Breast Reduction Surgery in Singapore - How does it work & how much does it cost?

Breast reduction surgery, more accurately termed reduction mammoplasty/mastopexy, is not as widely discussed as procedures like breast augmentation or enlargement.

There exists a group of women who require a breast reduction surgery. Unlike breast enlargement, this procedure is a medically-indicated treatment than a cosmetically driven one. 

The medical condition which afflicts these women is termed macromastia, where the women’s breasts are disproportionately large and heavy since teenage years. Often, this happens to women who are not obese or large-built, but average-sized with disparately large and heavy breasts.

Many a time, these women have been suffering quietly with macromastia before seeking treatment because they are not aware of the good surgical options that are available now. 

What are the symptoms of macromastia? 

I typically divide the symptoms into 2 major categories - physical symptoms and psychological symptoms. The physical symptoms of this condition include:

●    Upper back and neck pain
●    Poor hunched posture
●    Bra strap grooving
●    Recurrent rashes in the cleavage and lower breast fold (inframammary fold), also known as intertrigo
●    Finger tip numbness in the particularly severe ones (paraesthesia) due to the chronic hunched posture of the neck

The psychological symptoms, which may not be as apparent as the physical ones, include:

●    Social ridicule or embarrassment, particularly in the school-going years
●    Inability or difficulty in finding clothes and undergarments that fit
●    Inability to participate well in certain activities and exercises  

Many of my macromastia patients come to me with a collection of some or all of the above symptoms. Unfortunately, the symptoms do not go away with age. In fact, some progressively get worse with age, such as the upper back and neck pain, as well as the rashes which may result in abnormal skin pigmentation or scarring.

Furthermore, they do not get a good understanding from others, even from other women, on their degree of suffering with this condition. Many people, especially men, do not comprehend how having large breasts can be a problem, much less a medical one.

The breast reduction patients that come to see me are usually in the younger age group, between 20 to 40, with the youngest patient I have treated for this condition being 16. For the younger patients, they are accompanied by their parents (usually the mom), which is important, as this procedure is a permanent, life-changing one. The typical bra cup size of my patients that seek this procedure range from DD to H cup.

Why does macromastia occur? Will it recur after surgery?

Physiological macromastia[1] (the most common kind) occurs usually from teenage years after puberty, due to the increased sensitivity of the breast gland receptors to the circulating hormones. They usually do not grow much more after 16-18 years of age.

After a reduction surgery where the breast glands are removed, they do not grow back, hence the condition does not recur. If the patient puts on weight, the breasts will enlarge but with fat rather than breast gland tissue; fat being much lighter would not result in much increased strain on the neck or upper back, therefore, symptoms do not usually recur.

What happens during the consultation?

The first thing I do during the consultation is to assess their fitness and suitability for the procedure. This means that I screen through the patients to ensure that they are medically and psychologically fit to undergo this procedure.

Firstly, I emphasise that this procedure, unlike other procedures I perform such as double eyelid surgery and breast augmentation surgery, is a permanent irreversible procedure. Therefore, the patient must consider and be aware of all the factors and consequences before making the decision to undergo a breast reduction.

Secondly. I then ascertain the various symptoms that they may be experiencing due to the macromastia (listed above). This is followed by determining the patient’s current bra cup size as well as their target bra cup size. The most common refrain I hear from all my patients is to make their breasts “as small as possible”. While I can understand why, I do not encourage as in my opinion, there are 3 targets of this procedure:

1.    A safe breast reduction includes nipples having normal sensation, minimising the scar on the breast and minimal complications
2.    A resolution of the patients symptoms that they were having before the surgery. Often, one does not need to have a reduction to “as small as possible” to alleviate the symptoms; the weight of the removed breast is quite important in this aspect.
3.    A more lifted, aesthetic-looking breast

All 3 of these goals are equally important. 

I then discuss the important aspects and risks of the breast reduction surgery,[2] which will fall into the various sub-categories:

●    Scar: I typically perform a modified vertical short-scar breast reduction, which was popularised by Dr. Elizabeth Hall-Findlay in the U.S.,[3] for the majority of my patients, instead of the traditional form of breast reduction. This technique allows me to avoid the long “anchor-shaped”/Wise-pattern scar that traditional breast reduction entails. My technique yields a much shorter “lollipop-shaped” scar. The overall shape of the breast also looks more pleasing and less “boxy” in my opinion. The scar in most of my patients will initially appear red or pinkish and will take about a year to mature to a pale whitish scar. This scar is permanent and my patients must be able to accept the appearance before I proceed.


 

●    Nipple-areolar viability and sensation: This is extremely important as it impacts on the final appearance of the breast as well as the ability to breastfeed well in future. I typically will reduce the size of the areolar for my patients if they have been stretched out by the size of the breast during the reduction surgery. Careful measurements of the pedicle (the length of tissue supplying blood to the nipple) length and correct choice of the breast pedicle is vital to making sure the nipple stays alive during and after the surgery; if carefully performed, it is extremely rare to have the nipple die off. More commonly, the sensation of the nipple may be affected by the surgery in the initial few weeks after the surgery, being either too sensitive or less sensitive. In my experience, fewer than 1% of patients have permanent loss of nipple sensation after the surgery.

 
●    Breast feeding: As most of my patients are in the younger age group, I have to consider their future plans for pregnancy and breastfeeding. As some of the breast glands are removed during the breast reduction, it is expected that there will be a drop in the patients’ ability to breast feed in the future; they will still be able to breastfeed (I quote around 30-40% reduction in ability) but may require formula milk supplementation.
●    Infection: This is part and parcel of any surgery and we are very careful that they are covered with antibiotics during and after the surgery.
●    Stitch exposure: I use completely absorbable sutures for the procedure (Monocryl). There is no need for stitch removal after the surgery as the sutures are absorbed by the body, some of the knots may extrude outwards like a pimple. This only occurs in the first 2-3 months and is treated very simply with antibiotic ointment for a week.
●    Bleeding and blood clots (haematoma): This is a significant problem with certain methods of breast reduction. However, the technique I perform and the equipment I use allows for very little bleeding during the surgery. As such, I perform the procedure as a day surgery and I do not use any drainage tubes unlike the conventional technique. This allows for a more comfortable recovery period for my patients.

How do patients prepare for the surgery?

I will usually send my patients for a simple pre-operative screen, such as a mammogram or a breast ultrasound, so as to exclude anything suspicious. On the patient’s side, they would have to avoid certain foods, medications and/or supplements about 1 week prior to the surgery to reduce the chance of bleeding and blood clots.

What happens during the surgery?

The surgery is performed under general anaesthesia (GA) with an anaesthetist present to administer it. It is however, a modified version termed total intravenous anaesthesia (TIVA), which means my patients are not paralysed and breathing on their own. There is no breathing tube in their airway. This allows for a greater safety margin for my patients and a much more pleasant recovery period.

The entire procedure takes 4-5 hours, depending on the size of the breasts being reduced. I reduce between 600gm to 1.8kgs total in breast tissue for my patients. The important thing is how much I leave behind, as that determines the final size and shape of the breast, as well the resolution of the symptoms such as back and neck pain. In my experience, with reduction of 3 cup sizes or more, there should be almost complete resolution of symptoms.

What is the post-surgery recovery like?

The surgery is performed as a day surgery procedure in my centre. I do not put drainage tubes; my patients only need to wear a compression bra, for around 3-4 weeks. In terms of pain, my patients only require oral painkillers, of which a significant number do not even require or take. It is usually far more comfortable than breast augmentation for example.

In terms of return to work, my patients are given hospitalisation leave of around 1 week, although many go back even sooner. Return to the gym, pilates/yoga and strenuous physical activity typically is after a month from surgery.

What is the cost of the surgery? Is it Medisave and Insurance covered?

In order for the surgery to fulfil the criteria for Medisave and insurance claims, there is a minimum criteria in terms of weight - either 250gm from 1 side or 500gm in total from both breasts. The breast tissue would need to be sent to the laboratory for the pathologist to examine and weigh.

My surgical fee starts from $12 000. The cost of surgery is also dependent on the following factors: anaesthesia fees, facility fees, medication, garment and the equipment/medical consumables. GST is of course the last factor.

References:
1.  Rahman GA, Adigun IA, Yusuf IF. Macromastia: a review of presentation and management. Niger Postgrad Med J. 2010 Mar;17(1):45-9.
2.  Akyurek M, Chappell AG. Short-Scar Mammaplasty in Severe Macromastia. Ann Plast Surg. 2016 Dec;77(6):609-614.
3.  Hall-Findlay EJ, Shestak KC. Breast Reduction. Plast Reconstr Surg. 2015 Oct;136(4):531e-44e.

 


 

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