Breast Reduction in Turkey

Breast reduction surgery is a surgical procedure to reduce the breast size of women who have macromastia and other complaints associated with this condition, improving their quality of life. Breast reduction surgery not only improves appearance but also reduces the weight of the patients, thereby relieving back, shoulder, and neck pain, converting slouchy posture into an erect position, preventing intertrigo and fungal infections under the breast, as well as ulcerations, curtailing the opportunity for breast cancer with apoptotic regulation, and offering a more ordinary appearance in all clothes. In addition, the patients, finally regaining their health and peace of mind, can become active members of both working life and social life. Consequently, not only health professionals but also society is positively affected by this procedure.

Worldwide, breast reduction surgery is one of the most popular surgeries. The aim of this literature review is to emphasize the magnitude of this situation by revealing the changes and developments since it was first applied. Turkey is a country where international patients choose for breast reduction surgery. One of the most significant reasons is financial benefits, but Turkish culture is another reason. In Turkish culture, large breasts are not considered a symbol of beauty and sex appeal; rather, excessively large breasts are viewed as a body anomaly and a cause of social and psychological problems. Patients apply to private hospitals and want to have smaller breasts because of health problems, but breast reduction also improves aesthetic appearance and patient comfort. The aim of this study is to present the background of women who want breast reduction in Turkey by evaluating the literature from the beginning to the present.

Historical Background and Development of Breast Reduction in Turkey

Breast regulation and diagnosis are not new problems in our society, and breast size has been an important presentation for women since ancient times due to trends in clothing, fashion, and sociocultural factors. There have been no publications available on the subject in the Ottoman Empire and the Turkish Republic before 1940. This can be interpreted as little interest in anatomical and surgical studies on breasts in our culture. It is not possible to access enough data for research due to the status of women in society and the privacy of the body. The first local skin implantation with a fleece type of mastectomy was performed in Turkey in 1936. The Turkish female breast was defined in 1966, and cosmetic preferences related to the breast were defined in 1984.

Although there is data on this subject from 1922, there is no data on breast reduction surgery in Turkey before 1960. The first breast reduction surgery performed with the technique that was common in the world in the same period was reported in Istanbul in 1961. Until the 1980s, all of these studies were from the point of view of pedicle breast reduction and breast lift, and breast reduction in the sense we know today was not possible due to the breast. According to our literature review, the first reduction mammoplasty was published in 1978. Then, in 1983, interest in breast reduction was presented. No studies were reported in an effort to identify the first examples of breast reduction surgery in Turkey in 1982. Because new techniques have started to be developed since 1990 that reduce the risks of surgical procedures, reduce the complications that may occur after surgery, and provide a better quality of life, physicians have begun to make more serious efforts in this field and a significant resistance has emerged. In Turkey, even associations have been formed about the field. For this reason, societies related to aesthetic surgery were established in 2008 and 2016, respectively. Today, although Turkey is considered a leader in both aesthetic surgery and reconstructive surgery, it is not a fact that can be questioned.

Current Trends and Techniques in Breast Reduction Surgery in Turkish Medical Practice

Breast reduction is a common and effective operation performed for the treatment of symptoms developed due to excessively large breasts, providing smaller, more aesthetic, and younger-looking breasts. In Turkey, breast reduction surgery is performed by specialists using various surgical techniques and treatment approaches. This aims to evaluate this practice, discuss the current trends in breast reduction, and the advances and changes in treatment by scanning the current literature and sharing our practice, which is greatly influenced by young patients from abroad. The discussion emphasizes that satisfaction following breast reduction surgery is not only achieved by reducing the breast but also by shaping the whole body in accordance with the natural anatomy and adipose tissue ratio of the patient. As a result, the main principles determining the shape are the maintenance of the upper part of the breasts and their fullness by lifting them. Technically, this is achieved by only a few reductive operations such as superior pedicle, periareolar dermal suspension, and inverted T-incision or T-inverted L incision. Acute cellulite does not develop as much in large breasts around the implants placed between the mammary gland tissue and the pectoral muscle in patients with mammary gland ptosis. Therefore, the tension that needs to be applied to the pectoral muscle is significantly reduced, and consequently, no damage occurs to the muscle. Over time, we have successfully developed combined, mixed techniques in reducing operations, which often consist of placing a foreign object into developmental disorders and asymmetries of mammoplasty, such as reduction and lift. In younger patients, mammoplasty surgery is generally started earlier with less invasive intervention correction surgeries. Today, the number of young patients seeking treatment in this regard has increasingly increased both worldwide and in our country, a fact that experienced plastic surgeons and experts emphasize in their own groups and meetings.

Below are the current trends we are implementing in our practice for the treatment of breast reduction, which is gradually becoming less invasive and more in line with new cosmetic goals. Our approach is based on an individual and patient-specific treatment plan. We also compare our patient findings with the data in the literature to analyze the characteristics of our patient population.

Patient Selection Criteria and Preoperative Considerations

Patient selection is one of the most important factors for success in breast reduction surgery. The difficulties in making the necessary incisions and achieving desired wound healing in patients with amply extended breasts, the greater risk of nipple loss when reducing glandular tissue blood supply, and the prolonged recovery time in patients with poor general health status should be considered. During the preoperative planning, it is also taken into account that the patient has realistic expectations regarding the aesthetic appearance of the chest wall. Throughout the selection process, the criteria include comorbidities, the patient’s age and mental state, body mass, and the size of the breast to be reduced in relation to body weight, as well as the relevant presence of skin pathology, sexual function, and pharmacologic data that may contribute to breast hypertrophy.

Patients with a history of tobacco use, heavier body weight, and coexisting diabetes mellitus or coronary heart disease are more likely to experience delayed wound healing, wound complications, and other postoperative problems, compared with those who do not have these findings in their medical histories. As with any elective surgery, the relative risk of an intended procedure should be well analyzed according to the perceived benefit of the patient. During preoperative evaluation, a comprehensive medical history and physical examination are important. The patient’s expectations and the surgeon’s aesthetic understanding should be compatible. An impressive breast reduction result does not mean the same for each patient. Instead of recommending a certain breast cup volume, surgeons must focus on the patient’s wishes. In particular, patients’ complaints about body functions and daily activities need to be discussed in detail. It is necessary to measure the maximum breast width, the sternal notch-to-nipple distance, and the inframammary fold-to-nipple distance to estimate the maximal amount of tissue. This is primarily one of the physician’s responsibilities. Surgeon involvement in something as simple as weight management often results in weight loss of up to 10% of the original body weight, to lift healthcare practitioners’ spirits and to reduce the incidence of complications in the short and long term. Informed consent is essential.

Postoperative Care and Long-term Outcomes

The postoperative period requires utmost care to obtain optimal results. The typical recovery time is 2 weeks, and it may take up to 6–12 months for the breasts to regain normalcy. Most of the complications that arise during the postoperative period are related to incorrect wound care. Most of these complications may be avoided and can be managed with appropriate care. For a problem-free postoperative period, patients are instructed not to carry heavy loads or do excessive exercise for three weeks following surgery. They may then return to their normal lifestyle, except for heavy lifting or vigorous housework in the first 6–12 weeks. Patients should avoid sunlight, pools, and the sea for 2–3 weeks until the recovery process is completed, and they should be especially careful around pool water because infections can occur. Patients should use sunscreen and emollients for their scars for at least six months after the surgery. Because of their BMI, patients with pre-existing obesity-related illnesses may need more postoperative care. A suitable follow-up appointment is arranged 5–7 days after surgery to remove the drains and for examination of the healing tissues and the course of the disease. Patients are then invited for a regular long-term follow-up every four weeks to monitor the progress.

Complications of the reconstructive reduction mammaplasty need to be managed. The two most crucial wound-healing problems are fat necrosis and superficial epidermolysis. Wound problems may occur due to excessive tension and inadequate skin coverage. Patients should be managed properly to prevent any complications. Women who have undergone breast reduction have shown increased adaptation at the psychological level. Age and health status are factors affecting the long-term outcome, about which there are differing opinions. A few studies have shown that functional and cosmetic improvements following breast reduction decrease in older women. Reduced respiratory satisfaction is seen to an extent in those women who maintain an unhealthy lifestyle. Studies reporting quality of life and satisfaction in the long-term period are rather few. A year after reduction mammaplasty, most women feel comfortable with the improvement at the psychological level. One out of two young patients who underwent a psychological comfort assessment was fully satisfied with the results. In the same period, the same percentage was achieved by a group of older patients. An important part of risk management for breast reduction includes postoperative care and long-term outcomes in suitable environments. There are many contributing factors to deciding the optimum amount of breast tissue to remove. These factors include the patient’s anthropometric characteristics, the elasticity of the skin, the position of the breast, the amount of tissue to be removed, and the techniques employed in breast reduction. Misjudgment in any of these factors may result in dissatisfaction with the surgical outcomes and may threaten the patient’s physical integrity.