[doctor] patient is julia jones , date of birth 5/16/1996 . she is a new breast reduction consult . hello , how are you doing today ? i'm dr. gonzalez . it's nice to meet you .
[patient] nice to meet you , ma'am . how are you ?
[doctor] i'm doing good , thank you . so you're here to discuss a breast reduction , correct ?
[patient] yes . that's right .
[doctor] okay . perfect . let me just get logged in , here . have you met with anyone before about a breast reduction ?
[patient] no , i have n't .
[doctor] okay . and how long have you been considering this ?
[patient] it's probably been about six or seven years . but i mean , it's always been in the back of my mind .
[doctor] well , i perform a lot of breast reduction surgeries , pretty much every week , so it is a very common procedure .
[patient] okay , that's reassuring .
[doctor] yeah . so what i wan na do first is just get a little bit of history about the sort of symptoms that you're having . and then i'll do a quick exam .
[patient] okay . that sounds good .
[doctor] and then we'll talk more about the surgery and what it entails . and , um , at this point , who is your insurance provider ?
[patient] i have blue cross blue shield . well , actually , my husband just accepted a new job , and i will be on his plan , uh , which i believe is not going to be blue cross , but it may be changing .
[doctor] okay . what we typically do when we do a breast reduction consult , i'll document your symptoms , symptoms , we'll take some pictures , then , um , they get sent to the insurance company . and what they'll do is decide whether it's approved , or medically necessary , or not . but we wan na make sure we send it to the right insurance . do you know when you'll be on the new plan ?
[patient] most likely july .
[doctor] okay . so we may just wait until july to submit for approval at that time .
[patient] okay .
[doctor] so regarding your symptoms , do you experience back pain ?
[patient] well , i've been going to the chiropractor for a few years . i do have a lotta pain here and here . but i do n't know if it's all from my breasts or not . it gets painful and builds up . so i think i could attribute it to my breasts , when i'm working at my desk all day .
[doctor] okay . and in your neck and your upper back . and how long has this been going on ? would you say five years , 10 years , or even since puberty ?
[patient] i would say since i was in high school .
[doctor] okay . and do you have the bra strap indentations in your shoulders ? um , i saw that you're wearing about a g cup .
[patient] yes . i do get indentations , but i do n't really wear a regular bra that often . i mostly were a 34 e sports bra because it's more comfortable . and the others are expensive in my size .
[doctor] yeah , i have heard that as well . and , um , have you had any children , or are you planning to have any children in the future ?
[patient] no , i do not have any kids now . but we might plan to in the future .
[doctor] okay . and at this time , are you experiencing any numbness or tingling in the s- in the hands or any nipple pain ?
[patient] sometimes , yes .
[doctor] okay . and rashes , do you get any rashes underneath your breasts ? and , and it could be from sweating .
[patient] no , but they are always sweaty .
[doctor] okay . and then do you feel like your activities are limited because of the size ?
[patient] there's certain things i do when i have to hold them , like working out and any jumping or running . and it hurts .
[doctor] and it hurts , okay . and , and you saw a chiropractor . but what about physical therapy for your back pain ? or do you take any pain medicine for it ?
[patient] y- no , but i do take a migraine medication , propranolol .
[doctor] that's okay . so let's see . i know that you have a history of breast cancer in your family . have you had any mammograms ? and how old was your mother when she had it ?
[patient] mom was 40 . and they recommended me starting at age 30 for mammogram . i'm still ... i mean , i'm 25 . so i'm still a little bit young .
[doctor] okay . and otherwise , it seems like you're really healthy ?
[patient] yes , for the most part . i lost about 10 pounds over the past few months , and i still would like to lose about 20 more pounds .
[doctor] congratulations . that's great . and then , um-
[patient] thank you .
[doctor] . so then ... you're welcome . and so do you use any tobacco , drugs , or alcohol ? and then , um , you said that you were going to school . what are you going to school for ?
[patient] uh , i drink a little wine on occasion , and for school , i'm currently studying psychology .
[doctor] okay , that's great . all right . so what we'll do is we'll go ahead and take a look . i'm gon na take a couple of measurements . and we'll kinda talk about the surgery afterwards . um , so go ahead and stand up for me , julia . okay . so , looking at the measurements , it looks like one breast is a little lower than the other .
[patient] yeah .
[doctor] okay . well , thank you so much . it looks like i have all the measurements that we need . you can go ahead and cover up now .
[patient] okay .
[doctor] so i think you're a great candidate for a breast reduction . when we talk about a breast reduction , what happens is that we remove the tissue out of the breast .
[patient] okay . that's fine .
[doctor] and we would then lift them and elevate the nipple position in order to help with your back pain , neck pain , and because i'm a plastic surgeon , of course i want them to look nice as well .
[patient] right .
[doctor] so typically , when you do the breast reduction , we make an incision around the nipple straight down and then underneath . and it kinda looks like , um , an anchor below . then straight down , and underneath , and through that incision , we're able to f- to lift the breast . and we'll take off any extra fat and breash- breast tissue . so that way it becomes smaller in size . and i noticed that you would like to be a b cup . so i do tell every patient we can make you as small as your blood supply allows . and what that means is we must move the nipple without cutting off any of its blood supply during the surgery .
[patient] okay . well , thank you for explaining that .
[doctor] you're welcome . and in your case , you'll probably be a small c. um , a b cup might be a little bit small , but we'll see once i'm doing the , the procedure for you .
[patient] okay .
[doctor] and typically the surgery takes about three hours . you will have drains , one in each side . and that helps prevent fluid from building up in the breast . and that stays in for about a week . and then we'll remove them in the clinic . and you'll have a clear plastic tape over your incision that should help with the scars . and , um , we've seen that patients who have lighter skin , the scars will tend to be red at first . and then it takes about a year for a scar to mature in line .
[patient] okay . well , i'm not too worried about the scars .
[doctor] okay . and i do like to keep patients overnight . it's just going to be for one night in the hospital . and we just wan na make sure your pain is controlled , make sure you're not nauseated , all of that stuff . some patients wan na go home that same day . but you know that some people get nauseated , and the last thing that i want is for you to be vomiting at home alone without the , the support here at the facility .
[patient] okay , yeah , that sounds good .
[doctor] okay . and then about 30 % of patients say that they can not breastfeed after a breast reduction , and the reason is the breast is made up of fat . and it's also made up of a gland . and the gland is what produces the milk .
[patient] okay .
[doctor] and so in order to reduce the size of the breast , we have to take out both the fat and the glands . so it just depends on how much is left , whether you can breastfeed in the future . and then also , the breast will change over time . if you , um , gain weight , they will get larger , things like that .
[patient] yeah , okay .
[doctor] and if you have children , they will change as well . they will enlarge , especially if you can breastfeed . but they'll go back down and will appear , um , a little bit deflated .
[patient] yeah . i do n't know if i'm interested in breastfeeding .
[doctor] okay . um , the hormones of pregnancy , though , will change the breasts , so that's just something to be aware of , and i tell all younger patients that .
[patient] okay , yeah . absolutely .
[doctor] and then typically nipple sensation is fine after a breast reduction , but there is a slight chance that you'll have an alteration in the nipple sensation or not have any sensation in the nipple . generally the nipple is just fine unless it is a massive reduction . and it's quite normal after surgery to be a little bit bruised , and then it just takes some time for that to go away .
[patient] yeah , okay .
[doctor] but other than that , you know , most patients are very happy after the breast reduction because the symptoms of the back pain , the neck pain , you can feel relief almost immediately . so do you have any questions , julia , about the process or anything like that ?
[patient] no , not really .
[doctor] okay . and , i do think you're a good candidate for it . and i think you'll benefit from it as well .
[patient] good . i look forward to a relief .
[doctor] i think you just have to do it when you are ready , when you know that you feel like it's a good time , because it is a commitment , and you will have some activity restrictions for about six weeks after surgery , uh , no heavy lifting . and i do say no driving for two to three weeks . and the drains stay in , like i said , for about a week .
[patient] okay . well , i am ready as soon as my insurance is switched over .
[doctor] okay . well , i think from this point , if you want to , we can take photos today , while you're here . i have all the documentation now in the note about your symptoms , and that's what the insurance company is going to look for . so thank you for answering those questions . so once we have the new provider , we'll go ahead and get that submitted . and then , when they approve it , um , what the office will do , is they'll work with you on a surgery date , and then we'll meet again right before the surgery to answer any last minute questions and go over the instructions in more detail , things like that .
[patient] okay . well , i will notify the office as soon as i have the insurance information .
[doctor] that sounds great . and then we can get it all in process . and it was so nice to meet you . and catherine will be right in to get your photos . julia jones is a 25 year old female with symptomatic macromastia , presenting for evaluation of breast reduction . the patient has attempted nonsurgical treatments , but the minimal relief , and is an ideal candidate for bilateral reduction mammoplasty . her minimum required resection , based on a bsa of 2.65 , with the schnur scale is 1,792 grams , which should be attainable . given her extremely large breasts and the measurements above , there is potential for using a nipple graft .
[doctor] physical exam findings of breast , inspection reveals asymmetrical breasts with severe ptosis bilaterally . there is no nipple retraction or discharge bilaterally . no breast tenderness , masses , or axillary lymphadenopathy is palpable .

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