A primer on breast reduction surgery

November 1, 2005

Excessively large breasts can be so painful that even the rare risk of losing her nipples and areolae won't dissuade a woman from undergoing reduction surgery. This article—by two plastic surgeons—gives you information on the pros and cons of various surgical approaches so you can educate patients about all of their options.

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

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