There are many factors that merit specific attention when assessing a patient for a potential breast reduction. The most basic of these relates to the patient’s physical complaints related to her large breasts. It is important to document each patient’s specific complaints, which can include, but are not limited to, neck and back pain, headaches, shoulder grooving with painful indentations in the skin secondary to support garments, submammary intertrigo and paresthesias in the hands and fingers. More often than not, there is a general discomfort about the upper torso related to years of excess weight dragging down from the shoulders. One useful maneuver used to assess the effect of the weight of the breast on the upper torso is to gently lift each breast upwards with the examining hand while standing in front of the patient (Figure 7.1). By taking the weight of each breast off the chest wall, many patients will observe an immediate relief of symptoms. It should be stressed in each patient consultation that the purpose of undergoing a breast reduction is to relieve these upper torso complaints. Such a discussion, properly documented in the patient’s chart, has practical as well as medicolegal implications as some patients become so focused on the aesthetic appearance of the breast postoperatively that this basic fact is at times forgotten amidst discussions related to scarring or breast shape.

Figure 7.1 (A,B) By standing in front of the patient and lifting the breast until the weight is entirely supported by the lifting hand, the effect of a breast reduction can be simulated. This simple maneuver can be used to help demonstrate to the patient what effect the reduction in breast volume is likely to have on preoperative upper torso symptoms.

Childbearing can have a tremendous impact on the size and shape of the breast. To have a better historical understanding of the stresses that have been placed on the breast and the associated supporting soft tissue framework, it is helpful to document the number of children a patient has had, whether or not she breast-fed and how long it has been since she stopped. Also, the maximum size that developed either as a result of pregnancy alone, or during the breast-feeding process itself, can be helpful in understanding how dramatically the skin envelope was stretched. This information may explain why the breast has a certain appearance and, as well, allow the surgeon to predict, at least to some extent, how the skin envelope will react to surgical manipulation. Whether or not a patient wishes to attempt to breast-feed in the future should also be noted and discussed preoperatively. It is generally permissible to allow patients who wish to breast-feed after breast reduction to make the attempt. If the breast ducts are still in continuity with the nipple, it is entirely possible that a breast reduction will not appreciably interfere with the ability to breast-feed. Of course, this is by no means a guarantee and these issues must be discussed preoperatively to help head off any misconceptions on the part of the patient.

In patients who have recently given birth and who may or may not be breast-feeding, a common question relates to the timing of a proposed breast reduction. The most important variable affecting this decision is whether or not the breast has reached a stable size and shape. Once the swelling associated with childbirth and/or breast-feeding has subsided, the surgeon can optimally make intraoperative decisions concerning the long-term size and shape of the breast. Therefore, it is recommended to wait for 6–12 months after either the pregnancy or the cessation of breast-feeding before performing a breast reduction to allow full breast involution to occur. Some patients continue to demonstrate discharge from the nipple for an extended time after pregnancy or breast-feeding. If after 1 year this discharge persists, an evaluation by an endocrinologist may be helpful. In the absence of any other pathology, a breast reduction can safely be done under these circumstances; however, drains are recommended to help prevent fluid accumulation inside the breast.

Information relating to previous breast surgery must be documented as the location of previous breast biopsy scars may influence planning of the pedicle or skin pattern. For example, occasionally, a patient will present with a previous inframammary fold scar related to a thoracotomy performed as an infant. In these instances, the use of a superior pedicle may more safely carry the blood supply to the nipple and areola. Also, in patients who have undergone previous surgical procedures, the nature of these operations can provide a basis for comparison as to what to expect when a breast reduction is performed. Typically, the recovery from a breast reduction is not as taxing or painful as other commonly performed procedures such as hysterectomy or other types of abdominal procedures, and comparing the two can give a useful frame of reference that many patients can find reassuring.

Conditions that may influence the ability of a patient to recover from a breast reduction must also be considered. Systemic illnesses such as hypertension and diabetes are commonly noted and are associated with an increased incidence of wound healing difficulties. Any medical condition that can potentially impact on the viability of the nipple–areola complex (NAC), pedicle or skin flaps must be documented preoperatively to allow the patient fully to understand the risks involved. Armed with an understanding of these preoperative risk factors, the surgeon then has the ability to utilize a more conservative surgical approach as needed to maximize the chances for success.

It is helpful to make special note of any history related to inflammatory bowel disease. In particular, a past history of ulcerative colitis has been associated with the development of pyoderma gangrenosum, a condition characterized by a progressively enlarging and painful ulcer located at an incision line. Initially, the ulcer is small and is associated with a clear drainage that leads to a benign presumptive diagnosis of a ‘stitch abscess’ or premature erosion of an absorbable suture through to the surface of the skin. Generally, the ulcer enlarges despite the institution of oral antibiotic therapy. Eventually, the ulcer becomes painful in a manner that seems out of proportion to the appearance of the wound and the wound edges develop an irregular undermined purplish border (Figure 7.2). Biopsy reveals an inflammatory infiltrate and the process is rapidly reversed with a tapered course of oral steroids. Recognizing any previous history of diagnosed ulcerative colitis or even colitis-like symptoms can lead to a heightened index of suspicion and early diagnosis should this condition develop.

Figure 7.2 (A) Immediate postoperative appearance of a 35-year-old woman after undergoing routine breast reduction using the SPAIR technique. (B) After a period of several weeks, a small wound separation was noted inferior to the left NAC that was refractory to local wound care and antibiotics. A painful ulcer of significant size ultimately developed with irregular hemorrhagic borders. Biopsy confirmed the diagnosis of pyoderma gangrenosum and a course of systemic steroids was begun. The wound rapidly recovered and healed without further complication. (C) Appearance of the breasts roughly 3 years after the initial procedure.

Many patients assume a direct link between their own macromastia and the size of the breasts of first and even second and third degree relatives. Macromastia is generally not thought to be a directly transmissible genetic condition and it can be helpful to dispel these assumptions as the many variables that can affect the size of the breast are discussed during the consultation. Some women are actually relieved to receive this information as an unspoken worry for their own daughter’s potential for macromastia can be of some concern. More to the point, however, is any family history for breast cancer that may be present. This is important information to document as these patients are at a variably increased risk for the development of breast cancer and this information can guide the decision of whether or not to obtain a mammogram preoperatively. Current American Cancer Society guidelines recommend the initiation of mammographic surveillance of the breast to begin at the age of 40. For patients scheduled to undergo breast reduction, a much younger age guideline is used by many surgeons. The main reason for this is to document preoperatively the presence of any suspicious lesions in the breast before it is surgically altered and to allow these lesions to be appropriately dealt with. When an occult cancer is found in a breast reduction specimen, it can be difficult to isolate it to a specific area of the breast thus obviating the possibility for a lumpectomy with radiation treatment as a treatment option. Realistically, such patients are best treated with mastectomy to be certain any residual tumor is removed. In an effort to prevent as much as possible any potential for finding an occult breast cancer, many surgeons simply obtain mammographic clearance of every patient they see who presents for breast reduction. While complete, this strategy seems excessive when applied to younger women and another common strategy is to use an age cutoff for obtaining a mammogram of anywhere from 25 to 30 years of age. Also, when a history of breast cancer is present in a first degree relative, it is very common to suspend any type of age cutoff guideline and a mammogram is generally obtained in any patient with a family history of breast cancer.

A smoking history essentially doubles a patient’s risk for wound healing complications and for potential vascular compromise to the pedicle. This fact alone may affect the choice of technique for selected patients. For this reason, it is very important to document whether or not the patient smokes and to identify how many packs a day she smokes and how many years she has been smoking.

Another very important aspect of the social history relates to the nature of whatever interpersonal relationship the patient may have with a significant other. It would be less than optimal to perform a breast reduction only to find out later that the significant other was either not informed or, even worse, against the procedure being performed at all. Clearly, the breast can play a very important role in the personal life of the patient and any alteration in the size, shape or sensation of the breast with the addition of scars can have a significant effect on how the patient interacts in an intimate setting. For this reason, it is always recommended that the role of any significant other be assessed at the time of the initial consultation. Of course, the best of circumstances is when the significant other accompanies the patient to the initial consultation as preoperative education can occur and questions can be answered. If not, it is always prudent to ask if anyone else will have any interest at all postoperatively in the decision the patient is making so that person’s role in the recovery process can be assessed. If there is any suspected conflict regarding the decision to undergo a breast reduction, it is prudent to arrange a second preoperative consult with both the patient and her significant other being present to head off any potential misunderstandings postoperatively that may compromise the final result. If the patient acknowledges that her significant other is aware of her plans and is supportive, it is reasonable to proceed. This approach will help to proactively manage expectations ahead of time and will lead to a much more successful outcome rather than trying to deal with these issues after the fact.

There are three general time periods in a woman’s life where macromastia can develop to the point where upper torso symptoms begin to develop and surgery can become indicated. Macromastia can first present in adolescent girls in association with general pubertal development. Anywhere from the age of 12 up to 18 years of age, breast growth over and beyond what would be considered proportionate to the remainder of the body habitus can occur. This early phase of breast over-development presents challenges that are unique in the treatment of macromastia. Not only can there be the usual upper torso symptoms found in other types of macromastia, but other issues related to the emotional well-being of the patient during this very volatile and important part of a young woman’s life must also be considered. As breast volume increases, it is not uncommon for patients to become extremely self-conscious, often to a point of withdrawing socially. As a result, important social skills can either be delayed in developing or fail to develop altogether. Also, from a simple anatomic standpoint, it can be difficult for such young patients with macromastia to participate in sports or other athletic activities without the size of the breasts being a hindrance. For all of these reasons, it is completely acceptable to consider surgical correction of macromastia even as a young teenager. What must be balanced against the decision to perform surgery early is the potential for breast development to be incomplete with further growth postoperatively necessitating a re-reduction later on. For this reason, each case must be assessed individually to arrive at the best solution for the patient. If breast over-development is modest, it is reasonable to wait until the age of 16–18 in the hope that breast size will have stabilized toward the end of pubertal development. However, if at any time, even in patients as young as 14, breast over-development begins to interfere with what the family or the patient sees as normal social development, it is completely reasonable to proceed with a breast reduction, accepting the fact that another touch up reduction may well be required at a later date when breast development has completely stabilized.

The second life event that can significantly affect the size of the breast is pregnancy. How the breast will respond to pregnancy and subsequent breast-feeding is extremely variable from patient to patient. In almost all patients, a transient perinatal enlargement of the breast occurs that is sustained by a period of breast-feeding. After breast-feeding is suspended, many patients will not regress to their pre-pregnancy breast size and some degree of macromastia may persist as a permanent condition. Also, breast ptosis very often becomes exaggerated as a result of the cyclical expansion and involution of the soft tissue support structure of the breast associated with pregnancy and breast-feeding. For these reasons, many patients who demonstrated only modest breast hypertrophy prior to pregnancy will subsequently develop more severe macromastia after pregnancy and will present for breast reduction in the postnatal period. It is prudent to assess whether any further pregnancies are planned as the cyclical changes in breast size that can occur with pregnancy can adversely affect the result after breast reduction is performed.

Lastly, and usually somewhat later in life, many women will present with macromastia associated with weight gain as it is very common for the breast to increase significantly in size as the overall weight of the patient increases. In some patients, even only a modest increase in weight can result in a disproportionate increase in the size of the breast. In others, a weight gain that pushes the body habitus of the patient into the obese to morbidly obese category is required to affect significantly the size of the breast. No matter what the circumstance, in order to provide a stable result, it is best to delay surgery until the patient’s weight remains somewhat constant over a defined period of time. It is reasonable to delay surgery until there is a weight fluctuation of no more than 10 pounds (4.5 kg) over a time span of 6 months to 1 year to ensure that an unexpected change in the weight of the patient will not adversely influence the postoperative size and shape of the breast. Certainly, a further increase in the weight of the patient could create a recurrence of symptoms, but a much more common concern on the part of patients is related to what will happen to the breast should the patient lose weight. It can be very difficult to predict how the volume of the breast will change in association with a generalized weight loss and the exact relationship between breast size and overall body weight can be quite variable. What can be stated for certainty is that breast size will change in association with an overall reduction in body fat. In patients where breast volume has historically has been sensitive to the overall weight of the patient, the change in breast size that occurs can be significant. In other patients, there may be only a negligible change in the size of the breast. No matter what the circumstance, it is best to caution the patient that any change in body fat content can subsequently have an effect on not only the size but the shape of the breast as well (Figure 7.3).

Figure 7.3 (A) Preoperative appearance of a 28-year-old woman prior to undergoing breast reduction. (B) Three-year postoperative appearance after undergoing breast reduction followed by a gastric bypass procedure resulting in a 120 pound (54 kg) weight loss. Along with the general loss of body fat, a profound change in the size and shape of the breast is observed. There is a significant loss of volume along with a redundant and ptotic skin envelope. This case demonstrates the dramatic changes in the breast that can be observed when there is change in the weight of the patient.

Another common concern, particularly for younger patients who are of childbearing age, is the effect that breast reduction surgery has on the ability to breast-feed. The answer to this question is somewhat dependent on the technique employed to perform the procedure with the critical determinant being whether or not the substance of the gland has been divided from, and no longer communicates with, the nipple. Therefore, in patients who have undergone a free nipple grafting technique, there is little hope of maintaining breast-feeding potential as the direct ductal communication between the nipple and the gland has been severed. While it is remotely possible that an ‘inosculatory’ regrowth of the ductal remnants in the nipple and the gland could occur, allowing these structures to variably reconnect, the likelihood of this occurring to any functional degree is low. Alternatively, in the inferior pedicle technique, the main central substance of the gland remains connected to the nipple, which, theoretically, should preserve the ability to breast-feed. Other pedicled techniques such as the vertical breast reduction technique follow a similar logic. Therefore, if a superior pedicle or a superomedial pedicle is constructed so as to maintain a communication between the nipple and a large enough retained glandular segment, breast-feeding potential should be maintained. Of course, there are many other variables involved in successful breast-feeding that have nothing to do with the surgical alteration of the breast and many women who wish to breast-feed cannot for a host of different reasons. As a general rule, approximately two-thirds of women who wish to breast-feed are able to do so and this ratio is not changed by breast reduction surgery that maintains a direct nipple to gland communication.

After a general overview of the size, shape and symmetrical relationship of the breasts is completed, documentation of several key measurements is performed. First, the length from either the midclavicle or the sternal notch to the nipple is measured (Figure 7.7). This provides information regarding the length of the breast. In many instances of significant macromastia, this measurement will be in excess of 30 cm. The usefulness of this measurement is somewhat limited, however, in patients undergoing a breast reduction using an inferior pedicle technique as it does not have a direct bearing on the length of the pedicle that will ultimately provide vascular inflow to the NAC. Patients with an excessive clavicle to NAC distance may simply have a breast that is positioned low on the chest wall. For this reason, a second measurement is performed documenting the distance in the midline of the breast from the inframammary fold up to the nipple (Figure 7.8). When using an inferior pedicle technique, this measurement provides a direct measure of the length of the pedicle that will be providing vascular inflow to the NAC. As a general guideline, for patients who measure 15 cm or less, necrosis of any portion of the NAC or underlying fat or parenchyma is unusual and an inferior pedicle technique can be used with confidence. For pedicle lengths of 15–20 cm, the risk for vascular compromise increases but does not preclude the safe use of an inferior pedicle technique. For lengths of greater than 20 cm, greater care in the creation and management of the pedicle is strongly advised so as to avoid ischemic complications. Of course, numerous other factors enter into the usefulness of the length of the pedicle as a predictor for potential complications including obesity, volume of reduction, medical illness and a smoking history. It is possible to use inferior pedicles in excess of 30 cm in length without any hint of vascular compromise (Figure 7.9). Therefore, despite the lack of direct correlation between the length of the pedicle and the potential for ischemic complications, it is still a worthwhile effort to document this measurement as it can serve as a guide to assist the surgeon in predicting when ischemic complications might become more likely. Lastly, measuring the dimensions of the areola (in cases where the areola is asymmetric) can document the presence of an excessively large areolar diameter. This then triggers discussion of the fact that the areolar diameter will be made smaller. Rarely is this an issue for patients and special requests for an inordinately large or small postoperative areolar diameter can be factored into the surgical plan. As with the subject of asymmetry, it is far better to have these types of discussions ahead of time rather than trying to recover after the fact with the uncomfortable task of having to deal with a dissatisfied patient postoperatively.

Figure 7.7 (A,B) Preliminary measurements of the breast in preparation for breast reduction include documentation of either the clavicle to nipple distance (A) or the sternal notch to nipple distance (B). These measurements can serve as indicators not only of the size of the breast but also of the degree of ptosis that is present.

Figure 7.8 (A,B) A more clinically significant measurement in patients undergoing a breast reduction using an inferior pedicle technique is the measured distance from the inframammary fold to the nipple in the relaxed position. This measurement is a more direct indicator of the length of the pedicle. It is obtained by placing the tip of the measuring tape directly at the fold (A) and then allowing the breast to fall naturally under the influence of gravity alone. By gently pulling the measuring tape up to the level of the nipple (B), the pedicle length can be measured.

Figure 7.9 When using the inferior pedicle technique, pedicle lengths in excess of 30 cm can be used to maintain the vascularity of the NAC, particularly when the internal breast septum and the associated vascular arcade is preserved during the dissection of the pedicle.

Finally, an estimation as to the weight that will be removed from each breast is performed. This maneuver is extremely subjective and is influenced to a tremendous degree by the experience of the surgeon. To accomplish this task, the underside of the breast is supported with the upturned palms of both hands and the redundant breast is lifted until the weight of the breast is wholly supported by the surgeon. By gently lifting up and down, a ‘feel’ for the overall weight of the breast can be gained and the amount of excess estimated. This maneuver is performed separately for each breast and the weight estimations adjusted based on a visual determination of the level of volume asymmetry. This information is very useful at the time of surgery and can help guide the amount removed from each breast.

The individual approach that a given surgeon takes toward breast reduction can be quite variable. For instance, some surgeons are quite comfortable with one particular method of breast reduction and simply apply that method in every case, i.e. the inverted T inferior pedicle breast reduction. Other surgeons attempt to apply different techniques depending on several variables including breast size, shape, skin excess and degree of ptosis. Certainly, the variety of different techniques available for breast reduction has increased markedly over the past decade and much attention has been directed at ‘short scar’ strategies for the treatment of macromastia. Although the ‘one technique’ approach has served many surgeons well over the years, familiarity with these other techniques allows the surgeon to apply these methods strategically in appropriately selected patients to optimize further the consistency and aesthetic results of breast reduction.

While it is a more versatile technical strategy to attempt to apply different techniques depending on the preoperative appearance of the patient, it can be difficult to sort through the various procedures and, in particular, identify those attributes of each technique that may provide real advantage in specific clinical situations. This is particularly true when individual surgeon’s names are used as descriptors of a specific technique and no indication is given as to the specific details of the specific method. Also, small technical modifications are commonly employed by many surgeons that can often be at variance to the original description of a given technique. To avoid this confusion and to help properly evaluate the merits of each individual technique, it is helpful to realize that any breast reduction technique can be broken down into four elements with each element satisfying a specific surgical goal:

By using this strategy for describing and evaluating a breast reduction technique, it is possible to organize a surgical approach better and develop a understanding of how all the components of a breast reduction procedure fit together to create a successful more complete outcome. To this end, several different combinations of techniques that satisfy these requirements can be recognized as specific methods of breast reduction. Although minor variations on these themes exist, there are basically four distinct procedures that are used to perform breast reduction. These include liposuction breast reduction, vertical breast reduction, short scar periareolar inferior pedicle (SPAIR) breast reduction and inverted T breast reduction with or without a free nipple and areola graft. Each of these procedures will be described in detail.