Breast reduction surgery provides lasting relief for most patients. Very commonly, though, we see patients who have had a breast reduction previously. It could have been 10 or 20 years ago, and sometimes as little as a year or two ago, and they are looking for more.
A second breast reduction, also called a breast re-reduction or secondary breast reduction, is a fairly niche topic, and it is a different operation from a primary reduction. The blood supply to the breast has already been changed, the tissue planes are different, and the complication profile is not the same. That potential risk is why there are a lot of surgeons who won’t do them.
Watch our Plastic Surgery Consults podcast on breast re-reduction below, where we discuss why breasts can grow again after a reduction, how a second reduction differs from the first, the risks involved, and how much tissue can realistically be removed.
Why Do Patients Consider a Second Breast Reduction?
Patients who come in for a secondary breast reduction usually fall into one of two groups.
The first group had their original reduction 10 to 20 years ago. The first reduction gave them a lot of relief, but they feel their breasts have grown again. That could be because of hormonal changes, weight changes, or just general life. For whatever reason, the breasts have grown some more, and they would like to get the kind of relief they had the first time around.
The second group had their reduction more recently. Sometimes they haven’t had enough taken off and would like to get more off. Sometimes there are little issues with their primary reduction that they’re not happy with. Perhaps one side is significantly larger than the other, or they’re not happy with the nipple-areolar placement. Theoretically, it could even be one of our own patients who wants to be smaller than we could safely make them in the primary procedure.
Common reasons for a re-reduction include:
- The breasts have grown again after the first surgery
- The first reduction was not as large as the patient would now like
- Breast asymmetry after the primary procedure
- Dissatisfaction with nipple-areolar position
- Sagging of the breast over time
Gravity and the Lift Effect
Gravity does work on breasts, and it starts to work immediately, even after surgery. Very commonly, patients are also looking for the lift effect, or mastopexy effect, that often comes along with a reduction. A breast reduction includes a breast lift, or mastopexy, as part of the operation.
The position of the breast matters for comfort as well as appearance. Think of it as a lever arm, like when your arms are held straight out away from your body. If the breast is more centrally located, closer up and higher on the chest, there is less force on the neck and shoulder area, where patients get those symptoms. So even though a breast lift is not necessarily indicated for function, it can provide some relief of those symptoms.
Can Breasts Grow Back After a Breast Reduction?
A pretty common question we receive from women is: if I get a breast reduction, are my breasts going to grow back? We have always said that there is a potential for growth in the perimenopausal and post-menopausal population, and that it is quite rare. But we did a deeper dive into this question for the podcast.
A paper from 2004, so obviously dated, showed that about 1 in 5 post-menopausal women (18.6%) will experience a meaningful increase in breast size, defined as needing to purchase a larger bra size. Only 1.7% ever reported a decrease in bra size after menopause.
That is a little more meaningful than we had actually known, but it rings true with what people are coming into the office talking to us about. It really points to the changing hormonal milieu in the body and the effects it has. Of course, we have a bias in terms of the patients who actually present to us, so we don’t necessarily know how everybody changes over longer time frames.
How the Breast Changes With Age
The breast is made up of fibroglandular tissue, which includes the milk ducts and glands, and fatty tissue. As women go through the menopausal transition, the glandular tissue gradually shrinks in a process called involution. At the same time, fatty tissue makes up a growing proportion of the breast.
Studies show this changes at a rate of about 3.9% to 4% per year during the perimenopausal period. Dense breast volume decreases by about 2.2 cubic centimetres per year across the menopausal transition, based on a 2019 study in a cancer epidemiology journal.
It’s not one-size-fits-all. Genetically, some women have much more glandular and firm breasts, and that can change over time. But in general, the replacement of fibroglandular breast tissue by fatty tissue is pretty consistent across everyone. This is probably the patient who had a reduction 15 or 20 years ago and is coming in to see us.
Weight Gain Is the Strongest Predictor
In that 1 in 5 women whose breasts enlarge after menopause, the strongest predictor is actually weight gain. With each one-point increase in body mass index (BMI), the breast generally increases by a volume of about 30 millilitres.
BMI is calculated from weight in kilograms divided by height in metres squared. If a patient has gained weight and has a higher BMI, she is also in a population with a slightly higher rate of healing problems. It all kind of fits together.
Why a Secondary Breast Reduction Is a Different Operation
It’s important for patients, and even surgeons, to understand that a secondary reduction is a different operation. The complication profile is different, and there is a higher complication rate overall, both in the literature and in our experience.
The key reason is blood supply. In a primary reduction, the nipple and areola stay attached to a section of breast tissue called the pedicle, which keeps them supplied with blood. (We explain the pedicle in more detail in our article on breast sensation after breast reduction.)
If the first surgery disrupted the native blood supply to the breast, let’s say instead of four different vessels coming into the breast you’re down to one or two, you’re now relying more on blood supply from one direction. If a surgeon goes back in without knowing which pedicle was used, in theory that remaining supply could be divided.
Several factors make a re-reduction more complex:
- Disrupted blood supply: Fewer major vessels remain, so damage to any one of them has a greater effect.
- Scar tissue: You’re working in tissue planes that have already been operated on, which makes dissection a little more difficult and a little less predictable.
- Less tissue to work with: It’s just a smaller breast, so there’s less tissue available to safely design a blood supply for the nipple-areolar complex.
- Unknown original technique: Often, 20 years after a primary reduction, the surgeon who originally did that surgery is probably retired.
We do know the body adapts and recreates some blood supply. And if you know the primary reduction was done with an inferior pedicle, you can potentially use the same pedicle and preserve that same blood supply. If you weren’t the surgeon who did the primary surgery, it becomes a bit more tricky, but there are safe ways to do these secondary reductions even if you don’t know how the first one was done.
Risks and Complications of Breast Re-Reduction
Based on quite a few studies in the plastic surgery literature, the overall complication rate for secondary reduction is between 13% and 17%.
Fat Necrosis
Number one is fat necrosis. Fat necrosis is basically hard balls of fat within the breast after surgery. It points to a change in blood supply to the remaining breast, and it is particularly an issue in a secondary reduction because there are probably fewer feeding vessels to the breast after the primary surgery.
Wound Healing Problems
There is an increased risk of wound healing issues, particularly with a mismatch of the pedicle, or blood supply, used in the two operations.
Delayed Return of Nipple Sensation
There is more often a delayed return of nipple sensitivity after a secondary reduction.
Nipple-Areolar Complex Compromise
The most feared issue is necrosis of the nipple-areolar complex. In the historical literature, some series show an issue in as many as 50% of patients, and 67% in one series. But more recent case series show that with certain techniques you can really preserve the nipple-areolar complex, and there shouldn’t be any issues.
Seroma
The dramatically elevated risk is that of seroma. A seroma is excess fluid, basically like serum, so it’s not blood. There are open areas in the breast that can fill with fluid from inflammation, and if that fluid doesn’t get absorbed by the body properly, it’s called a seroma. It can be a little uncomfortable, cause swelling, and affect your cosmetic outcome.
A lot of these so-called complications can resolve with care and follow-up. They can, however, have an impact on the length of recovery and quality of life for a period of time.
Four Principles for a Safer Secondary Breast Reduction
Dr. Elizabeth Hall-Findlay is an incredible Canadian plastic surgeon with an incredible volume of cases done over many decades. She is amazing at distilling down the key points of how to do things well and how to do things safely. A 2017 paper in Plastic and Reconstructive Surgery, “Principles of Breast Reduction: A Reappraisal,” with Dr. Hall-Findlay as senior author, outlines four key principles for performing secondary reductions safely.
1. Move the Nipple by De-Epithelialization
Instead of cutting full thickness through the skin around the nipple-areolar complex to move it, you can just take off the superficial layer of skin, known as the epidermis. That allows you to move the nipple-areolar complex while preserving its blood supply, particularly the blood supply just deep to the skin in the subdermal plexus.
When you’ve had a reduction before, the position of the nipple-areolar complex has generally already been raised, so it doesn’t have to travel the same distance it did in the primary reduction. That primary reduction got the patient most of the way to where she needs to be. So why risk that blood supply further?
2. Remove Tissue Where the Excess Is
As Dr. Hall-Findlay describes it, the aging, drooping breast unwinds like a Slinky. Even the volume that recurs tends to go down, most commonly inferiorly and laterally. So you need to remove breast tissue where it is in excess, and that is usually inferiorly and laterally.
This is especially true for patients we see from 20 years ago. Most of those patients received breast reductions based on an inferior pedicle, meaning most of the tissue is inferior. That may change over time, with a lot of patients now coming back who have had superior or superior-medial pedicle reductions.
3. Use Liposuction as an Adjunct
Liposuction is a really safe way to get additional volume off the breast because you do not risk the blood supply. The liposuction cannula tends to preserve the nerves and the blood vessels. It may come in contact with the nerves, but it won’t necessarily cut them.
Liposuction is absolutely critical, particularly if it wasn’t used in the primary reduction, and very often it was not. It is a way to get a good volume off without any risk to the nipple-areolar complex. We always use liposuction in our techniques, but we rely on it a little more in secondary reductions.
4. Be Careful With Skin Excision
Be careful with any horizontal incision below the level of the inframammary fold, the crease beneath the breast. With her technique, and a lot of people’s techniques, the breast is brought up the chest wall. So be careful about what tissue you remove, and avoid making a scar on the abdominal wall, which would be unsightly and aesthetically displeasing.
Twenty years ago, more surgeons used the Wise-pattern (anchor-shaped) incision, where the distance from the nipple-areola to the inframammary fold was significantly decreased. Making an incision below that and shortening the distance further would probably be a no-no for those patients. For patients who had a vertical, or lollipop breast reduction, it could be the opposite, and there could be excess skin inferiorly that should be removed.
How Breast Reduction Techniques Have Changed
Twenty years ago, most breast reductions used an inferior pedicle with a Wise, or anchor-shaped, incision pattern. Over the past decade, more surgeons have shifted to vertical reductions based on a superior or superior-medial pedicle.
These shifts will change the approach to secondary reductions as we go forward, with more patients having received a vertical reduction based on a superior pedicle. Dr. Hall-Findlay is a Canadian surgeon, and a couple of other very well-known Canadian surgeons, Dr. Jamil Ahmad and Dr. Frank Lista, also published a very good paper on their clinical experience with a vertical pattern. It’s a kind of hybrid of the Hall-Findlay technique with some modifications, also relying on liposuction, and it shows a very good safety profile.
How Much Tissue Can Be Removed in a Second Breast Reduction?
When we go back for a secondary surgery, we’re not going to be able to take off as much as we did before, and that is echoed in the literature. Generally speaking, you’re going to get less out, and the techniques we use will be slightly different.
There are limits even in a primary reduction. If someone’s breast is 1,000 grams, the max we usually advise is that we can take off about 500 grams safely. That way we can preserve the nipple-areolar complex, hopefully preserve sensation, and, for a young woman, even potentially preserve the ability to breastfeed.
One of the larger published series on secondary reductions, from the Cleveland Clinic and published in the Journal of Plastic, Reconstructive & Aesthetic Surgery, found that patients generally had around 455 grams removed per breast in their initial reduction, versus a reduction weight of typically around 225 to 325 grams per breast in the secondary reduction. The series also showed that liposuction is an important adjunct.
A Typical Example
| Stage | Approximate breast weight |
|---|---|
| Before the first reduction | 1,000 g |
| After the first reduction | 500 g |
| 20 years later, after weight and hormonal changes | 600 g |
| Tissue removed in a second reduction | 250–300 g |
So you’re going to get substantially less than with a primary reduction. That doesn’t mean it’s not worthwhile, and it doesn’t mean you won’t get symptomatic improvement. That is generally true in our experience as well, having done quite a few of these ourselves.
Every breast is also so different. Some breasts are very broad-based and wide, so they may appear larger. But when you’re doing a breast reduction, you can’t narrow a chest wall. You can only narrow a breast slightly within it, with different techniques. Reviewing breast reduction before-and-after results can help patients understand how different starting anatomy affects the outcome.
Patient Factors That Increase the Risk of a Re-Reduction
The same things that make a primary reduction more risky also make a secondary reduction more risky.
Body mass index (BMI): As people get older, their body mass index may fluctuate or somewhat increase. In primary reductions, we know a higher BMI raises the risk of infection about double and the risk of seroma about triple, along with the risk of fat necrosis. These risks are elevated even further in the secondary breast reduction population.
Smoking: Smoking is an independent risk factor that makes things a little less safe.
Diabetes: Diabetes is another independent risk factor.
These are all taken into consideration by your surgeon when deciding whether or not the surgery is safe for you.
Can Imaging Help Plan a Secondary Reduction?
There has been some decent research on preoperative imaging to help determine the blood supply, including ultrasound, Doppler, CT angiography, breast MRI, and indocyanine green (ICG), which can be injected to assess perfusion.
None of these studies would necessarily push us toward these invasive modalities. We would need a lot better studies to prove they’re worthwhile. At this stage, we don’t think they will really move the needle on what we do clinically.
Making the Decision Together
Ultimately, this is something for the patient to really consider. The surgeon can advise, but you’re taking on that risk together. There is a certain amount of risk the surgeon can tolerate, and we also don’t want to do something that is potentially going to be a problem.
You have to really weigh the pros and cons. Based on the number of risk factors you have coming in, your surgeon can give you a better idea of whether the surgery is worthwhile. Your motivations and goals matter too. It’s a delicate conversation that needs to be considered closely.
Breast re-reduction is a surgery we offer. Many plastic surgeons do, but we also understand why many don’t, because there is a slightly higher risk. For surgeons, it’s wise to get a lot of primary reductions under your belt before moving into the secondary reduction population.
The Outlook for Breast Re-Reduction Is Positive
In our experience, secondary reductions can be done safely. Techniques such as de-epithelialization, targeted tissue removal, and liposuction help protect the blood supply to the nipple and areola.
We do everything we can to make sure someone considering the surgery knows what the risks are and also understands what can be delivered. With adequate counselling and education before surgery, you wind up with a very happy patient population.
You can also learn more about what to expect during healing in our breast surgery recovery timeline and about the cost of breast reduction in Canada.
Considering a second breast reduction? Contact McRae Plastic Surgery to arrange a personalized consultation in Toronto or Burlington.
