Breast reduction surgery is rapidly becoming one of the most common procedures in plastic surgery, with more than 100,000
reduction mammoplasties performed in 2004 in the United States—up 25% from 2000.1 Macromastia can cause a host of signs and symptoms, including back and neck pain, breast pain, decreased sensitivity of
the breast and nipple areola complex, shoulder, arm, and hand pain, painful bra grooves, as well as unpleasant intertrigal
rashes and itching.2 Patients often have difficulty running and playing sports, and even finding properly fitting clothes can be daunting.
Along with the relief that reduction surgery gives a woman by reducing the mass and volume of her breast, the procedure can
also significantly lift the ptotic (sagging) breast, giving a woman much more attractively shaped breasts. Large or hypertrophic
areolae may be reduced at the same time, further contributing to the breast's overall improved appearance. Given that the
surgery can enhance the appearance of a patient's breasts while reducing her symptoms, it's not surprising that many studies
have shown that reduction mammoplasty can significantly improve a woman's quality of life.3-11
Candidates for surgery
Importantly, there's no strictly objective definition of macromastia; it's more appropriate to apply the term subjectively,
when a patient feels that her breasts are of a large enough size to cause any of the symptoms or problems we've mentioned.
Although studies show that a reduction of only a few 100 g can significantly improve a woman's symptoms, many insurance carriers
have set an arbitrary lower limit of 500 g or more of tissue resection per breast.2 If less breast tissue is resected, then it is often considered a lift only (mastopexy) and may not be reimbursed.
The ages of patients seeking breast reduction range from late teen years all the way to sextogenarians and beyond. It's generally
recommended that teenagers should not undergo breast reduction until their breasts have ceased growing in order to eliminate
any need for re-operation.12 A rare exception to this rule is juvenile breast hypertrophy, caused by end-organ hypersensitivity to normal hormonal stimulation.
In this condition, the breasts enlarge to such a degree that reduction surgery is indicated before a teen's breasts stop growing,
even though a subsequent resection may also be required.13 To help prepare a patient for a consultation with a plastic surgeon, you may wish to share the "Patient Information".
Discuss scars and breastfeeding preoperatively
The surgeon should discuss five crucial points with each breast reduction patient. In addition, an ob/gyn might want to discuss
some of these points—like the breastfeeding issue—in advance of a patient's surgical consultation. You may also want to recommend
that women aged 40 and older have a mammogram before undergoing the surgery.
(1) There will be scars.
The amount and degree of scarring depend on both the surgeon's approach and technique and the patient's inherent wound healing/scar
formation. Depending on the technique, the amount of scarring can be as little as circumferentially around the areola (Benelli
technique),14 peri-areolar plus a vertical limb on the breast (vertical reduction),15,16 or peri-areolar, vertical limb on the breast and an infra-mammary crease incision, as well (Inverted "T" or Wise pattern).17,18
Variables that determine the technique chosen are the size of the reduction, breast shape, the degree of ptosis, skin quality,
and perhaps most importantly surgeon preference. In general, the cumulative length of incisions is inversely correlated to
the difficulty of resection, for reasons beyond the scope of this article. Furthermore, not all approaches can be applied
to all patients. With few exceptions, large reductions (>1,000 g per breast) or extremely ptotic breasts (nipple elevation
>12 cm) require the inverted "T" approach to ensure nipple viability and acceptable cosmetic appearance.2
It is possible to perform breast reduction with virtually no scar by using suction-assisted lipectomy (SAL).19,20 Unfortunately, this technique isn't suitable for most patients, because it doesn't address the issue of excess and sagging
skin and therefore may result in a less-than-ideal cosmetic outcome. SAL tends to be more acceptable to an older patient who's
unconcerned with the cosmetic appearance of her breasts and whose goal is simply to reduce breast weight.21
(2) Always discuss with each patient the potential for breast reduction surgery to affect breastfeeding—and if breastfeeding
is of vital importance to a patient, advise her to defer surgery until after she finishes nursing her children.
Although it may seem counter-intuitive, most studies have shown that reduction mammoplasty does not interfere with a woman's
ability to breastfeed.22-24 This finding is true regardless of which reduction technique is used. Specifically, the percentage of women who successfully
breastfeed after breast reduction roughly equals the percentage who successfully breastfeed without prior surgery. Even though
the data suggest that breast reduction surgery does not lessen the likelihood of successful breastfeeding, patients should be warned that after undergoing the surgery, they might
be unable to produce enough milk. Obviously this discussion is unnecessary if the patient is postmenopausal.
(3) It's also essential to discuss with patients the possibility of decreased nipple sensation and erectile function
after breast reduction surgery.
Although it's believed that the fourth intercostal nerve supplies sensation to the nipple areola complex, many other nerves
contribute to the innervation of this structure.25 This multiple innervation likely explains why most studies show that although sensation in the nipple areola complex declines
after surgery for up to several months, it usually returns to preop levels within 1 year.26,27 Interestingly, some studies involving large reductions have found increased post-operative nipple and breast sensation,
which likely indicates that the surgery can have neuropathic effects.28
(4) Especially when a large resection or significant nipple elevation is anticipated, the possibility of losing part
of—or even all of the nipple areola complex (NAC) must be discussed with every patient.
Appropriate preoperative planning is the best way to prevent this relatively rare (<2%) and unfortunate event.26 Certain reduction techniques are more likely to threaten the viability of the NAC. For especially large reductions (>2,000
g per breast), it may be prudent to recommend a plastic surgeon who will perform the breast reduction with a "free nipple
graft" technique, in which the NAC is removed at the beginning of the procedure, trimmed, and then reapplied to the reduced
breast essentially as a skin graft.12 With few anecdotal exceptions, free grafted nipples will have very little sensation, if any. In addition, nipple projection
is usually lost and the areola may suffer de-pigmentation, especially in darker-skinned patients.
Although these consequences may seem drastic, many patients with extreme macromastia will gladly trade them for the significant
symptom relief they get by having 4 or more pounds of tissue per breast removed.
(5) Finally, surgeons must discuss with each patient postoperative breast size expectations.
Because patients—especially those with ptotic breasts—often overestimate the size of their breasts pre-operatively, surgeons
must make them aware of their "true" breast size before surgery or risk the perception that they've made women's breasts too
small.29 In addition, although a desired final cup size can be discussed, a patient should be told that exact matches are not guaranteed.
This is because it's impossible to "measure" breast size intra-operatively, although with increasing experience this type
of judgment becomes more refined. Furthermore, patients and surgeons alike vary greatly in their perceptions of what constitutes
a "C" or "D" cup. Finally, the surgeon should make a patient aware of any preoperative asymmetries between her breasts and
inform her that although the breast symmetry will be significantly improved after surgery, perfect symmetry is unattainable.
Pros and cons of various operative techniques
Table 1. Comparing breast reduction techniques
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As we've suggested, each technique for reduction mammoplasty has its own particular advantages and disadvantages (Table 1).
Our preference is the "vertical" or short-scar breast reduction (shown on the right side of Figure 1) when the anticipated
resection is less than 1,000 g per breast and the nipple will be moved less than 12 cm (see "Short-scar breast reduction/repositioning
technique").
Figure 1. Conventional vs. 'short-scar' incision
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Perhaps the biggest problem with traditional breast reduction is the large potentially unsightly "inverted T" scar (some say
it looks more like an anchor) that results on and below the breast (Figure 1). Unfortunately, the scar that results in the
inframammary crease from the "Wise pattern" breast reduction tends to enlarge, especially along the bottom and stem of the
anchor, which are precisely the areas most likely to be visible when the patient wears a swimsuit or other revealing attire.
Furthermore, the tri-point of the "inverted T" incision is vulnerable to breakdown, which leads to delayed wound healing,
more noticeable scars, and of course, frustrated patients and surgeons alike.
Figure 2. Vertical short-scar technique: before and after
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Another key drawback to traditional breast reduction methods is inherent in the design of the operation: a tendency towards
creating a somewhat flattened, boxy breast.30 Furthermore, although a suitable shape may be created "on the table," the traditional breast reduction design results in
a "bottoming out" phenomenon in which a large portion of the glandular tissue gravitates down below the nipple areola complex
(NAC) and the inframammary fold (IMF).30 Over several years, this may result in emptiness of the "northern hemispheres" of the breast, precisely where most women
desire maximal fullness. In general, the vertical technique is superior to traditional methods in maximizing outward projection
of the breasts while minimizing scarring (Figure 2).
Currently, most of our reduction mammoplasties are outpatient procedures. Patients are discharge home with drains, which are
removed at the first postoperative visit, usually 3 to 5 days after surgery. We instruct a woman to wear a sports brassiere
after her first postop office visit, and then to gradually increase her activity level. Patients may return to work as early
as 1 week after surgery depending upon the type of work. They can engage in full activity after 3 to 4 weeks.
Reduction mammoplasty significantly relieves macromastia-related symptoms and improves a patient's overall quality of life.
But it must be tailored to each individual's anatomy and surgical goals. In general, breast reduction will not decrease a
patient's ability to breastfeed nor will it significantly decrease nipple sensations in the long term. Finally, be sure to
tell your patients to choose a plastic surgeon who is familiar with several techniques.
REFERENCES
1. http://www.plasticsurgery.org/public_education/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=16160. American Society of Plastic Surgeons National Plastic Surgery Statistics. Accessed August 29, 2005.
2. Culliford AT, Karp NS, Kleinerman R, et al. The Vertical Reduction Mammoplasty: A Prospective Analysis of Patient Outcomes.
Poster presented at the Plastic Surgery 2004 meeting, Philadelphia, Pa., October 10, 2004.
3. Shakespeare V, Cole RP. Measuring patient-based outcomes in a plastic surgery service: breast reduction surgical patients.
Br J Plast Surg. 1997;50:242-248.
4. Faria FS, Guthrie E, Bradbury E, et al. Psychosocial outcome and patient satisfaction following breast reduction surgery.
Br J Plast Surg. 1999;52:448-552.
5. Behmand RA, Tang DH, Smith DJ, Jr. Outcomes in breast reduction surgery. Ann Plast Surg. 2000;45:575-580.
6. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. 1997;100:875-883.
7. Chadbourne EB, Zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammaplasty: a systematic review and meta-analysis
of published studies. Mayo Clin Proc. 2001;76:503-510.
8. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction
mammaplasty. Plast Reconstr Surg. 2001;108:62-67.
9. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms
of macromastia. Plast Reconstr Surg. 2002;109:1556-1566.
10. Lee MC, Lehman JA Jr, Tantri MD, et al. Bilateral reduction mammoplasty in an adolescent population: adolescent bilateral
reduction mammoplasty. J Craniofac Surg. 2003;14:691-695.
11. Freire M, Neto MS, Garcia EB, et al. Quality of life after reduction mammaplasty. Scand J Plast Reconstr Surg Hand Surg. 2004;38:335-339.
12. Bostwick J III. Reduction Mammoplasty. In: Bostwick J III, ed. Plastic and Reconstructive Breast Surgery. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2000:371.
13. Baker SB, Burkey BA, Thornton P, et al. Juvenile gigantomastia: presentation of four cases and review of the literature.
Ann Plast Surg. 2001;46:517-526.
14. Benelli L. A new periareolar mammaplasty: the "round block" technique. Aesthetic Plast Surg. 1990;14:93-100.
15. Lejour M. Vertical mammaplasty. Plast Reconstr Surg. 1993;92:985-986.
16. Lassus C. A technique for breast reduction. Int Surg. 1970;53:69-72.
17. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg. 1977;59:64-67.
18. Georgiade NG, Serafin D, Morris R, et al. Reduction mammaplasty utilizing an inferior pedicle nipple-areolar flap. Ann Plast Surg. 1979;3:211-218.
19. Matarasso A, Courtiss EH. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 1991;87:709-717.
20. Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuction breast reduction. Plast Reconstr Surg. 2004;114:55-61.
21. Matarasso A. Suction mammaplasty: the use of suction lipectomy alone to reduce large breasts. Clin Plast Surg. 2002;29:433-443, vii.
22. Cruz-Korchin N, Korchin L. Breast-feeding after vertical mammaplasty with medial pedicle. Plast Reconstr Surg. 2004;114:890-894.
23. Hefter W, Lindholm P, Elvenes OP. Lactation and breast-feeding ability following lateral pedicle mammaplasty. Br J Plast Surg. 2003;56:746-751.
24. Brzozowski D, Niessen M, Evans HB, et al. Breast-feeding after inferior pedicle reduction mammaplasty. Plast Reconstr Surg. 2000;105:530-534.
25. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nipple-areola complex: an anatomic study. Plast Reconstr Surg. 2000;105:905-909.
26. Nahabedian MY, Mofid MM. Viability and sensation of the nipple-areolar complex after reduction mammaplasty. Ann Plast Surg. 2002;49:24-32.
27. Greuse M, Hamdi M, DeMey A. Breast sensitivity after vertical mammaplasty. Plast Reconstr Surg. 2001;10:970-976.
28. Temple CL, Hurst LN. Reduction mammaplasty improves breast sensibility. Plast Reconstr Surg. 1999;104:72-76.
29. Greenbaum AR, Heslop T, Morris J, et al. An investigation of the suitability of bra fit in women referred for reduction mammaplasty.
Br J Plast Surg. 2003;56:230-236.
30. Lejour M. Vertical mammaplasty: early complications after 250 personal consecutive cases. Plast Reconstr Surg. 1999;104:764-770.
Article at a glance- The amount and degree of scarring will depend on the surgical technique and a woman's individual inherent wound healing ability.
- Talk to patients about breast size expectations, the postsurgical possibility of decreased nipple sensation—and especially
the rare risk of losing nipples/areolas.
- Tell your patient to choose a plastic surgeon who is familiar with several techniques.
- If breastfeeding is of vital importance to a reproductive-aged woman contemplating breast reduction surgery, warn her to defer
surgery until after she finishes childbearing and breastfeeding.
Short-scar breast reduction/repositioning technique
Our method of short-scar breast reduction is based in part on Dr. Karp's modifications to the Hall-Findlay technique.1,2 Briefly, with the patient standing, we mark the new nipple position at the inframammary fold. Using a custom pattern to
outline the future nipple areola complex, we then mark areas to be resected with a breast displacement technique. These lines
are curved gently and connected to a point 2 to 4 cm above the inframammary fold, depending upon breast size. The medially
based pedicle is made between 6 and 10 cm wide, with half of the pedicle within the pattern.
We first de-epithelialize the pedicle, then elevate a thin inferior flap to the chest wall fascia, and subsequently resect
the "southern hemisphere" of the breast from below the subcutaneous plane to the level of the pectoralis fascia. Breast tissue
is resected laterally and medially according to desired breast size. We're careful to leave the bottom of the breast "empty"
while leaving the upper part of the breast largely intact.
After insetting the areola, we suture the parenchyma of the medial pedicle to the tissue of the lateral "pillar"—sutures that
are critical for setting the ultimate breast shape. We then place the woman in a sitting position to assess her breasts for
size, shape, and symmetry. Returning her to the supine position, we adjust the pillar sutures and perform any other necessary
resection. At this point, especially for obese women, liposuction is useful for removing axillary breast tissue. After obtaining
hemostasis, we place a closed-suction drain into each breast. Finally, we close the skin incisions in layers and usually send
patients home the same day without any external breast support (e.g., brassiere).
REFERENCES
1. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg. 1999;104-748-759.
2. Karp NS. Medial pedicle/vertical breast reduction made easy: the importance of complete inferior glandular resection. Ann Plast Surg. 2004;52:458-464.
Patient Information
Common questions about breast reduction surgery
What is breast reduction surgery?
The various types of breast reductions (mammoplasties) are operations that reduce the weight and volume of overly large breasts
that are causing a woman physical or psychosocial distress. The goal is to improve her physical and emotional well-being.
Breast reduction is done for medical reasons, so insurers usually cover it, although some might not if they think not enough
breast tissue needs to be removed and they consider it merely a "lift." The techniques for reshaping, sometimes lifting, and
reducing the size of large breasts involve making incisions on the lower part of the breast. While it's not considered cosmetic
surgery, surgeons usually aim for an attractive cosmetic result. A plastic surgeon removes extra skin and glandular and fatty
breast tissue, moves nipples to a higher position, and later, when stitching the incisions, tries to keep scarring to a minimum.
Your ability to breastfeed may be affected to some extent because no matter which surgical technique you choose, some milk
ducts will be cut.
Should I have my breasts reduced?
The decision whether to have reduction surgery is very personal. You should carefully weigh the pros and cons of undergoing
surgery if you're seeking relief from painful physical signs and symptoms that large, heavy breasts can cause—like breast,
arm, and upper back pain, neck and shoulder pain and strain, rashes under the breasts, and shoulder grooving from bra straps.
Some women may also choose the procedure because excessive breast size is causing embarrassment, emotional stress, or shyness,
or keeping them from participating in sports and exercise.
Can women of all ages undergo reduction surgery?
Although patients range from late teen years all the way into their sixties and beyond, teenagers are usually told to wait
until their breasts have finished developing so they won't need to be operated on a second time. If you're 40 or older, your
ob/gyn will advise you to first have a mammogram.
Will breast reduction surgery prevent me from breastfeeding someday?
If breastfeeding is of vital importance to you, many surgeons recommend that you hold off on reduction surgery until after
you've finished childbearing and breastfeeding. The decision is a difficult one because on the one hand, some women in retrospect
regret not having waited until after they breastfed their children to undergo reduction surgery because of the hardships they
encountered. But on the other hand, some women point out that their enormous breasts made them so socially isolated and miserable
that they may never have found someone to marry and had children if they hadn't first had the surgery.
What's the downside of surgery?
Although increasingly common, breast reduction is still major surgery and carries with it the usual risks of major surgery.
The decision is not to be taken lightly. You should go into it with eyes wide open, asking lots of questions, aware that no
reduction surgery is scar-free, and that you could wind up with reduced feeling in your nipples. Also make sure that you and
your surgeon are on the same page when it comes to expectations (breast size, realization that breasts won't be perfectly
symmetrical), and be aware that one of the worse case scenarios—while admittedly rare—includes losing your nipple.
Should I look for a surgeon who performs more than one type of reduction procedure?
Yes, because one technique may be more appropriate for the size or shape of your breasts than another, one may cause less
scarring than another, and some affect future breastfeeding ability to a greater extent than others. For a comprehensive description
of available reduction procedures, consult with a plastic surgeon recommended by your ob/gyn, since that information is beyond
the scope of this guide. For example, if you have excessively large breasts, you might needa surgeon who performs the "free
nipple graft" technique, in which the nipple and areola are removed at the beginning of the procedure, trimmed, and then reapplied
to your breast somewhat like a skin graft. Keep in mind, however, that this procedure will undoubtedly affect your ability
to breastfeed. The traditional reduction technique—called the "inverted T pattern"—can be used for nearly any size breast,
whereas something called the "short-scar vertical pattern" is better suited for small-to-moderate reductions.
Where can I get more information?
Defining Your Own Success: Breastfeeding After Breast Reduction (BFAR) Surgery (available from La Leche League International), by Diana West, BA, IBCLC, might be helpful. Ms. West is a La Leche League
leader who wrote the book after finding few resources available on the topic when she set out to breastfeed her children following
her own breast reduction surgery.
Ms. West also has a Web site for "BFAR" women and physicians who seek information on breastfeeding after reduction surgery
(http://www.bfar.org. One of the key points on the site is that most women who have breast reduction surgery before having their babies will not have a full milk supply and will most likely have to supplement. That doesn't mean you can't have a satisfying breastfeeding
experience, she says, but you do need to carefully weigh the advantages and disadvantages of breast reduction surgery and
consider whether you'd be happier waiting to have the surgery until you've finished breastfeeding your babies.
The Web site for the American Society of Plastic Surgeons (http://www.plasticsurgery.org/public_education/BRAVO-Pre-Surgery.cfm) includes Frequently Asked Questions about breast reduction surgery.
Sources: Spector JA, Karp NS. A primer on breast reduction surgery. Contemporary OB/GYN. 2005(Nov);50 (9);58-70; American Society of Plastic Surgeons, La Leche League, BFAR Information and Support Web site.
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