Breast Reduction (Reduction Mammaplasty)

Overview

Breast reduction, or reduction mammaplasty, is a surgical procedure that aims to reduce the size and volume of large breasts by removing excess fat, glandular tissue, and skin.

This procedure is often performed to alleviate physical discomfort such as back, neck, and shoulder pain, as well as to improve breast aesthetics by enhancing shape, symmetry, and positioning of the nipple-areolar complex (NAC).

The operation is typically done using pedicle techniques that preserve the blood supply to the nipple while removing tissue and reshaping the breast for a more proportional appearance.

Key Considerations

The key anatomical structures involved include the glandular breast tissue, subcutaneous fat, and Cooper’s ligaments, which provide structural support to the breast.

Preserving the vascular supply to the nipple-areolar complex (NAC) is critical. The internal mammary artery (via the medial pedicle) or the lateral thoracic artery (via the inferior or superior pedicle) supplies the blood flow that maintains the viability of the nipple.

The balance between tissue removal, nipple positioning, and maintaining nipple sensation and function (including breastfeeding) is an important consideration for both the patient and surgeon.

Pre-Procedure Preparation

Equipment and Tools Checklist

Scalpel (No. 10 and No. 15 blades) for precise skin and deep tissue incisions.
Electrocautery (monopolar and bipolar) to achieve hemostasis and aid in dissection.
Metzenbaum scissors, tissue forceps, and needle holders for fine tissue handling and reshaping the breast tissue.
Hemostatic agents such as Surgicel or Gelfoam to manage oozing during dissection.
Absorbable sutures (3-0 Vicryl, 4-0 Vicryl) for deep tissue closure.
Non-absorbable sutures (4-0 Prolene) for skin closure.
Jackson-Pratt drains (optional) for larger reductions to prevent fluid accumulation.
Marking pens for precise preoperative skin marking, especially for repositioning the nipple and defining the amount of tissue to be excised.
Surgical bras and compression garments for postoperative support.

Patient Preparation

A comprehensive medical history is crucial, especially assessing for conditions such as diabetes, obesity, smoking, or coagulopathies that could affect wound healing.
Conduct a detailed physical examination of the breasts, assessing skin quality, glandular composition, and degree of ptosis (drooping), measured from the suprasternal notch to the nipple.
Mark the new position of the nipple-areolar complex (typically positioned 18-22 cm from the suprasternal notch) based on the patient’s frame and aesthetic goals.
Take preoperative photographs for surgical planning and postoperative comparison.
Informed consent: Discuss with the patient potential complications, including changes in nipple sensation, scarring, asymmetry, and the ability to breastfeed.
Skin preparation: Thorough antiseptic cleansing of the chest and abdomen with chlorhexidine or povidone-iodine.
Anesthesia: General anesthesia is typically required for breast reduction surgery.

Positioning

The patient is positioned supine with arms abducted at 90 degrees on padded arm boards. The chest must be fully exposed to allow the surgeon access for tissue excision and reshaping.
Intraoperatively, the patient may be placed into a semi-sitting position during the procedure to assess breast symmetry and shape.

Key Procedural Steps

Step 1: Incision Planning and Marking

Marking is done with the patient in a standing position, as breast shape and volume change significantly when upright. The Wise pattern (anchor-shaped), vertical scar (lollipop), or short-scar techniques may be chosen based on the breast size and desired outcome.

Wise pattern (Anchor-shaped): A periareolar incision with a vertical incision from the areola to the inframammary fold (IMF) and a horizontal incision along the IMF. This allows for significant tissue removal.

Vertical scar (Lollipop): Includes a periareolar incision and a vertical incision from the areola to the IMF, used for moderate reductions.
- Mark the new location of the nipple-areolar complex (NAC), typically 18-22 cm from the suprasternal notch in proportion to the patient’s anatomy.

Step 2: Skin and Tissue Excision

Using a No. 10 blade, the skin is incised along the marked lines. Dissect the skin flaps carefully to expose the glandular and fatty tissue beneath.

Excise the glandular breast tissue, subcutaneous fat, and excess skin, preserving the nipple-areolar complex on a vascular pedicle:
- Superior pedicle: Preserves blood supply from the superior breast (based on the internal mammary artery perforators).
- Inferior pedicle: Commonly used for larger reductions, preserves blood flow from the inferior breast (based on the lateral thoracic artery).
- Medial pedicle: Derived from the internal mammary artery, favored for its reliable vascular supply.

Ensure careful hemostasis, particularly when dissecting near the lateral thoracic artery and intercostal perforators.

Step 3: Nipple-Areolar Complex (NAC) Repositioning

Elevate the NAC to its newly marked position. It is crucial to maintain an adequate pedicle length to ensure a reliable blood supply and prevent nipple necrosis.
Areolar reduction may be performed, if necessary, by excising a small ring of tissue to achieve a smaller and more proportionate areola.
The NAC is typically reshaped to a diameter of 4-4.5 cm to achieve a youthful appearance.

Step 4: Breast Reshaping and Internal Suturing

Reshape the remaining breast tissue by suturing the glandular tissue with deep absorbable sutures (3-0 or 4-0 Vicryl) to provide a conical, natural breast shape. Attention should be paid to preserving upper pole fullness, which is critical for an aesthetically pleasing result.
Avoid over-resection of breast tissue in the upper pole, as this can lead to a flattened appearance over time.
Reshaping the breast tissue internally also reduces tension on the skin, improving the quality of the final scar.

Step 5: Skin Closure

The periareolar incision is closed using 6-0 Prolene sutures for a precise closure with minimal scarring. The vertical and horizontal incisions are closed in layers using 3-0 or 4-0 Vicryl in the dermis and subcutaneous layers, followed by 4-0 Prolene or Monocryl for the skin.
The inframammary fold (IMF) must be meticulously reconstructed to provide a natural breast contour.
Avoid excessive tension on the skin closure to reduce the risk of wound dehiscence or hypertrophic scarring.

Step 6: Hemostasis and Drain Placement

Achieve meticulous hemostasis using bipolar cautery to prevent hematomas. Special care should be taken near the medial pedicle and lateral thoracic vessels.
Drains may be placed in the inframammary fold, particularly in large reductions, to manage fluid accumulation. Drains are typically removed once drainage is minimal (2-5 days postoperatively).

Step 7: Dressing and Compression

Apply sterile dressings over the incisions, followed by a surgical bra or compression garment to minimize swelling and support the new breast shape.
Avoid placing excessive pressure on the NAC to ensure adequate blood supply.

Tips & Tricks

Challenges: Symmetry between the breasts can be difficult, especially when significant asymmetry exists preoperatively. Careful preoperative marking and intraoperative adjustments are key to achieving a balanced result.

Tips: When using the superior or medial pedicle, ensure adequate length to avoid kinking of the blood vessels, which can lead to nipple necrosis. Always avoid over-tightening the skin, as this can result in wound dehiscence and poor scarring.

Pitfalls: Over-resection of breast tissue in the upper pole can lead to flatness over time, reducing the aesthetic appeal. Avoid aggressive excision to maintain a full, youthful breast shape.

Post-Procedure Considerations

Aftercare Instructions:

Instruct the patient to wear a surgical bra or compression garment continuously for the first 4-6 weeks to reduce swelling, support the breast tissue, and promote proper healing.
The patient should avoid heavy lifting and strenuous activities for at least 4-6 weeks to prevent tension on the incision lines.
Scar management: Begin silicone gel or sheeting therapy 2-3 weeks post-op to reduce scar formation.

Follow-up Recommendations:

Schedule follow-up visits at 1 week, 2 weeks, and 6 weeks to monitor healing, assess for any complications, and ensure breast shape symmetry.
Remove drains within 2-5 days depending on fluid output.
Additional follow-ups at 3 and 6 months will assess final breast shape, symmetry, and scarring.

Potential Risks and Complications:

Nipple necrosis: Inadequate blood supply to the NAC can result in ischemia or necrosis, particularly if the pedicle is overly stretched or twisted.
Hematoma: Failure to achieve proper hemostasis can result in blood accumulation within the breast tissue, requiring evacuation.
Seroma: Fluid accumulation may occur in larger reductions, requiring drainage.
Scarring: Hypertrophic scars or widened scars may result if there is excessive tension on the incision or poor healing.

✏️ Quick Review Checklist

✔️ Confirm precise preoperative markings for symmetric incision placement and nipple positioning.

✔️ Choose the most appropriate pedicle (superior, medial, or inferior) to preserve NAC blood supply.

✔️ Reshape the breast tissue to ensure upper pole fullness and natural breast contour.

✔️ Achieve meticulous hemostasis and consider drain placement in large reductions.

✔️ Apply compression garments and schedule regular follow-ups to ensure proper healing and breast symmetry.