There are many aspects of nerve pain after breast reduction. The first thing is that you need to be aware is that it is going to happen especially in the recovery period. That being said, there are steps that you can take to help relieve the discomfort and make sure your healing process goes smoothly. This guide will cover everything you need to know about nerve pain after breast reduction, including common problems after breast reduction surgery and pulling feeling after breast reduction.
In this guide, we review the aspects of Nerve Pain After Breast Reduction, how to relieve nerve pain after breast augmentation, common problems after breast reduction surgery, and pulling feeling after breast reduction.
Nerve Pain After Breast Reduction
Nerve pain after breast reduction surgery is a common condition. The good news is that there are ways to treat it, so keep reading for tips on how to minimize your post-op pain and get back to normal life as quickly as possible!
Why Does It Happen?
Nerve pain after breast reduction surgery is a common side effect. It’s caused by damaged or irritated nerves, and it can be very painful.
There are two main reasons why nerve pain happens:
- The nerves that carried sensation to your chest before the procedure were cut during the operation, which means that they no longer have their normal function. In time, these nerves regenerate and rewire themselves so that they can carry sensation again—but this process takes weeks or months. During this time, you may feel numbness in some areas of your chest as those nerves recover.
- Damage from scar tissue may also cause ongoing nerve damage leading to chronic nerve pain after breast reduction surgery if not treated properly by your surgeon
What Can I Do About It?
The good news is that nerve pain after breast reduction usually goes away on its own in several weeks to months. The bad news is that you’ll need to live with the pain while it heals. Follow these steps to get through it:
- Take painkillers as directed by your doctor to help ease your discomfort during recovery. If you’re having trouble sleeping because of the nerve pain, ask your doctor about taking a prescription sleep aid or anti-anxiety medication for those nights when nothing else works. * Try heat and ice packs on painful areas of the breast tissue as needed—heating up one side of your chest can sometimes relieve pressure on nerves in one area and cool down another, which may offer some relief from discomfort from damaged nerves.* Avoid driving long distances or lifting heavy objects until all symptoms are gone—you don’t want to make things worse by forcing yourself into activities that could cause further damage.* Avoid activities that make you breathless or tired for extended periods of time (such as running), since severe exertion can aggravate nerve damage and add more stress onto an already aggravated system
Which Is The Best Option For Me?
It’s important to understand that you can’t choose an option without first understanding the pros and cons of each one. For example, if you have a history of allergies or asthma and need to have general anesthesia (or remember having an allergic reaction or asthma attack during previous surgeries), you should probably opt for local anesthesia. If something goes wrong during your surgery, this will help ensure your safety.
Local anesthesia is also a good option if you want minimal pain after your reduction surgery—it’ll make it easier for doctors to get to the nerves without them being irritated by the area around them, which can cause severe nerve pain afterward. Another benefit of local anesthesia is that it allows surgeons more control over their actions—they’ll be able to see exactly what’s happening on their monitors and adjust as needed in order to prevent any damage from occurring. One downside is that this type of procedure may take longer than other types because there are fewer options available for controlling pain after surgery has already begun; however, this isn’t usually an issue since most people who choose local anesthesia don’t feel much discomfort at all during their breast reduction procedure anyway!
General Anesthesia involves putting patients under with drugs so they’re unconscious while having their surgeries performed; then afterward they wake up immediately afterwards with no recollection of anything happening during their operation time (because they were asleep) but still feeling some soreness afterwards due to muscle recovery time required afterwards too.”
How Long Will It Take To See Results?
How long it takes to see results is different for everyone. The amount of fat and muscle tissue removed, as well as the size of the breast reduction will determine how quickly you see improvement. Generally, you should see improvement 3-6 months after your procedure. If you’re concerned about nerve pain after breast reduction, talk to your surgeon about other options available to help manage the pain until it improves on its own.
What Will My Breasts Look Like After Surgery?
Breast reduction surgery is a safe procedure that can be performed with or without general anesthesia. Your surgeon will discuss the risks and benefits of each type of anesthesia before deciding which one to use.
Breast reduction surgery can also be performed with or without liposuction, which removes excess fat from the chest and upper arms (bruising may be present for up to 6 weeks after surgery). Finally, breast reduction surgery may include a breast lift (a procedure that raises sagging breasts) as well as other modifications depending on your needs and goals.
how to relieve nerve pain after breast augmentation
The authors conducted a systematic review to provide evidence-based information on the incidence and treatment of nerve injuries resulting from aesthetic breast surgery.
A broad literature search of Medline, Embase, and the Cochrane Database of Systematic Reviews was undertaken to identify studies in which nerve injury occurred after breast augmentation or mastopexy. Specific inclusion and exclusion criteria were established before the search was performed.
The initial 4806 citations were narrowed by topic, title, and abstract to 53 articles. After full-text review, 36 studies were included. The risk of any nerve injury after breast augmentation ranged from 13.57% to 15.44%. Specific nerve injury rates were calculated for the intercostal cutaneous nerves, branches to the nipple-areola complex, intercostobrachial nerve, long thoracic nerve, and brachial plexus. Also calculated were the total estimated risks of chronic pain, hyperesthesia, hypoesthesia, and numbness. The meta-analysis showed no associations between the rates of breast nerve injury or sensation change and implant size, incision type, or implant position in patients who underwent breast augmentation. The data were insufficient to determine rates of nerve injury in mastopexy.
The possibility of nerve injury, sensation change, or chronic pain with breast augmentation is real, and estimating the incidences of these conditions is useful to both patients and surgeons. Optimizing patient outcomes requires timely treatment by a multidisciplinary team and may include peripheral nerve surgery.
In the United States in 2012, a total of 330 631 breast augmentation procedures were performed, representing a 227% increase from 1997.1 This trend, which is expected to continue, emphasizes the importance of patient and surgeon knowledge of the safety and morbidity associated with breast augmentation.
Overall, breast augmentation is considered well tolerated by and highly satisfactory to the patient; it is generally safe, with a low incidence of hematoma, infection, deep vein thrombosis, and pulmonary embolus.2,,,,,-8 However, an underappreciated risk of augmentation mammaplasty is nerve injury leading to chronic breast pain and changes in sensation of skin and the nipple-areola complex (NAC). Although nerve injuries and changes in sensation are more traditionally associated with procedures that require extensive surgical incisions, such as breast reduction9,-11 or mastectomy,12,-14 their incidence with breast augmentation is not negligible. Chronic breast pain can be severe, often interfering with sexual activity (48% of patients), physical activity (36%), social activity (13%), and work or school (6%).15,16 Nerve injuries also are associated with substantial patient anxiety and must be differentiated from infectious, neoplastic, or wound-related causes, often initiating a costly and complex workup when the diagnosis is unclear.17,18
We sought to characterize the incidence of nerve injury and change in sensation after augmentation mammaplasty by performing a systematic review of the literature and pooled analysis. We also present a comprehensive treatment algorithm for patients who do experience nerve injury. This information is important to provide patients with a full picture of the risks of breast augmentation and to raise awareness among plastic surgeons of the risk and treatment of nerve injury after augmentation mammaplasty.
Methods
Search Strategy
A literature search was conducted in March 2013 throughout Ovid Medline, Embase, and the Cochrane Database of Systematic Reviews. The general strategy was to combine terms identifying procedures with terms identifying nerve injury and the “and” function. Key search terms for breast augmentation included breast aug* and breast implant.* Key search terms for nerve injury included nerve injur*, nerve damage, numb*, hypesthesia, neuroma, paresthesia, pain, paraly*, paresthesia, paresis, neuropath*, neuralg*, weak*, and sens.* Subject headings were incorporated wherever possible. The search was deliberately broad to capture the greatest number of articles. The search was not limited by date of publication but was limited to English-language publications; it excluded narrative reviews, editorials, letters, commentaries, and errata. Additional studies were identified by reviewing citations of relevant articles found during the search and then locating those articles.
A separate search was conducted to investigate nerve injury in mastopexy procedures. Key search terms included mastopexy, nerve, nerve injury, and sens*. Preliminary search results yielded no mention of nerve injury, and the data were not included.
Selection Criteria
Specific inclusion and exclusion criteria were established before the search was conducted (Table 1). The initial search captured nerve injury related to various cosmetic procedures; results specific to breast augmentation were selected from that pool. Procedures that were nonsurgical, reconstructive (correcting a defect or pathology), or revisional (correction after a primary procedure) were excluded. Articles that contained no mention of nerve injury in the full text were excluded. Importantly, if the author(s) reported no incidence of nerve injury, the study was included and “0” was recorded on the data input form. Thus, publication bias was eliminated to the greatest extent possible, and the rates of nerve injury in our meta-analysis should closely represent actual rates.
Inclusion and Exclusion Criteria for Studies
Quality Assessment
After titles and abstracts were examined by 3 reviewers (S.F., J.M.F., and H.M.Z.), all irrelevant studies (those not meeting the inclusion and exclusion criteria) were eliminated. The pool was narrowed further based on the availability of full text. When the research was conducted, S.F. and H.M.Z. were medical students and J.M.F. was a plastic surgery resident; all had previous experience conducting literature reviews in the field of peripheral nerve surgery. Study quality was assessed with the American Society of Plastic Surgeons Evidence Rating Scale for Prognostic Studies.19
Data Extraction
One investigator (H.M.Z.) reviewed articles for data extraction. Characteristics of each publication were recorded on a data input form, including publication year, journal title, study type, and level of evidence (LOE). Population characteristics, such as location, practice type, and average age, also were recorded. Any mention of nerve injury, including no nerve injury, was documented. If published, the specific nerve injured, deficits associated with the nerve injury, and duration of injury were noted.
Statistical Methods
The specific data points from each article were gathered and systematically recorded on a Microsoft Excel (Microsoft Corp, Redmond, Washington) data sheet. All data were pooled for analysis; specifically, we combined the number of patients from each article, the number of nerve injuries from each article, and the number of nerve and sensory deficits from each article. From our combined data, we were able to calculate pooled risks by dividing the total number of nerve injuries by the total number of patients. For the meta-analysis, Microsoft Excel was utilized to isolate articles that presented individual data from the desired variable (incision type, implant placement, volume of implant). We calculated P values, performed linear regression analysis, and graphed the data with the same software.
Results
The initial search yielded 4806 citations, 717 of which were duplicates and eliminated (Figure 1). Full text was obtained for 458 citations, 53 of which were identified as relating to breast augmentation. Of those, 26 were eliminated after full-text review based on the predetermined inclusion/exclusion criteria. Another 9 studies that met the inclusion/exclusion criteria were identified by reviewing citations of relevant articles found during the search and then locating those articles. A total of 36 citations were included and reviewed.
Citation attrition diagram.
Clinical Data
The 36 studies comprised 3 case reports,20,-22 1 case series,23 19 retrospective cohorts,24,,,,,,,,,,,,,,,,,-42 and 13 prospective cohorts.43,,,,,,,,,,,-55 Study details are summarized in Table 2.
Studies Gathered During Systematic Review
Total Risk of Nerve Injury
The risk of any nerve injury was calculated after pooling all studies. However, the literature data were presented heterogeneously. In most articles, the incidence of nerve injury was reported as the number of patients injured. However, in some articles, the incidence of specific sensory deficits was provided without mention of the total number of patients affected. The latter studies were excluded from the pooled cumulative risk analysis (Table 3) but included in the calculation of risk of deficits (Table 4).49,54,55 In a few articles, only the number of breasts injured was reported—not the total number of injured patients.43,50,-52 We presented our pooled calculated risk with these articles excluded (a best-case scenario). In addition, we assumed that each breast injury occurred in a unique patient (unilateral injury; a worst-case scenario).
Pooled Total Risk of Nerve Injury After Breast Augmentation
Pooled Total Risk of Sensory Deficits After Breast Augmentation
The total risk of any nerve injury, calculated by pooling all studies, was 13.57% (1135/8361) of patients (Table 3). For articles in which only the number of injured breasts was given, the calculated risk was 15.44% (1297/8361). The intercostal cutaneous nerves to the breast were the most likely to be injured; the risk ranged from 8.86% to 10.01% (741-837/8361). The T3-T5 intercostal cutaneous nerves to NAC were the second most likely to be injured, at a rate of 4.64% to 5.43% (388-454/8361). Other injured nerves included the intercostobrachial nerve (0.05% of patients [4/8361]) and the long thoracic nerve (0.01% [1/8361]) (Figure 2).
(A) The general course of innervation to the breast, showing medial and lateral branches of the intercostal nerves (numbered). The accessory deep branch to the nipple of the T4 lateral intercostal nerve is shown as a dotted line. (B) Detail of innervation to the nipple, which is predominantly from T4. Branches arise medially and laterally and course toward the nipple. Note that the lateral intercostal branch of T4 sends a deep branch along the muscular fascia that runs inferomedially before turning upward to penetrate the breast gland and innervate the nipple. NAC, nipple-areola complex.
The pooled calculated risks of chronic pain, hyperesthesia, hypoesthesia, and numbness after augmentation mammaplasty are presented in Table 4.
Subjective Assessment of Changes in Breast Sensation
When presenting information on nerve injury after augmentation mammaplasty, many authors simply referred to “breast pain” or general changes in skin sensation; some did not identify the location of the patient’s symptoms. However, we assumed that the symptoms occurred within the breast. Sensory changes to the NAC were noted separately, even though branches of the T3-T5 intercostal nerves innervate the NAC.
For most articles in our study, changes in sensation to the breast and NAC were reported subjectively. The pooled calculated risks of pain, hyperesthesia, hypoesthesia, and numbness in the breast and the NAC after breast augmentation are shown in Tables 5 and 6, respectively. From this large data set, we were able to perform a meta-analysis of the association between changes in sensation and submuscular vs prepectoral implant placement (Figure 3), inframammary vs areolar incision (Figure 4), and implant volume. Linear regression analysis did not show a correlation between implant volume and the percentage of patients with changes in sensation (r2 = 0.0027; Figure 5).
Pooled Risk of Sensory Deficits in the Breast After Breast Augmentation (Excluding the Nipple-Areola Complex)
Pooled Risk of Sensory Deficits in the Nipple-Areola Complex After Breast Augmentation
Submuscular vs prepectoral implant placement and changes in breast sensation after augmentation: meta-analysis of 36 studies. Bars indicate mean ± standard error of the mean.
Areolar vs inframammary incision placement and changes in breast sensation after augmentation: meta-analysis of 36 studies. Bars indicate mean ± standard error of the mean.
Linear regression analysis of implant volume and mean percentage of patients injured: meta-analysis of 36 studies.
Several articles were particularly relevant and warrant individual discussion. Dorsi et al22 described a 30-year-old woman who experienced severe bilateral pain in the T3-T5 dermatomes, from the midaxillary line to the sternum, after breast augmentation. Opioid analgesics, gabapentin, and 9 intercostal nerve blocks provided only minimal or transient relief. Physical examination revealed diminished sensation to light touch, temperature, and pinprick, from the midaxillary line to the sternum along the T3-T5 distribution, with intact sensation posterior to the midaxillary line. The patient had a positive Tinel’s sign along painful regions, and local bupivacaine blocks provided relief. The surgeons opted to perform bilateral T3-T5 dorsal rhizotomies rather than neurectomies because the latter would potentially require extensive incisions due to lack of specific localization, leading to unnecessary scarring.22
In the case series by Lu et al,23 11 patients experienced severe nonexertional chest pain associated with breast tenderness, heat and swelling, and nipple numbness at 6 weeks to 7 years after breast augmentation. Findings from an extensive cardiac workup were negative for these patients. All 11 patients had their implants removed, which relieved symptoms in 2 patients and reduced them in 9. Biopsies showed evidence of neuroma, neurogenic muscle atrophy, chronic inflammation, and foreign-body giant cells.23
In a retrospective study, von Sperling et al41 evaluated persistent pain and sensory changes at a mean of 2.65 years after breast augmentation. Among the responders, 17.9% were bothered significantly by hyperesthesia and 35.6% by hypoesthesia. The authors also noted that 44.21% of patients reported pain as a consequence of the surgery, mostly localized to the NAC or the inframammary fold. Pain symptoms were moderate to severe in 9.5%, affecting daily activities in 13.7%; 6.3% of responders regretted the surgery because of the pain. Some patients reported regular consumption of acetaminophen or nonsteroidal anti-inflammatory drugs for pain control. A total of 38.2% of patients who experienced pain (16.8% of responders) met the neuropathic pain diagnostic questionnaire (DN4) cutoff criteria for neuropathic pain, and 78.6% (34.7% of responders) had 2 or more descriptors consistent with neuropathic pain. The authors found no statistically significant association between pain and prosthesis placement, or between pain and patient age, height, or weight.41
The prospective, randomized, controlled, and double-blind studies by Romundstad et al49 and Kaasa et al55 were performed at the same medical center. A group of women who had undergone subglandular breast augmentations received postsurgical follow-up for up to 4 years. The patients were grouped into 3 cohorts according to whether they received preoperative intravenous administration of methylprednisone 125 mg, parecoxib 40 mg, or saline placebo. At the 1-year follow-up, the authors noted that methylprednisone administration significantly reduced the odds of hyperesthesia compared with parecoxib and placebo and that the findings of acute postoperative pain, hyperesthesia at 6 weeks, and the presence of hyperesthesia all increased the odds for pain at 1 year.49 At this time point, pain affected activities of daily living in 14% of patients, and 13% of patients had contacted a clinic or doctor because of the pain.49 At the 4-year follow-up, the authors found no significant differences between the cohorts but attributed this to limited study power. They found that evoked pain at 6 weeks, concomitant pain and hyperesthesia at 6 weeks, concomitant pain and hyperesthesia at 1 year, and hyperesthesia at 4 years all significantly increased the odds of pain at 4 years postoperatively.55 At this time point, 15% of patients had experienced pain during the previous week, and 3% had sought medical support because of their pain.55
Objective Assessment of Changes in Breast Sensation
Objective measurements of breast and NAC sensitivity after breast augmentation were utilized in 5 studies.32,34,48,50,52 The findings are summarized in Table 7.
Studies That Included Objective Assessment of Breast Sensation After Breast Augmentation
Other Nerve Injuries
Tebbetts45 noted that 4 of his first 20 patients who underwent transaxillary subpectoral augmentation mammaplasty reported unilateral numbness and paresthesias in the upper inner arm. These sensory changes were attributed to dissection injury of the intercostobrachial nerve or the medial brachial cutaneous nerve. Modification of the dissection technique prevented future injuries, and sensation became normal in 3 of the 4 patients after 6 months.45
Laban and Kon20 described the case of a 40-year-old woman at 4 months after transaxillary subpectoral breast augmentation. She was unable to lift her right arm above her head. Examination revealed winged scapula, with likely injury to the long thoracic nerve. She recovered completely half a year later without treatment.20
Berry and Stanek21 described a 28-year-old woman who had undergone submuscular breast augmentation that was complicated by a hematoma requiring evacuation and hemostasis. She also required bilateral capsulotomy, implant exchange, and revision mastopexy 6 months after surgery. One month after the revision surgery, she experienced right breast pain with movement that radiated into her shoulder and arm, precipitated by a period of active swimming. Her symptoms persisted for 2 years until she presented to the authors for pain consultation. Physical examination was remarkable only for pseudoptosis, and magnetic resonance imaging confirmed that the implant was intact. Surgical exploration showed tight muscular pockets that extended superiorly to the level of the clavicle with subsequent prosthesis impingement on the patient’s lower brachial plexus. Correction of these abnormalities relieved her symptoms.21
Discussion
Thirty-six reports included mention of a change in sensation or nerve injury after breast augmentation, only 1 of which stated no nerve injury or sensory change.31 Pooled data from these studies showed that approximately 13.57% (1135/8361) to 15.44% (1297/8361) of patients who underwent breast augmentation had some sort of nerve injury or change in sensation. Therefore, of the 330 631 breast augmentations performed in the United States in 2012,1 approximately 45 000 patients would experience this morbidity.
Risk of sensory deficits ranges from 8.86% (741/8361) to 10.01% (837/8361) in the breast and from 4.64% (388/8361) to 5.43% (454/8361) in the NAC. Other injured nerves were the intercostobrachial nerve (0.05% of patients [1/8361]) and the long thoracic nerve (0.01% [1/8361]) (Table 3).
For practicing physicians, patient complaints are more germane than nerve injury; therefore, we calculated symptoms of nerve pathology separately. The most common nerve deficit is hypoesthesia, with 8.72% (729/8361) to 9.56% (799/8361) of patients experiencing it. Pain is the second most common symptom, with incidence ranging from 7.51% (628/8361) to 7.55% (607/8361). This is followed by hyperesthesia, with an incidence of 4.71% (394/8361) to 5.26% (440/8361), and numbness, with an incidence of 2.28% (191/8361) to 2.31% (193/8361) (Table 4).
Many authors attempted to identify specific factors that are significantly associated with pain or changes in sensation. In 1 study, the inframammary approach was more likely to cause sensory changes than the periareolar approach50; in another study, the opposite was true.40 In 6 others, no differences in pain or sensation changes were noted between the 2 approaches.26,28,34,39,43,52 Our meta-analysis showed no difference between inframammary and areolar incisions (P = .2744; Figure 4).
With respect to submuscular vs prepectoral prosthesis placement, submuscular was associated with sensation changes in 1 study,29 subglandular was implicated in another,33 and placement location resulted in no difference in 3 articles.28,41,51 A meta-analysis of the available data revealed no difference between submuscular and prepectoral placement (P = .2613; Figure 3).
The authors of 2 articles reported that larger prosthesis volume34,52 and/or smaller breasts52 were associated with changes in sensation. In 7 other studies, volume reportedly had no impact on sensation changes.28,38,40,48,50,51 Linear regression analysis of the available data showed no association between implant volume and sensory changes (r2 = 0.0027; Figure 5).
Increasing age was associated with decreased return of sensation in 1 study.50 In another, younger age was associated with pain.38 In 4 other studies, age was not associated with any sensation changes.29,34,40,41 The authors of 2 articles38,41 reported that patient weight was not associated with sensation changes. However, these studies differed with respect to patient height: shorter stature was associated with sensation change in 1 study38 but not the other.41 The conflicting information may relate to the wide variety of surgical approaches, prosthesis placements types, study types, sample sizes, and follow-up times included in our review.
It is important to note that subjective perceptions of sensory changes do not necessarily correlate with objective assessments. For some patients who reported sensory complaints, no nerve-related pathology could be identified objectively.48,50 In other studies, an observed objective decrease in sensation did not coincide with subjective complaints.32,52 This illustrates that the final recovery and judgment of breast sensibility depends not only on regeneration of severed nerve fibers and axons but also on physiologic and psychologic factors.32 A consistency among most articles was the negative effect of these symptoms on quality of life.
Nerve injury is best avoided by knowledge of the relevant anatomy (Figure 2; Table 8).56,,-59 The five regions of the breast where nerves are vulnerable to injury, in order of frequency, are the lateral breast (anterior axillary), inferior breast, medial breast, central/NAC, and superior breast.18 Ducic et al18 have shown that each zone of the breast correlates with a specific approach during augmentation. Periareolar augmentation can injure T3-T4 at the central zone; inframammary incisions can injure T5-T6 at the inferior zone; transaxillary approaches can harm any nerve within the axilla, including the intercostobrachial45 (incidence as high as 62.7%)60 and long thoracic20 nerves, as well as T2 within the lateral zone; and transumbilical augmentation can injure T10 at the site of the incision, as well as inferior-zone nerves, including T3-T4.18
Anatomy Relevant to Nerves in the Breast
Even with intricate anatomic knowledge, some nerve injuries may be impossible to avoid, such as those due to unusual anatomic variations or indirect nerve injuries caused by nerve entrapment during the normal process of scar tissue formation. The cases reported by Dorsi et al,22 Lu et al,23 and von Sperling et al41 exemplify such injuries, with documentation of neuroma and neuropathic pain after breast augmentation.
The mechanisms of nerve injury during any surgery may include direct mechanical injury (eg, by scalpel, suture, or cautery), indirect neuropathy caused by nerve entrapment in scar tissue created during surgery, or indirect compression neuropathy as a result of surgical intervention, creating tissue edema in and around a nerve that lies in an already tight, unyielding anatomic space. Augmentation is a unique procedure in that prosthesis placement to create a larger volume may induce traction-stretch neuropathy.18 Blunt tissue dissection, such as that in augmentation-pocket dissection, also may cause direct nerve trauma. Such injuries result in 1 of 3 pathophysiologies: stump neuroma (in the case of transection), neuroma in continuity (in a mixed or incomplete direct nerve injury), or compression neuropathy (from scar or tissue edema at vulnerable anatomic tight points).
These scenarios are the most frustrating because, although the surgeon may have attentively sought to avoid nerve injury, the patient presents with prolonged postoperative neuropathic pain. In such a case, and certainly in the case of a recognized direct nerve injury, the best outcomes will be achieved by following an evidence-based approach to diagnosis and a management algorithm that emphasizes efficient diagnosis of the injury and early intervention of a peripheral nerve surgeon to treat refractory pain.17,18
On the basis of our findings, we present the following comprehensive treatment algorithm for nerve injuries after breast augmentation. As with all diseases, management principles in peripheral nerve surgery begin with a rigorous diagnostic workup. Without a high index of suspicion, peripheral nerve injuries often go misdiagnosed or improperly managed for extended periods, such as in the cases of Dorsi et al22 (2 years) and Lu et al23 (6 weeks to 7 years), leading to drastically diminished patient quality of life and dissatisfaction with the results.22,23,25,38,41,49,50,55 Without any obvious pathology, these patients are chronically and unnecessarily prescribed opioids and other pain medications for symptom relief. Moreover, psychiatric referrals and antidepressant medications are not uncommon. Risks associated with prolonged medical management include medication morbidity, abuse, and dependence. Addition-ally, untreated neuralgic pain becomes amplified through peripheral and central sensitization61,-63; if treatment is initiated too late, the pain can become centrally generated, no longer responding to deactivation of peripheral pain generators and effectively becoming permanent.
Although postoperative pain is expected in any patient, it can mask the initial presence of nerve injury. Diagnostic workups for patients with chronic breast pain after augmentation require a thorough history and physical examination to exclude other causes, including infection, fluid collections (eg, seroma, hematoma), and malignancy (eg, carcinoma, anaplastic large cell lymphoma, neural tumors). If these causes are ruled out, then consideration of neuropathic pain is prudent.17,18
The pain of nerve injury may present as sharp or burning, with associated areas of paresthesia, hyperesthesia, and allodynia. Typical onset is shortly after the procedure, and pain persists beyond the expected recovery time; however, onset can be delayed for months postoperatively. The pain is often near the incision site and may be duplicated by light pinching of the skin in a discrete and localized area, resulting in a positive Tinel’s sign. Lidocaine nerve blocks are helpful for confirming the diagnosis of nerve injury and for localizing the affected nerve. Pain reduction of a minimum of 5 points on a 10-point scale after nerve block is the traditional indicator of a surgically correctable nerve injury.18
If the diagnosis of nerve injury is confirmed or is highly likely, conservative therapies are initially appropriate, including scar massage (by the patient or a physical therapist), desensitization, and sensory reeducation with purposeful touching or running water over the area. Also important is optimizing the medical management of neuropathy-contributing conditions, such as diabetes mellitus and hypothyroidism. Following treatment, Sunderland grade I to III lesions typically resolve on their own. Active communication and explanation to the patient, along with validation of the pain, may help ease the emotional stress and anxiety associated with chronic pain. Short-term pharmacologic management with pain medications (opioid and nonopioid), anticonvulsants, tricyclic antidepressants, nerve blocks, or steroid injections may also be beneficial.
If no improvement occurs within 3 months to a maximum of 6 months following conservative management, consultation with a peripheral nerve surgeon is appropriate. Again, in patients with chronic pain, symptoms may become progressively centralized and difficult to treat definitively.61,-63 The potential for this progression may be lessened by peripheral nerve surgery to remove the cause of the patient’s symptoms.
Timing of surgical intervention is variable. Patients with debilitating and well-localized pain that responds to local anesthetic blocks are more likely to benefit from early surgery. Patients with less acute and more poorly localized pain, who are gradually improving between office visits, can be appropriately observed until 6 months have elapsed to allow for maximal recovery time. Surgical treatment of nerve injuries after breast augmentation involves exploration of the suspected injured nerves with neurolysis of entrapped nerves or neuroma excision. The proximal nerve stump should be implanted into a muscle bed to prevent neuroma recurrence. Because of the highly variable anatomic course of these nerves and to avoid further risk of nerve injury, only a surgeon who is experienced in these surgeries should undertake them.
Limitations
This review is limited by the lack of emphasis in the literature on nerve injuries and sensory changes after breast augmentation. Although general advancement in breast augmentation procedures is the focus of many studies, most authors do not mention the presence or absence of neurologic symptoms (eg, pain, increased/decreased sensation) in their assessment of complications. Such articles were excluded from our review because it was not possible to determine whether the lack of discussion related to lack of injury (n = 0) or to lack of consideration of neurologic deficits as a potential complication (n ≥ 0?). Our search and review identified only 1 article in which the absence of neurologic symptoms was mentioned.31 Although our selection process may have introduced a selection bias, in that we included only articles that mentioned neurologic deficits, it ensured that the extracted data reflect a highly accurate measurement of the incidence of nerve injury after breast augmentation.
The quality of available studies and their differing levels of evidence also represent limitations. Our review included 19 retrospective cohorts24,,,,,,,,,,,,,,,,,-42 and 13 prospective cohorts.43,,,,,,,,,,,-55 We also included 1 LOE 423 and 3 LOE 520,-22 studies in our review and calculations, representing 14 additional patients. Excluding the latter articles would have omitted the findings of injury to the long thoracic nerve20 and brachial plexus,21 in turn preventing awareness and minimizing the potential importance of these nerves. Two of these reports provide evidence of severe and extensive nerve injuries after breast augmentation,22,23 which are relevant to this review. It is unlikely that including these 14 patients in our calculations had a significant effect on our results, because they account for only 0.17% of the total patient population (14/8361).
Moreover, our review was limited by the heterogeneity and format of available information. Some authors did not specify the total number of injured patients, and others provided results only for breasts with sensory deficits. Thus, we opted to create a range of percentages, from a best-case scenario (that excluded these articles) to a worst-case scenario (that included them as unilateral injuries).
Because some authors did not specify the locations of symptoms, or simply indicated “the breast,” it is likely that our NAC percentages are underestimates and our breast percentages are overestimates. Other authors provided only percentages of patients with injury, which required calculation on our part to determine the actual number of patients injured. For the sake of simplicity, we combined several terms for data analysis. For example, paresthesia, hypersensitivity, and allodynia were considered “hyperesthesia.” If the type of sensory deficit was not specified, such as “change in tactile sense,” we assumed it to be hypoesthesia. This likely resulted in underestimation of the overall risk of nipple numbness and in overestimation of the hypoesthesia risk. Some patients presented with numerous deficits or with deficits of 2 areas with similar anatomic distribution (eg, breast and NAC). To prevent percentages from exceeding 100, we included only the anatomic area within which there was the greatest number of patients reporting nerve deficits.
A symptom of capsular contracture is pain from nerve compression. We were unable to distinguish capsular contracture from specific surgical neuropathy as a source of pain in some studies, especially those with long-term follow-up. A significant association between capsular contracture and pain was noted in only 1 article,37 and the lack of an association was reported in another article.38 In the remaining articles, the incidence of capsular contracture was either mentioned23,25,26,28,47,53 or merely speculated to be a source of pain in certain patients.29,40,41
Additional study characteristics, including study type, practice type, length of follow-up, male to female ratio, and type of prosthesis, were recorded in the present review. However, due to small sample sizes and study heterogeneity, we were unable to perform a meta-analysis on these data or to draw any conclusions from them.
common problems after breast reduction surgery
Breast reduction surgery, which doctors may call reduction mammoplasty, is a medical procedure that reduces the overall size of a person’s breasts.
According to the authors of a 2019 article, breast reduction surgery is one of the most common cosmetic procedures.
In this article, we discuss breast reduction surgery, including the procedure and how it differs between males and females, what to expect during recovery, and the associated risks.
People who have overly large breasts that cause neck, shoulder, or back pain may benefit from breast reduction surgery.
Large breasts can make exercising and other activities difficult. Having large breasts can also have negative psychological effects, as some individuals feel self-conscious about their breast size.
Doctors may recommend breast reduction surgery for males who have gynecomastia, which is a medical condition in which the breast tissue swells due to high levels of estrogen.
Breast reduction surgery can help improve people’s physical and psychological well-being.
A doctor will first determine whether someone is a candidate for the surgery. This evaluation can include:
A breast reduction usually takes place under general anesthesia. Most people go home straight after surgery, but some do spend 1–2 nights in the hospital.
Before surgery, a person may need to stop taking over-the-counter anti-inflammatory medications, such as aspirin and ibuprofen, as these can increase bleeding.
Doctors also encourage people who smoke to quit several weeks before the procedure. Smoking will increase the risk of nipple or areolar damage, tissue necrosis, and other complications. Therefore, it is essential that people discuss any tobacco product use, including vaping, with the doctor.
The plastic surgeon performing the procedure will use a marker to draw guidelines for the incisions. The size of the breasts, the position of the nipples, and the person’s preferences will determine the exact incision pattern.
The wise pattern, or anchor pattern, is the most common skin removal technique for breast reduction surgery, according to the authors of one 2019 article.
A surgeon starts by making an incision around the areola. Then, they continue the incision beneath the breast, at which point they may remove excess skin from the sides of the breast.
After making the incisions, the surgeon will remove excess breast tissue, reshape the remaining tissue, and reposition the nipple and areola. The surgeon will close the remaining skin with sutures and surgical tape.
If the breasts are particularly large, it may be necessary to remove the nipples and areolas from the body and then place them back on the breasts in a procedure called a free nipple graft. The nipples will regrow into the new position, but they will usually be permanently numb afterward.
After the procedure, the surgeon or a nurse will wrap the breasts in gauze bandages. The insertion of small tubes into the breasts is sometimes necessary to drain excess fluid and reduce swelling after the operation. People should avoid showering until a nurse removes these drainage tubes.
The goal of male breast reduction surgery is to remove any excess fatty or glandular tissue to achieve a flatter, firmer-looking chest.
Males undergoing breast reduction surgery will receive a local or general anesthetic before the procedure. The procedure can involve liposuction, excision, or a combination of the two.
Liposuction can correct gynecomastia that is due to excess fatty tissue. The surgeon will make micro-incisions along the sides of the breast and insert a thin tube called a cannula. The surgeon will use the cannula to loosen and remove excess fatty tissue.
Gynecomastia can also cause excess skin and glandular breast tissue. In this case, a surgeon will use excision techniques to cut off this tissue.
After reducing the size of the breast, the surgeon will reposition the areola and nipple, if necessary, and close the incisions with sutures.
Most people can go home a few hours after the surgery, as long as they do not experience any complications.
Before they leave the hospital or clinic, they will receive specific postoperative instructions that cover what types of oral and topical medications can help reduce pain and scarring and prevent infections.
People will need plenty of rest while their breasts heal. They should avoid any movements that might stretch the chest muscles or tear the sutures.
People may have difficulty lifting their arms during the first couple of weeks, so they may want to ask a close family member or friend to help them during this time.
They should avoid heavy lifting for several weeks or until a doctor removes their sutures.
People may experience minor complications after breast reduction surgery, such as:
Smoking can increase the risk of complications and delay the healing process. People who have obesity may also have a higher risk of postoperative complications.
It is important to note that the breasts may have very small asymmetries after surgery. Most breasts are not exactly the same size or shape to begin with, and the surgeons do try to remove more tissue from the bigger side. However, after the procedure and months after the completion of the healing process, there may be small differences between the breasts.
Also, breast reduction surgery can affect a person’s ability to breastfeed.
According to the American Society of Plastic Surgeons, breast reduction procedures cost, on average, approximately $5,680. People will also need to pay for the cost of consultations and follow-up appointments.
Some insurance companies may partially or completely cover the cost of breast reduction surgery if a person needs this procedure to relieve chronic pain or other medical problems.
People who are thinking about having breast reduction surgery may wish to contact their insurance company to inquire about coverage.
Breast reduction surgery is a relatively safe and effective medical procedure that reduces the overall size of a person’s breasts.
A plastic surgeon will remove excess fat, breast tissue, and skin through incisions underneath the breasts. They may also reposition the nipple and areola.
Breast reduction surgery is an outpatient procedure with minimal risks. Rare complications include infection, scarring, and loss of sensation in the nipples or breasts.
People considering breast reduction surgery can make an appointment with a board certified plastic surgeon. At the appointment, the surgeon will evaluate a person’s medical history and current health status to determine whether breast reduction surgery is a suitable option.
pulling feeling after breast reduction
Breast reduction surgery is a life-changing event for women who have suffered from the physical and emotional pain that can result from having large breasts. Even though the benefits of the outcome of breast reduction surgery almost always outweigh potential risks, knowing what to expect during recovery is an important part of the decision-making process. At Schaffer Plastic Surgery, we want our patients to be as informed as possible and to feel confident in their decision to undergo any procedure.
Healing From Breast Reduction Surgery
Breast reduction, also known as reduction mammaplasty, works by surgically removing excess glandular tissue, breast fat and skin to create a smaller, more-shapely breast. It is an outpatient procedure, meaning patients can recover in the comfort of their own homes. However, plan to have someone drive you home from our surgery center since you may feel weak right after surgery. For two to three weeks after breast reduction surgery, you may feel sore and experience some pulling sensations in the breast area.
Considerations for Breast Reduction Surgery Recovery
Since most women feel soreness for a few weeks after breast reduction surgery, you may need pain medicine for a week or two. Keep in mind that taking prescription pain medications may prevent you from driving. Additionally, for several weeks, you may tire easily or have less energy than usual. You may also have the feeling that fluid is moving in your breasts, which is a normal sensation and will go away over time. Stitches are usually removed in five to ten days.
Breast Reduction Surgery FAQs
What Should I Wear After Breast Reduction Surgery?
It is important to wear a surgical bra or compression garment for approximately six weeks—day and night—after breast reduction surgery. Dr. Schaffer will recommend the appropriate undergarment that will hold your bandages in place after the surgery.
When Can I Sleep Without a Bra After Breast Reduction Surgery?
It is important to sleep in the surgical bra or compression garment recommended to you by Dr. Schaffer for six to eight weeks after breast reduction surgery. The exact period of time depends on the patient’s age, weight and other lifestyle factors.
Can I Breastfeed After Breast Reduction Surgery?
New techniques in breast reduction surgery allow for the preservation of lactation-related structures in the breast, meaning it is highly likely to be able to breastfeed after breast reduction surgery.
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When Can I Lift My Arms After Breast Reduction Surgery?
Lifting your arms over your head, bending and heavy lifting should be avoided for the first few days after breast reduction surgery. After several days have passed, you may gradually increase your daily activities. Anything strenuous should be avoided for a minimum of six weeks to promote complete healing.
When Can I Sleep On My Side After Breast Reduction Surgery?
Sleeping on your back for the first two weeks after breast reduction surgery is important, as it keeps the breasts in an optimal position for healing and prevents any pressure from being placed on them. After two weeks, it is safe to sleep on your side again, although stomach sleeping should be avoided until the four-week mark.
When Can I Resume Exercise After Breast Reduction Surgery?
Dr. Schaffer typically advises his patients to wait four to six weeks after breast reduction surgery to resume exercise, especially high-intensity cardio workouts. Easing back into any exercise routine, such as going for short walks or lifting light weights, is the safest way to resume exercise.
Will My Breast Reduction Surgery Scars Go Away?
Dr. Schaffer takes special care in keeping postsurgical scarring to a minimum. Any scars you do have after breast reduction surgery will be easily concealable and should fade over time with proper care. The scar healing process varies from person to person. For stubborn scars, we offer laser resurfacing solutions that can help to dramatically reduce their appearance.