Bye-Bye Big Breasts: A Guide to Breast Reduction

Dr. Gallus (00:02):
You are listening to another episode of All the B's with me, Dr. G and my scrub tech Bri. Hi, I am Dr. Kat Gallus and you're listening to All the B's, the unfiltered plastic surgery podcast with me, Dr. G and Bri, my scrub tech. Hi Bri.

Bri (00:20):
Hey everyone.

Dr. Gallus (00:23):
So on this podcast, we love to chat about Daily Mail and any upcoming or recent plastic surgery articles and then reacting to 'em, right?

Bri (00:35):
We love it. It's what we do all surgery days.

Dr. Gallus (00:40):
Right, that's right. I know it's important to stay up to date. So we're going to be talking about breast reduction today.

Bri (00:47):
Small boobs matter.

Dr. Gallus (00:50):
Small boobs matter. Before we get to that, we're going to talk about some other Daily Mail stories. So I feel like this is super on topic because I feel like I'm slowly getting to the point where I might be offering this in my office. So Macy Gray, 56, reveals brutal Ozempic side effect that kept her all up all night. And she took the weight loss drug over fear she'd looked fat on TV. So do you know what

Bri (01:20):
Was she up all night because she's constipated?

Dr. Gallus (01:23):
Yeah, I thought that was weird, kind of. I would've guessed the opposite problem like diarrhea. But she said it just really, you hurt constipated. I know. Well, I think because Ozempic is, it slows everything down. It slows the gut down, and I feel like one of the more common side effects is nausea, and that is due to delayed gastric emptying. So I think just the whole gut slowing process. But I've also heard of people having the opposite problem where maybe their stomach is slow to empty, but their rest of their gut is working and they have diarrhea. So either way it sounds super fun.

Bri (02:05):
Sounds miserable.

Dr. Gallus (02:07):
Yeah, a little bit dramatic I feel like because in order to do any of these GLP-1s properly, you really should start with a low dose and titrate up. So I feel like you could maybe not go to a max dose and have all these symptoms and then have to back off if you just started slowly.

Bri (02:27):
Do you still have symptoms with a lower dose or do you think these are mainly at the higher dose?

Dr. Gallus (02:31):
You don't. Yeah, lower dose is related to less symptoms, so you only need to increase the dose. If you're not seeing a benefit ie, you're not losing weight and then you can titrate up for weight loss and titrate down for symptoms. So it's not a perfect medication, but a lot of people have done really well on it. So I don't know, maybe she just needs to try a lower dose.

Bri (02:56):
The things we do to be skinny.

Dr. Gallus (03:00):
And then speaking of skinny, Emily Ratajkowski, I can never say her whole last name.

Bri (03:05):
We call her Em Rat.

Dr. Gallus (03:07):
That's right, Em Rat puts her toned abs on display in a bra and unbuttoned shirt as her slacks almost fall off her hips in New York City. So Em Rat is from here, right? She went to Torry Pines High School.

Bri (03:21):
Yeah. My girlfriend went to high school with her. She looks amazing.

Dr. Gallus (03:25):
She does look great.

Bri (03:27):
Do we think she's had plastic surgery?

Dr. Gallus (03:29):
I mean she's had a kid, but she looks pretty good.

Bri (03:34):
I did not look like that after I had kids.

Dr. Gallus (03:37):
I mean, I saw you in a bikini this weekend. You looked great.

Bri (03:41):
Thank you. It's all natural.

Dr. Gallus (03:46):
We did have our second annual Christmas in July pool party. We love Christmas in and it was a lovely day.

Bri (03:52):
It was.

Dr. Gallus (03:53):
Yeah, it was a lovely day in San Diego. So we all donned swimsuits. But yeah, she looks fantastic. Actually, Em Rat was also in Encinitas because she's from the San Diego area and schlepping around. I mean, she doesn't look like she's had a tummy tuck, but she probably didn't need one, but she could have done a little liposuction, some skin tightening with Renuvion. I think there's a lot of noninvasive things you can do to tone your abdomen besides just working out and dieting, which I'm sure she does both. And some people do naturally spring back a lot faster. And the other variable is how much weight you gain with your pregnancy. So if you gain a hundred pounds and do that in short order, then it's going to be a little bit harder to bounce back. Also, if you have twins, if you have a really large baby, those are all things that you can't control. So I feel like just do the best you can and figure it out afterwards.

Bri (04:52):
I don't even think she has a stretch mark on her belly.

Dr. Gallus (04:55):
No, she does not.

Bri (04:58):
She looks amazing.

Dr. Gallus (04:59):
She does look good. Okay. Well let's talk about the breast reduction stories. There are so many. The Daily Mail has a lot, and I feel like for once it echoes real life in how our patients who come in with large breasts who are interested in breast reduction surgery really, really do find that it's a life-changing operation. So story number one is my 34 H boobs. Bri explain to us what 34 H means. I feel like a lot of people aren't aware of the H or J or K.

Bri (05:35):
So big.

Dr. Gallus (05:38):
Where can you find that bra size?

Bri (05:40):
I don't even know.

Dr. Gallus (05:42):
Yeah, you have to buy 'em off the internet.

Bri (05:44):
It has to be special custom made.

Dr. Gallus (05:48):
Yep. So that's a common thing that breast reduction patients share is that they're not able to buy off the shelf bras from Victoria's Secret or any of those, Nordstrom, any of that stuff. Those bras tap out at triple D and then after that you can go to size E, F, just the rest of the alphabet. You can go up to a K. I've met a K size breast. Yeah, that's a lot of breast tissue. It's hard if you have large breasts and it can lead to other problems like back problems, a shoulder grooving, which this patient describes and she talks about how she went from a 34 H to a 34 B, which pretty awesome, honestly.

Bri (06:36):
Huge change. Her back's got to feel so good.

Dr. Gallus (06:38):
Yeah, I mean her ability to wear clothes and all of those things are vastly improved with that procedure.

Bri (06:48):
Is there any other reason that somebody would get a breast reduction?

Dr. Gallus (06:52):
I think besides fitting and clothes and then I would say upper neck and back pain is the most common reason. It can impede your ability to do certain things. So athletes find it hard to carry that weight around. So if you're a runner, you end up using two sports bras. Yeah, I've had patients that were avid horseback riders, track stars.

Bri (07:19):
It has to affect, can it affect your balance when you're horseback riding?

Dr. Gallus (07:24):
I don't know.

Bri (07:25):
Is that a thing?

Dr. Gallus (07:26):
I just can't imagine it being comfortable. So you really have to strap in with a couple of sports bras and wear a lot of compression. So I mean, I cannot, the Olympics are on now, I can't think of a single sport where having really large boobs would pay off.

Bri (07:43):
No.

Dr. Gallus (07:44):
They're just in the way.

Bri (07:45):
I know, and I find that a lot of the patients that we see are on the younger side.

Dr. Gallus (07:50):
Yes. I mean you can assume that your breasts can get larger with time if you gain weight and that's kind of where you put the weight. But these patients are young, healthy, relatively healthy weight and just have proportionally larger breasts.

Bri (08:09):
Is there an age where you would have a patient hold off until they got older? Do you have an age where you're like, no, you have to wait to get a breast reduction?

Dr. Gallus (08:22):
So that's interesting. That comes up quite a bit. So I don't have a hard cut age, but I would say that teenage years are a little dicey. And I feel like there was an article about somebody who had a breast reduction and then had a second breast reduction, years later. This yoga teacher, Echo Elliot, which is kind of a cool name, had a second breast reduction eight years after she had surgery. But her original surgery was pretty young. So I would tell women who are 15, 16, anywhere from 15 to 20 that it's best to wait until your breasts are not growing. So that means that you haven't changed your bra size for at least a year, otherwise you are hitting a moving target, you're going to do a reduction and then maybe by the time you're 18 or 19, you need a second reduction. And so that's way too soon.

Bri (09:16):
Such a bummer.

Dr. Gallus (09:18):
That would be. So some surgeons will have a cutoff no less than 16. I think I've seen 15 year olds for consultation just to discuss it and so that they can know what to look forward to. Let's see you annually until your breasts stop growing. Right? And then again, the younger that you are, I say that you can potentially need to have this surgery again and not because your breasts are going to keep growing per se. I don't know the circumstances of this yoga teacher in particular, but if you have children and you breastfeed, any kind of hormonal change can change your breast size. So sometimes people return for a second breast reduction surgery after they're done having kids.

Bri (10:05):
So would you suggest that if they wanted to have kids in the future that they should wait or are they still okay to have it? Does it affect breastfeeding?

Dr. Gallus (10:17):
That's a great question. I do not tell them to wait just because on the other end of the spectrum, the women that I've done breast reduction surgeries who are in their fifties and older, wish they had done it sooner. Now you're saying, okay, well I'm just going to suck up a lifetime of having large, heavy breasts not being able to do anything, you have back pain for some potential down the road. Now if you come in for breast reduction, you're 22 years old, you just got married and you're planning to have kids right away, then yeah, wait, because you can't predict the changes. But if you're 18 and I say, oh, you'll still be able to breastfeed later, and they're like, give me that look like why are you talking about breastfeeding? Then I say, go ahead and have the surgery because maybe you don't have kids until you're 35, so that's half your life you're going to spend with large breasts. So it's just an individual timing for each patient.

Bri (11:14):
What is the scarring like? Looks like the incisions are pretty big in that picture.

Dr. Gallus (11:19):
Yes. I would say the trade-off for this surgery are incisions. Typically this is done with an anchor incision, meaning an incision around the nipple areola complex, straight down and then underneath the breast. So an upside down T. But because patients are so happy with the results of having smaller breasts, they don't mind the incision.

Bri (11:41):
Nowadays, there's so many things you can do to cover it up. You can do tattooing, laser.

Dr. Gallus (11:47):
I have seen some elaborate bra tattoos, usually in breast cancer patients. My breast reduction patients tend not to tattoo over the scars, but you can. And we laser all our incisions at about four to six weeks after surgery and then again, twice more. So we offer scar cream, we use Steri strips over the incisions, and we do a bunch of things to help the incisions heal as nicely as possible. And the idea is that they fade to be nearly invisible over the next year to two years.

Bri (12:20):
And is that your only option for, and what if somebody was like, I want the smallest scar possible. Is that your only option for a breast reduction? I know for a lift, there's a couple options, but.

Dr. Gallus (12:33):
Right. So you can do a vertical breast reduction if the patient has large but not too large. I think once you get beyond a certain size and we measure your breast, there's a bunch of measurements that we do from your collarbone to your nipple, from your nipple to where your crease is. If those distances are really long, then it's hard to do it with just the lollipop incision. But if you have a smaller breast and we're doing not as large of a reduction, sometimes we can do what we call a lollop reduction. So around the nipple areola complex, and then straight down, those are about the only ways to get around it. There is a technique where they just go inframammary crease and then around the nipple areola complex. So they avoid that straight down incision. But the technique in order to create that I think in my opinion, leaves a very boxy breast.

(13:28):
And I think the shape that you get from using a more traditional incision outweighs any advantage of not having that lollipop. And then in older women, you could do a liposuction only breast reduction, which are very small incisions, but those patient who will do well with that are very rare. They have to have enough fat in their breasts. So younger patients tend to be more dense breast tissue, so not amenable to liposuction. The older patients have more fat versus breast tissue, so could do liposuction, but then their skin quality maybe not be such that if you do liposuction the breast, the skin is going to retract.

Bri (14:09):
And then you are talking about the areola, you can make that smaller. I feel like a common thing we've been recently asked is the nipple in the areola. Sometimes I feel like I would think that's one and the same if I didn't know better, because I know we did a nipple reduction not too long ago and I was like, oh.

Dr. Gallus (14:30):
Wait, what's this? Yeah.

Bri (14:31):
Yeah.

Dr. Gallus (14:32):
Right. So that's two different entities. Plastic surgeons tend to talk about the nipple, which is in the center, and then the areola, which is that outer pigmented tissue. Those are two separate entities, but we tend to refer that as the NAC, the nipple areola complex. But we do reduce the size of the areola at the time of surgery. So no matter whether you're getting a breast lift or breast reduction, a lot of times if you have large stretched out breast tissue, that areola is also stretched out. And we reduce that to some average sizes that are either 38 to 42 to 45 millimeters. For some reason that, you know what that or tool is called right?

Bri (15:18):
The cookie cutter is what we call it. We're very informal though.

Dr. Gallus (15:25):
Everything in medicine ends up going back to food. So yeah, we use a cookie cutter to mark out that distance and then can make the areola smaller. I think 95% of our patients are excited about that prospect. I feel like we've had a few patients who don't want their areola to be too small. And so when people bring that up, I like to know what your definition of too small is. So you're usually talking 48, 50 millimeters maybe, but it's an uncommon request and you can reduce the size of the nipple as well. I'm trying to remember, oh, that more recent patient was an implant removal, and certainly I can reduce the nipple width and the nipple projection. Those are two different things that can be addressed. It's a possibility for sure.

Bri (16:13):
And then do you just take the nipple off completely? Do you leave it on?

Dr. Gallus (16:18):
That's another good question.

Bri (16:20):
I'm full of good questions.

Dr. Gallus (16:23):
With a nipple areola complex reduction, which is part of a breast reduction, we're not taking it off. But I do find sometimes I have to explain this to the patients because even though you and I know what we're doing, if you don't know anything about the surgery, your imagination goes crazy and you think, oh, we're just taking the nipple off and then we're putting it, I don't know, on ice or something, and end of the case, putting it back on where we want it, but that's not what's happening. So it stays attached to the breast tissue and then everything else is kind of rearranged around it. In rare cases, you would take that off as what we call a free nipple graft. So you take the areola and the nipple off and put it back on. And those are in very, very, very large reductions.

Bri (17:06):
We did one of those a couple of weeks ago.

Dr. Gallus (17:09):
Yes, very large. We took off, what, sic pounds?

Bri (17:11):
We guess every breast reduction, we always guess I try and make a bet for whoever wins has to buy lunch. But that only worked once.

Dr. Gallus (17:21):
That's right. It did work once though, so that was worth doing. Yeah. You know what another question I get for breast reduction is if I'm going to use drains, and 99% of the time I don't use drains, I feel like

Bri (17:32):
Why would you not use drains?

Dr. Gallus (17:34):
I just don't think you need them. You're going to have a little bit of fluid collection buildup in the wound bed, but it gets absorbed by your body. Drains are annoying. I think if you stay in that light compression bra that you wake up in and the weight of the surrounding breast helps prevent any fluid collections from happening. So I haven't used drains except for once or twice in the last 10 years. And I actually was bullied into stop using drains by my PA when I was in the Navy. I was making fun of one of the other plastic surgeons because the very, very old school way of doing a breast reduction was to do the reduction, put the drains in, and then we would ace wrap the patient instead of putting them in a bra. Because postoperative surgical bras were not that commonplace. So I was saying, it's such a pain to ace wrap a patient that is asleep, you have to lay him on a board and lift them up and slide it out.

Bri (18:36):
It's whole process.

Dr. Gallus (18:37):
It's a whole process. So I was saying we were doing the case and anesthesia was like, oh, when are we going to do the pizza board? And I was like, what a pizza board. Now there's this thing called a bra.

Bri (18:52):
It's 2024.

Dr. Gallus (18:54):
So we're just going to put the bra on. And they're already laying on it, it's magical. And as I was making fun of the idea of using a pizza board, my PA goes, yeah, but you still use drains. And I was like, oh, burn.

Bri (19:10):
You're right. You're right.

Dr. Gallus (19:12):
It's hard to go away from something that's been traditionally done for decades and decades, and you've trained that way. And to take that leap to know, oh, there's no evidence-based medicine to support it, it gets really hard for doctors to break that mold. So anyway, I stopped using drains. It was much easier to transition to using bras. And then

Bri (19:36):
I can imagine

Dr. Gallus (19:37):
Never looked back.

Bri (19:39):
Now, why would you use drains on a patient? What are drains for?

Dr. Gallus (19:43):
So drains are there to take any fluid that is produced by your body in that potential space that you don't think you can absorb in that period of time. So if your body produces 30 ccs of fluid, so that's about a shot glass, your surrounding tissue can absorb it, and you're going to expect that's going to come from just trauma from having something done. So if you scrape your knee, how it gets a little oozy, well, think of that on a larger scale, there's fluid that gets oozed as the body is trying to heal. And most of the time your body is able to absorb that fluid. But if you build more fluid than your body can absorb in a 24 hour period, it just sits there and builds on itself. And then you have something called a seroma, which is a fluid collection. And our bodies don't like fluid collections, so they'll wall them off, or you'll just feel like you have fluid sloshing around inside. And so that's why we use drains sometimes to prevent that.

Bri (20:45):
And then how long do you keep the drains in for?

Dr. Gallus (20:47):
So a lot of times if somebody has a drain in place, I'll say approximately five days, but what I want to see because of that 30 cc rule is the amount of fluid coming out of that drain is dropping off. So less than 30 ccs in a 24 hour period. They're commonly used in breast reconstruction surgery, so surgery for cancer because you don't want any additional fluids surrounding the breast reconstruction.

Bri (21:13):
We love drains.

Dr. Gallus (21:16):
Yeah. I don't love having a drain, and I know my patients don't either. So if there's a way to safely avoid doing it, we don't use 'em.

Bri (21:24):
Okay. We segued back to Doja.

Dr. Gallus (21:28):
Oh, Doja Cat?

Bri (21:29):
Yes.

Dr. Gallus (21:30):
Oh, I love talking about Doja Cat. So she has incisions, is that what we're talking about? That she loves to flaunt?

Bri (21:38):
Breast reduction.

Dr. Gallus (21:41):
Oh yeah. She is no

Bri (21:44):
I love how confident she is.

Dr. Gallus (21:47):
Yeah, I've seen her now in concert twice, and she does not care about her incisions. So she shows her breasts all the time and see-through stuff. I feel like she competes with Bianca Censori for

Bri (22:01):
Oh yeah, racy outfits?

Dr. Gallus (22:03):
Most revealing looks, yes. Yeah. And so her breasts look fantastic, but I'm not sure she had a breast reduction. I feel like she almost had her, I mean, I guess she did a lift, but yeah, her breasts look fantastic. And if you see her in almost any picture in concert, she was wearing a white sheer mesh shirt. And as she got sweaty, I was like, Hey,

Bri (22:27):
Oh yeah.

Dr. Gallus (22:28):
Those are some incisions. But yeah, you can see it's a nice straight fine incision. But because she's darker skinned, it's darker than her surrounding tissue, and so it's a faint dark line that you can see. And she had liposuction surgery at the same time, which they can go hand in hand.

Bri (22:45):
I wonder how big her breasts were before.

Dr. Gallus (22:47):
I know she doesn't really say, because I feel like I've seen photos of her where she wasn't particularly busty. But

Bri (22:54):
Yeah, I was like, I haven't ever looked at up and been like, oh my goodness, those are huge.

Dr. Gallus (22:58):
Right. But she does love her body and she also,

Bri (23:02):
I love that.

Dr. Gallus (23:03):
Loves plastic surgery.

Bri (23:05):
I love plastic surgery too.

Dr. Gallus (23:08):
So she's had a lot of areas liposuctioned as well. I'm guaranteeing she's had a BBL, so fat transferred to the buttocks and yeah.

Bri (23:19):
I don't see them being huge.

Dr. Gallus (23:21):
She's gone so under so many transformational changes that it's hard to know. Like do you have hair, do you have her eyebrows? What's going on?

Bri (23:28):
Every time I see her, she looks so different. I'm like, oh, that's her.

Dr. Gallus (23:32):
Yeah, she's definitely a chameleon.

Bri (23:34):
I'm all for the pink hair though.

Dr. Gallus (23:37):
Yes, she does mention though having another procedure at the same time. So liposuction and you can combine breast reduction with other surgeries. You can also do liposuction as an adjunct to your breast reduction if there are areas that you want addressed like your lateral chest wall or that what we like to affectionately call the chicken nuggets. So that little tissue that sits right in front of your underarm area, so that gets stuck in clothes.

Bri (24:05):
Stuck between your bra.

Dr. Gallus (24:07):
Yeah, your bra and your axilla. So we love doing adjunctive liposuction at the same time. Speaking of drains though, if I'm going to do drains with a breast reduction, I would say the odds are a little bit higher if I'm doing aggressive liposuction around your lateral chest wall and in your axilla because not all of that fluid gets suctioned. And it's nice to have the addition of a drain to help that along. But it can provide a very nice contour for the lateral breast wall, chest wall area to do a little bit of liposuction in the right patient. And then of course you can have other procedures done at the same time. So breast reduction and a tummy tuck at the same time is pretty common. Breast reduction and additional liposuction either on your abdomen or your thighs is common.

Bri (24:56):
Mommy makeovers.

Dr. Gallus (24:58):
Yes.

Bri (24:58):
I made Dr. Gallus lipo, my chicken nuggies. Best thing ever.

Dr. Gallus (25:03):
I know it's an easy in-office under local procedure and surprisingly so many women have it and it bothers you, so it's easy.

Bri (25:14):
You would be surprised how such a small amount of fat makes such a difference.

Dr. Gallus (25:18):
It really does in the wrong place, right.

Bri (25:21):
Yeah, thanks. How long do you think her recovery took for breast reduction?

Dr. Gallus (25:28):
I would say if you're just doing a breast reduction two weeks and most people are feeling pretty good and after two weeks you can start increasing your activity level, meaning you can get your heart rate up, you could do maybe a walk of the treadmill or a light jog with a good bra on, and then most patients are back to regular activities at that three to four week point in time. Definitely you want to stay out of the water. So again, in San Diego, it's sunny and nice out. You don't want to be getting in the pool or the hot tub or even our ocean when it's being condemned. So you want to stay out of any water, bodies of water. You can shower certainly for at least two weeks, and then I usually see you and if everything looks great and it's healing, then I give you the thumbs up. And if there's a couple little areas that need a little more time, then it's closer to three or four weeks.

Bri (26:19):
I feel like the healing is a little bit easier for patients compared to at least a breast aug where you're going under muscle and it's super painful.

Dr. Gallus (26:28):
Yeah, I think the recovery is faster because their back pain and ability to stand up straight is relieved, instantly.

Bri (26:36):
Outweighs the scars.

Dr. Gallus (26:38):
Yeah, it's great.

Bri (26:39):
So when patients come back at three month mark, what do you find that they say is the most common as far as their results? Are they loving it? How do they feel?

Dr. Gallus (26:50):
I love to see my patients back at three months. So at that point in time, they're back to regular activity. They've had three laser treatments for their incisions. They've bought new bras, which you don't want to buy too soon because there's some swelling that needs to settle out. So I tell them not before six weeks, and they come sliding into clinic, super happy, excited with their new size, excited about being able to wear clothes. I've had patients that are excited about little things that I think you and I take for granted. I had one patient who was super excited that she could buy cheap flip flops at Target now because her back wouldn't hurt. So she had to have special, she had to pay attention to her footwear because her back was always hurting. And now she's like, I can buy those cute cheap flip-flops now. Okay. And she was a hairdresser, so she was on her feet all day. And then I just had another patient roll back in. She was getting Botox, but I had done her breast reduction and she was like, it's the bra free summer. I was like, okay.

Bri (27:51):
I love that.

Dr. Gallus (27:53):
So it is kind of funny. People are excited about wearing a strapless clothes or strapless swimsuits, a sundresses maybe without a bra or also they can wear those bralettes that are, basically offer no support. So I think that's what my patients are most excited about at three months.

Bri (28:14):
What is an ideal candidate for surgery?

Dr. Gallus (28:16):
Someone who's healthy, someone whose breasts are not currently developing, so your breasts are not getting larger. The same goes for patients who are losing weight. I know we talked about Ozempic earlier in the podcast, but if you're on Ozempic or another weight loss medication and you have large breasts, but you're rapidly losing weight, we don't know where that weight is going to come from. So if you're on a weight loss journey, then wait until that's stabilized before having any breast surgery, and certainly breast reduction. Someone who is pregnant obviously is not going to have surgery, but after you've had the child, I tell patients to wait at least six months because again, your breasts are changing after the pregnancy, so you want to make sure that you're at a stable point. If you're breastfeeding, you want to wait until you're at least three to six months done with breastfeeding before you pursue surgery. But for most women being young and healthy or even older, I've done breast reductions on patients who are in their seventies who just put it off and are so happy with the results. So any age, as long as you're healthy and pretty active is okay.

Bri (29:24):
And is there anyone that wouldn't be a good candidate for this surgery?

Dr. Gallus (29:27):
I think really there's very few people who aren't a good candidate for breast reduction surgery. When I used to do a lot of breast reconstruction surgery, there are patients who had had lumpectomies and radiation. Certainly if your breast has been radiated, you are at a much higher risk of having complications with the breast reduction surgery. And I think if you're going down that pathway with a breast cancer lumpectomy and radiation, then you need to have that conversation with your breast surgeon that you're considering having breast reduction surgery because it's kind of off the table, or lot less options after you've gone through that treatment. And then smokers, you know how we don't love smoking,

Bri (30:08):
Do not smoke.

Dr. Gallus (30:10):
I'll ask patients and I'll be like, okay, you're not smoking great. Don't start. So smoking cigarettes, any form of nicotine impairs wound healing. And we don't want anybody actively smoking prior to and after the surgery because it just does not go well with having a good postoperative course.

Bri (30:29):
And what are your thoughts on marijuana? We get this question quite a bit if people are vaping.

Dr. Gallus (30:35):
Right. So again, I try not to come across as being like, oh, the doctor's saying it's bad, but nicotine does inhibit wound healing, so it is bad. Please don't use it around surgery. Marijuana is, there's no such thing as bad or good. I just don't want you smoking it before surgery because it's not great for your lungs. And so you're going to have this procedure under general anesthesia. And in order to reduce any side effects of having a general anesthetic, we would prefer that you just eat your marijuana in the form of edibles prior to and after surgery. So I think those are the things that we've been looking for is smoking marijuana. And now we ask people about GLP-1s or Ozempic because as we talked about earlier in the podcast, it slows your digestive system down and so you really need to be off of it for about two weeks before going under anesthesia so that you don't aspirate or vomit when the anesthesiologist puts you to sleep. So just being NPO, which is nothing to eat after midnight, doesn't work for someone who's on Ozempic or another GLP-1.

Bri (31:45):
Yeah, I think transparency is super important. I feel like we've had a lot of patients that come in and then you're like, oh, I'm on nothing. And then the morning of they're like, oh, by the way.

Dr. Gallus (31:55):
Right. Yeah. There is no reason to not tell us.

Bri (31:59):
We do not care.

Dr. Gallus (32:01):
Yeah, we're not judging. We just need to know so that we can provide the safest experience for you.

Bri (32:06):
And what would make the scars harder or easier to heal? Does everyone scar the same?

Dr. Gallus (32:13):
That's a great question. Everyone does not scar the same. I tell patients I'm going to try to close the incisions under the least amount of tension and multiple layers. We add Steri strips, then we put bio cornium on after the Steri strips fall off. So a type of scar cream, if you will, that helps with healing. And then laser the incisions at four to six weeks. All of that is helping both support your healing and then also help the collagen remodel so that it lays down flat. And then the other thing I forgot to mention earlier is that we do provide everybody with heal fast. So it's a vitamin supplementation that they take prior to surgery and afterwards and just has that array of vitamins to support wound healing as well. And basically everything we can do to optimize that your incisions close and heal and the collagen lays down nice and neat so that you get a nice thin line.

Bri (33:10):
And what other medications do you prescribe for this procedure to help people heal pain meds? Do they need antibiotics?

Dr. Gallus (33:19):
I do prescribe pain medication, both a narcotic and non-narcotic alternative. And then I prescribe an antibiotic, which you take for a few days after surgery. And obviously you get an IV dose of antibiotic prior to the procedure. And a lot of times we'll provide a scope patch, scopolamine patch for our patients. And that's because nothing makes a procedure suck more than being nauseous afterwards. So for patients who have a tendency for nausea and vomiting, get motion sick anesthesia does everything they can to make sure you're waking up not feeling sick to your stomach, but sometimes putting it on that little patch the day before really helps and so

Bri (34:03):
Helps so much. Yes. I was like, how many of these can I get prescribed?

Dr. Gallus (34:09):
You only need one. And we had to peel it off your little neck I feel like a week later. We're like, that only needs to be on for three days.

Bri (34:14):
She's like, are you still wearing that. I was like, I'm sure it's helping.

Dr. Gallus (34:19):
I think it's, possibly though it's a game, I get motion sick with everything, so it's a game changer if I'm going to go, if someone's like want to go deep sea fishing. Sure, but I'm going to put the scopolamine patch on. So we all know from the anesthesia literature that for postoperative nausea and vomiting, some of the risk factors are being young, being female and having breast surgery. So I mean you can't control any of those, so you can't change those things. So our anesthesiologist uses the minimum amount of narcotic he needs to ensure that you get a nice safe sleep, but not too much narcotic because it'll make you sick when you wake up. And some of that's on my end. I use a lot of local anesthetic and long-acting local anesthetic to help and then having the scopolamine patch and then having a coordinated wake up so that people aren't overmedicated when they wake up really helps people wake up not feeling nauseous.

Bri (35:17):
We love that. And the most common question, do you take insurance? And are these surgeries covered by insurance typically or what would make somebody come in and pay out of pocket versus going through insurance?

Dr. Gallus (35:32):
Sure. So breast reduction surgery is one of those surgeries that can be covered by insurance. I don't take insurance, but I do a lot of breast reduction surgery for a few reasons. Sometimes patients aren't happy with the providers that they have in their network, so they would rather go elsewhere and pay out of pocket. Sometimes patients want a little bit more control over how much breast tissue is being removed. Insurance companies vary, but most of them mandate a minimum amount of tissue to be removed, which can be tough. So if you're 4' 11"

Bri (36:05):
Is it a strict number?

Dr. Gallus (36:06):
Yeah, a strict number of grams. So 400 grams or 500 grams. And so you can imagine that if you're six one and you have large breasts, it's probably easier to get four or 500 grams of tissue easily off. I'll probably take more. Certainly the young lady that we did that was 3000 grams that met that requirement. But then the other thing some insurance companies are asking for is that your BMI be below a certain level. And so these patients who desperately need breast reduction surgery are not able to get it covered by insurance because of an arbitrary BMI cutoff, whether it be 30 or 35. And so I think for those reasons that some patients would just prefer to get it done and worry about the rest of it. I've had patients that had very large breasts but didn't want to be too small. So you have a little bit more control when you're coming in to see me and I say, okay, well I'm not hamstrung by the fact that I need to take 500 grams off and if you really only want 300 grams off, we can do that. So it happens. It's so individual based on the patient. And just like anything else, something like an insurance policy is not going to be individualized towards patients.

Bri (37:19):
I feel like we had a patient not too long ago who didn't qualify BMI wise, even though her breasts were so large and then they told her to what, diet first?

Dr. Gallus (37:31):
Yeah, we've had a handful, I think there's a system in Southern California that is creating a strong cutoff of 30, which I understand, but some of these patients are clearly, like some of that BMI is coming from their chest. So it's not like they have B breasts and are overweight. It's the opposite problem. And I really think that they can embrace a healthier lifestyle once you make their breasts more proportional to the rest of them.

Bri (38:01):
And if I were to call the office, who do I talk to about getting a consultation?

Dr. Gallus (38:06):
So if you call the office, you might talk to any one of us, but you will be referred to speak with Megan, our coordinator, and she can walk you through what to expect in a consultation with me. You end up meeting both myself, our nurse Azella and Megan at the consultation. And Azella will talk to you more about your medical history. And then I and Azella will go over your measurements, your photos, the breast reduction surgery itself. And then Megan is our coordinator and she will talk to you about scheduling, financing and all of those other aspects. Well, thanks for joining us, that's it for today.

Bri (38:44):
We'll be back.

Dr. Gallus (38:46):
If you're listening today and have questions, need info about scheduling, financing, reviews, or photos, check out the show notes for links. Restore SD Plastic Surgery is located in La Jolla, California. Learn more about us, go to RestoreSDPlasticSurgery.com or follow us on Instagram @RestoreSDPlasticSurgery. If you enjoyed this episode, please share it and subscribe to All the B's on YouTube, apple Podcasts, Spotify, or wherever you like to listen to podcast.