Women with very large, pendulous breasts may experience a variety of medical problems caused by the excessive weight - from back and neck pain and skin irritation to skeletal deformities and breathing problems. Bra straps may leave indentations in their shoulders. And unusually large breasts can make a woman - or a teenage girl - feel extremely self-conscious.

Breast reduction, technically known as reduction mammaplasty, is designed for such women. The procedure removes fat, glandular tissue, and skin from the breasts, making them smaller, lighter, and firmer. It can also reduce the size of the areola, the darker skin surrounding the nipple. The goal is to give the woman smaller, better-shaped breasts in proportion with the rest of her body.

If you're considering breast reduction, this will give you a basic understanding of the procedure - when it can help, how it's performed, and what results you can expect. It can't answer all of your questions, since a lot depends on your individual circumstances. Please ask Dr. Freedland if there is anything about the procedure you do not understand.

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Breast reduction is usually performed for physical relief rather than simply cosmetic improvement. Most women have the surgery because very large, sagging breasts that restrict their activities and cause them physical discomfort trouble them.

In most cases, breast reduction isn't performed until a woman's breasts are fully developed; however, it can be done earlier if large breasts are causing serious physical discomfort. The best candidates are those who are mature enough to fully understand the procedure and have realistic expectations about the results.

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Thousands of these procedures are performed successfully each year. When done by a qualified plastic surgeon, the results are generally quite positive. Nevertheless, there are always risks associated with surgery and specific complications associated with this procedure.

Post-operative complications such as infection and blood clots are rare, but can occur. Infection can be treated with drainage and antibiotics, but will prolong your hospital stay. You can minimize the risk of blood clots by moving around as soon after the surgery as possible.

Poor healing, which results in conspicuous scars, may necessitate a second operation. Smokers should be advised to stop, as smoking may increase the risk of complications and delay healing. Often there is temporary loss of sensation, which may last up to a year after surgery.

You can reduce your risk of complications by closely following Dr. Freedland's instructions before and after the surgery, especially with regard to when and how you should resume physical activity.

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In your initial consultation, it's important to discuss your expectations frankly with Dr. Freedland, and to listen to his opinion. Every patient and every physician, as well has a different view of what is a desirable size and shape for breasts. He invites you to view Before and After photos of his patients.

Dr. Freedland will examine and measure your breasts, and will probably photograph them for reference during surgery and afterwards (the photographs may also be used in the processing of your insurance coverage). He will discuss the variables that may affect the procedure - such as your age, the size and shape of your breasts, and the condition of your skin. You should also discuss where the nipple and areola will be positioned; they'll be moved higher during the procedure, and should be approximately even with the crease beneath your breasts.

Dr. Freedland will describe the procedure in detail, explaining its risks and limitations and making sure you understand the scarring that will result. He will also explain the anesthesia he will use, the facility where the surgery will be performed, and the costs (some insurance companies will pay for breast reduction if it's medically necessary; however, they may require that a certain amount of breast tissue be removed. Check your policy, and have Dr. Freedland write a "predetermination letter" if required).

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Individuals considering breast reduction often feel a bit overwhelmed by the number of options and techniques being promoted today. However, Dr. Freedland can help. In deciding which is the right treatment approach for you, Dr. Freedland will consider effectiveness, safety, cost and appropriateness for your needs. This is called surgical judgment, a skill that is developed through surgical training and experience. Dr. Freedland also uses this judgment to prevent complications; to handle unexpected occurrences during surgery; and to treat complications when they occur.

Dr. Freedland's education and training, which he received at the University of Michigan, has helped to form his surgical judgment. Patients are encouraged to consider a doctor certified by the American Board of Plastic Surgery ("ABPS"). By choosing a plastic surgeon who is certified by the ABPS, a patient can be assured that the doctor has graduated from an accredited medical school and completed at least five years of additional residency - usually three years of general surgery (or its equivalent) and two years of plastic surgery. To be certified by the ABPS, a doctor must also practice surgery for two years and pass comprehensive written and oral exams.

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Dr. Freedland will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding vitamins, iron tablets and certain medications. If you develop a cold or an infection of any kind, especially a skin infection, Dr. Freedland may have to postpone your surgery.

If you smoke, plan to quit at least two weeks before your surgery and not to resume for at least two weeks after your surgery. Avoid overexposure to the sun before surgery and do not go on a stringent diet, as both can inhibit your ability to heal. Though it is rarely necessary, Dr. Freedland may recommend that you have blood drawn ahead of time in case it is needed during surgery.

Whether your surgery is done on an outpatient or inpatient basis, you should arrange for someone to drive you home after your surgery, and to help you out for a day or two after you leave the hospital, if needed.

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Breast reduction surgery may be performed in a hospital, an outpatient surgery center or an office-based surgical suite. Dr. Freedland feels a hospital provides the safest environment for your surgery and therefore performs almost all of his procedures at a JCAHO accredited hospital. If you are admitted to the hospital, your stay will be a short one. The surgery itself usually takes two to three hours, but may take longer in some cases.

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Breast reduction is nearly always performed under general anesthesia. You'll be asleep through the entire operation.

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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 surgeon removes excess glandular tissue, fat, and skin, and moves the nipple and areola into their new position. He or she then brings the skin from both sides of the breast down and around the areola, shaping the new contour of the breast. 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 areolar tissue).

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.

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After surgery, you'll be wrapped in an elastic bandage or a surgical bra over gauze dressings. A small tube is occasionally placed in each breast to drain off blood and fluids for the first day or two.

You may feel some pain for the first couple of days - especially when you move around or cough - and some discomfort for a week or more. Dr. Freedland will prescribe medication to lessen the pain.

The bandages will be removed a day or two after surgery, though you'll continue wearing the surgical bra around the clock for several weeks, until the swelling and bruising subside. Your stitches will be removed in one to three weeks.

If your breast skin is very dry following surgery, you can apply a moisturizer several times a day, but be sure to keep the suture area dry.

Your first menstruation following surgery may cause your breasts to swell and hurt. You may also experience random, shooting pains for a few months. You can expect some loss of feeling in your nipples and breast skin, caused by the swelling after surgery. This usually fades over the next six weeks or so. In some patients, however, it may last a year or more, and occasionally it may be permanent.

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Although you may be up and about in a day or two, your breasts may still ache occasionally for a couple of weeks. You should avoid lifting or pushing anything heavy for three or four weeks.

Dr. Freedland will give you detailed instructions for resuming your normal activities. Most women can return to work (if it's not too strenuous) and social activities in about two weeks. But you'll have much less stamina for several weeks, and should limit your exercises to stretching, bending, and swimming until your energy level returns. You'll also need a good athletic bra for support.

You may be instructed to avoid sex for a week or more, since sexual arousal can cause your incisions to swell, and to avoid anything but gentle contact with your breasts for about six weeks.

A small amount of fluid draining from your surgical wound, or some crusting, is normal. If you have any unusual symptoms, such as bleeding or severe pain, don't hesitate to call Dr. Freedland. Dr. Freedland can instruct you on skin care products that can help make your scars less visible.

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Although much of the swelling and bruising will disappear in the first few weeks, it may be six months to a year before your breasts settle into their new shape. Even then, their shape may fluctuate in response to your hormonal shifts, weight changes, and pregnancy.

Dr. Freedland 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.

Of all plastic surgery procedures, breast reduction results in the quickest body-image changes. You'll be rid of the physical discomfort of large breasts, your body will look better proportioned, and clothes will fit you better.

However, as much as you may have desired these changes, you'll need time to adjust to your new image - as will your family and friends. Be patient with yourself, and with them. Keep in mind why you had this surgery, and chances are that, like most women, you'll be pleased with the results.

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