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Archive for the ‘breast reduction’ Category

Case Study – Older Maximum Breast Reduction

Monday, June 19th, 2017


Background: Reduction of large breasts is one of the most common body contouring procedures in plastic surgery. It has been around in various forms for almost one hundred years. It is a uniformly successful procedure for reducing the back, neck and shoulder pain that typically accompanies large sagging breasts as well as positioning the breasts back up on the chest wall.

By the way it is designed every breast reduction procedure is also a breast lift. While a breast lift can be done without a breast reduction, the reverse is not true. A reduced amount of breast tissue means that the skin that contains it also must be less. The markings made on the skin before surgery is the breast lift part and is a very mathematical and precise part of the procedure. The reduction of the breast tissue is internal and is much more of an artistic technique rather than one that lies on measurements of angles and linear distances.

Breast reduction in older mature women. often has a slightly different flair to it. Women that have had large breasts all their life, and who have finally come to the point of wanting them smaller, usually want a more aggressive reduction. The need for symptomatic paint relief and the desire to look less matronly mandate that larger amounts of breast tissue be removed.

Case Study: This 65 year-old female had large breasts her whole life. (DD + cup size) She had three children and her breasts always ended up looking about the same afterwards albeit a bit more droopy. She was ‘over’ having large breasts and wanted the freedom in its clothing and exercise to have more freedom of choice.

Under general anesthesia an inferior pedicle breast reduction was performed with the removal of approximately 800 grams per side. Her nipple-arolear complex was raised 9 cms from a 30 cm length from the sternal notch to the nipple to a 21 cm length.

Older women are almost always more concerned about having a ‘maximal’ reduction procedure on their breasts than they are about having a fuller lifted shape. As  long as they sit much higher up on they chest wall with a more centered nipple with a low volume, they will enjoy the benefits of less to no musculoskeletal discomfort and the freedom should they so choose to even go without a bra.


  1. Breast reduction in older women is often a ‘maximum’ reduction and lift procedure.
  2. Getting reduced breast tissue back up on the chest wall is ultimately what causes a reduction in musculoskeletal symptoms.
  3. The inferior pedicle breast reduction technique offer a reliable and safe method for larger breast size reductions.

Dr. Barry Eppley

Indianapolis, Indiana

Shoulder Groove Fat Grafting in Breast Reduction Surgery

Tuesday, January 17th, 2017


Breast reduction is a combination reconstructive and aesthetic body contouring procedure. It relieves the musculoskeletal symptoms from large hanging breasts as well as lifts and reshapes it higher up on the chest wall. While it does so a the expense of anchor-pattern scars of some length, it is a tremendously effective operation for the large breasted woman.

One of the classic physical signs of breasts that are too heavy for one’s body frame is the presence of shoulder grooves. These occur from the compression of the bra straps on the skin from the weight of the breasts in a bra. Shoulder grooves occur partially from fat atrophy from the constant compression of the bra straps compressing it down on the muscle. They can occur as quite striking and deep on some patients, particularly those with very large breasts.

An interesting question is whether shoulder grooves resolve/go away after a breast reduction. In theory they should go away as the weight of the breasts is relieved on the supporting bra straps. There are, however, no studies which have ever evaluated the resolution of these after breast reduction surgery. Since their presence partly occurs from fat atrophy one could presume that they will persist even after a successful reduction and lift of the breasts.

Fat Grafting Shoulder Grooves at time of Breast Reduction Dr Barry Eppley IndianapolisA treatment for shoulder grooving at the time of breast reduction surgery is fat grafting. Fat harvested from the abdomen can be used to inject into the shoulder grooves. These are beneficial in the deepest of shoulder grooves. It usually takes 20cc to 30cc of concentrated fat into each shoulder groove.

Fat Grafting Shoulder Grooves Breast Reduction Dr Barry Eppley IndianapolisInitial fat take is fairly good and many will show good persistence out at six months after surgery. While the pressure of a bra strap is never completely negated and is certainly not a favorable feature for fat graft persistence, it does not appear to have a completely adverse effect on fat grafting to the shoulder grooves.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Reduction with Breast Lift

Sunday, July 12th, 2015


Background: Breast reduction persists as one of the most common of all body plastic surgery procedures. Breasts that are too large  and heavy are common and ultimately the back shoulder and neck pain that they create is best relieved by making the breasts smaller and more uplifted. The improvement is musculoskeletal symptoms is as much the  result of the lift as it is from the volume of breast tissue removed…contrary to popular perception.

Many patients ask whether there is a lift that is done with the breast reduction or whether the breast reduction leaves the breasts smaller but still hanging. When looking at the design of how a breast reduction is done, the marked skin pattern that is drawn on the breasts represents the lift that will result. Thus a breast reduction can not be done without a breast lift but a breast lift can be done without a breast reduction.

Case Study: This 44 year-old male had always had large breasts since she was a teenager. But with getting older and having children her breasts actually became somewhat larger but had fallen and gotten very heavy. They were now so large that she was embarrassed to wear a swimsuit and would not do any water sports which her family loved to do.

Large Breast Reduction results front viewLarge Breast Reduction result oblique viewUnder general anesthesia, an inferior pedicle breast reduction was performed. The amount of breast tissue removed was 450 grams per side. The amount of skin removal and tightening exceeded visually the amount of breast tissue removed. The areoalas were reduced in diameter from 65 mms to 40 mms in diamater.

Large Breast Reduction result side view Dr Barry Eppley IndianapolisHer postoperative results showed much smaller and more uplifted breasts. She was thrilled with the result as she felt more comfortable with her breast size and could now resume all water sport activities with her family. Like all breast reductions and/or full breast lifts the scar burden is significant but well worth the tradeoff for the psychological and pain relief benefits.


1) Every breast reduction is a breast lift also. Thee relief of musculoskeletal symptoms is a result of a combination of both effects.

2) Breast reduction produces a fair amount of breast scarring but is usually viewed as a worthwhile tradeoff.

3) Nipple sensation preservation through retained attachment and mound relocation is usually successful.

Dr. Barry Eppley

Indianapolis, Indiana

GalaFLEX Mesh Use In Breast Lift Surgery

Saturday, December 27th, 2014


Early Breast Lift results Dr. Barry Eppley IndianapolisBreast lift surgery has been around for almost a hundred years in a variety of different excisional patterns based on the amount of breast sagging. While the initial breast lift results can be very satisfying, many long-term results have lost some of that early luster. This is caused by the so called ‘bottoming out’ effect due to loss of tissue support from the lower pole of the breast. What holds up the breast tissue is the skin envelope which is very prone to stretching on the lower half of the breast. This can allow the breast mound to relax or fall over the lower lower breast fold. This always results in loss of upper pole fullness which will mar any long-term breast lift result.

Adding support to the lower pole of the breasts during a breast lift procedure has been done with a wide variety of methods. These have included autologous methods using sutures to resuspend and support the lifted breast mound as well as repositioning/reshaping the breast mound itself. A number of mesh or slings of various materials have also been used, most recently allogeneic dermis (e.g., Alloderm) and synthetic fibers. (e.g., Siri) All have been associated with a variety of successes and also complications. (e.g, infection) The perfect breast lift material/method remains to be developed and/or determined.

Galaflex Mesh in Breast Lifts Dr Barry Eppley IndianapolisGalaflex Mesh Indianapolis Dr Barry Eppley Plastic SurgeryGalaFLEX mesh is the newest material that has become available for use in breast lift surgery. It is an FDA-approved material for soft tissue reinforcement. While synthetic meshes are not new, GalaFLEX is unique because it is completely resorbable. It is a knitted mesh that is composed of P4HB (poly-4-hydroxybutyrate) which is a synthetic polymer that is broken down by hydrolysis (water absorption) and eliminated as natural breakdown products of carbon dioxide and water over a time period of 12 to 18 months after implantation. But as it is resorbed it is replaced by collagen ingrowth that has been demonstrated to persist as a supporting scaffold long after the material has been absorbed. This has been reported to make the lower breast pole tissues up to 4 to 5 times stronger than they were before surgery.

GalaFLEX is currently available in typical mesh configurations which must be cut and shaped to provide the desired lower pole sling effect. Once shaped it is sutured into position onto the chest wall and acts like a cradle to support the lifted breast tissue. But new GalaFLEX shapes specifically for breast lift and/or breast reduction surgery are being developed that will make it more of an ‘out-of-the-box’ device that requires minimal manipulation of the material for proper placement.

The concept of adding support to maintain upper pole fullness and prevent/reduce secondary breast sagging has long been recognized as being needed for some breast lift patients. This support is always done the easiest by adding a graft or implant to achieve it. Whether GalaFLEX is the best choice out of all our current material options will ultimately be determined by the proverbial test of time.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Healing and Scars From Breast Reduction Surgery

Friday, September 19th, 2014


Background: The treatment of large breasts has been done for almost one hundred years with a variety of surgical techniques. Despite the many techniques that have been used to create a smaller breast, the one that has stood the test of time is the inferior pedicle method. Also known as the Wise pattern (as the skin excision pattern looks like a W), this method provides a real three-dimensional skin and breast tissue reduction with a significant breast lift.

Wise Pattern Breast Reduction Dr Barry Eppley IndianapolisWhile effective, it is not a perfect operation as it results in substantial scars. Fortunately most of these scars lie in favorable breast locations such as around the areola and across the inframammary fold. Only the vertical limb between the areola and the lower fold is in an unnatural skin location when it comes to resisting the forces of tension on it. But it does lie on the lower pole of the breast which is not a highly visible location from a woman’s perspective of her own breasts.

Case Study: This 35 year-old female had DD cup breasts that were problematic from both a clothes and musculoskeletal standpoint. She had back, shoulder and neck pain with shoulder grooving. She had always wanted smaller breasts since she was a teenager but waited until she was done with having children.

Breast Reduction early result front view Dr Barry Eppley IndianapolisBreast Reduction early result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, an inferior pedicle breast reduction was performed removing 655 grams of tissue from each breast. All sutures were placed under the skin and no drains were used. This was a three hour operation done as an outpatient.

Breast Reduction early result side view Dr Barry Eppley IndianapolisHer recovery took about ten days to remove to work but her incisions took much longer to heal. She developed about three weeks after surgery small opening at the inverted T areas (junction of vertical and horizontal incisions) that spread open to about the size of a dime on one breast and a nickel on the other. These openings took almost one month thereafter to granulate in and heal.

There are two expected events that occur in breast reduction, extensive scars and time to heal them. One has to certain that the benefits of making breasts smaller are worth the scar trade-off to do so. There is also the time needed to reach optimal scar appearance which is at least six months and could be as long as a year after surgery. Also such extensive incisions will result in wound healing problems, albeit often minor, that will take longer to completely heal than most women anticipate.

Case Highlights:

1) Breast reduction is a highly effective breast reshaping procedure but does so at the expense of scars.

2) Significant breast reduction requires the classic anchor or invert T pattern scars that enables a complete three-dimensional beast change.

3) The scars from breast reduction will often take up to 8 weeks after surgery to completely heal and up to one year for complete scar maturation.

Dr. Barry Eppley

Indianapolis, Indiana

Patient Testimonials: Tummy Tuck and Breast Reduction (Mommy Makeover)

Monday, September 30th, 2013

 The Mommy Makeover – Tummy Tuck and Breast Reshaping (Reduction)

I couldn’t remember if I sent you guys an after surgery picture. I just wanted to thank you guys again for all your help with the tummy tuck and breast reduction. I’ve been exercising 2 hours a days and eating right. I am not quite where I am want to be yet but I am getting a lot closer!


Indianapolis, Indiana


Tummy tuck surgery done with liposuction can produce some dramatic body change by the sheer amount of skin and fat tissue removed. But when tummy tucks are combined with a lot of personal effort after the surgery, the results can be even more strikingly dramatic. Patients who take advantage of the catabolic effects of wound healing after major body contouring surgery can really drop a lot more weight than what was ever removed during the procedure in the immediate after surgery period. But some patients take the changes that have occurred from surgery and become very motivated to do even better. A few even see it as the chance to make a total break from a body that had spun out of control for years for a multitude of reasons. This is a phenomenon I call ‘accomplishment feedback’ in which one positive change motivates one to raise the level of the obtained result even higher. While plastic surgery is a physical process, its potential effect on one’s self-image and psyche can create even greater effects. This woman’s dramatic body transformation illustrates what a powerful effect the combination of physical and mental changes can be.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Breast Lift with a Little Reduction

Sunday, July 7th, 2013

Background:  Breast reshaping surgery includes three basic manuevers, making the breast smaller (reduction), uprighting a saggy breast (lift) or adding volume.(implant vs. fat injections) They can be done alone or in almost any combination depending upon the patient’s aesthetic breast desires.

Breast reduction surgery is very common and extremely effective at not only reshaping the breasts but alleviating many of the musculoskeletal symptoms from their weight. Contrary to the concerns and perceptions of some patients, every breast reduction is also a full breast lift. It is simply not possible to do a satisfying reduction without elevating the nipple position and repositioning the breast mound  back up onto the chest wall at the same time. That is exactly why the breast is so measured and marked before surgery, that represents the pattern of skin removal to create the lift and the resultant inverted T or anchor scar pattern seen afterwards.

Conversely, breast lifts can and are often done without removing any breast tissue. If the patient’s breast volume is adequate, the excess skin is removed and tightened around the existing volume to reshape and lift the breast mound. But is some cases of breast lifts, there is a little too much volume to accomodate the amount of lifting needed. This is usually in the upper pole of the breast and it can prevent the ‘stuffing’ of the breast mound tissue into the reduced and tightened mound skin without causing undue tension on the wound closure.

Case Study: This 46 year-old female had saggy level III ptosis of her breasts that she felt were a little too big. She was not entirely displeased with their size (44 DD) but they had sagged a lot over the years after children and with age. She also had near constant pain in her back, neck and shoulders from what she thought had to be from her saggy breasts.

Right before surgery, the markings were made for an inferior pedicle type breast reduction. Under general anesthesia, the same areolar size was maintained and all skin within the keyhole pattern was de-epithelized. Skin flaps of 1 cm thickness were raised over the entire breast mound down to the pectoralis fascia. The skin flaps were wrapped around the breast mound and temporarily sutured together but it could be seen  that the closure was very tight. After taking the flaps apart, breast tissue was removed from the upper pole of 110 grams per side. The flaps were put back together, sutured closed and the nipple-areolar complex brought through a new site at the upper end of the vertical closure. Drains were not used.

Her recovery was typical for any breast reduction or lift patient. Swelling and bruising in the skin flaps persisted for just under 3 weeks after surgery. She did not have opening of the junction of the vertical and horizontal incision lines which many such patients do. Interestingly, even with very little breast reduction, her musculoskeletal pain was relieved.

Breast lift surgery can include a bit of a breast reduction if for no other reason than  to reduce the tension on the wound closure if necessary. Such reduction will not significantly reduce the final breast size.

Case Highlights:

1) Breast lifts can incorporate varying amounts of reduction (removal of breast tissue) at the same time if desired.

2) Breast reduction surgery, however, can not be performed without doing a full breast lift at the same time

3) Both breast reduction and full breast lifts use the same incisional pattern and resultant scars. (anchor pattern)

Dr. Barry Eppley

Indianapolis, Indiana

Top Plastic Surgery Searches in 2012

Tuesday, January 1st, 2013


On the final day of 2012, it is interesting to look back and see what some of the trends and interests were in plastic surgery over the past year. While plastic surgeons may perform the surgeries, the interest of patients drive the number and type of surgeries that are done. For this reason, it is noteworthy to look at what procedures were most searched for online.

The popular plastic surgery website, Real Self, reported its top searches for 2012 based on over 50 million searches. The top 10 included tummy tuck, breast implants/augmentation, rhinoplasty, Brazilian butt lift, Botox, Coolsculpting, Breast Reduction, Cellulaze and Liposuction. The procedures that had the greatest increase in interest over the past year were the Brazilian butt lift (up 28%), Cellulaze (up 32%) and labiaplasty. (up 22%)

These search results, albeit just from one source but a very reliable one, provides insight into the public’s evolving interest in face and body modifications. Three of the historically popular and still highly performed procedures, tummy tuck, breast augmentation and rhinoplasty, remain on the top of the list. Not surprisingly, flatter stomachs and more shapely waistlines, larger breasts and nose reshaping are still highly desired. While they were far from being up on % increase in searches, it would be hard to do so when you have been so popular for decades.

The popularity of the Brazilian butt lift, a procedure that was largely unknown just less than a decade ago, is a reflection of society in general. Largely an ethnic procedure for Hispanics and African-Americans, it parallels the changing population mix of the U. S.  It is also an indication of the influence of celebrities on plastic surgery. (the Kardashian effect) While buttock implants have been around for awhile, the allure of using one’s own natural fat and getting some fat reduction in other body areas as part of the procedure is undeniably appealing. The large percent increases in interest in the procedure over the past two years is primarily a result of its ‘newness’. But I would wager five or ten years from now, buttock augmentation will be a permanent member of the all-time top 10 plastic surgery procedures of any year.

Coolsculpting and Cellulaze have made their way on the list because they are new body contouring technologies. Both have been approved for use less than five and two years ago respectively and offer non-surgical methods for common concerns about fat reduction and improvement in the appearance of cellulite. Whether they will be on the top ten list a few years from now will depend on how effective they turn out to be in widespread use.

Botox, one of the few drugs used for aesthetic changes, keeps it place in the top ten list and may well be the number one cosmetic procedure performed in the U.S. by number of treated patients. (amongst surgery and minimally invasive procedures) Despite the large number of treated patients, it is not searched as much as some of the other popular procedures largely because its effects and benefits are so well known.

Labiaplasty, reshaping of the external vagina, is gaining in popularity and public awareness. Once just done by a few gynecologists, it is becoming more widely practiced by plastic surgeons as well. As women become increasingly aware of its potential benefits, the interest in how and where it can be done is rising as well.

Dr. Barry Eppley

Indianapolis, Indiana

The Sister Concept in Cosmetic Breast Surgery

Wednesday, November 14th, 2012


Cosmetic breast surgery encompasses a wide array of procedures from the placement of implants, lifts, reductions, liposuction and fat grafting. This is not to mention another list of potential changes that can be done to the nipple-areolar complex with or without concomitant mound reshaping. But what makes breast reshaping surgery a very unique collection of procedures is that there are two paired breasts and they sit side by side. This makes comparing the surgical results of both breasts unavoidable.

Patients would like and expect near perfect symmetry in their breast surgery no matter how comparable (or not) that they were before. But the reality is that few breast surgeries result in ideal symmetry between the paired structures no matter how well executed the surgery is. Tissues mend, scars mature and breast skin relaxes differently as they heal. Even though the breasts are still next to each other in plain view during surgery and the exact same procedure may have been done to both (e.g., breast implants, breast reduction) that does not always guarantee ideal symmetry after surgery.

One of the main reasons is that most women have some degree of congenital breast asymmetry. It may be very slight and often unnoticed, particularly if the breasts are small, but it is almost always there. When the breasts become enlarged during augmentation, what was once a slight and unnoticeable difference can now become more magnified and apparent…often prompting the thought or statement from the patient…how could this happen? (thus the value of before surgery pictures and the pointing out of any asymmetry in the mounds and nipples beforehand) Mathematical operations such as lifts and reductions will have presurgical markings that are identical in all dimensions and this can certainly improve many pre-existing significant breast asymmetries. But the healing process rarely responds in a predictable measurable way. The amount of bruising, fluid collections and tissue reactions at the suture lines all control how the mound will end up being shaped and the scars will look.

These breast surgery considerations brings me to the concept of ‘sister surgery’, which is well known amongst plastic surgeons. This is the reality that perfect breast symmetry should not be expected after any breast reshaping surgery. They may look somewhat similar, like sisters, but they are not going to be identical twins when all healing is done. This may seem to set the bar for expectations as fairly low, but it is an unavoidable reality. I certainly have seen numerous breast surgeries that looked about close to ideal as possible but this is more uncommon than common.

The sister concept most certainly is evident right after surgery and during the weeks to months that follow as they heal. They never look the same even if it is as straightforward as just the placement of breast implants. This is why one shouldn’t be too critical right after surgery. It will take up to three months, regardless of the breast procedure performed, to make a final judgment as to the shape and symmetry between the breasts. This is why revisional breast surgery should wait at least three months after surgery before doing a critical comparison of the two sisters.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Breast Reduction in Older Women

Monday, September 10th, 2012


Background:  A large breast size is well known to put a strain on back, shoulder, and neck muscles. The constant pulling of the breast weight across the shoulders strains the entire upper body. This is magnified when the large breast also have a large amount of ptosis or sagging, as most large breasts do particularly in older women. In some cases of large breasts, their weight has been shown to affect lung expansion with lower recorded oxygen saturations due to underventilation.

The basis of a breast reduction procedure is a combined breast tissue removal with a major lift and nipple relocation. The outside marks or operative design that many patients see is the lift part of the procedure and includes skin removal, the pattern of breast skin tightening, and an areolar reduction. The actual removal of breast tissue is not outwardly obvious because there are no marks done on the skin to indicate it. The removal is a reduction in the size of the mound of breast tissue keeping the nipple attached to it and being careful not to undercut its blood supply.

Breast reduction can physiologically be done at any age. There are risks of going under anesthesia for an operation that can take two to four hours to complete and the patient’s medical history must be considered. But from a tissue healing standpoint, a woman’s age does not affect it. Thus, it is never too late to get the health benefits of what a breast reduction can achieve.

Case Study: This 65 year-old female had been bothered her entire adult life by the size and weight of her breasts. She finally decided that it was time to solve this problem as she did want to be hobbled with her back pain as she became more elderly. She was 5 ‘ 4” tall and weighed 198lbs with size 44 DDD+ breasts.

Under general anesthesia, she had an inferior pedicle technique breast reduction done. Weights of 1,250 grams was removed from her right breast and 1,175 from her left breast. The nipple-areolar complex was moved upwards 14 cms from its low position. Her surgery was done as an outpatient and was completed in 2 ½ hours.

Her drains were removed the next day after surgery and she commented that her back and shoulder pain was already better. The tapes from her incisions were removed at 10 days after surgery with no healing problems. At her one month follow-up visit, her breasts had a much better and smaller shape and were higher up on her chest wall. Her incisions had continued to heal well.

There is no reason that breast reduction surgery can not be done on someone in their 60s or even older. Despite the magnitude of the procedure in terms of breast tissue trauma and reshaping, wound healing will occur as well as in someone much younger. More importantly, the improvement in musculoskeletal pain may mean more to an older patient who may already have other joint and muscle pains.

Case Highlights:

1) Breast reduction can have a dramatic impact on reduction of musculoskeletal pain from large breasts.

2) Very large breasts can be safely reduced with an inferior pedicle technique without free nipple grafting.

3) Even in older women, it is never too late to acquire the health benefits of breast reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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