, but I would say around three months they're still settling for sure. So it's all about time and letting them settle and just being patient with them. But majority of them do feel an immediate difference during those first couple of weeks, once the swelling's starting to go down as far as their back pain, their neck pain getting better, even their clothes fitting differently too. So that's the biggest thing is just giving it some time for sure. And then just making sure you're taking care of your incisions, the better you take care of them, keep them nice and clean, they're going to heal so well. I know everyone's scars differently and scars are the angriest the first couple months, but by a year they really fade nicely. They really do because your body goes to that remodeling stage and if you use the right topical things on them as well as silicone strips or creams or anything like that, that also can really help a ton too. So it's just making sure that you're prepared for afterwards and just listening to the, instructions.

Dr. Houssock (17:49):
Yeah.

Val (17:50):
But patients do really well. I mean, they really do.

Dr. Houssock (17:52):
It really seems like, you think this would be a huge surgery with a lot of pain, but it just is not, it just isn't very well tolerated.

Val (17:58):
It's mostly skin.

Dr. Houssock (17:58):
Yeah, yeah, totally. It's mostly skin and then future stuff. As far as limitations, there's not a whole lot to it. Yes, you can have another one in the future if you have to have one, you can. Let's say, gosh, we've seen it, people will then lose significant weight and then maybe they want to breast augmentation, which it happens. It sounds crazy, but it happens and you could have that happen. The one thing we do educate patients who are still within child rearing age is about breastfeeding. There is a risk that you could potentially disrupt the ducks around the nipple and be unable or have difficulty breastfeeding. That being said, it's not a hundred percent. I think Val will be comfortable talking that she's been able to, and she had a lift, and that's similar incisions.

(18:42):
So it doesn't mean that you will have that problem, but the problem is most women who are coming in and are having a reduction or a lift in child rearing years, they don't know if they're going to be breastfeeders. And about 30% of women have difficulty breastfeeding at baseline. So I just educate, it's potentially going to create a problem for you, but it's not a hundred percent. So just important to know that because in the future, if you decide you really want to breastfeed that this could affect that. Finally, before we sign off, I just wanted to, because I said breast lift, what's the difference between a breast reduction and a breast lift? I would say they're about the same, however, meaning the incisions are about the same, but the amount of breast tissue we take is different with a lift. Really, it's like a time continuum. A formal lift is just taking skin to get you perky, a reduction is, taking skin and fat, and in between oftentimes there's something else. And so we can do, based on what the patient's looking for, and again, you have to rely on a little bit of my artistic ability to see you in the OR, we may take just skin, a lot of breast tissue or some breast tissue. And it just depends on what you want and also what your anatomy has. Right?

Val (19:59):
So true. Definitely.

Dr. Houssock (19:59):
You were a breast lift during your augmentation right Val?

Val (20:03):
So I was in an aug lift, so I had implants put in and then the surgeon lifted around the implant.

Dr. Houssock (20:09):
Yes.

Val (20:10):
So I really wanted that upper pole fullness. I wanted more cleavage, I didn't really have any, and I also wanted my nipples lifted up a little bit more. So with having that implant, she didn't have to lift me as much because the implant did lift me a little bit, but I did have a little bit of ptosis that needed to be resolved, and so I decided to do that knowing that yes, there was a risk that in the future I might not be able to breastfeed and thank God I did. So

Dr. Houssock (20:35):
Yeah, no problem.

Val (20:36):
It was great. It was great. And now that I've done breastfeeding, I will say the implants I think helped me a little, kinda keep me up with that lift, but know that this is not going to be my only surgery. I know that in the future I'll need to do something else with it. We'll, cross that bridge.

Dr. Houssock (20:53):
Yeah, there's always something. There's always something to be done.

Val (20:57):
Yeah. But I'm happy.

Dr. Houssock (20:57):
Our body are going to change. Things aren't forever, so it's just none of the surgeries that we do, especially to the breasts, do I ever say that this is the one time you're going to see me for the most part?

Val (21:08):
Nope.

Dr. Houssock (21:09):
There's a good chance at some point in your life, you'll see me because your body's going to change, so.

Val (21:12):
Exactly. We're here when you're ready.

Dr. Houssock (21:14):
Yeah. Alright, Val, love you. Carry on.

Val (21:19):
Love you. Thank you for having me, Dr. Houssock. Carry on.

Dr. Houssock (21:21):
Perfectly Imperfect is the authentically human podcast navigating the realities of aesthetic medicine. JEV Plastic Surgery is located in Owings Mills, Maryland. To learn more about us, go to JEVplasticsurgery.com or follow us on Instagram @DRCareHoussock, spelled D-R-C-A-R-E-H-O-U-S-S-O-C-K, or just look in the show notes for links. If you enjoyed this episode, please share it and subscribe to Perfectly Imperfect on YouTube, Apple Podcasts, Spotify, or wherever you'd like to listen to podcasts.