Life after breast reduction: what to expect [Kyle Baltrusch, MD, Portland]

Dr. Baltrusch (00:00):
My name is Kyle Baltrusch. I'm a plastic surgeon in Portland, Oregon.

Eva Sheie (00:04):
In terms of recovery, is this a relatively easy surgery to bounce back from once it's over?

Dr. Baltrusch (00:10):
So after we go into the operating room, we have our anesthesiologists do pectoralis level one and two blocks. Basically, once the patient is under anesthesia, they can localize the nerves of the chest between the muscle layers with ultrasound guidance, and it does kind of help numb, it's kind of like an epidural of the chest. So it's a regional block and it helps numb the chest so it's easier for patients to transition onto oral medications. So we all do a short course of narcotic. Oftentimes that's like Norco or hydrocodone or oxycodone, and patients usually don't require much of it, maybe a few days. So it is truly a short course before we have patients transition just onto Tylenol and ibuprofen. So we have patients hold ibuprofen for three days, but kind of keep doing Tylenol around the clock. But some surgeons will leave drains, others won't, and sometimes it's just case by case or dependent on the amount of reduction that is being done.

(01:01):
So the drains can stay in from anywhere for days to maybe a week, but otherwise all the sutures are under the skin and dissolvable. And we just have patients wear a bra for those first few weeks kind of around the clock other than to shower. So patients will be sleeping on their back and we want to keep the breast supported, keeping tension off of the repairs. So we have patients wear bras at night and they're post operative bras, so they're the ones that close in the front. I think what we worry about is it's hard to know what you're going to do in your sleep. And so we don't want patients to roll over onto their chest and potentially cause trauma, which could always incite something to start to bleed. But oftentimes we see patients postop day one or two and they're already off of narcotic medication onto just Tylenol. So I would say overall it's a well tolerated procedure.

Eva Sheie (01:40):
What kinds of things do the patients say to you when they've gotten through recovery and they're sort of on the other side?

Dr. Baltrusch (01:46):
Patients will tell me that it was probably easier than what they were expecting. So I think a lot of patients come in expecting that they're going to have drains, that they're going to have pain for multiple weeks, that they're going to be in bed. And after our consultations, we want our patients up and walking around day one. I think most patients are surprised that they didn't require that much narcotic medication, maybe a day or two, or just to help them sleep. And that they were, it was a much quicker recovery than they expected. And I think most patients are kind of surprised that they didn't require drains.

Eva Sheie (02:20):
What is the purpose of the drain? What does it actually do? There's been a fair amount of drainless gimmicks going around, and I wonder if it's a gimmick or if there's something valid there.

Dr. Baltrusch (02:34):
So we use a lot of drains for a lot of different procedures. In breast reductions, I am a believer that it's not indicated. In our literature, there's a few indications for leaving a drain, and that's if the patient is morbidly obese. Oftentimes they're probably not a great surgical candidate to begin with, or they need to lose weight before in surgery for peri-operative reasons, or if the specimens are going to be over a kilogram per breast. And even at that, that I think is a case by case. And so you're creating a dead space that you're rotating tissue into to create a smaller breast mound or get the breast tissue up higher onto the chest wall. And so fluid can accumulate in that dead space. And so we worry about seromas and hematomas. The drains will identify those, but they don't necessarily prevent them. So we worry most about a hematoma if something were to start bleeding. It's pretty obvious if something does bleed, the breast swells. And so regardless if you have a drain or not, you would have to go back and stop that bleeding. So I don't necessarily think drains are warranted with breast reductions, but certainly with other procedures.

Eva Sheie (03:36):
How rare are those kinds of complications that you're mentioning?

Dr. Baltrusch (03:39):
Yeah, so hematomas probably 1% or less. Looking at my numbers over the last few years, I've done well over a hundred breast reductions and I've had probably two hematomas. So one 2% maybe, and that's the one complication that would require us to go back to the operating room.

Eva Sheie (03:58):
Is it noticeable if it's happening to you? Is it obvious?

Dr. Baltrusch (04:02):
It's pretty obvious. So it does depend if it's like venous or arterial. Venous, lower pressures, and so sometimes those will stop on their own. And they can be monitored or just aspirated in clinic once they liquefy. Certainly an arterial hematoma or if something were to start bleeding, the pressure is much greater and so it will fill that dead space pretty significantly, or even dissect planes. So the breast becomes two, three times the size of the other breast, significant bruising and pain because of that pressure. And so it is pretty obvious if there's an arterial bleed and a need to go back to the operating room.

Eva Sheie (04:33):
What causes that?

Dr. Baltrusch (04:34):
There can be multiple reasons. So with certainly bleeding diathesis if patients have any bleeding disorders, but with anesthesia, blood pressures are dropped. And so as patients recover, blood pressures come up, with increased blood pressure, it can cause something to start bleeding. It is also why we tell our patients to just take it easy for a few weeks because those first two weeks, there can always be a risk for delayed hematoma or something to start bleeding. So certainly things like trauma, even, no exercise, so we don't want our patients to do anything that gets their heart rate or blood pressure up as that could also start something to bleed. And then just the liquefaction process. So we use electrocautery, but we're clotting basically, or embolizing vessels as we dissect. And the body naturally liquefies clot after a few weeks. And so sometimes that can just spark something to start bleeding.

Eva Sheie (05:21):
On this podcast, we bring you directly to the doctors who are, where before meets after Links to our guest's website and contact info are in your show notes. Follow us on Instagram @wherebeforemeetsafter. Where Before Meets After is a production of The Axis, the podcast agency for aesthetics, theaxis.io.