Key points

Breast reduction surgery, a common procedure in plastic surgery has enjoyed high satisfaction ratings well into the mid-90% level. In recent years, however, breast reduction has risen to the second highest procedure associated with breast litigation. What has changed? It is unknown whether patient expectations have evolved beyond appropriate, if practices misrepresent the risks and concerns of this procedure, or if a general lack of patient accountability exists. Regardless of the reason, it behooves plastic surgeons to understand the increased risk of breast reduction and incorporate an appropriate amount of time and discussion to address concerns. First, this article is separated into areas of general risk, which include general scarring, infection, and anesthesia, to name some. Second, specific risks associated with scarring, loss of nipple areola, size, asymmetry, and laxity along with many patient misconceptions about the level the breast remain. Third, there are specific issues with insurance coverage that pose significant risks to patients at the practice. Last, in the digital age, there must be a discussion of protecting patient information, especially photographs, and other patient identified drawings and information used in the process known as informed consent.

General risks

General risks can be found in most informed consent documents and it is suggested that the included items be discussed and understood so that patients have an understanding of general risks with any surgery and anesthetic and of the preparation, preoperative, intraoperative, and postoperative requirements and instructions.

General risks

General risks can be found in most informed consent documents and it is suggested that the included items be discussed and understood so that patients have an understanding of general risks with any surgery and anesthetic and of the preparation, preoperative, intraoperative, and postoperative requirements and instructions.

Specific risks

There are many specific risks attributable to breast reduction surgery. There are however specific risks associated with this procedure attributable to the many different techniques used that should be understood. I recall a lawsuit many years ago that I reviewed of a surgeon who showed photographs of bad thickened wide scars. The patient, however, had scars that were worse than the worst depiction shown to her. Surgeons must be careful to not represent the level of scarring or how bad scars may become or how good they might be over time. Every patient is different and it is important to not create a warrantee that will be discussed later about the end result. Smoking has been well shown to affect healing and can have devastating effects on breast reduction. Generally it is recommended to stop any form of nicotine usage whether by nicotine patches or other nicotine related uses devices or a tobacco 3 to 4 weeks before the surgery date. I understand smoking is an addiction and some patients are dishonest or embarrassed to acknowledge they have not stopped; a urine cotinine test can detect nicotine usage up to a month prior. It is important that patients acknowledge they smoke and are aware of the effects of nicotine on potential loss of nipple areola and poor scars. Another issue arises when a practice becomes aware of a patient’s continued use of tobacco. The warnings alone are not a protection to the practice if blood supply is affected. The practice may have a duty to cancel surgery and consider alternative means to protect and assist patients’ results. I am aware of many instances where the surgery time is blocked and at the morning of surgery it becomes evident a patient has continued to smoke. Having the patient acknowledge the dangers is an advantage but the practice knowingly continuing to proceed with surgery may remove that help completely.

Patients unrealistically may seek the breast form at a higher level on the chest and mistakenly believe that breast reduction procedure can achieve that. The base of the breast is where it is anatomically located and, if there is a degree of ptosis, that usually is adjusted during surgery, but it cannot reposition the base of the breast to a higher position. There should be a specific discussion in tall-chested patients about realistic results as well as a possibility of additional maneuvers to increase the upper pole, such as fat injections into the upper chest. The entire area of patient expectations is fraught with misconceptions and challenges. The misunderstanding of being able to raise the base of the breast higher on the chest is an example of an incorrect patient expectation. Many patients believe that once a reduction occurs, any future level of ptosis will not occur. It is important to mention that their skin texture is unchanged and whatever genetic propensity for stretch and laxity they have will remain. I have discussed with my patients that bottoming out or relaxing the inferior pole can be common, and often an office procedure in the future to regain breast shape may be indicated.