Breast Surgery After Weight Loss

The breast is the area patients are most often unprepared for. Most people expect loose skin on the abdomen after major weight loss. Far fewer expect the breast to empty from the top, flatten, and sit lower on the chest with a nipple that points down — and for that to happen whether they lost 30 kilograms or 70. It is one of the most common reasons patients come back for a second stage, and it is a different problem from the breast surgery most surgeons are used to.

• What weight loss does
• Which operation
• Medicare
• Cost
• The downsides
• Recovery and pain
• Questions

What major weight loss does to the breast

Four things happen, and they happen together, which is why the breast after weight loss behaves differently from a breast that has simply aged or been through pregnancy.

• Volume goes, and it goes from the top. The breast is largely fat and glandular tissue. Lose a large amount of body fat and the breast loses it too, disproportionately from the upper pole. What is left settles into the lower half.
• The skin envelope stays stretched. The skin that held the larger breast does not shrink back, so there is now more envelope than contents.
• The nipple and areola descend and rotate to point downwards, and the areola itself is usually stretched wider.
• The footprint widens. The base of the breast spreads sideways onto the chest wall, so the breast looks flatter and further apart than it did, and the fold often sits lower than it should.

Two consequences follow. First, skin quality is poor — thin, stretched and with little elastic recoil — which makes the closure less forgiving and revision more likely than in a standard lift. Second, and this is the one patients find hardest to hear, a lift alone will make the breast tighter and higher but not fuller. If the upper pole flatness is what bothers you, skin surgery on its own will not fix it.

Which operation: lift, lift with fat, lift with an implant, or reduction

A lift alone (mastopexy). Removes excess skin, repositions the nipple and areola higher, and reshapes what tissue remains. It suits patients who still have reasonable breast volume and whose complaint is position rather than emptiness. It does not add volume, and in a breast that is genuinely empty the result can look tight but flat. There is a fuller account of the lift on its own — the anchor scar pattern, being ready for surgery, and combining it with other procedures — on the breast lift after major weight loss page.

A lift with fat grafting. Adds a modest amount of volume using your own fat, harvested by liposuction from the abdomen, flanks or thighs. It suits patients who want the upper pole filled without an implant and who have enough donor fat — which, after major weight loss, not everyone does. Not all of the transferred fat survives. There is more detail on the breast lift with fat grafting page, including the Medicare consequence of choosing fat over an implant.

A lift with an implant. Gives the most volume and the most predictable upper pole fullness in a single operation. It is also the most complex option, with a higher revision rate than either procedure alone, an implant that is not a lifetime device, and — importantly for cost — no Medicare item, because item 45558 excludes any procedure in which a prosthesis is inserted. See breast lift with implants.

A breast reduction. Some patients after major weight loss still have heavy breasts, and the complaint is weight, neck and shoulder pain, bra strap grooving and rashes under the fold rather than emptiness. That is a breast reduction, and it has its own Medicare item with its own criteria.

For men, the equivalent problem is loose chest skin after weight loss, which is routinely confused with gynaecomastia. They are different conditions, different operations and different Medicare items — see male chest contouring after weight loss.

Does Medicare cover a breast lift after weight loss?

It can, and this is worth understanding in detail because it is where most of the money sits.

Item 45558 — correction of bilateral breast ptosis by mastopexy. The requirements are specific:

• at least two thirds of the breast tissue, including the nipple, lies below the inframammary fold, with the nipple at the most dependent part of the breast;
• photographic evidence is documented in your records — anterior and both lateral views, with a marker placed at the level of the fold;
• it is claimable once per lifetime, other than in defined reconstructive circumstances;
• it excludes any procedure in which a breast prosthesis is inserted.

Item 45523 — bilateral reduction mammaplasty with repositioning of the nipple. This is the relevant item where the problem is macromastia with neck or shoulder symptoms rather than ptosis alone. It also excludes the insertion of a prosthesis.

Fat grafting is not rebatable in this setting. Items 45534 and 45535 exist for autologous fat grafting to the breast but are restricted to breast cancer defect correction, preparation of thin or irradiated flaps, reconstruction, and developmental disorders. Restoring volume lost through weight loss does not fall within those indications.

The practical point. The rebate itself is a partial contribution to the surgeon’s fee. What matters far more is that an applicable item number is what allows your private health fund to contribute to the hospital admission and theatre costs. Choose a lift with an implant and no item applies at all — so the fund contributes nothing to hospital either, and the gap is usually much larger than the implant itself. That is not a reason to rule out an implant, but it belongs in the comparison, and almost nobody puts it in front of patients before they decide.

What it costs

There is no single price. The cost depends on which operation, whether fat grafting or an implant is involved, how long the operation takes, whether you stay overnight, and whether a Medicare item applies.

After your consultation you will receive a written, itemised quote covering the surgeon’s fee, the anaesthetist’s fee, the surgical assistant’s fee where one is required, the hospital or day-facility fee, garments and follow-up appointments. A cooling-off period applies before booking, as required for cosmetic surgery in Australia.

The initial consultation with Dr Kumar is $400, with a Medicare rebate of approximately $88 where you have a GP referral. A referral is required.

If the breast is one of several areas you need treated, it is worth planning the whole sequence before the first operation rather than one procedure at a time — see staged body contouring.

The downsides, stated plainly

Every one of these operations trades a problem for a set of permanent consequences. They are worth reading before you decide, not afterwards.

• Scars. Around the areola and vertically down to the fold, and after major weight loss usually with a horizontal component in the fold as well, because there is more skin to remove. They are permanent, they take 12 to 18 months to fade, and some patients form thickened or pigmented scars.
• Sensation. Altered nipple sensation is common in the early months and usually recovers. A proportion of patients are left with permanently reduced sensation or numbness. The risk rises with the amount of lift required.
• Breastfeeding. Often still possible, because the nipple stays attached to the underlying tissue, but it cannot be guaranteed.
• Recurrence. Skin quality after major weight loss is poor, so some settling and stretching over the following years is more likely than in a standard lift. Revision surgery is more common in this group.
• Wound healing problems. Higher where nutrition is uncorrected after bariatric surgery, and substantially higher in smokers.
• General surgical risks — bleeding, infection, asymmetry, poor scarring, blood clots, and risks of anaesthesia. Partial or complete loss of the nipple and areola is rare but real, and the risk is higher where the lift required is large.

Recovery and how painful it is

Most patients find breast surgery less painful than abdominal surgery, because the abdominal wall is not involved and you can move freely. Expect soreness, tightness and a heavy feeling rather than sharp pain, worst in the first three to five days.

Surgery is performed under general anaesthesia by a specialist anaesthetist in an accredited private hospital, usually as a day case or with one night. A support bra is worn day and night for around six weeks. Most patients doing desk-based work return at one to two weeks. No heavy lifting, overhead work or strenuous exercise for about six weeks. Swelling settles over three months and the final shape is not apparent before then; scars continue to mature for 12 to 18 months.

If fat grafting is part of the operation, the donor sites are usually more uncomfortable than the breasts, and a compression garment is worn over them.

Common questions