It seems incredibly tempting for surgeons to paint breast reduction surgery in a certain, inevitably positive light. No doubt, breast reduction is a procedure which typically leads to high rates of satisfaction, and it offers both aesthetic and functional benefits. Having said that, the typical social media portrayal of breast reduction surgery with supposed patient quotes of “I can’t believe I waited so long to do it!” has a tendency to downplay the important considerations patients need to make when deciding to have surgery.
Another thing that has grabbed me over the last couple of years is the dramatic uptick in young ladies seeking/having breast reduction surgery.
That isn’t to say that breast reduction surgery is an operation only for ladies after having kids, late 30s to early 40s, and finally “doing something for myself after thinking about it for years” – hence the typical quotes I have alluded to above. We have always seen women across the age spectrum.
However, I think we are seeing more young women than previously.
I have noticed two things in particular: I am seeing more young women in their late teens (sometimes still at school or just starting university), and I am seeing more women who, whilst planning to have kids at some stage, haven’t done so yet but still want the surgery.
These young ladies often present with disproportionate breast size, and often they will have some degree of asymmetry as well.
I bring this up because there are unique aspects to the conversation I have with these younger patients which, whilst in some cases still relevant to those ladies in their late 30s and 40s (and beyond), perhaps have a greater relevance in youth. It is probably fair to say also that the willingness of these younger ladies to undergo surgery in spite of the potential challenges is worth contemplating. Has something shifted in the way young women think about breast reduction? Are there individual, peer and societal influences on those shifts? Is there a greater awareness of being different now, and is that exacerbated by social media and fashion trends? And what does that mean for the surgeon who offers and performs these procedures?
To be clear, I am particularly conscious of the fact that I am a male talking about a bunch of issues with an awareness which is limited to that of an external observer rather than an active participant (for want of a better term). I obviously cannot pretend to speak with the perspective or experience of a woman in this, so you’ll have to bear with me to some extent (or not – happy to be told that I have it all wrong). There is also an element of me “reading between the lines” when I try to explain my understanding of my younger patients’ experiences. I say that because I think it is often more challenging for those younger women to articulate their rationale for considering breast reduction surgery with me. I think that relates to their relative youth, the fact that they are having to chat to a man, as well as the fact that there is something quite particular about the lived experience of a young women with a disproportionately large bust in our current times (yeah, I know, we can't blame social media for everything, but surely it has a role here).
So, what do I talk about with my younger patients when it comes to breast reduction, and how does that differ with how I might otherwise discuss this topic? I’ll stress that I discuss the same topics (with the exception of breast feeding…for obvious reasons) with all patients, but as you can imagine, I try to tailor the way I deliver that information according to the person I speak with. I don’t think I am out of line in saying that it would be understandable that a 19 or 20 year old woman may have different priorities to those of a 45 or 50 year old woman, although it isn’t always the case I guess.
I think it is fair to say that breast reduction surgery remains a procedure with a functional priority. Interestingly, despite my early assumptions, I have found that my younger patients are not necessarily more concerned with the aesthetic outcome of this procedure than others. That has surprised me. However, in saying that, I find myself being more cautious in how I discuss the cosmetic consequences of breast reduction. I certainly take more time to stress the inherent trade-off in breast reduction surgery: that being, a whole bunch of scars in exchange for a smaller, perhaps more appropriately shaped bust.
At least in part I thought I would write this article as a way of questioning my own approach to this topic. Why do I think about breast reduction a little differently for younger patients? Should I? Not sure I’ll get a clear answer on that, but worth considering.
I guess there is a sensitivity to this issue. Younger women have not (yet) been forced to medicalise their breasts like women who may have breast fed children, had mammograms, or been examined by doctors after feeling a lump. There is probably a discussion to be had about the influence of medicine/health care provision on self-image. Over time, women are subjected to so many situations in their lives in which the breast is treated as a medical curiosity rather than a private aspect of one’s physical self. In any case, younger women very likely view their breast through a lens which is tinted differently to ladies who are a bit older. I get the feeling that after having kids (for example), breasts can become rather functional appendages! For women in their late teens and early 20s however, breasts are an object of (often unwanted) attention, sometimes affection, still largely viewed as erogenous aspects of the body. I think it realistic to consider that for younger women, the thought of having a surgeon (male or otherwise) examine their breasts would be…challenging. I guess I approach the topic in this way to ensure that whatever I talk about or suggest to these young ladies, it minimises the sheer awkwardness that might exist for them. These young women, often still in or just beyond their teens, evidently feel sufficient justification to fight through that awkwardness – and it is important that we understand what that justification is.
Ok, so with that all out of the way, let’s talk in a slightly more focused way about breast reduction for young women.
I want to break this down into a couple of areas that have particular relevance (I think) to young women. I’ve mentioned scars above. Scars matter because they are permanent. Once they are there, they’re an enduring stigma of what has taken place. There are three other things that I give priority in my discussions. The first one is sensation; and in particular, nipple sensation. I think the importance of that might be one of those things that we can make some erroneous assumptions about. The second one is breast feeding. A contentious topic anyway, and one that deserves a little air time. And finally we need to think longer term about the fact that breast reduction does not result in a static, unchanging breast over time. Which means that the idea of re-do reduction needs to be entertained.
Scars are, or should be, the default assumption when it comes to breast reduction. Of course there are scars. I know that some surgeons love to try to sell the idea of scar minimisation, with concepts like “vertical scar” or “lollipop scar” breast reductions. But that is, at least in my hands, a sure recipe for sub-optimal outcomes. If the scars are a concern, then maybe this is the wrong operation for you.
Every breast reduction I do entails the full set of scars, in what is commonly referred to as an “anchor” pattern: around the areola, vertically down the front of the breast, and in the breast crease. Each of those scars serves a purpose, and perhaps most importantly for anyone thinking about trying out a “lollipop” technique, it is the long scar in the crease under the breast that really does a lot of the heavy work, and in particular, it is this scar which is instrumental in allowing precise control of the breast crease, using what some surgeons love to call an “internal bra” technique.
Scars are a given. Embrace them, or don’t have the operation. There really isn’t any half-way option.
Nipple sensation is a standard part of every discussion. But nipple sensation means different things to different people. For some young ladies, nipple sensation sits right at the core of any meaningful sexual experience. For other ladies, the nipples might as well not exist for all the pleasure they offer. So understandably, not only must we not generalise, we must ensure that we cover our bases here.
My consent forms state that one of 3 things can happen after surgery: no change, loss of sensation (often permanent), or GAIN of sensation (often temporary). The whys are perhaps beyond this article, but the variability matters. Obviously, for the young lady with nipple sensation pre-op, who cares about that sensation, if she runs the risk of losing it, that has to be factored in to any decision to have surgery. Equally, for a young lady with large breasts and no nipple sensation to speak of (which is common), if we create a hypersensitivity (even if only temporary), this can be a rather unpleasant experience.
So not only do we need to warn patients about the risks, but we need to understand how those risks can be interpreted in the context of a young woman’s lived experience. And we have to also accommodate the fact that for our younger patients with a big bust, they may have avoided sexual intimacy (this is something I hear a lot) due to body-image discomfort with their own breasts, and so we are encroaching on previously uncharted territory in altering their sensation. Which requires a fair amount of insight and consideration (on the part of the patient) before surgery is entertained.
This is the big one, in that it is the main thing that I am asked about by my younger patients. In their late teens and early 20s, not every young lady knows how they feel about the thought of having children. Nor should they be expected to. But the possibility of having children is important for many of my patients and therefore, the impact of breast reduction surgery on breast feeding matters.
If we look to the scientific literature, we see old data that says something like: only 50% of women can breast-feed exclusively, and that number remains unchanged after breast reduction surgery. We also see things like: breast reduction won’t stop breast feeding, but may cause reduced milk supply. And then we see other (totally unqualified) comments about the time between breast reduction surgery and pregnancy as having some impact on that.
If we dig into the science a bit, there are some comments that I think are appropriate to make. With modern reduction techniques (ie. the "superomedial" pedicle techniques in particular), the impact on breast feeding is minimised (when compared to older techniques). It is entirely fair to assume that breast feeding may be altered by surgery, but long-term observational studies would suggest that provided the nipple remains attached to a meaningful portion of functional breast tissue, then the ability to lactate is preserved.
So I guess the old data is reasonable in making a general comment about breast feeding being possible (for anyone, whether they have had breast reduction surgery or not), but never guaranteed.
This is a reasonably contentious question: do young women who have breast reduction surgery end up needing more surgery down the track?
The answer is (perhaps obviously) variable.
I guess one way to think about it is this – no matter what happens in the future, the breast will always be smaller than it would have been without surgery.
The more nuanced answer is that it is going to depend enormously on the life, and lifestyle, of the individual woman in question. If a young lady has a breast reduction, and then never has children and maintains a fairly stable body weight, the chance of needing more surgery is going to be low.
If however a patient who has a breast reduction in her late teens chooses to have children, perhaps experiences some weight fluctuation over her lifetime, or has some change in the breast in the peri-menopausal years, then sure, it is possible that patients can experience recurrent symptoms relating to the size/weight of the breast. The flipside of course is that the same patient will likely have had 20 odd years of substantially improved symptoms even in the event of recurrent breast growth.
Should we use the possibility of needing re-do surgery as a reason for not offering surgery to younger women? Of course not.
Can re-do surgery be performed safely? Absolutely.
How common is it? No idea. We just don't have anywhere near enough data to make a comment on that. All I can tell you is that I see a few ladies here and there who present for re-do reduction (often after having had kids) who had an original procedure in their early 20s.
I figured I would close this off with a few comments about when I might choose to really slow down a conversation about breast reduction for a young lady.
There are probably two main “red flags” that will give me pause.
The first is age – I (and I would think most sensible people) generally recommend that surgery should not be offered to a young lady who’s development hasn’t completed. We often will therefore ask whether the breast size has been stable, and if so, for how long. Puberty is variable, and development is variable, so there is no hard rule about what age is appropriate to consider surgery.
The second is context - of course, tied in with age (but not necessarily determined by it) is maturity. It is vital that for any young lady considering surgery, a) it is her choice, and her choice alone; and b) we must be sure that the young lady is able to appreciate the longer term ramifications of a choice to pursue surgery. Which is what all the stuff above is about. If I see a teenager who presents with a parent who seems to be leading the conversation, I will often ask mum (it’s normally mum) or dad to leave the room for a few minutes,and I’ll ask my nurse to come in with me so we can have a quiet chat with our prospective patient. On the other hand, I may see a young lady who presents on her own, and when we dig into the reasons she is considering surgery, we come across a bunch of other stuff going on in her life which may be influencing a decision for surgery. We hear stories about bullying (often from girls), boys being little jerks (I am sure you know what I mean), and occasionally other far more serious things come up that need to be addressed very carefully. At the very least though, we have to keep these issues in mind to ensure that at all times, we are doing the right thing for our patient.
So, at the end of the day, there is no right or wrong age for a woman to consider breast reduction surgery. It is a deeply personal consideration, which may be influenced by a number of factors.
My job is to offer advice and guidance, and manage expectations carefully. Beyond that, the technical exercise of performing the surgery is pretty straight forward.
As always, any questions, please get in touch and we’ll be happy to help. To read more about breast reduction, click here!