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Dr. Barry Eppley

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Archive for the ‘breast reduction’ Category

Plastic Surgery’s Did You Know? The Benefits of Breast Reduction

Saturday, April 28th, 2012

Breast reduction surgery helps reduce the symptoms of neck, back and shoulder pain that large hanging breasts create. Much like a rope around a women’s neck onto which are attached several lb. sacks, the continuous pull of the weight of the breasts causes musculoskeletal pain from the neck into the back. But the amount of breast tissue weight removed during surgery is not the only reason these painful symptoms are relieved. Much of the relief comes from the accompanying breast lift or resuspension of the remaining breast tissue back up onto the chest and off the stomach area, eliminating the downward pulling effect. This is why every breast reduction also includes a breast lift as well.

The Role Of Plastic Surgery In Bullying Management

Monday, April 16th, 2012

Bullying for school age children and teenagers has reached unprecented awareness recently. While it is a social phenomenon that has gone on forever, many recent examples of internet intimidations and even suicides has made it newsworthy of late. The recent movie release “Bully’ has brought an awareness particularly to adults that brings back unfortunate memories for many and is perhaps why the movie has appeal to more than just those in school. Unlike days of old when bullying may have been limited to school time, there is nowhere to hide in today’s internet and smartphone age.

While bullying occurs for many reasons, physical deformities and differences are a frequent source. It is one thing when a child and teenager know that they are structurally different, but it reaches a malicious and psychosocial altering situation when it is brought to public attention. Whether it is a big nose, ears that stick out or breasts that are too large, such visually apparent features can be a source of torment and intimidation.

Is plastic surgery a solution for bullying when these physical conditions exist? Before bullying reached its current awareness, such plastic surgery procedures have been done for a long time for those children and teenagers whose self-images were affected by them. There is no question that such operations as rhinoplasty, otoplasty, congenital facial deformity surgery (e.g., cleft lip and palate) and breast reduction have psychologically helped many young patients. I have seen and been told by parents of patients that they have become less introverted and shy after their plastic surgery. I can often see it in their eyes and facial expressions that they are feeling better about themselves.

But that does not make plastic surgery a solution for bullying? You can change the physical deformity but you can’t change their social circumstances. Plastic surgery is but one tool, one aspect of the therapy so to speak, in bullying management for the physically affected. In the properly selected patient who has parental support and permission, plastic surgery correction can make an invaluable contribubtion.

This should not be confused with other plastic surgery procedures that do not correct a physical deformity but are done in an effort to alter one’s natural, albeit not desired, body shape. These would be so-called efforts to make one look more thin or shapely. Or to help one have a body that is more like that of some celebrity or model. Breast augmentation and liposuction, while a personal decision for adults, are not what I would consider important self-image surgeries for younger patients to help them escape bullying or criticisms from their peers.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? The Conical Geometry of Breast Reshaping Surgery

Sunday, April 1st, 2012

Breast reduction and advanced breast lift surgery uses basic geometry to surgically reshape the breast mound. Much like making a cone out of a flat piece of paper, it requires a modified wedge-shaped removal of skin from the lower half of the breast. After this skin is removed, the remaining breast skin is brought together and wrapped around the breast tissue in an uplifted and more conical shape. This results in the classic anchor closure and scar pattern. The artistic or judgment part of aesthetic breast reshaping surgery is to design the angles and limb lengths so that the right shape and symmetry is obtained between the two breasts.

The Role Of Liposuction In Breast Reduction

Monday, January 2nd, 2012

Breast reduction is one of the common body contouring procedures and is a mixture of both a reconstructive and a cosmetic procedure.Breast size and shape are dramatically changed and the breasts both feel and look better. But it is an operation that is associated with scars and that is its one liability. This has led to the concept of performing breast reduction in a scarless manner using liposuction. This leaves only minimal scars from the cannula entry sites.

The appeal of breast reduction by liposuction is obvious offering essentially no scarring but also shorter operation times and even the ability to perform it under IV sedation or local anesthesia. Because liposuction does nothing to improve loose skin and the sagging breast, which almost every large breast has, it is only a rare procedure that I have offered in my practice as a primary method of breast reduction. The overwhelming majority of macromastia patients that I see need a breast lift in addition to breast tissue removal to both tighten the enveloping skin envelope and radically lift the nipple to a more central mound position.

However, for a few select patients that can accept keeping their existing degree of breast sagging (or it becoming even worse) then liposuction alone may be a reasonable breast reduction approach. Like male gynecomastia liposuction, how successful liposuction is depends on the fat vs. glandular component of the breast. The more fat tissue that is in the breast, the more effectively it can be removed and sculpted. Lumpy, firm and very glandular breasts do not reduce and sculpt as well.

Breast liposuction is done similarly to any other body area. The breasts are initially infused with a tumescent solution for bleeding/bruising control and to make the cannula slide through the tissues easier. The key to a good result is multidirectional liposuction. This means coming from at least two directions, usually with an entrance site from close to the axilla and one from the lateral end of the inframammary fold. There is no reason to be close to the skin when suctioning and given the size of the breast mound an aggressive approach can be used.

An interesting and relevant question is whether liposuction of the breast produces calcifications that can be seen in mammograms. Studies have shown that breast liposuction does not create such calcifications and that the internal scarring created from the procedure did not make it more difficult to detect breast cancer.

The most common use of liposuction in breast reshaping, however, is when it is combined with a traditional breast reduction technique. Most women are not aware that the fullness and heaviness that wraps around the side of the breast into the back will not be improved by the reduction-lift procedure. This is a discovery often made afterwards much to the patient’s dissatisfaction. This extra tissue is not part of the breast mound but a part of the chest wall. This is an issue that I discuss before breast reduction surgery and give the patient a choice of whether to have it done concurrently.

Dr. Barry Eppley

Indianapolis, Indiana

The Effects of Breast Lifts and Reductions on Upper Pole Fullness

Tuesday, December 6th, 2011

Lifting and reduction techniques are common methods of cosmetic breast reshaping. Whether it is to lift up a smaller sagging breast or to reduce a large and pendulous breast, pushing up breast tissue and encasing it in a smaller and tight skin envelope is the basic approach. It would seem logical that by so doing the upper pole of the breast would be made fuller. There is no doubt that this is initially true but what happens long term?

There have been numerous breast lifting and reduction techniques that claim improved and persistent long-term upper pole fullness. Some use sutures to sew breast tissue pillars up to the fascia while others move breast fat flaps upward to replicate the effect of an ‘implant’. While short-term pictures appear encouraging, there has been no objective measurements to assess the validity of these breast reshaping claims.

In the December 2011 issue of Plastic and Reconstructive Surgery, a well-crafted photometric study was reported on how well breast lifts and breast reductions work for creating upper pole fullness. The author looked at 82 international publications using a wide variety of breast reshaping techniques. Measurements were made on a variety of breast landmarks, including upper and lower pole fullness and projection. The study found that no method of lifting or reduction increased upper pole fullness significantly. In fact, nipple overelevation occurred in a significant number of studies (42%) undoubtably due to an initially full upper pole that went on to bottom out later. In over half of the studies, a tear drop nipple deformity was seen with a less than round areolar shape.

This study and other findings not mentioned here bring forth many breast reshaping misconceptions. The first as already mentioned is that no method of breast reshaping will enhance upper pole fullness long-term. Many patients think it will but it does not. This is why implants are often suggested as part of a breast lifting procedure to do exactly what it doesn’t…create long-term fullness in the upper pole. Secondly, breast lifts do not make a breast look bigger. Rather a breast lift or mastopexy is really a bit of a breast reduction as well. The breast may be uplifted but it will appear smaller. Again, another reason why an implant may be needed in a breast lift to overcome this ‘downsizing effect.’

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Breast Reduction with Free Nipple Grafting

Sunday, September 25th, 2011

Background:  Breast reduction remains one of the most common reconstructive plastic surgery procedures. It provides not only reduction in the size of a large breast but it also lifts and reshapes it as well. The amount that the breast is reduced or how much it is lifted is based on patient preference and what the breast tissues will allow.

In the most traditional and commonly used breast reduction method, known as the inferior pedicle technique, the operation is based on maintaining survival of the nipple-areolar complex. The nipple remains attached to the breast tissues and the excessive breast tissue is removed  around the base or sides of the breast mound. This way the blood supply to the nipple coming up from the underlying chest muscle remains intact ensuring its survival and function after surgery.

But when the breast is very large and hangs down low on one’s stomach, the breast tissues which are attached to the nipple (known as the pedicle) becomes very long. Reducing and lifting such a large breast increases the risk of kinking or cutting off the blood supply to the nipple. Furthermore, in an effort to keep the pedicle as thick as possible to prevent nipple survival problems, the amount that the breast can be reduced is much less.

An alternative breast reduction method in extremely large breasts is the free nipple grafting technique. In this procedure, the desired size of the nipple-areolar complex is first removed, the breast reduced to any desired size, and the nipple put back as a full-thickness skin graft at the end of the operation. This method allows great versatility in size reduction without concerns about nipple survival afterwards. There is the issue of how well the nipple graft will survive, identical to any skin graft take.

Case Study: This 36 year-old female had suffered with massive breasts (38 J cup) since she was a teenager. Their size was made worse since having children. They gave her severe neck, back and shoulder pain and made it impossible for her to exercise. Any effort at weight loss did not change the size or sagging of her breasts.

With a very long pedicle due to her sagging breasts and her desire to have a substantial size reduction, she opted for a free nipple grafting breast reduction method. During her operation, slightly over 4 lbs (1750 grams) of tissue was removed from each breast. Her areolar diameter was reduced from 72 mms to 44mms.

Bolsters (compression dressings) were used on the nipple grafts as is standard for many types of skin grafts. They were removed 10 days after surgery. She went on to have near 100% take of her nipple grafts. By three months after surgery, she is completely healed. The redness from all of the scars and in the grafts will take another six months to fade. Her back, shoulder and neck pain was dramatically decreased beginning almost immediately after surgery.

Case Highlights:

1)      Breast reduction is a highly successful procedure regardless of breast size. In reduction of very large breasts, the risk of nipple loss is increased.

2)      The free nipple grafting breast reduction technique is useful in very large breast reductions and avoids the risk or partial or complete nipple necrosis.

3)      Free nipple grafts will not have feeling or nipple erectile or lactation capability. They will also have changes in pigmentation and nipple projection.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Breast Reduction in African-American Women

Monday, September 5th, 2011

Background:Breast reduction is one of the most common of all reconstructive plastic surgery procedures. Large heavy breasts produce back, shoulder and neck pain as well as poses clothing and social concerns. While breast reduction does result in substantial length of scars, it produces highly satisfied patients despite this aesthetic tradeoff. The improvement in pain and having bras and clothes that fit make the scars a generally well-accepted liability.

While large breasts (macromastia) occur across all ethnic groups, it is disproportionately more common amongst African-American women. I would estimate that more than half of my Indianapolis breast reduction patients are African-American even though that does not reflect the region’s population ratio. Many African-American breasts are quite large and it is not uncommon to have bra sizes that range from G to J.

One of the main concerns about breast surgery in African-Americans is the risk of adverse scarring. Given the location and amount of scarring, this is a very legitimate concern. Scarring concerns are about either thick scarring (hypertrophic scars) or that of keloids. (pathologic scarring) These two scar problems, while often used interchangeably, are not the same and are quite different. Hypertrophic scars are wide scars that are slightly raised but remain within the boundaries of the scar’s width. Keloid scarring is a genetically inherited disorder where the scar runs wild, growing and overflowing the scar’s borders. Prior laceration or surgical history will reveal if one is a keloid-former. If they are then breast reduction surgery should be avoided.

Case Study: This 35 year-old African-American female wanted a breast reduction procedure due to her back and neck pain and grooves in her shoulders. She wore a 38 DD bra and much of her breast tissue hang over and below her inframammary crease. Her areolar diameter was enlarged at 55mms. Her sternal notch to nipple distance was 29 cms and the nipple to inframammary fold distance was 12 cms.

Under general anesthesia, a breast reduction was performed on both sides using an inferior pedicle technique. The areolas were reduced to 42mms in diameter. A total of 625 grams was removed from the right side and 640 grams from the left side. Her procedure was done as an outpatient. All incisions were closed with sutures underneath the skin and were taped afterwards. She went home in a bra with a drain on each side.

She returned to the office the next day to have her drains removed. She showered afterwards and there is no concern about getting the tapes wet. The tapes were removed 10 days after surgery. She continued to wear a soft bra and returned to work two weeks after the procedure.

At eight weeks after surgery, no signs of hypertrophic scars were evident nor do I anticipate any. I have yet to see any adverse scarring in African-American breast surgery is they did not have a prior history of scarring issues elsewhere.

Case Highlights:

1) Breast reduction is a common request amongst African-American women and is highly successful at musculoskeletal relief and breast shape improvement.

2) The techniques for breast reduction in African-Americans are no different other than a more frequent consideration for a free nipple grafting method in cases of gigantomastia.

3) While the risk of hypertrophic scarring and keloid formation is greater in this ethnic group, it is not a scar problem that I have yet observed in my breast reduction patients.

Dr. Barry Eppley

Indianapolis, Indiana

Common Patient Questions about Breast Reduction

Tuesday, November 30th, 2010

How many techniques are there for breast reduction surgery?

There are a variety of different techniques for reducing the large breast. They all fundamentally, however, revolve around keeping the nipple alive while reducing breast size and creating a better breast shape by skin removal and tightening. The scars that are created are very similar resulting in fine lines around the nipple and then vertically downward into the lower breast crease. The common breast reduction technique used in the United States is known as the inferior pedicle method.

Is breast reduction permanent?

In the vast majority of cases, yes. Once breast tissue is removed, it will not regrow. Only when the breast reduction was done in the early teenage years couldsome regrowth potentially be seen as one continues to develop. The breast shape seen after breast reduction, however, is subject to change based on potential weight changes (gain or loss) and future pregnancies.

What does a typical breast reduction consultation entail?

Besides the usual taking of a medical history, examination and measurements of the breasts are taken as well as a family breast cancer history and documentation of a recent (in the past year) mammogram. If submitting to insurance for pre-determination, photographs of the breasts are also taken.

How is breast reduction surgery performed?

Breast reduction surgery is an outpatient procedure done under general anesthesia. It usually takes about 2 to 3 hours to perform. All sutures are under the skin so there are none to remove. The breasts are simply taped and you wear a surgical bra. Most plastic surgeons do place drains and they will be removed the following day in the office.

Is it painful?

Contrary to popular perception, there is only mild discomfort and not severe pain after breast reduction surgery.

Where are the incisions made?

Where the incisions are made is not as important as to where the final scars end up being. The final scar placement in breast reduction is known as the anchor pattern. The final skin closure and scars go around the nipple, then down vertically to the lower breast fold, and thenalong the lower breast fold. This ends up looking like an inverted-T or anchor pattern.

Is there much breast reduction pain?

There is some mild burning and pressure which occurs during the first night. By the second day most patients report general soreness but not significant pain. Many breast reduction patients do not take pain medication for more than a few days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Large Breast Reduction with Free Nipple Grafting

Friday, August 13th, 2010

Background:  Breast reduction is one of the most commonly performed plastic surgery procedures of the body. Because it not only reduces the size of the breast but also reshapes it, every breast reduction is a breast lift also. Because a lift is involved, the nipple must be moved into a better centered positioned on the reshaped breast mound.

While the nipple makes up a very small percent of the total breast, it receives an inordinately greater amount of aesthetic significance. This is acknowledged in the breast reduction operation as most ways of doing this operation is based on keeping the nipple attached and alive to the underlying breast tissue. In very large breast reductions, the nipple will be at some increased risk of survival if kept attached.

Case: This is a 55 year-old African-American female who came in for breast reduction. She had the typical back, shoulder and neck pain that is associated with such large breasts as well as deep grooves on her shoulders from her bra straps. She was an F cup and wanted to be a full C or small D cup after surgery. Such significant reduction in size would place the nipples at risk for survival due to the long tissue pedicle that would be needed to carry the nipples on.

In discussing choices of a more significant reduction in size or keeping the feeling and color in the nipples, she preferred the method that would give a smaller breast size. She opted for breast reduction with free nipple grafting. In this method, the nipple is removed initially and put back at the end of the operation as a full-thickness skin graft. This allows virtually any size reduction to be done but at the expense of loss of nipple feeling. In patients with more skin pigment, particularly African-Americans, there would be some changes in the color of the nipple and areola as well.

During her breast reduction surgery, a total of 1850 grams (4 + lbs) was removed from each side. Interestingly, the final pathology of her breast tissue found an area of DCIS breast cancer. The size of the specimen removed captured all of the involved area with wide margins free of tumor.

She had an uncomplicated recovery with good take of the nipple grafts and no healing problems with any of the incisions. Note in these three months after surgery pictures the loss of nipple projection and spotty areas of hypopigmentation in the grafts. These are typical for free nipple grafts in African-American patients. She felt this was a good trade-off for the size reduction but she was 55 years of age. Such a change in nipple appearance would likely be more unacceptable to a younger patient.

Because of her found breast tumor in the pathology specimen, she was recommended by the hospital’s tumor board to receive radiation therapy as a precaution. Because of healing, I advised that this should not start until four months after her surgery.

Case Highlights:

1)      Surgical reduction of large breasts must take into account the balance of nipple survival and how much breast tissue can be removed.


2)      The greatest amount of breast reduction can be achieved with a free nipple grafting technique.


3)      Free nipple grafts, like full-thickness skin grafts, will not have feeling afterwards, will have a flattened nipple and will usually undergo some pigment changes of the areolas.


Dr. Barry Eppley

Indianapolis Indiana

Considering Breast Reduction in Teenage Girls

Sunday, March 28th, 2010

One of the most common plastic surgery procedures done for teenage girls is breast reduction. Most women, young or older,  have this surgery because they have large breasts that restrict their activities and give them pain. While older women usually have large breasts that have considerable sag (ptosis), teenage girls will not have as much sag due to never having yet been pregnant in most cases.


Teens with very large breasts will have numerous symptoms including back, neck and shoulder discomfort from by the excessive weight. The bra straps will often leave groves or indentations in the shoulders. But of equal importance is that most teens will feel extremely self-conscious. So much so that they alter their wardrobe to hide the size of their breasts and will often not participate in any sporting activities.


One form of a developmental breast deformity that should not be confused with just that of simple juvenile breast hypertrophy is gigantomastia. This is an extreme form of breast overgrowth where the size of the breasts are remarkable and massive. It is unique to the teen years and is an exaggerated response to higher levels of estrogen after puberty. If it appears in only one breast with significant differences in size, one should think of a tumor specifically a large fibroadenoma. This needs further evaluation with an MRI before surgery.


A key question is the timing of breast reduction in teens. In most cases, breast reduction is not considered until at least age 18 when the breasts more are fully developed. However,  it can be considered earlier depending upon the size of the breasts and how much physical discomfort they are causing. Because of the changes that will occur to the breasts from pregnancy, ‘pre-childbirth’ breast reduction should be considered carefully so that its benefits are too short-lived. It has been recommended that breast reduction should not be done in those women who intend to breast-feed, but the operation does not preclude the ability to breast feed after as the nipple is not removed during the operation.


Breast reduction is a measured and complicated procedure. It is a combination breast lift, reshaping, and reduction operation. A precise geometric pattern of skin excision is marked out on the breasts before the patient ever goes back to the operating room. It removes fat, glandular tissue, and skin from the breasts, while making them smaller, lighter, and uplifted higher onto the chest wall. The diameter of the areola is almost always reduced in size as well. How much size reduction is done is a matter of judgment, making sure that the blood supply to the nipple is not cut off. In teens it is important to not reduce too much, allowing for further size reduction that will eventually occur after childbirth. (post-partum breast atrophy)


Permanent scars in the form of an ‘anchor’ pattern is the long-term price to be paid for a breast reduction, but the comfort and pain relief with smaller breasts are worth that trade-off for most teens. But the creation of scars is the reason why breast reduction should not be done for cosmetic reasons only. While plastic surgeons are experts at making scars as thin as possible, they are nonetheless extensive and permanent. They will feel firm and appear red in color for months, eventually fading to thin white lines.


Swelling and bruising are typical for the first few weeks after surgery, but it takes months before the breasts settle into their final shape. Being a teen, breast shape will still be affected by future events such as hormone changes, weight gain and loss and most certainly pregnancy.


Of all plastic surgery procedures, breast reduction done at any age produces an immediate body image change. The pain from the weight of the breasts is instantly gone, even in the face of discomfort caused by the surgery. Despite its many benefits, teens need parental consent and counseling with their parents before considering this breast changing operation.


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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