Upon reviewing the height weight and bra size given, my first response is to your body size and image.  For a woman who is reported to be 5 feet 7 inches in height, the Metropolitan height weight table suggests weight would be in the range of 121-147 pounds, depending on your body frame size.  Your reported weight is 223 pounds which conservatively means you should first reduce your weight by approximately 76 pounds.  An overall weight reduction program would be an excellent goal to improve your overall health and fitness.  Weight loss will also reduce the weight on your musculoskeletal system and decrease the stress on your spinal column and shoulders.

The second issue is your breast size.  Your breasts are composed of a certain percentage of fatty tissue, which increases with age (fatty tissue to glandular tissue ratio).  At 19 years of age, most of your breast tissue would be glandular.  However at a weight of 223 pounds there is most likely an increased percentage of fatty tissue present.  My suggestions would be to first incorporate a plan of healthy eating, exercise and overall weight reduction.  As you approach your more ideal weight and build stamina and improved fitness you should be evaluated for a possible therapeutic breast reduction.  I would work on both of these together as a holistic approach to your issues of large breast and shoulder grooves.

Although many might feel that 16 years of age is too young for a breast reduction, they are not considering the psychological, emotional and physical problems that these individuals undergo and suffer.  I would certainly have a consultation with a Board Certified Plastic Surgeon and find out what options are available.  Chronologic age is not the only determinant for interventional surgery.   

Removal of the fat under the arm during reduction surgery depends on whether you are a smoker or not, the type of reduction done and the tightness of the skin closure.  The surgery itself under insurance is to reduce the size of the breast.  Extra work done is not required and when done it will be up to the surgeon to do or not to do.  In cosmetic surgery not covered by insurance more is done for refining the final results.

There is not a general answer to the question. The appropriate recommendation depends upon the ratio of excess skin to breast tissue volume. It also depends upon whether the patient's goal is primarily size reduction, or mainly reshaping.  If size reduction is the main goal, an implant is not usually placed, since the improvement in shape would be offset by adding back volume.  If reshaping is the main goal, an implant to add to upper breast contour could be beneficial.

The combination of breast lift/reduction operations is on the top of the list of operations in aesthetic surgery accompanied most commonly by complications.  Therefore, your plastic surgeon will try to avoid placing an implant at the same time.  Depending on the characteristics of your particular breasts, as a result of a reduction and/or lift (without an implant) you may end up not only with a pleasing appearance, but also with sufficient breast firmness.  When more projection and firmness would be desirable, an augmentation in a separate operation may be the most prudent way to proceed.  As in any aesthetic surgery, there are exceptions to the above, based on findings that can properly be determined only through an in person examination by a board certified plastic surgeon.  I hope this is informative.

In the course of a consultation for breast reduction there takes place a discussion of expectations, specifically, upon recovery from surgery, how will the breasts look and what size will they be.

The primary goal of breast reduction is to alleviate the symptoms of the breasts being disproportionally large.  The usual goal is to make the breasts proportional to the torso. Usually the patient's first instinct is to make the breasts very small, but a year after surgery when it's time to put on the evening gown or bathing suit, proportionality usually prevails.  In any event, prior to surgery there should be a long discussion and clear communication regarding outcome and post-operative size.  Although, as surgeons we don't have a cup size measurer in the operating room, usually the results will reflect the patient's desires.

If expectations exceed what can be reasonably accomplished during the course of a breast reduction it is imperative that those red flags are raised prior to surgery. The patient needs to be honest with the surgeon regarding goals, and if those goals can not be reasonably met by the surgeon, surgery should not go forward.

You may be a good candidate for breast reduction surgery; however it depends if you have other illnesses like high blood pressure, diabetes, heart disease, smoking history, asthma or emphysema, etc. If you don't have other medical issues, the breast reduction surgery can certainly help reduce your breast size and help with the drooping of the breasts. Most of the time, this helps with back pain, but there is no guarantee.


Furthermore, you would be classified as morbidly obese with a body mass index of 43. It has been shown in several published reports that patients with body mass indexes over 30 are at much higher risk of operative complications including wound breakdown, delayed healing and deep vein thrombosis and pulmonary embolus.
The stretched skin is really not a problem at this point, but the blood supply to the nipple can be compromised if the distance it has to be lifted up is excessive. Only in consultation with a board certified plastic surgeon would your true risks, benefits and likelihood for success be properly assessed.

That is a difficult question to answer since pregnancy can affect both of the causes of breast enlargement: hormonal changes and weight gain. I tell every patient that any body contouring procedure is best done on somebody at a stable weight within a range where they are "supposed" to be. If you choose to have a breast reduction before being finished with child bearing then you must accept the possibility that another procedure may be required later. You may not gain back all of the size and weight. In fact, you may actually decrease in size. But you certainly need to be open to the possibility of additional surgery to make your breasts look the way you want them to look. You must decide how badly you want to have a reduction now, rather than waiting until later.
There is no right answer or wrong answer possible here. There is also no way of predicting what your breasts will look like after pregnancy.

The short is "no," but the longer answer is more complex. Standard breast reduction (reduction mammaplasty) surgery generally involves an incision (and later a scar) around the areola (the pigmented area around the nipple), down the front of the breast (vertical incision), and (sometimes) along the fold or crease under the breast (the IMF or inframammary fold incision). However, not every breast reduction involves all of these scars. Some breast reductions involve simply an incision around the areola, but that is not usual. Breast reductions also can be done with tiny incisions by using only liposuction, but that is even more unusual.



The incision pattern is determined by the needs of the patient and the size and shape of the breasts. Very "droopy" or ptotic breasts can be lifted by altering the skin only. If, in addition to being ptotic the breasts are overly large, then some breast tissue must also be removed. This is done to relieve neck, back and/or shoulder pain related to the large size of the breasts. The incision pattern can be the same either way. It is generally called a "Wise pattern" or "anchor pattern," the latter name coming from the shape formed by the combination of the incision around the areola, down the front of the breast and the IMF incision. Another possible incision pattern is the "lollipop" or what we call "circumvertical", which is a combination of the incision around the areola (circumareolar) and the vertical incision. This is also called a "vertical reduction mammaplasty."



One other option is a breast reduction done with a combination of a periareolar incision and an IMF incision, leaving no vertical scar. This can leave a lot of bunching at the IMF incision which can compromise the result, and it is not the preferred technique of most plastic surgeons.



For patients who have breasts that are larger than they would like, but do not have much "droop", liposuction alone may be a reasonable option. This can be done with small incisions under the breast, leaving scars that are virtually invisible.

Timing of breast reduction after having a baby depends on several things. First of all, you want to be at your ideal weight so that there would not be any changes in breast size after the operation. The exact timing will vary because women lose their pregnancy weight at a different rate. Next thing is breast feeding. If you are breast-feeding your baby, you have to wait until you are done with it. You want to make sure that the breasts have settled to a stable size without active milk production. Therefore, if you have not breast-fed and have lost your weight successfully, 6 months should be adequate. Otherwise, you should wait until milk is dry and weight is down. Lastly, you need to consider your family plan. If you are planning on having more children, you should wait until you are done with child-bearing.
Flying after an operation is no problem physically. The concern is mainly possible interruption of follow-up care. You want to make sure there are no complications and healing is progressing well before you travel away from your doctor. This may take a couple of weeks. However, it is not a hard and fast rule. If you have a good doctor available where you are traveling to, it could be sooner.

Thank you for your email concerning revision breast reduction surgery. The use of liposuction as a technique in breast reduction surgery is well documented and accepted. The skin of the breasts after the liposuction needs to re-contour about the remaining glandular tissue. Depending on the patient’s age, weight, medical history and smoking history, the skin may not contract and tighten about the breast gland, as one might wish.
In those cases, a formal breast lift (mastopexy) may need to be performed in order to tighten and re-shape the breast. At the same time a revision of the breast reduction can be performed if one wants additional tissue to be removed; the size and shape of the nipple and areolar appearance can also be altered if desired.

After performing the procedure, I would care for the patient for the first week of the healing process. She should be able to travel back overseas (barring any complications) one week after the surgery. At this point, once she has returned home, a board certified plastic surgeon there can take over her care.

Age 18 is a common time for breast reduction and can be very helpful for a young woman who is self conscious. You should seek out an American Board of Plastic Surgery certified plastic surgeon and have a thorough consultation. You should feel free to bring your mother or trusted confidante to the consultation and ask the surgeon any questions that you need answered before making a decision to have the procedure.

Breast reduction surgery can be a life changing operation. The complaints that your granddaughter has are common for women with large breasts. Pain occurs primarily in the lower neck, upper back and shoulders, but the breasts themselves can also be painful. Constant skin to skin contact beneath the breast can result in a recurrent rash that can be difficult to treat. The benefit of breast reduction surgery is that these types of problems usually improve, and in many cases completely resolve. While the benefits may seem obvious, the risks also need to be discussed in detail with the Board Certified Plastic Surgeon you choose. Here are a few things to consider:



Development of the breast is not complete at age 12. It is best that the breasts are stable in size prior to reduction surgery. There is an increased risk that the procedure will need to be repeated in the future when breast reduction surgery is performed at a young age. In other words, if the breast is still growing, it will likely continue to grow after surgery.



Psychological development in a patient is not complete at age 12. Maturity occurs gradually and faster in some than others. It would be important for the plastic surgeon to evaluate your granddaughter's maturity to see if she is ready to make the decision. This can help not only to determine if she is equipped to handle the surgery and subsequent recovery, but also to minimize the risk of this being a surgery that she regrets in the future.



There is scarring as a result of breast reduction surgery, and this is the big tradeoff. Most patients are very happy to trade in their back and neck pain for scars that are covered by clothing. Moreover, clothing tends to fit better after the surgery. It may be easier for patients who are married and already have had children. Most are in a stable, supportive relationship. They have had a chance to discuss the surgery with their mate prior to having the operation, and they do not have to worry about dating someone new and explaining the scars.



Breast feeding will likely be affected. The most common types of breast reduction surgeries maintain the connection between the nipple and a portion of the remaining breast tissue. This may allow for breast feeding in the future, but breast reduction patients need to accept the fact that breast feeding may not be possible after surgery. Since a significant percentage of the breast is removed, a much smaller amount of breast tissue remains to produce milk.



Other considerations are needed, and additional information is available on the ASAPS web site at www.surgery.org. I have tried to focus in on the unique issues that pertain to breast reduction surgery at an early age. It is not possible to be precise via e-mail. If your granddaughter is seriously considering breast reduction surgery, she will need to make a consultation appointment with a Board Certified Plastic Surgeon. After a brief history and physical examination, the surgeon can provide you with specific information.



It would be important that family be involved, and should attend all doctor’s visits, especially the consultation appointments. You may want to give your granddaughter some privacy during the brief physical examination, but she will probably find it reassuring to have supportive family members around. This can help her ask pertinent questions, and remember the answers. All will get a chance to ask questions and get comfortable with the idea prior to proceeding - this can only help make the experience a good one. Whether the decision is made to proceed or wait, you will have all the information you need to make an informed decision.

Your heart arrhythmia would likely not preclude you from having your surgery. After a thorough evaluation by your cardiologist, you may be cleared for surgery. Of course, each individual case varies and you would want to discuss the risks versus benefits of this procedure with your board certified plastic surgeon as well as your cardiologist. You should also discuss the location of the surgery - whether it is to be performed in a stand-alone office or surgi-center versus a hospital. Included in the discussion should be the type of anesthesia that will be administered, such as general anesthesia or twilight - each type has its advantages and drawbacks. In short, with proper pre-operative evaluation and assessment, appropriate understanding of the goals and risks, and choosing the right setting, you may be able to proceed safely. Both your cardiologist and your plastic surgeon will want to make sure that your safety is paramount.

Following breast reduction surgery, as a plastic surgeon, I am most concerned about allowing the scars to heal without spreading. To accomplish this I ask that the patient keep her arm activity to a minimum for 4 to 6 weeks. However, I teach the patient slow deliberate shoulder and pectoralis stretching exercises that do not spread the scars starting two days after surgery and ask the patient to do them two to three times a day. This will not affect the scars but will prevent shoulder and pectoralis stiffness.

I generally have patients wait a minimum of six months following breast-feeding before undertaking breast reduction. This allows for the secretory phase to subside and for the breasts to assume their normal volume and position.

Having high blood pressure will not prevent your having the breast reduction surgery, but it certainly does complicate it. First, you should not even think about having the surgery until your blood pressure is well controlled in a normal range. Once it is controlled, you need to meet the anesthesiologist who will be doing your anesthesia. He or she needs to be aware of the problem and of what medications you are on. This is important since different medications will affect anesthesia differently. The anesthesiologist will also have to watch your blood pressure more closely to make sure it does not rise either during or after anesthesia, as this could cause bleeding and hematoma (blood clot in the breast) which could lead to loss of skin or the nipple. For the same reason, you may want to consider an overnight stay to monitor your blood pressure until your body stabilizes somewhat. Having the doctor who is caring for your blood pressure available that first night is another precaution to improve your chances of having no problems. With these precautions, however, you should be able to have your surgery with only minimal increased risk.

During the physical exam, the surgeon estimates how much extra breast tissue there is. During surgery, as the tissue is removed, the surgeon will compare the two breasts to get the size match as close as possible.

A breast size of 34DD is often associated with back pain, dents in the shoulders, and the other characteristics you describe. Patients with these symptoms usually are appropriate candidates for breast reduction surgery. A thorough consultation including assessment of your overall health status, body-mass index, psychological profile, and physical findings would offer the plastic surgeon an opportunity to make a more definitive recommendation. It is often possible to go down to a C-cup, though it depends on a number of factors. Though attempts are made to disrupt the breast ductal system as little as possible during surgery, there are certain unavoidable risk factors that any patient must understand before surgery. Impairment of lactation and loss or change in breast sensation, for example, are both well-documented risks.

The initial healing for breast reduction surgery is generally about 10-14 days. By two weeks, most of the significant swelling and bruising have gone away, and the incisions have healed well enough for the stitches to be removed. I usually recommend to my patients that they should not do any heavy lifting or vigorous upper body exercise for about 3-4 weeks after surgery, to be on the safe side, but this can vary. Many of my patients have returned to work duties by a week or two after the operation. Most patients are fully recovered and back to all activities by 6 weeks after surgery, at the latest. Fortunately, most patients find that the surgery is less painful than they expected, and most also find that the back, neck and shoulder pain that led them to undergo breast reduction surgery tends to decrease almost immediately. As with any breast surgery, final shaping and scar change may take a few months to almost a year.

The areolas (pigmented skin surrounding the nipples) can be reduced. The recommended size is between 3.8 and 4.2 centimeters in diameter. We generally try to make the areola round. However, it can change shape over time because of the weight of the breasts and gravity. I do not advise reducing the nipple size in a young woman since that may interfere with breast feeding.

As a diabetic you are at higher risk for wound complications such as infection and wound separation. Having said this, a vertical type reduction (leaving the scar in the shape of a lollipop) leaves less scarring and also less chance for skin breakdown than a "Wise Pattern Reduction" (scar in the shape of an anchor).

The initial healing for breast reduction surgery is generally about 10-14 days. By two weeks, most of the significant swelling and bruising have gone away, and the incisions have healed well enough for the stitches to be removed. I usually recommend to my patients that they should not do any heavy lifting or vigorous upper body exercise for about 3-4 weeks after surgery, to be on the safe side, but this can vary. Many of my patients have returned to work duties by a week or two after the operation. Most patients are fully recovered and back to all activities by 6 weeks after surgery, at the latest. Fortunately, most patients find that the surgery causes less discomfort than they expected, and most also find that the back, neck and shoulder pain that led them to undergo breast reduction surgery tends to decrease almost immediately. As with any breast surgery, final shaping and scar change may take a few months to almost a year.

As you are a 36DD, your large size may require a more traditional breast reduction procedure. The so-called "limited incision" or “short scar” techniques are most often used when the breasts are smaller. Of course, a recommendation could only be made on the basis of a personal consultation and exam by a qualified plastic surgeon. Many insurance companies view this surgery as reconstructive and may actually pay for the procedure. Surgery is done as an out-patient and post-surgical discomfort can be controlled with medication.

It is generally believed that you should not undergo surgery until lactating has stopped. This usually means waiting for 6 months after you stop nursing your child. In addition, you will find that the shape and size of your breasts will change during this period, which is important to the proper planning of your breast reduction surgery.

Many young women undergo breast reduction surgery. Your age is less important than your history of breast development. If your breast size has remained stable for six months or more, you may be a good candidate for breast reduction surgery.



You indicate that you feel you are overweight. Ideally, it would be best to lose some weight before considering this surgery. However, it is not uncommon for women to complain that even with weight loss, their breasts do not reduce significantly. If this has been your experience, or you simply cannot lose weight, you can still undergo breast reduction surgery. Many woman find that the surgery actually gives them the incentive to lose weight.



Finally, you asked about going back to school without anyone knowing that you had this surgery. I think this would depend on the type of clothing you wear when you return to school. Comfortable, loose fitting tops would be less "revealing" and your schoolmates might be less inclined to notice the change in your breast size. Over time, you should feel less self-conscious and begin to enjoy your new breast contour.



The most important thing that you can do if you are considering breast reduction surgery is find a board certified plastic surgeon who is a member of the American Society for Aesthetic Plastic Surgery. Make sure that he or she is experienced in breast reduction surgery and ask lots of questions when you go for your consultation.

Considering that it takes 1 year for the scars to mature, and that the breasts start to increase in size after 3 months of pregnancy, I advise my patients to wait at least 9 months before becoming pregnant.

Insurance companies have specific requirements for a minimum amount of breast tissue to be removed during breast reduction surgery in order for it to be considered a reconstructive procedure covered by your insurance policy, rather than a cosmetic operation which typically is self-paid by the patient. Please consider, though, that you need to be satisfied with the outcome of your surgery both in terms of relief from symptoms such as shoulder and back pain, and achieving a breast size that is in proportion to your height and weight.



I could make a guess that your breasts would likely be half their present size after surgery, perhaps at the small end of the C-cup range, but this is a question that can’t be answered accurately without examining you. As far as your current cup size, many large-breasted women wear bras that are smaller than what a bra-fitter would place them in, because the smaller, tighter bra gives more support. Also, using a larger band-size with a smaller cup – for example, wearing a 36 DD instead of a 34 DDD or 34 E -- can serve as a "minimizer." During a plastic surgery consultation, a board-certified ASAPS-member plastic surgeon would be able to give you a good idea of your postoperative size based on the requirements of your insurance company, but ultimately you will need to decide what size you want to be. If it comes down to a choice of insurance coverage or being satisfied with your appearance, you would be wise to consider paying for the operation yourself to achieve a result you can be happy with for the rest of your life.

Once breast tissue is removed, it cannot be put back. Breast reduction surgery is irreversible, so you are correct to approach the surgery with the utmost caution. However, in many cases, breast reduction surgery is the right choice and can significantly improve a woman's quality of life. If your daughter's large breasts interfere with normal physical activity, or if their weight causes back or shoulder pain, breast reduction may be recommended. In addition to relieving these symptoms, the surgery may improve the shape of her breasts. It also is likely to make her feel less self-conscious about her appearance.



Your daughter needs to be realistic about what is involved -- breast reduction is a major operation, usually requiring a brief stay in the hospital. There are a number of possible techniques, but, in most cases, there will be visible scars. However, most women who decide on breast reduction find that the freedom from pain and the ability to find clothes that fit well are worth it. Most plastic surgeons agree that breast reduction surgery has one of the highest satisfaction rates of any surgical procedure they perform. Start by taking your daughter to a board-certified plastic surgeon for an evaluation. The doctor can help you decide if breast reduction is appropriate and if your daughter has the maturity to make such an important decision at this time of her life.

Currently the best intervention for lightening the areola or any pigmented area would be with skin bleachers, such as hydroquinone and kojic acid that will remove pigment with continued use. You should be able to receive guidance in this regard from an ASAPS-member plastic surgeon. Cost would be ongoing, and would include charges for office visits and products. Costs may vary depending on your geographic area and the surgeon you select. Risks and side effects are minimal, assuming the patient is not allergic to the product(s). This treatment would be contraindicated during pregnancy or breast-feeding.