Women with very large, pendulous breasts may experience a variety of medical problems caused by the excessive weight of their breasts, from back and neck pain and skin irritation to skeletal deformities and breathing problems. Bra straps will leave indentations in their shoulders. Unusually large breasts can make a woman or a teenage girl feel extremely self-conscious.

The size of a woman's breasts may be determined by several factors, such as inherited genes, body weight and hormonal influences. They can, therefore, be a problem to someone in early adolescence, or may not become uncomfortable until middle-age following the menopause or the use of HRT. Because of the sexual nature of breasts, the undue prominence may attract unwanted attention from the opposite sex. This can cause psychological distress to many women. One of the commonest complaints of women with large breasts is that it is very difficult to wear fashionable clothes and indulge in active sports, particularly in the summer months.

A breast reduction, technically known as reduction mammaplasty, is designed for such women. The procedure removes fat, glandular tissue and skin from the breasts, making them smaller, lighter and firmer. It can also reduce the size of the areola, the darker skin around the nipple. The goal is to give the woman smaller, better shaped breasts in proportion to the rest of her body.

In most cases, breast reduction is not performed until the breasts are fully developed. However it can be done earlier if large breasts are causing serious physical discomfort. The best candidates are those who are mature enough to understand fully the procedure and have realistic expectations about the results. Breast reduction is not recommended for women who intend to breast-feed.

A reduction mammaplasty may be used to correct asymmetry of the breasts, where one breast is very much larger than the other and where it is considered to be the least normal of the two.

Apart from a change of shape and reduction in size, the most obvious consequences are the scars. These are designed to be invisible when wearing normal clothing and as far as possible are designed to lie under the average bra or bikini top. During the months following surgery the scars will fade from being red, possibly thick and uncomfortable, to becoming much more pale and less obvious. However they will always be present and visible when clothing is not worn and the scars will vary from one woman to another. In some they may be very thin, in others they may stretch and become red and sometimes ugly. In the vast majority of women the scars are acceptable and a small trade off for the benefit of dealing with problems of large breasts.

Very few women are able to breast-feed following reduction surgery as the nipples are separated from the underlying milk ducts and at the time of pregnancy the milk supply will gradually dry up, sometimes with the assistance of hormone treatment. Breast reduction is no contra-indication to pregnancy but young women may wish to take the fact that they are unable to breast-feed into account before embarking on this operative procedure.

The nipples are likely to be less sensitive following surgery due to the nature of the incisions and the nerve supply and and it is quite possible that numbness will extend over part of the breast as well. The procedure can also leave you with slightly mismatched breasts or unevenly positioned nipples. Rarely the nipple and areola may lose their blood supply and the tissue will die. A nipple and areola can usually be reconstructed using skin grafts from elsewhere on your body.

During your initial consultation, it is important to discuss your expectations frankly with me. Every patient and every plastic surgeon has a different view of what is a desirable breast size and shape.

I will examine and measure your breasts and photograph them for reference. We will discuss the variables that may affect the procedure such as your age, the size of your breasts, and the condition of your skin. We will discuss where the nipple and areola will be positioned as they will be moved during the procedure and should become positioned approximately level with the crease beneath your breast.

I will discuss the procedure in detail, explaining the risks and limitations and ensure that you understand the scarring that will result. I will also explain the anaesthetic to be used and the costs. Some insurance companies will pay for breast reduction if it is medically necessary, however, they may require that a certain amont of breast tissue is removed. You should check your policy regarding this.

Preparing for your surgery

I will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain medications. Poor healing and wider scars are more common in smokers. If you are overweight it is likely that I will recommend that you reduce weight. You should also make alternative arrangements if you are taking the contraceptive pill, for a period of at least six weeks prior to your operation.

While you are making your preparations, it is wise to arrange for someone to drive you home after surgery and to help for a few days at home if needed.

Types of anaesthesia

Breast reduction is performed under general anaesthesia. You will be asleep through the entire operation. The operative procedure usually takes two to three hours.

The surgery

The procedure involves an anchor shaped incision that circles the areola, extends downwards and follows the natural curve of the crease beneath the breast. Excess glandular tissue, fat and skin are removed and the nipples and areola are moved into their new position. The skin is then brought down from both sides of the breasts down and around the areola, shaping the new contour of the breast.

In most cases the nipples remain attached to their blood vessels and nerves. However if the breasts are very large or pendulous, the nipple and areola may have to be removed and grafted in a higher position. This is known as a free nipple graft and will result in loss of sensation in the nipple and areolar tissue.

Stitches are located around the areola, in a vertical line extending downwards and along the crease under the breast. These will be buried beneath the skin surface and will dissolve. You will have a small drainage tube placed in each breast to drain blood and fluid for the first day or two. You will have some pain for the first couple of days, especially when you move around or cough, and some discomfort for a week or more. You will be prescribed medication to lessen the pain.

The dressings will be removed a few days after surgery. You will be advised to wear a sports bra during the day and night for the first four weeks, until the swelling and bruising subside. After this time you can wear a normal bra, underwired if you wish.

Your breasts may swell and hurt during your first menstrual period after surgery. You may also experience shooting pains for a few months. You can expect some loss of feeling in your nipples and breast skin caused by the swelling after your surgery. It usually subsides over the next six weeks although in some patients it may last a year and may occasionally be permanent.

What are the risks?

Any major operation under general anaesthetic carries a small risk of a chest infection, particularly among people who smoke and there is also a small risk of thrombosis in the veins of the leg, particularly if a patient is taking the contraceptive pill.

Occasionally bleeding can occur after the operation is finished and this may require further surgery and a blood transfusion.

Occasionally, infection from bacteria harbouring in the ducts of the breast can be troublesome. Infection can be treated with antibiotics but it will delay the healing process, and the scars are likely to be worse.

Occasionally the skin can become sloughy and form a scab which gradually separates to leave a broad scar. The areola and the skin where the scar meets under the breast are the areas most likely to be affected. People who smoke are at greater risk of this happening. Usually the scars will end up as white lines but they are always visible. However, some people have an inborn tendency for scars to stretch and sometimes they can stay thick, red and irritable for a long time.

When reducing large breasts it may occasionally be necessary to adjust the folds of skin at each end of the scar, both between the breasts and at the sides. This can simply be carried out under local anaesthetic several months later.

There is no evidence that breast reduction increases your risk of breast cancer. Nor does it prevent your breast from being examined for cancer in the usual way.

Getting back to normal

Although you will be up and about in a day or two, your breasts may still ache occasionally for a couple of weeks. You should avoid lifting or pushing anything heavy for three or four weeks. Most women can return to work and social activities in about two weeks. You will find that you have much less stamina for several weeks and should limit your exercises to stretching, bending and gentle swimming until your energy returns.

It is advisable to avoid sexual activity for a week or more, since sexual arousal can cause the incisions to swell. You should avoid anything other than gentle contact with your breasts for about six weeks.

A small amount of fluid draining from your wound, or some crusting, is normal. If you have any unusual symptoms, such as bleeding or severe pain, you should not hesitate to contact your doctor.

Although much of the swelling and bruising will disappear in the first few weeks, it may be six months to a year before your breasts will settle into their new shape. Even then the shape may fluctuate in response to your hormonal patterns, weight changes and pregnancy.

Will the improvements last?

Unless your operation is done at an age when your breasts are still growing, they should not regrow afterwards. They will, however, increase in size if you put on weight or become pregnant and decrease in size if you lose weight. Breasts tend to droop with time and you can expect some change in shape to occur after your breast reduction. You can delay this tendency by supporting your breasts in well-fitting bras.

Your new appearance

Every effort will be made to keep your scars as inconspicuous as possible. It is important to remember that breast reduction scars are extensive and permanent.

Breast reduction results in a rapid body image change. You will be rid of much of the physical discomfort of large breasts, your body will look better proportioned and clothes will fit you better.

However, you will need time to adjust to this new image, as will your family and friends. Be patient with yourself and you are likely to be delighted with the results.