What is a breast reduction, and who is qualified for one?

Ariel: What is a breast reduction, and who is qualified for a breast reduction?

Dr. Katzen: Breast reductions are, as the name implies, a breast size reduction. Today, we're

going to be talking about female breast reduction. Breast reductions are for women that are

looking for smaller-sized breasts.

Ariel: Okay. So, does anyone with breasts qualify for a breast reduction?

Dr. Katzen: Yes, if you feel your breasts are too big for your body. That can be due to your

breast getting very large during puberty or maybe you were overweight. Some women have

breast reductions because their breasts are out of proportion with the rest of their bodies,

and they are just looking to reduce the size of their breasts.

Ariel: And what's the difference between breast reduction and a breast lift?

Dr. Katzen: Good question. A breast lift is just lifting the breast. When performing a breast

lift, I must consult with the patient to determine exactly what they want. When I see

patients, one of the first questions I ask them is, “what are you looking for?” Typically, I'll

get answers like, "I want my breasts back to where they were." So, to me, that means a

breast lift. And then I'll ask them, “do you like the breast size?” And if the answer is yes. I

like the breast size”, which means I perform a breast lift. Sometimes patients answer, No, "I

want my breasts smaller." That means I should perform a breast reduction. Also whenever I

perform a breast reduction, I always do a breast lift. However, not all breast lifts are breast

reductions.

Ariel: Okay, that makes sense.

Dr. Katzen: Sometimes, when I perform a breast lift without a reduction, the amount of

tissue removed can be about a teaspoon or a tablespoon of tissue. That is not much because

what I am doing in a breast lift is removing just breast skin. With a breast reduction, I am

removing skin and a lot of breast tissue. In a breast reduction, the proportions are about

99% breast tissue and 1% skin. So, in a breast reduction, I am removing much skin, and the

majority of the specimen is breast tissue in a breast reduction.

Ariel: And have you noticed, like, a specific cup size where it seems to be too big for

women? Does it tend to hurt their back? Is that why they come in?

Dr. Katzen: There are multiple reasons why people come in for breast reductions, many

patients present for breast reductions due to neck pain, upper thoracic, upper back pain,

and bra strap groove pain. Those are the pains that are associated with large breasts.

Another reason women present for breast reduction is because they develop rashes

underneath the breast. The breasts hang over the upper abdominal wall, and they trap

moisture, This can cause fungal or bacterial infection.

Ariel: Okay. When we come in for a consult for a breast reduction, what's that like?

Dr. Katzen: You'll call the office. You'll schedule a consultation. I'll examine you, and we'll

examine the mass of your breasts individually, in comparison, and in terms of the

proportion to the rest of your body. Some larger breasts fit larger patients. Some smaller

breasts fit smaller patients. So, you can see not everyone needs breast reduction. The need

for breast reduction is based on physical examination including height, weight, and body

surface area. There's this funny thing called a Schnur scale, which evaluates your height and

weight and determines how much breast tissue needs to be removed to qualify for

insurance coverage of a breast reduction. That's if we go the insurance route. Now, if you

desire elective cosmetic breast reduction, that's different. Now, we don't have to worry

about qualifications based on height and weight.

Ariel: How do we determine how much you will reduce the breast?

Dr. Katzen: That's completely patient-dependent. Now, I reduce the breast size as to what

the patient wants, not necessarily what the insurance wants. Insurance coverage is great

and if we have coverage for that, that's fantastic. However at the end of the day, you're the

patient, and you have to live with the size of the breast. So, I consult with my patients. I ask

them, “What size do you want to be?” Some patients typically want to be like a B or a C or

sometimes even a D.

Ariel: Okay. So, we're coming in for our consultation. We're determining the breast size.

When we're doing breast augmentation, making the breasts more prominent, we have a

rice test we could do at home to determine how big we want the breast. Now, what is the

alternative for breast reduction?

Dr. Katzen: Determining breast size after breast reduction is different because there's no

real test you can do at home to visualize or see what size your breasts will be. So, what I

would advise patients is, "Look. Go online. There are millions of pictures of different-sized

breasts. You can look for body shapes like yours. So, find a body shape like yours with the

breast shape you would like." Print this picture and bring it to my office. This picture gives,

in my mind, the visual you are seeking. Some patients for breast reductions say, "I just want

my breasts smaller." Well, that can mean a variety of things. It can be a D, C, B, or A. Those

are all smaller and have a wide variety of shapes and sizes. So, it's much better to come into

the office, in my opinion, with a collection of pictures. Don't go crazy. Maybe bring about 5

or 10 pictures. We don't need a hundred pictures of breasts you like or bodies similar to

yours. Also, if you're 200 or 250 pounds, please don't bring in pictures of patients that are

100 or 120 pounds of breasts you like because those body types aren't going to match.

Instead, bring in pictures with bodies similar to you.

Ariel: Okay, great. And let's talk about surgery now. Is this done under general anesthesia?

Dr. Katzen: Yes, the breast reduction surgery is done under general anesthesia, completely

asleep. I use a MD doctor Anesthesiologist. I don't think it makes sense to do

these procedures under local anesthesia. Typically, done in a surgicenter, and you go home

the same day. Sometimes Breast reduction is done in the hospital, but even when it's done

in the hospital, typically, it's an outpatient surgery, and you go home the same day. Usually,

I don't use drains, but a lot of plastic surgeons do use drains. Drain usage for a breast 

reduction procedure just depends on your plastic surgeon's comfort level. Typically, the

breast reduction procedure takes 3 to 4 hours, depending on how large the breasts are and

what needs to be accomplished.

Ariel: Okay. And what are the possible complications of breast reduction?

Dr. Katzen: Like any other surgery, there are possible complications. Problems under

anesthesia, are rare nowadays. Again, I use a MD doctor anesthesiologist.

For general anesthesia, I do an extensive workup preoperatively. There's always a risk of

infection. To minimize that risk, you'll get antibiotics before, during, and after the surgery.

So, the risks of infection are very low. Now, there's always a risk of the incision opening

either partially or fully. I've never seen the incision completely open, but that's always

possible. Though rare. Then there's also a possibility of you rejecting the sutures that I use

to close the incision. There's always a risk of part or all of the areola (the pigmented area

around the nipple) dying. This is a possible complication because when I move the nippleareola complex and I am relying on your blood supply to keep it alive.

Ariel: Okay. And what do you do to prevent these things from happening? Especially the

dying nipple part because I know that's a big concern for people.

Dr. Katzen: A considerable concern. The most important thing is you must quit smoking. You

must quit smoking 3 to 4 months before the surgery. Nicotine in cigarettes affects the

survival of the nipple-areola complex. The other thing is if the nipple hangs very low on the

breast, I will have to move it. If this distance to move this nipple-areola is long, then there's

a higher chance of necrosis or death. If this distance goes beyond a certain length, we may

think about doing a free nipple graft, where I take the nipple off entirely and put it back like

a post-it stamp to maximize survivability. Now, if I've done the surgery and I am worried

about the blood supply to the area, in the operating room, sometimes I may release the

sutures. Releasing the sutures to get some blood supply. Then, I close it up again.

Sometimes I may put some tacking sutures to relieve the pressure going into the nippleareola complex. Now, suppose there's some ischemia or some questionability of the nippleareola complex after the surgery. In that case, we may apply Nitro paste to increase the

blood flow to the nipple-areola complex by reducing the venous load. Another thing I can do

is I can get you in a hyperbaric chamber to force oxygen into the tissue. Those are some of

the maneuvers I can do after the surgery.

Ariel: So, there are complications like all surgeries, but there are also a lot of preventative

things that we can do to avoid that.

Dr. Katzen: Absolutely. Quit smoking. Eat right. Make sure your garment is positioned

correctly. Call your plastic surgeon immediately after the procedure if anything feels wrong.

Ariel: And what are the chances of insurance covering this procedure?

Dr. Katzen: Insurance coverage for breast reduction depends on your anatomy. Also,

insurance coverage depends on your individual symptoms. Do you have fungal infections?

Do you have bacterial infections? Are they tough to treat? Have you been trying to treat 

them for the past five years, and they haven't gotten better? Do you have chronic neck pain,

back pain, or shoulder groove pain? Are you having difficulty finding bras that fit? All of the

above, as well as the physicality and the dimensions of the breasts. Are you a D, or are you

the size K, and are the breasts below the beltline? Different patients. Another factor besides

your physical form and conditions is the insurance type you have.

Some insurance companies categorically deny all breast reductions. Some insurance

companies approve most breast reductions. I can have two patients with the same-sized

breasts, one will get approved, and one will get denied. It is just based on the quality of their

insurance. The better your insurance, the more likely it is that these insurance companies

will cover breast reduction. Insurance approval also depends on your plastic surgeon's letter

submission. Does your plastic surgeon have a detailed letter? 3, 4, or 5 pages with pictures

included. Or is your plastic surgeon saying, "Yeah, she might do better with a breast

reduction."? The insurance company is much more likely to reject that claim.

Ariel: Is the letter something you've helped patients with in the past?

Dr. Katzen: Oh, yes. When patients come to the office, if I think it's acceptable, I will write a

14-15 page letter to the insurance company explaining, based on this patient's symptoms,

anatomy, and things she's complaining of, that this patient would benefit from a breast

reduction.

Ariel: Do you think some people must get a breast reduction?

Dr. Katzen: Oh, yes. There are many patients for whom breast reduction would significantly

help with their neck pain, back pain, shoulder groove pain, and rashes. The benefits of the

surgery far outweigh the risks of potential complications.

Ariel: All right. And let's talk about recovery time.

Dr. Katzen: Recovery is pretty easy compared to other plastic surgery procedures. Give

yourself about a week to return to a sitting job. If you have a very physically active job,

we're looking at about two weeks of recovery…maybe about three weeks, depending on the

physicality of your job.

Ariel: That's a quick turnaround time.

Dr. Katzen: Yes, it's a pretty quick surgery. Also, of all the plastic surgery procedures I

perform from head to toe, (whether it's rhinoplasty, liposuction, tummy tucks, buttock

implantations, or BBL). My happiest patients by far are the breast reduction patients. We've

known that as a collective. That means plastic surgery societies worldwide have experienced

the same thing. Usually, breast reduction patients are usually the happiest of all our plastic

surgery patients.

Ariel: Wow, that's good. That's good for everyone.

Dr. Katzen: So, it's a very worthwhile surgery. It may be covered by insurance, depending on

you and the insurance. It's a very worthwhile surgery to perform.

Ariel: What other procedures can be performed with breast reduction?

Dr. Katzen: Combining breast reduction with other surgeries depends on your health. If

you're not healthy, I am not going to combine other surgeries; However, if you are healthy,

other procedures can be combined. With a breast reduction, I can include a tummy tuck

with a breast reduction. This is common. It is called a combination “mommy makeover”. We

can combine liposuction with breast reduction. We can combine arm lifts, facelifts,

liposuction, and thigh reductions. All those combinations can be performed with the breast

rduction. There's no procedure that I can think of that can't be done with breast reduction.

But, again, it depends on your health.

Ariel: Okay, great. The last thing is people always ask for BMI requirements. How would you

answer that one?

Dr. Katzen: Sure. BMI is an essential number used by insurance companies for approval of

cases for breast reduction. BMI is a significant number, but it's not the end all that tells your

entire medical history. For example, I have some patients with a higher BMI who are very

healthy. Even though they have a high BMI, they are much healthier than they used to be

because their BMI was sometimes double that number. Insurance authorization for breast

reduction base their authorization on your height and your weight. So, if your weight is

elevated, there is a higher chance they will reject the breast reduction based on your BMI.

So if you're looking for insurance qualifications for breast reduction, you must get your BMI

as low as possible. Your BMI should be less than 30.

Ariel: I understand. All right. Well, that's all the questions we have for today's podcast. Next

week, we'll be talking about VASER high-def liposuction.

Dr. Katzen: All right. Good. Well, thank you for having me.

Ariel: Thank you so much. And if you guys have any questions, please contact Dr. Katzen at

310-859-7770 or message us at @drkatzenmd on Instagram. All right. Have a great day.