Breast Reduction

Anatomy and Physiology

The breast is a subcutaneous structure that originates at the fourth interspace. The breast is held in place by the skin-fascial attachments at the inframammary fold and the sternum, but not to the pectoralis fascia. Skin adherence to the deep fascia at the inferior and medial borders makes this area less mobile than the lateral and superior breast borders. The most important aspect of breast reduction anatomy is understanding the blood and nerve supply to the nipple-areolar complex. There are 3 primary sources of blood supply to the breast, and sensory innervation is divided into sections of the breast and the nipple-areolar complex.

The internal mammary artery supplies approximately 60% of the breast parenchyma, mainly the medial portion, through medial perforators. The anterior cutaneous divisions of the second through seventh intercostal nerves supply the medial breast skin. The lateral thoracic artery supplies 30% of breast parenchyma, primarily the superior, outer, and lateral portions. The superior portion of the breast sensation is supplied by the supraclavicular nerves formed from the third and fourth branches of the cervical plexus. The anterior and lateral branches of the third, fourth, and fifth posterior intercostal arteries supply the lower outer breast quadrant. The nipple receives its blood supply from the convergence of multiple vascular networks, while the lateral cutaneous branch of the fourth intercostal nerve provides sensation.[1]

Indications

Women inquire about breast reduction for physical, psychological, and medical reasons. The most common indication for breast reduction is the relief of physical pain and discomfort associated with heavy, pendulous breasts. Patients often complain of chronic back and neck pain, headaches, shoulder pain, deep bra-strap grooves, and rashes beneath both breasts. The breasts can also become chronically painful. Upper extremity neuropathy, postural changes, intertrigo, maceration, irritation, rashes, and other dermatologic manifestations are common. Large breasts can affect daily functioning; this can include difficulty with many forms of exercise and the inability to find properly fitting clothes. 

In patients who have had autologous reconstruction, especially given the prevalence of obesity, these flaps tend to be larger, and some patients may indeed benefit from a secondary breast reduction, whether shortly after the initial surgery or several months to years later. The psychological impact of macromastia is significant, and many patients are embarrassed and self-conscious about their size. Reduction mammaplasty can eliminate or decrease these problems in most instances. Breast reduction may also be indicated to correct asymmetry caused by unilateral hyperplasia or to achieve symmetry after unilateral breast reconstruction.[4][5]

Contraindications

The patient should meet the usual criteria for undergoing an elective surgical procedure. There is no specific age limit, as long as the patient is reasonably healthy. Medical conditions such as diabetes and hypertension should be well-controlled. Smokers should be encouraged to quit several weeks before surgery and must be informed of the increased risks of flap necrosis, nipple-areolar complex loss, and complications with wound healing. A mammogram should be obtained for patients aged 40 and older or with a family history of breast cancer. A surgical oncologist should address any suspicious findings before undertaking elective breast reduction.[6]

Technique or Treatment

Breast reduction is by no means an easy procedure; although several techniques have been developed to perform this procedure, each has its risks and complications. All patients need to be educated about the procedure and potential complications. Recovery can be prolonged, and scar avoidance is not always achievable. Recently, liposuction has been used to elevate the nipple-areolar complex; however, concerns have been raised about the safety of this technique, as the removed tissue is not available for histological evaluation.

The specific reduction technique selected should depend on the patient's physical characteristics, attitude toward scars, the surgeon's judgment, and experience. The superior pedicle, inferior pedicle, and partial breast amputation with free nipple-areola grafting are 3 common techniques that effectively meet these goals. The inferior pedicle technique is currently the most widely used approach in reduction mammoplasty. This technique can be used on virtually any size and shape of the breast, with a high degree of patient and surgeon satisfaction. The nipple-areola complex can be transposed over a considerable distance without losing the nipple-areola sensation or the ability to lactate. The technique is also helpful for the correction of breast asymmetries and ptosis.[7]

A variety of superior pedicle techniques have been described. One specific variant is vertical mammoplasty, eliminating the need for a horizontal inframammary scar. This is based on the principles of wide skin undermining to promote skin retraction, overcorrection of the lift to produce better long-term results, and liposuction to facilitate breast shaping and tissue removal. The vertical mammoplasty technique is best suited for small to moderate reductions. Not requiring the inframammary incision benefits patients with a propensity toward hypertrophic scarring or those significantly concerned about the scars. The main disadvantage of this technique is that the final results are not obtained immediately, and the patient has to deal with the deformed, wrinkled breasts for the first few postoperative months; this is important to understand before surgery.

Amputation with free nipple-areola graft is a rapid and effective reduction mammoplasty technique when patient safety or nipple-areola viability is of concern. This method is chosen when transposition on a pedicle would be too long to be safe. Another indication is massive reductions where large volumes of glandular tissue are resected, allowing no option for a vascular pedicle. Other indications include a high degree of anesthetic risk or previous breast surgery with potentially compromised pedicle vascularity. Major disadvantages are the loss of nipple-areola sensation, inability to breastfeed, and hypopigmentation of the nipple-areola complex. Hypopigmentation occurs because a portion of the graft is lost with subsequent secondary healing.[8]

For secondary breast reduction after a free pedicle flap, liposuction is suitable for minor reductions (less than 200 g) and can even enhance breast contouring. Waiting several months before undergoing secondary reduction to allow for vascularization and reduction in edema following the flap reconstruction is essential. In patients with ptosis or who require a larger reduction (greater than 200 g), a vertical wedge resection is performed with liposuction, in addition to the possibility of a horizontal wedge resection. During a wedge resection, the pedicle is of utmost importance; thus, fat does not get removed from the medial aspect of the breast.[5]

No matter which technique is selected, during the consultation, the patient and surgeon thoroughly discuss the risks and benefits of the procedure, the patient's wishes, and limitations based on her morphologic characteristics. Accurate preoperative marking is important. However, the final breast shape and symmetry are achieved intraoperatively. After the initial tissue resection, the breasts are inspected in the upright position, and adjustments are made with "tailor-tacking" sutures or staples. The proper determination of the new nipple-areola complex location is essential. Nipple-areola complex malposition is challenging to correct secondarily. Preserve nipple-areola viability by developing a well-perfused pedicle or dermal graft bed. Avoid the tendency to undermine the pedicle. If the pedicle nipple-areola complex viability is questionable at the end of treatment, it should be converted to a free graft.

The patient can be admitted to the hospital overnight if the pain is severe and can not be managed. No laboratory studies are required after surgery. Dressings can be removed on the first postoperative day and replaced with clean gauze or a surgical bra. A support bra should be worn day and night for 2 months after the procedure. If drains are used, the output is carefully recorded, and the drains are removed when the output is less than 30 mL in 24 hours. If no drains are present, the patient can shower on the first postoperative day. Otherwise, the patient may wait until they have been removed. Patients should avoid heavy lifting for at least 4 weeks following surgery. After 6 to 12 months, mammograms are obtained on all patients aged 40 or older as new baseline films documenting the radiographic changes of the breast following the operation.[1]

Complications

Complications are common after reduction mammoplasty, but most are minor and do not require additional surgeries. A body mass index over 30 and smoking are risk factors that increase the risk of complications. As the quantity of breast resection increases, so does the chance of complications. Minor complications in the early postoperative period include hematoma, seroma, cellulitis, wound infection, delayed wound healing, and minor wound dehiscence. Major complications that often require surgical intervention are major wound dehiscence, flap necrosis, and nipple-areolar necrosis. The most frequent complication is wound dehiscence, especially at the T-junction. The contributing factors that have been identified are smoking and steroid use. Once all wounds are well healed, cosmetic complications are asymmetry, lack of proper shape, dog ears, under resection, over resection, and unsightly scars. Complications of oncoplastic reduction are similar to reduction mammoplasty, but with the added complication of potentially requiring a reexcision of margins or even a completion mastectomy.[3][6][9]

Clinical Significance

Breast reduction holds significant clinical value by addressing macromastia's physical and psychological burdens. Patients frequently experience chronic back, neck, and shoulder pain, skin irritation, postural issues, and psychosocial distress that diminishes quality of life. Clinically, reduction mammoplasty has been shown to improve physical function, alleviate pain, reduce skin complications, and enhance body image and mental health. Once it is determined that a patient is a suitable candidate, the surgical technique selected must minimize the risks of serious complications such as wound dehiscence, flap necrosis, overelevation, or ischemic loss of the nipple. The chosen approach should also meet reconstructive goals by achieving weight reduction, creating aesthetically pleasing breasts with minimal scarring, and reducing the need for future revision surgery.

In oncologic cases, oncoplastic breast reduction is especially valuable, as it allows for wider tissue excision than standard lumpectomy, enabling the removal of larger tumors while preserving breast shape and symmetry.[7][10][11] This approach achieves broader surgical margins, reducing the likelihood of reexcision and recurrence. Whether performed for functional relief or cancer treatment, breast reduction significantly enhances patient-centered outcomes, surgical precision, and long-term satisfaction.

Enhancing Healthcare Team Outcomes

Optimal care in breast reduction surgery requires a multidisciplinary, patient-centered approach that integrates the skills and collaboration of various clinicians, including physicians, advanced practitioners, nurses, pharmacists, and allied health professionals. Surgeons must demonstrate technical expertise, sound clinical judgment, and the ability to communicate procedural expectations, risks, and recovery protocols. Advanced clinicians and nurses are critical in preoperative education, perioperative monitoring, and postoperative care coordination, ensuring early recognition and management of complications such as infection, hematoma, or wound dehiscence. Pharmacists contribute by optimizing pain control and antibiotic regimens, ensuring safe prescribing, minimizing drug interactions, and counseling patients on appropriate medication use, including considerations for venous thromboembolism prophylaxis.

Interprofessional communication enhances surgical outcomes and patient safety by fostering shared decision-making and seamless care transitions. Strategies such as structured handoffs, interdisciplinary rounds, and standardized protocols support consistency and reduce variability in care. By engaging the entire care team in collaborative planning and follow-up, clinicians can better address psychosocial factors, align goals with patient expectations, and ensure continuity of care across settings. This coordinated effort improves clinical outcomes, reduces complications, strengthens team performance, and reinforces a culture of safety and mutual respect.