The power of a smaller breast

Tiffany Dena Loftin, who is 35 and a labor organizer in Atlanta, was emboldened to undergo breast reduction after scrutinizing the naked breasts of her friend Jamira Burley, 36, over FaceTime: her bandages, her incisions, her bruised nipples. Loftin doesn’t like hospitals. Needles terrify her. But, Burley said, “Tiffany, the relief and the joy that I’m feeling is also available to you on the other side of your fear.”

After liposuction, breast augmentation is the most popular cosmetic surgery procedure in the country, with about 300,000 women choosing implants each year. But the growth area in cosmetic breast surgery is in making them smaller.

In 2023, more than 76,000 American women had elective breast-reduction surgery, a 64% increase since 2019, according to the American Society of Plastic Surgeons. (That number doesn’t include gender-affirming top surgeries or breast reconstructions after illness.) The increase is reflected across all age groups, but especially among women younger than 30. Girls younger than 19 represent a small but fast-growing part of the market.

Reduction surgeries deemed “medically necessary” and covered by insurance represent a far smaller group than cosmetic operations, but the broad trend lines — a recent, sudden increase, especially among younger women — are the same.

Ideas about breast perfection infuse the worlds of young girls. Teenagers with large breasts frequently struggle with low self-esteem and eating disorders. Young women learn to cover themselves up under extra-large hoodies and T-shirts. They compress with double jog bras and stop figure skating, dancing and running track. They hear the negative words directed at their bodies — droopy, deflated, “stretched the hell out,” in the words of one plastic surgeon — and turn these descriptions on themselves.

American women are perpetually at odds with their bodies, which reliably fall short of the perfection embodied by models and influencers. Some 70% of women worldwide dislike the size of their breasts. This may be because a woman’s breasts are subject to constant evaluation and critique. Always on view, breasts evoke in others thoughts and feelings about a woman’s femininity, her sexual availability, her age, her weight, her attractiveness, her maternal role.

Large breasts draw more attention — positive and negative — than smaller ones. A 2013 market survey by a lingerie maker put the average American cup size at DD. The majority of breast-reduction patients are bigger than that. The weight of large breasts can cause back, neck and shoulder pain. They can impede mobility and fitness.

So to decide to reduce them, to make them lighter, smaller, easier to carry and cover — more discreet — can be seen as an act of self-love and empowerment, a woman’s prioritization, finally, of her own comfort and independence over what others have traditionally found sexy. Or it can be interpreted as self-loathing, an agreement with a sexist culture that can also regard larger breasts that aren’t youthfully round and upright as repulsive: droopy, flabby, jiggly, hard to contain.

Or the choice to undergo breast reduction can be, in some paradoxical way, pragmatic. Perceiving, rightly, that she can’t change the culture she lives in, a woman might find that the easier path to loving her body is to alter herself.

Doctors say their patients seem willing to live with the scars, which encircle the nipple, course down the lower part of the breast like a longitude line, and sometimes trace the ribs under the breast where an underwire might sit.

And many women are undeterred by the possibility that the surgery might impede breastfeeding. According to one research review, women who have had a reduction are more than three times more likely to be unable to breastfeed.

Cheyenne Lin, who is 26 and a substitute teacher in Fresno, California, is married and said she probably wants children someday, but most women in her family have struggled to breastfeed.

“So when they said, ‘You might not be able to breastfeed,’ I was like, that was not even on my list of concerns,” Lin said. She had her reduction surgery in July.

Before her breast-reduction surgery, Lin was in pain and hated the way her breasts hung down to her belly. (Maggie Shannon/The New York Times)

Who Pays?

If a single procedure can alleviate back pain and headaches, promote mobility and fitness, and also enable a woman to un-self-consciously wear a tube top, is it a medical procedure or a cosmetic one? For the patient, of course, it can be both. But from the point of view of an insurance company, it’s one or the other, reimbursable or not.

Most insurers want proof of medical necessity: back, shoulder or neck pain; grooves in the shoulders from bra straps; skin rashes. They require evidence that the patient has tried nonsurgical remedies, including pain relievers, physical therapy and custom support bras. And most plans include minimums for the number of grams of breast tissue that must be extracted based on a woman’s breast size, height and weight.

Suma Kashi, who is 41 and lives in Los Angeles, is 5 feet, 2 inches tall and before her reduction was wearing an H-cup bra. When she was initially considering surgery, she weighed 178 pounds, and her insurance company told her that she would have to get 755 grams — more than 1.5 pounds — per breast removed to qualify for reimbursement. But to get her to her desired C cup, her surgeon estimated that she would need to remove much less: 415 grams per breast. Kashi tried to reduce what the insurance company called her “BSA” — body surface area — by losing 25 pounds. Even so, her claim was denied. She ended up paying out of pocket: about $23,000.

Burley, on the other hand, was 5 feet, 5 inches and weighed 185 pounds before her reduction. She wore a 34DDD bra, and her insurance covered her surgery. She now wears a B cup and, after additional weight loss, weighs 155.

Lin couldn’t have paid for her breast reduction on her own. And she was hurting: Starting around her sophomore year in college, she had constant searing pain between her shoulder blades. The difference between the size of her breasts had affected her posture, placing uneven weight on her back. She couldn’t go hiking with her friends or snowboarding with Jaylen Lin, the exchange student who became her husband.

At 21, she said, “I felt like I was trapped in the body of someone in their 70s.” She was diagnosed with depression.

Lin was covered by Medi-Cal, California’s Medicaid program, and her general practitioner wasn’t interested in helping her navigate the route to the reduction surgery, she said. When she Googled the surgeon who accepted her insurance in Fresno, his ratings were so low, she didn’t make the call.

Jaylen Lin’s parents in Taiwan stepped in. They helped the couple find an insurance plan with an out-of-network option and gave the Lins a credit card to pay Killeen’s $15,600 fee.

Lin expects her insurance to reimburse between $2,000 and $4,000 and considers the gift from her in-laws life-changing. Her back pain is gone. She hasn’t taken antidepressants since her surgery.

‘I’m Not Doing This for Men’

What does it mean to want to be small? Do smaller breasts reflect a refusal to inhabit any longer the fantasies of men? Loftin believes her breast reduction is a signal of her confidence and autonomy. To spend her own money to live in a body that works better for her is power.

Women in her friend groups “don’t need the expectations of Western beauty or male beauty to live up to. This is my body. I’m not doing this for men,” she said. Lin considers her reduction an explicitly political act, prioritizing her own health and happiness.

Sarah Thornton, 59, a sociologist who lives in San Francisco, was a B cup before her double mastectomy. After breast reconstruction, she had Ds, which felt huge to her — “bulky and cartoony,” she wrote in “Tits Up,” her recent social history of the breast. Eventually, she had another surgery to reduce the size of her implants. But she wouldn’t call the decision a liberation, necessarily.

“I went from an uncomfortable implant that I really hated to a smaller one that’s placed slightly differently,” she said.

Having immersed herself in women’s feelings about their breasts during the four years she researched her book, Thornton worries about casting breast reduction solely as feminist emancipation. For one thing, she said, “plastic surgery is a consumer option. There’s usually a lot of money involved.” For another, women’s body dissatisfaction is “pernicious” and “contagious,” Thornton said, contributing to the idea that there’s always something about women’s bodies that needs to be fixed.

For a woman to withdraw from the male gaze, to assert herself in her refusal to be ogled, to relieve her own pain, to be able to comfortably run or dance — that is liberation. But it’s a personal, individual one, said Thornton.

“If women are going to have an emancipated rack,” she said, “then men need to change.”