Overview of breast reduction

INTRODUCTION — The extent to which extremely large breasts can negatively impact a woman's life is often underappreciated. For those who live with unwanted macromastia and its associated symptoms, the relief from pain and tension that breast reduction can produce is immediately noticeable after surgery. Recovery from surgery leads to additional benefits, and the majority of women enjoy an improved quality of life [1,2].

An overview of breast reduction, including patient selection, techniques, and complications, is presented here. An overview of the flap and graft techniques used for breast reduction is reviewed separately. (See "Skin autografting".)

MACROMASTIA — Women with excessively large breasts (macromastia) who seek breast reduction often experience chronic pain and tension in their neck, shoulders, and upper back and a feeling of heaviness of the breasts. Symptoms are generally worse at the end of a day of upright posture. The sturdy support bra worn by many women with macromastia can cause visible, as well as palpable, tender grooves overlying the trapezius near its insertion site on the acromion (picture 1). Over the years, these can become permanent troughs that do not resolve even after the bra is removed.

A typical woman seeking breast reduction (reduction mammoplasty) will have two to five pounds (900 to 2200 grams) of excess breast tissue weight that pulls the shoulders forward (picture 2). The trapezius muscles may hypertrophy to compensate. Women with macromastia complain of chronic pain in the breasts, shoulders, neck, or back as a result of the weight of their breasts. (See 'Indications' below.)

Women who choose to undergo breast reduction surgery are generally seeking symptomatic relief. An additional benefit is a dramatic change in the appearance of their breasts, which typically includes an elevation in the height of the nipples and reorientation that allows the nipples to point outward (not downward) and breasts that are higher, more rounded, and in better proportion to the rest of their body. An extensive body of literature supports the use of breast reduction techniques to reduce symptomatology and improve quality-of-life in appropriately selected patients [3].

PATIENT SELECTION — The majority of women who present for breast reduction have straightforward complaints and consistent clinical findings; however, occasionally a patient will present a dilemma as to whether or not breast reduction is the right operation at a given time. Age at presentation, childbearing status, weight fluctuation, resulting scars, and medical comorbidities all need to be considered when selecting candidates for breast reduction surgery. However, considering the physical and psychological burden and the proven benefits of correction, evaluating all women who present with symptomatic macromastia for a potential surgical solution is appropriate.

Older women tend to have primarily physical complaints. Most patients state that they have considered the procedure for several years before finally seeking treatment. Often, they are motivated to seek treatment by the suggestion of their primary care doctor or physical therapist. In addition to their complaints of chronic neck, shoulder, and/or midthoracic back pain, they often describe difficulties with self-breast exam and mammograms.

By comparison, preteens and teenagers who develop juvenile breast hypertrophy often are subjected to cruel remarks and unwanted attention, and may have psychological issues as a result. Massive breasts in adolescents may lead to embarrassment and problems with self-esteem and school performance. For girls whose lives are significantly impaired, early breast reduction is advantageous in spite of ongoing breast growth. In general, breast growth is completed at the time of skeletal maturity, which usually occurs by age 18 [4]. Younger symptomatic patients with severe macromastia (picture 3) benefit from early treatment [5-7]. The patient and parents or caregivers need to be counseled that repeat breast reduction may also be beneficial once growth is completed.

Indications — One or more of the following symptoms may lead the plastic surgeon to recommend breast reduction:

Chronic pain — The primary indication for breast reduction surgery is chronic pain in the breast, neck, shoulder, or midthoracic region of the back, often requiring pain medication for relief. Woman may also complain of headache, which is attributed to the constant neck and shoulder strain. Women who have underlying spine disease can have significant aggravation of their back pain. Pain, as an indication for surgery, has generally been present for several years and is intractable to standard treatments, such as physical therapy. A temporary improvement in pain immediately after a treatment may occur, but it often recurs once normal activities are resumed. Other failed treatments such as chiropractic treatments, massage therapy, and acupuncture also serve to support the medical indications for surgery.

Breast discomfort and physical impairment — Significant discomfort that interferes with daily activities and leads to behavior modification to achieve some relief is another indication for breast reduction. Woman may complain of difficulty obtaining adequate support for their breasts during exercise, or discomfort in their breasts leading to a reduced level of physical activity. As a result, many women with macromastia find it difficult to lose weight.

Chronic skin changes — Another indication for breast reduction surgery is skin changes, which include rash, hygiene problems, and skin infections in the intertriginous areas. The pendulous breast creates a large area of skin-on-skin contact in the region of the inframammary fold. Perspiration becomes trapped, particularly during hot weather, and fungal infections, skin maceration, and folliculitis are common problems (picture 4). Chronic inflammation weakens the skin's tensile strength, leading to fragile skin that can tear along the inframammary fold and in the intertriginous areas.

Neuropathy — Neuropathy of the upper extremities can also occur as a result of macromastia. The ulnar nerve is usually affected (compression of the anterior T1 rami) and manifests as numbness and paresthesias of the small and ring fingers [8].

Negative psychological effects — The negative psychological effects associated with macromastia are also compelling indications for surgery. Many women feel self-conscious about their appearance and do not want to draw attention to their large breasts. They have difficulties finding clothes that fit, they slouch, and they complain of poor posture. Some patients, especially younger women who seek this operation, have poor self-esteem and are reluctant to take part in activities in which they cannot easily hide their figure.

Contraindications — High-risk surgical patients with severe medical comorbidities (eg, cardiopulmonary disease) are not offered reduction mammoplasty, even if they meet the criteria listed above for breast reduction.

COUNSELING AND INFORMED CONSENT — It is incumbent on the plastic surgeon to ensure that the patient has taken the appropriate steps with regard to counseling and lifestyle changes before undergoing surgery [9]. During the informed consent discussion, it is important to address patient expectations, including the scarring associated with breast reduction surgery, potential complications, the impact on future breastfeeding, and the effects of future weight change. Complications are discussed below. (See 'Complications' below.)

Expectations — Women with chronic pain from other etiologies may have unrealistic expectations for the outcomes of breast reduction. Women anticipating massive weight loss may have unpredictable ultimate aesthetic results and proportionality if breast reduction is done prior to a significant change in weight. These types of patients will require more focused efforts on the part of the plastic surgeon to ensure that reduction mammoplasty is indicated and that true informed consent can be obtained.

Visible scarring is an expected outcome for all breast reduction techniques except liposuction. Patients who cannot accept scarring on the breasts are not candidates for most procedures; however, for these patients, liposuction-only reduction may be an excellent option. (See 'Liposuction' below.)

A thorough understanding of the anticipated scar pattern and the time frame for scar maturation (typically 12 to 18 months after surgery) will help set the patient's expectations. (See 'Postoperative care and follow-up' below.)

Change in sensation of the nipple may occur after breast reduction surgery. In general, after breast reduction, sensory loss to the nipple may be diminished or complete. When diminished, improvement can be expected over several months. Sensation will often return gradually over several months, and though rare, the possibility of permanent sensory changes should be discussed as a possible outcome after breast reduction [10]. The incidence of this complication is related to technique and the volume of resected breast tissue. (See 'Surgical techniques' below.)

●Small reductions with any technique are less likely to result in permanent loss of sensation.

●Larger reductions using central and inferior pedicle techniques are associated with a loss of sensation in 9 percent of patients [11]. Up to 50 percent of those undergoing superior and inferior pedicle procedures have reduced sensation compared with their preoperative measurements [12].

●Limiting the depth of the lateral breast resection helps to preserve sensation to the nipple-areolar complex.

●Some women report overall improved sensation to the nipple-areolar complex after breast reduction and some will experience temporary hypersensitivity. In patients with severe macromastia, it is likely that baseline nipple sensitivity may have been diminished, possibly due to stretch on the sensory nerves, which is somewhat relieved after breast reduction.

In addition to the possible sensory changes of the nipple-areolar complex, other complications should be discussed. These include nipple-areolar necrosis, areolar pigmentation changes, wound healing complications, fat necrosis, and abnormal pathologic findings. (See 'Breast cancer screening' below and 'Complications' below.)

The possible need for revisions for asymmetry or contour irregularities should also be discussed with patients preoperatively. The most common reason for revision is a standing cone "dog-ear" deformity developing either at the medial or lateral corners of the inframammary incision, or at the inferior aspect of the vertical incision. These minor revisions can often be managed under local anesthesia. A significant asymmetry may require a more extensive surgical revision. The incidence of postoperative asymmetry has been reported at 8 percent [13].

Impact on future breastfeeding — Women who undergo breast reduction before or during their childbearing years should be informed about the potential inability to breastfeed [14]. The reported ability to breastfeed after breast reduction surgery ranges from 20 to 90 percent [15-17]. All breast reduction techniques will remove glandular tissue, leaving less breast parenchyma with ducts that drain to the nipple, which can decrease the amount of milk produced and/or the amount of milk that can be expressed from the breast. The only technique that completely eliminates the possibility of breastfeeding is a free nipple technique that separates the nipple from all of the glandular tissue and the ducts. Specific techniques can be used to try to maximize the ability to breastfeed. Pedicled techniques can leave an adequate amount of parenchyma with ducts intact to allow for future breastfeeding and preserve sensation to the nipple. Central and inferior pedicle techniques, which preserve abundant breast parenchyma under the nipple, are the best techniques to use in women who are interested in future breastfeeding. (See 'Surgical techniques' below.)

Studies that have followed women after breast reduction surgery have found that nearly all women who do successfully breastfeed need to supplement breast milk with formula to completely nourish their babies [18,19]. All women who want to attempt breastfeeding after a breast reduction procedure should be encouraged to do so.

Effects of future development or weight fluctuation — Teenagers who undergo reduction for virginal hypertrophy may have a first procedure before their breasts have completed development. Ongoing breast development after reduction may cause substantial recurrent hypertrophy. In these young patients, the benefits of early reduction may outweigh the risks of a secondary procedure, and the informed consent process should include discussion of the possible need for a second reduction procedure.

In adults, the breast size can change if a patient gains or loses a substantial amount of weight. Women whose weight is not stable prior to a breast reduction procedure should be aware that their results will not be completely predictable if their weight fluctuates postoperatively, and those at a near-ideal weight should be encouraged to maintain it.

Breast cancer screening — Prior to embarking on any elective breast procedure, the need for breast cancer screening should be determined. Patient age, family history of breast cancer, and findings on physical exam will be the most important determinants of need for screening and type of test. Prior to breast reduction surgery, candidates for breast cancer screening should undergo the appropriate testing, which is discussed separately. (See "Screening for breast cancer: Strategies and recommendations".)

The incidence of breast cancer found incidentally during pathologic examination of breast reduction specimens is reported as 0.06 to 2.4 percent [20,21]. The incidence may be higher (1.2 percent in one study) when reduction mammoplasty is performed on the contralateral breast in a patient with a known breast cancer [20]. High-risk lesions (eg, atypical ductal hyperplasia and atypical lobular hyperplasia) have been found in 3 to 4 percent of reduction mammoplasty specimens [21-23].

Patients who undergo breast reduction surgery and who are candidates for breast cancer screening should resume their screening schedule, but mammograms should not be performed any sooner than six months after the surgery. (See "Screening for breast cancer: Strategies and recommendations".)

SURGICAL PLANNING — Most surgeons will use the technique with which they can most safely and predictably offer the best results to their patient. Although a single technique done well may be applicable to many patients, the surgeon should be familiar with more than one technique. The available techniques for breast reduction differ with respect to the pattern of skin resection, as well as the method for removing breast tissue and moving the nipple to a new location. (See 'Surgical techniques' below.)

Factors identified on the preoperative breast evaluation that are important for determining the best approach include preoperative breast size and degree of ptosis, desired postoperative breast size, skin quality, and a history of prior breast surgery. Among these, preoperative breast size and estimated breast reduction volume are the most important factors influencing the technique selected. Although no terms are universally or strictly applied, breast hypertrophy is stratified according to the estimated volume to be resected.

●Small reductions remove 200 to 400 grams per side.

●Moderate reductions remove 400 to 700 grams per side.

●Large reductions remove 700 to 1200 grams per side.

●Reductions in patients with gigantomastia involve massive reductions of more than 1200 grams per side.

Several methods are available to help surgeons estimate breast resection volumes. The two most common methods are the Schnur sliding scale and the Descamps formula [24,25]. The Schnur sliding scale estimates resection weight based on the patient's body surface area [25]. The Descamps method estimates resection volume based on a regression analysis that identified the following formula [24]:

Although almost any technique will work well for smaller (200 to 400 grams) reductions, gigantomastia poses technical and aesthetic challenges. When the breast size is massive and the nipple position is extremely ptotic, a very long pedicle may not provide adequate arterial inflow or venous drainage to ensure nipple-areolar complex survival, and thus, a free nipple graft may be necessary. (See 'Surgical techniques' below.)

A prior history of breast surgery, including augmentation, prior reduction, or lumpectomy, may alter the natural blood supply to the nipple and remaining breast tissue, requiring a thoughtful, individualized approach. Ideally, prior operative report(s) should be obtained and reviewed prior to the surgery. If such documentation is not available, then an inferior wedge resection with no nipple-areolar complex transposition, liposuction only, or significant nipple-areolar transposition with free nipple graft are all considered safe to perform. (See 'Surgical techniques' below.)

SURGICAL TECHNIQUES — Breast reduction is accomplished using pedicled flap or free graft techniques [26]. The basic principles of flaps and grafts are reviewed in detail elsewhere. (See "Skin autografting".)

Pedicle techniques — Most breast reductions are performed using a pedicle of breast parenchyma as the blood supply for the nipple-areolar complex. The nipple-areolar complex is left attached to some portion of breast tissue, which captures the vasculature from the chest wall while the excess breast tissue is resected from around the pedicle. The pedicle should provide the ability to rotate or advance the nipple to the desired location higher on the chest. A successful operation using a pedicle should ideally accomplish the following:

●Allow the desired amount of resection

●Preserve an adequate blood supply for healing (ie, no fat necrosis or nipple-areolar complex compromise)

●Preserve sensation to the nipple

●Produce an acceptable aesthetic result

In designing the pedicle, the surgeon must consider several factors. The absolute length of the pedicle is measured from the nipple to the inframammary fold. If the pedicle length is long, there is increased risk that the pedicle may not be adequate to support the nipple-areolar complex [27]. As an example, the average pedicle length was 14 cm in one study [27]. One way to counteract this problem is to create a wider base for the pedicle, reducing the length-to-width ratio to improve the chance for nipple survival. However, this will limit the amount of breast tissue that can be resected and may produce a result that appears under-reduced. In cases where the pedicle is extremely long, a free nipple graft should be considered. When performing a pedicled technique, if the nipple-areolar complex appears congested intraoperatively and showing signs of vascular compromise, then conversion to a free nipple graft may be indicated. (See 'Free nipple grafting' below.)

One feature of most pedicled techniques includes the preservation of deepithelialized dermis over the pedicle corresponding to the location of the blood supply. This technique is meant to preserve the subdermal plexus within the pedicle, thus improving circulation to the remaining breast tissue and to the nipple-areolar complex [28]. Although there are no data to prove the advantage of de-epithelialization of the pedicle, many surgeons continue to de-epithelialize the pedicle. One small trial involving women undergoing bilateral breast reduction compared full-thickness skin removal plus partial de-epithelization (one breast) with de-epithelialization only (opposite breast) for inferior pedicle breast reductions [29]. There were no advantages, and longer operative times for the breast that had complete de-epithelialization of the pedicle.

Inferior pedicle — The most commonly used pedicle technique is the inferior pedicle. The key to its enduring popularity is its versatility for all breast sizes. Inferior pedicle techniques are commonly used for all size breast reductions: small, medium, or large. These definitions are given above (see 'Surgical planning' above). However, the inferior pedicle technique has been criticized for a tendency toward the "boxy"-shaped breast and for more extensive scarring. This technique generally uses the Wise pattern skin resection, which creates both inframammary and vertical incisions (picture 5 and picture 6 and picture 7). (See 'Handling the skin' below.)

The inferior pedicle is designed as a pyramidal flap of dermoglandular breast tissue that is centered over the breast midline. The nipple sits at the anterior apex of the pyramid (picture 8). The terminal branches of the lateral thoracic artery, the perforating branches of the internal mammary artery, and the musculocutaneous branches of the thoracoacromial artery all contribute to the blood supply of the inferior pedicle. Intercostal vessels supplying the inferolateral breast may also be captured depending on the pedicle design.

The larger the breast, the wider the pedicle is designed along the inframammary fold, generally measuring 8 to 10 cm. The thickness of the pedicle varies greatly. Some surgeons create a less pyramidal, more tongue-shaped pedicle that reduces the bulkiness but may compromise blood supply or venous drainage. Others will leave a mesentery of tissue along the chest wall medial and lateral to the actual pedicle to improve vascularity and preserve nipple sensation. The inferior pedicle can also be designed with varying amounts of breast tissue remaining superiorly to maintain upper pole fullness and increase the capture of vessels off the chest wall. A common problem associated with the inferior pedicle technique is the "bottom out" deformity, which can be minimized by closing the superficial fascia of the breast tissue. Reinforcement of the inframammary fold can also help to prevent "bottom out" phenomena [30].

Superomedial pedicle — Surgeons comfortable with the superomedial pedicle technique will frequently use this pedicle with a vertical skin resection pattern. The vertical skin resection pattern limits the skin excision and scarring and allows the skin to slowly remodel over time to contour to the internal shape of the parenchymal pedicle. With a more ptotic breast, a longer medial pedicle may need to be paired with a Wise pattern skin resection. (See 'Handling the skin' below.)

The superomedial pedicle is designed to capture perforators from the internal mammary system, which is the dominant blood supply in the majority of patients [31]. The dermoglandular pedicle is based on the perforators from the second through fourth interspaces, and the excess breast tissue is removed inferiorly from along the inframammary fold laterally and superiorly (picture 9). The nipple-areolar complex is easily rotated into the ideal inset position, and this technique naturally produces a nice rounded breast shape (picture 10). This pedicle flap can be paired with a short scar skin resection [32]. (See 'Handling the skin' below.)

Others — Other pedicle approaches include the lateral pedicle, superior pedicle, and central mound approaches.

The lateral pedicle has not proved to be easily used or versatile. The laterally based pedicle is not the best design, as the majority of the breast tissue is located superolaterally, and as this is a natural position to resect breast tissue in order to accomplish a substantial reduction. A lateral dermal-only pedicle has been described [33], as well as a laterally based dermoglandular flap [34], but the less reliable and less robust-based blood supply from the lateral thoracic artery alone has limited the use of this pedicle.

The widespread adoption of the superior pedicle technique is limited by difficulty with rotating the pedicle in some patients, particularly those with dense glandular tissue. The superior dermoglandular pedicle provides blood supply from the lateral thoracic artery and the internal mammary artery. A modified technique uses a superior central pedicle and a vertical skin resection pattern [35,36].

Another technique, the central mound approach, uses only centrally based glandular tissue carrying the nipple-areolar complex [37]. This block of tissue is carved to taper down onto the chest wall, and no rotation of the pedicle is required.

Free nipple grafting — When the breast size is massive (an estimated resection of 1200 grams or more per side) and the nipple position is extremely ptotic, a nonpedicled, free nipple graft reduction technique may be a better option than a pedicle graft. Simple lower pole breast resection combined with nipple transposition as a free full-thickness skin graft reliably results in an adequate resection volume and a viable nipple-areolar complex (picture 11). This technique is always associated with inability to breastfeed and loss of sensation to the nipples. Thus, informed consent is extremely important with this technique. (See 'Counseling and informed consent' above.)

The free nipple graft technique can be performed by a simple parenchymal wedge excision along the inframammary fold, which leaves only a horizontal scar along the natural fold. This technique is simple to perform but may result in a flattened breast shape. This occurs because the majority of the breast volume hanging below the inframammary fold is resected and the residual upper chest tissue, mainly subcutaneous fat, does not maintain an aesthetic round shape. To restore projection in the breast, the lower pole resection can be performed with the creation of medial and lateral pillars of breast tissue. These are advanced to the midline of the breast for the closure, resulting in vertical as well as horizontal scars but a more aesthetic shape.

The ideal nipple position, once determined, is marked and the skin is deepithelialized to provide a dermal bed to support the graft. The graft, after harvest from the breast reduction specimen, is thinned slightly, particularly centrally within the nipple, and secured in place over the recipient bed with circumferential sutures and a bolster. The principles that apply to skin graft healing (ie, imbibition, inosculation, angiogenesis) also apply to the nipple-areolar complex. Graft "take" is generally established within five days. (See "Skin autografting".)

Handling the skin — Skin resection is a component of all breast reduction techniques except for liposuction-only reduction. (See 'Liposuction' below.)

Ideally, the skin resection and the resulting scars are limited to the area around the nipple-areolar complex and below so that no scars are visible above the bra line. The traditional "Wise" pattern is the standard approach to breast reduction and results in a periareolar scar, a scar along the inframammary fold, and a vertical scar that connects the two (picture 12). This familiar pattern is described as an anchor type or inverted T (the point at which the vertical incision meets the horizontal incision is called the "T" junction).

Skin is removed along two vectors:

●Along the inframammary fold, thus shortening the skin envelope and creating a horizontal scar along the fold, with medial and lateral extents based on the patient's needs.

●A vertical resection centered over the midline of the breast, which tightens the skin and results in a vertical scar extending from the areola to the inframammary fold.

Short-scar techniques — Several short-scar techniques have been developed to improve the scar burden. A disadvantage to short scar techniques is that removal of less skin relies on contraction of the skin envelope around the breast parenchyma. These techniques are used with medial and superomedial pedicles, which are based higher on the chest and are not reliant on the skin to maintain their position on the chest wall. (See 'Superomedial pedicle' above.)

Short scar techniques include the following:

●Skin may be removed only from the medial and lateral breast as in a vertical-type reduction. The vertical approach results only in the periareolar and vertical scar, avoiding the transverse scar along the inframammary fold (picture 13). This is described as the lollipop-type scar.

●Skin may also be resected in a vertical only pattern while adding a short horizontal scar along the inframammary fold. The horizontal scar can also be limited to just the lateral half of the inframammary fold [38].

●The periareolar reduction is an alternative short-scar approach that eliminates all but the circumareolar scar [39-41].

●Lastly, skin may be removed only from the lower pole of the breast along the inframammary fold in a horizontal scar reduction [42-44]. This results in periareolar and inframammary fold scars but no vertical scar.

Liposuction — Liposuction-only is appealing as a method of breast reduction because there is no scarring. Originally considered more of an adjunct procedure to assist with breast reduction [45,46], liposuction-only has become established as a useful technique for selected patients [47-49]. Fatty breasts are more amenable to liposuction reduction than dense fibrous breasts, and thus, the ideal candidate for liposuction-only reduction has a predominantly fatty breast with minimal ptosis and good skin quality. Stretch marks indicate skin that has dermal fractures and has lost its elasticity. This type of skin will not retract to adapt to the new breast size.

Correction of ptosis is not reliable with liposuction alone. Some nipple elevation can be seen with liposuction alone, but, generally, significant corrections in nipple-areolar complex position will require skin incisions and nipple transposition.

COMPLICATIONS — The main complications of breast reduction are minor and self-limited and include breast asymmetry, cellulitis, hematoma, seroma, and minor skin necrosis where skin incisions meet (at the areola-cutaneous junction and the T-junction at the inframammary fold). A more serious complication is the loss of the nipple-areolar complex due to ischemia. The occurrence of complications can negatively impact patient satisfaction [50].

Mild cellulitis is the most common infectious complication seen after breast reduction. The incidence is generally low (1 percent) [51], but higher incidences (12 to 22 percent) have been reported [13,52]. (See "Breast cellulitis and other skin disorders of the breast".)

Hematomas will generally occur within 12 hours of the breast reduction. Late hematoma can occur up to two weeks after surgery. The incidence is reported as 0.3 to 2 percent [51,53,54]. Many hematomas will resolve without intervention, but hematomas that are visible, cause asymmetry of the breasts, or place tension on the skin flaps and nipple-areolar complex should be drained in the operating room. Breast abscess, although rare, may develop from a hematoma and require surgical drainage.

Postoperative seromas are most commonly associated with the use of adjunctive liposuction and are otherwise uncommon. An incidence as high as 7.4 percent has been reported after vertical reductions, for which liposuction is a significant and routine component [55].

Skin necrosis, fat necrosis, and loss of the nipple-areolar complex can all occur after breast reduction. These complications are technique-dependent and affected by the size of the reduction and other patient factors, such as smoking. The Wise pattern of skin resection compromises the skin flaps to a greater degree than a vertical or periareolar reduction. Tension on the skin flaps at the time of the closure can lead to ischemia at the distal skin flaps at the central lower breast and at the points at which the vertical and horizontal suture lines meet, commonly referred to as the "T" point. (See 'Handling the skin' above.)

Significant loss of skin flaps may require prolonged local wound care or skin grafting in more extreme cases. Compromise of the nipple-areolar complex, if recognized intraoperatively, should be assessed immediately. Torsion of the pedicle may result in venous congestion or ischemia and must be corrected. If no correctable cause of vascular compromise is identified, intraoperative conversion to a free nipple graft technique may be the best way to preserve the nipple-areolar complex. If this is performed, debridement of the pedicle back to well-perfused tissue is required to prevent fat necrosis. The nipple-areolar complex should be thinned of all excessive ductal tissue. In addition, closure of the skin flaps and creation of a dermal bed in the appropriate location for the nipple is required to ensure successful engrafting of the nipple-areolar complex.

Postoperative recognition of nipple-areolar complex compromise should lead to consideration of hematoma or other compressive situations. If no other intervention is required, local wound care (eg, silvadene for superficial skin slough) will often result in healing with a reasonable appearance.

The incidence of unsatisfactory scarring is reported to be 4 to 18 percent after Wise-pattern type skin resection [13,52]. The vertical reduction and short-scar techniques were designed, in large part, to limit the scar burden caused by the operation; however, unsatisfactory scarring can occur with these techniques as well. In one study, the incidence of unsatisfactory scarring after the vertical breast reduction was 2.8 percent [35]. Unsatisfactory scarring may involve widened scars or suboptimally placed scars, such as those that extend down onto the upper abdomen as can occur with the vertical reduction.

Pathologic scarring can also occur. The periareolar scar and the medial and lateral aspects of the inframammary scar are more prone to hypertrophic scarring than the vertical limb. Intralesional steroid injections are very effective treatments to reduce the inflammation. Silicone gel sheeting is also a useful treatment; when used continuously after the procedure, it appears to promote scar maturation without hypertrophy. (See "Keloids and hypertrophic scars".)

POSTOPERATIVE CARE AND FOLLOW-UP — Most patients do not require hospitalization after breast reduction surgery. An overnight stay with observation may be necessary for some women with medical comorbidities (eg, obstructive sleep apnea). Patients who experience severe postoperative nausea and vomiting may require extended observation or admission for intravenous fluid therapy and antiemetics. (See "Postoperative nausea and vomiting".)

Closed suction drains have not proven to be essential in breast reduction surgery and are often a cause of increased postoperative discomfort compared with no drain. Although there are no proven benefits for drain placement, their use by some breast reduction surgeons continues. When placed, drains are typically left in place for one to five days [56-59].

The type of dressing used postoperatively is also variable and surgeon-specific. Surgical bras with front clip closures are easy for patients to put on and remove, provide support for the breasts, and hold absorptive gauze in place, without need for tape on the skin. A bra can also provide a means to secure drains, if they are used. Some surgeons will use a circumferential compression wrap over the breasts instead.

Routine follow-up appointments are based upon the need to remove drains and any non-absorbable sutures, and to provide care that will minimize the appearance of scarring.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breast surgery".)

SUMMARY AND RECOMMENDATIONS

●Macromastia – The extent to which excessively large breasts (macromastia) can negatively impact women's lives is often underappreciated. Women with macromastia often experience chronic pain and tension in the neck, shoulders, and upper back and a feeling of heaviness of the breasts. These symptoms are generally worse at the end of a day of prolonged standing. Bras that are used to provide sufficient support can create additional problems. (See 'Macromastia' above.)

●Patient selection – One or more of the following symptoms may lead the plastic surgeon to recommend breast reduction to their patient (see 'Indications' above and 'Patient selection' above):

•Chronic pain (breast, chest, shoulder, back), which is typically present for several years and intractable to standard treatments.

•Breast discomfort leading to behavior modifications and interfering with daily activities and the ability to exercise.

•Skin changes such as hygiene problems, chronic rash, and chronic skin infections in the intertriginous areas.

•Upper extremity neuropathy.

•Negative psychological effects.

•High-risk surgical patients (eg, cardiopulmonary disease) are not offered reduction mammoplasty, even if they meet the criteria listed above for breast reduction. (See 'Contraindications' above.)

●Patient counseling – Prior to breast reduction surgery, the patient should be counseled regarding expectations (appearance and scarring), potential complications, the effects of future weight change, and the possibility that breastfeeding may not be possible, depending upon the type of breast reduction surgery performed. (See 'Counseling and informed consent' above.)

●Breast cancer screening – Prior to breast reduction surgery, candidates for breast cancer screening should undergo the appropriate testing, if not already performed. Following breast reduction surgery, candidates for breast cancer screening should resume their screening schedule, but mammography should not be performed any sooner than six months after the surgery. (See 'Breast cancer screening' above and "Screening for breast cancer: Strategies and recommendations".)

●Surgical planning – Preoperative breast size and estimated reduction volume are the most important factors influencing the selection of technique for breast reduction. A history of prior surgery that may have altered the blood supply to the nipple and remaining breast tissue is also important. (See 'Surgical planning' above.)

●Surgical techniques – Breast reduction is accomplished using a pedicled approach for the nipple-areolar complex (inferior, superomedial, lateral, or superior) or free grafting of the nipple-areolar complex. Liposuction can be used either as an adjunct or a stand-alone technique. Almost any technique will work well for smaller breast reductions (200 to 400 grams per side), but gigantomastia (>1200 grams per side, long pedicle length) is technically challenging and may require free nipple graft techniques. (See 'Surgical techniques' above.)

●Complications – The common complications of breast reduction are minor and self-limited. These include cellulitis, hematoma/seroma, and minor skin necrosis where skin incisions meet. Serious bleeding requiring reoperation, if it occurs, will usually happen within the first 12 hours after surgery. More serious complications, such as the loss of the nipple-areolar complex, or flap necrosis, can occur but are rare with proper planning. (See 'Complications' above.)