Breast Reduction Scars: Where They Go, How They Heal, and What You Can Do About Them

Scars are one of the first things patients ask about in a breast reduction consultation, and for younger patients they are often the single biggest hesitation. In this episode of Plastic Surgery Consults, Dr. Mark McRae and Dr. Matthew McRae work through the question in detail: where the incisions go and why, what happens in the skin during the year after surgery, and which scar treatments have evidence behind them.

What’s Covered in This Episode

Why This Question Comes Up More Than It Used To

When the McRaes started operating independently in 2014, the typical breast reduction patient was in her fifties or sixties, usually done having children, often prompted by a friend who had already had the surgery and talked about the relief in her back and shoulders.

That has changed. Over the past five or six years, both surgeons have seen a sharp rise in patients in their late teens and twenties. Neither is willing to give a single tidy explanation for it. More information is available now, plastic surgery carries less stigma than it did twenty years ago, and the message that patients almost universally wish they had done it sooner seems to be reaching people earlier. Dr. Matthew McRae also points out how often the referral is simply a family one: he operates on a mother, and her daughters are dealing with the same symptoms.

Whatever the cause, a younger patient is looking at a permanent mark on her body with sixty years ahead of her. It is reasonable that she wants to know exactly what that mark will look like.

The Two Scar Patterns You Will See

Almost every breast reduction uses one of two incision patterns.

The lollipop, sometimes called a vertical reduction, has two components. One scar circles the areola, because the areola is nearly always moved upward during a reduction and often reduced in size at the same time. The second runs from the six o’clock position on the areola straight down to the inframammary fold, the crease under the breast.

The scar around the areola has a quiet advantage. The areola and the surrounding skin have different pigmentation, and a scar placed on that natural border is much less noticeable than one placed on uniform skin. The eye simply does not catch it the same way.

The anchor, also called a Wise pattern, adds a third scar running horizontally along the inframammary fold. That extra incision lets the surgeon remove skin horizontally as well as vertically. There are modifications where the horizontal limb curves upward onto the chest wall, which can improve breast shape further.

Both are useful. In the McRaes’ practice the lollipop is now far more common, because it means fewer incisions and less scarring overall, and Dr. Mark McRae notes that most patients want that. He tends to reach for the Wise pattern more often in reconstructive work, particularly when the goal is symmetry with the other side.

One clarification worth holding onto: the incision pattern is not the same thing as the surgical technique. People often name the whole operation after the skin pattern, but what happens to the breast tissue underneath is a separate decision.

What Determines Which Pattern You Need

Skin quality does a lot of the work here. A patient with a thick dermis and skin that rebounds well can often have less skin removed and still get a good result, which keeps her in lollipop territory. A patient with significant excess skin or marked ptosis, where the breast sits very low, may need more skin taken than a lollipop allows in order to get a shape that is reliable on the table. In that case a transverse incision at the fold gets added.

Liposuction is the other lever. Used well, it reduces volume without a corresponding increase in incision length, which lowers the total scar burden on the breast.

Why the Scars Sit on the Lower Half of the Breast

There are two separate reasons, and they get tangled together easily.

The surgical reason is that tissue is removed from the inferior part of the breast so the remaining tissue can be reshaped and rebuilt higher on the chest wall. That relates to how blood supply to the nipple is handled, which has changed considerably since the McRaes trained in the 2000s.

The scar reason is simpler. Scars on the lower half of the breast are covered by a bra, a bikini, and most clothing. Scars on the upper pole are visible in anything with a low neckline. Dr. Mark McRae makes the related point that bringing the areola too high is a common error early in a surgeon’s career, because an areola that peeks out of a dress or a swimsuit is a problem that is very hard to undo. Position matters as much as technique.

What Is Actually Happening in Your Skin

Surgery is an injury, and the repair starts almost immediately. Blood arrives, macrophages come in to clear the area, and within a couple of days fibroblasts show up and begin laying down collagen. They do this vigorously and, at first, without much order. Think of collagen being thrown down in a random pattern rather than woven.

That heavy deposition happens mostly in the first four to six weeks. It is why the scar looks and feels worst during that window. Over the following months, and continuing for a year or two, the body reorganizes that collagen into a smoother, more linear arrangement. How robust the initial response is depends partly on your age and general healing capacity.

Two layers matter here. The epidermis is the surface layer that turns over constantly and responds to things like chemical peels. The dermis underneath is structural, and as Dr. Matthew McRae puts it, the dermis you are born with is the dermis you live with. It does not regenerate. Once it is cut, it is repaired with collagen, and something will always be left behind.

What You Will See, Month by Month

When the dressings first come off, the incision lines usually look lumpy and uneven. That is swelling, it is normal, and both surgeons warn patients about it in advance.

Over the next month or two the line smooths down and often becomes redder or darker. All that immature collagen is now in place. On lighter skin this reads as red or injected. On darker skin it is better described as hyperpigmentation, more pigment than the scar will eventually have. The scar also tends to feel thick and hard at this stage, which is called induration.

Across the following year the scar flattens, softens back toward the surrounding skin, and fades. A scar is considered mature once the colour has settled to roughly the colour of your normal skin. The hardness resolves over months.

The thing worth repeating: what a scar looks like in the first couple of months bears very little relationship to what it looks like at the end. Our breast reduction before and after gallery shows healed results at various stages.

Normal Scarring, Hypertrophic Scarring, and Keloids

Underneath most scar questions is a different question, which is whether this person’s scarring is going to be normal or not.

The best single predictor is your own history. If you have had previous surgery or previous injuries, how those healed tells you more than anything a surgeon can guess. Beyond that, a lot of the fibroblast response and the amount of collagen laid down is genetically determined, and different areas of the body scar differently depending on skin thickness and tension. The breast tends to be a favourable area, largely because it is under relatively little tension, and tension is one of the things associated with thicker scarring, along with infection.

Patients and even primary care doctors use hypertrophic and keloid interchangeably, but they are different problems. A hypertrophic scar is thicker than normal but stays inside the boundary of the original incision. A keloid behaves almost pathologically, spreading well beyond the original wound into skin that was never cut. Keloid formation is strongly genetically linked, and how your skin reacted to something like ear piercing is a useful clue.

What the Research Says About Risk

The McRaes cite a 2015 series in the Annals of Plastic Surgery looking at outcomes in roughly 2,100 breast reduction procedures. Poor or hypertrophic scarring showed up in around six percent of patients overall, but in the younger cohort that figure ran as high as twenty percent.

Dr. Mark McRae’s reading is that younger skin has a thicker dermis and a more robust healing response, so the scars genuinely are thicker. He also suspects younger patients are more sensitive to how the scar looks, which is a different thing but matters just as much clinically. Either way, roughly one in five younger patients will have some real concern about how her scars are healing, which is an argument for spending more consultation time on this topic with that age group rather than less.

A 2019 paper in Plastic and Reconstructive Surgery on complications and quality of life following reduction mammaplasty in adolescents and young women adds a few risk factors. Smaller breasted patients have a slightly higher rate of thicker scarring. Younger age, again, appears on the list.

Two other risk factors show up consistently in larger series and are worth taking seriously:

Smoking is close to a non-starter for elective breast surgery in Canada. It compromises blood supply to the healing tissue, raises infection risk, and can lead to incisions coming apart entirely, which is called dehiscence. A dehisced wound heals into a far worse scar and may eventually need revision. The Aesthetic Surgery Journal has a systematic review on this.

A body mass index of thirty or above is associated with higher complication rates across many operations. In breast reduction specifically that includes increased risk of seroma and of dehiscence. A seroma is a fluid collection that the body cannot reabsorb on its own. Some fluid after surgery is expected, but a seroma is fluid that persists, and it can become chronic, encapsulated, or infected.

The Part That Gets Lost in All of This

Both surgeons wanted to close the risk discussion on a more accurate note, because the complication list is not the whole picture.

An Annals of Plastic Surgery outcome study from 2000 found that around 95 percent of patients reported the decision to have a breast reduction was the right one, with substantial scar fading observed at long term follow up. The 2019 Plastic and Reconstructive Surgery paper found something more striking: quality of life improvements persisted whether or not the patient had a scarring complication.

That matches what the McRaes see anecdotally. Occasional patients have real problems. Very few of them regret the surgery.

How to Look After Your Scars

Our post-operative instructions cover the full recovery protocol. On scars specifically:

Massage. Manual massage helps the body break down and reorganize that disordered collagen. Dr. Mark McRae typically starts patients at around three to four weeks, once enough collagen is in the incision line that things are not going to open up. Dr. Matthew McRae tends toward four to six weeks. The rule underneath both answers is the same: wait until the skin is fully closed. If there are still small openings or any drainage, pressing on the scar risks introducing bacteria.

Silicone. There is limited evidence that silicone products improve overall scar quality, or at least the speed at which a scar reaches its final quality. This comes largely out of the burn literature. Silicone is available as creams and as tapes, and the tapes are typically recommended for up to 23 hours a day over about three months. Both cost money, and the time commitment is real.

Moisturizer. Scars cannot moisturize themselves the way normal skin does, and they tend to flake and dry out, particularly in winter. Any moisturizer your skin already tolerates is a reasonable choice. Dr. Matthew McRae’s honest view is that part of the benefit of applying anything at all is that it guarantees the scar gets handled and massaged daily.

What to avoid. Some patients apply a wide range of products, and Dr. Mark McRae is relaxed about most of them provided they do not cause irritation. Some do, and irritation makes scarring worse. One specific caution: Polysporin contains a large mix of ingredients and is fine for a few days on a small area, but used daily beyond a week or two it often produces a red reaction that is genuinely difficult to distinguish from infection.

Sun. This is the one both surgeons emphasize. During the first year, while the scar is remodelling, UV exposure causes hyperpigmentation, and the entire improvement process depends on that scar becoming less pigmented over time. Cover it or use sunscreen. Dr. Mark McRae now specifically advises putting sunscreen on the breast scars before putting on a bathing suit, because most swimwear offers only partial UV protection and his patients, feeling more confident after surgery, tend to spend more time outdoors. Once the scar is mature, usually at about a year, it can be treated like normal skin.