7.1.1 Definition of Macromastia

The definition of macromastia is not always clear, and therefore, the preoperative management of patients with breast hypertrophy is a complex topic. However, there are a few minimum criteria that must be met in order to classify a patient as having symptomatic macromastia. History and physical examination are an essential part of the preoperative evaluation, and certain topics, as described in the following sections, must be addressed to support the diagnosis adequately. It has been argued that symptomatic macromastia is better defined by a complex combination of physical and emotional complaints than simply by breast volume and the amount of tissue to be removed. ⁸

7.2.1 Presenting Symptoms

If it is established that the motivation for surgery is therapeutic rather than cosmetic, most insurance companies require patients to obtain preauthorization for surgical procedures. It is essential that the physician be aware of the required information and documentation at the preoperative appointment, since preauthorization is based heavily on subjective information and symptom duration that may not surface unless the appropriate questions are asked (Box 7.1 , Box 7.2). ⁶

A subjective history of neck pain, shoulder pain, lower back pain, and mastodynia is the most common combination of presenting symptoms of patients with macromastia. ⁵ These symptoms must be causing significant pain for greater than 1 year in order for the condition to be acknowledged by insurers. ^{3 ,​ 9 ,​ 10} Typically, the natural history involves the onset of pain during late adolescence with slow progression of symptoms as the breasts fully develop over time. Breast hypertrophy may eventually cause a change in posture resulting in progressive kyphosis, which could possibly be a subconscious attempt to hide the macromastia or the inevitable result of excess weight on the anterior chest wall. ^{7 ,​ 11} When present, kyphosis should be documented through plain film X-rays of the cervical and thoracic spine, and any patients with chronic back pain should be evaluated by a qualified spine surgeon to rule out neurologic pathology. ¹¹

Patients may attempt to offset the added weight of their breast hypertrophy with use of wide-strap support bras or even multiple sports bras; however, this often fails to improve the pain and may actually cause new-onset shoulder pain and shoulder grooving due to the pressure of the bra straps. The use of multiple support or compression garments naturally leads to the onset of intertrigo. Baby powder or antiperspirant may improve the symptoms temporarily; however, chronic skin irritation will ultimately occur and lead to superficial bacterial or fungal infections and tissue maceration with skin breakdown. ^{9 ,​ 10} Additionally, the long-term result of macromastia is ultimately breast ptosis. The weight of the excess breast volume will pull the tissues caudally, necessitating the use of constant support bras, which further exacerbates the issue of intertrigo, as just mentioned.

Other serious complaints often associated with macromastia include respiratory difficulty, which can lead to inability to exercise and, ultimately, decreased functional capacity. ³ In extreme cases, this debilitation can prevent patients from performing physically demanding jobs and cause lifelong disability. ³ Less common presenting complaints include neurologic symptoms such as ulnar paresthesias and chronic occipital headaches. ⁴ Since patients may not be aware of the association between breast hypertrophy and these complaints, they may not mention them unless specifically asked by the physician.

It is generally recommended that conservative treatments be attempted prior to proceeding with reduction surgery. Insurance companies may ask for documentation showing that the patient has failed conservative measures for at least 3 months prior to seeking approval for a therapeutic reduction mammaplasty. ^{9 ,​ 10} Nonsurgical treatment options include trials of nonsteroidal anti-inflammatory medications, dermatologic intervention for skin concerns, and use of specialized support bras. Even physical therapy and chiropractic manipulation are encouraged before surgical intervention is considered indicated. However, these nonoperative interventions have been shown to be only rarely successful in improving symptoms in the long term. ¹²

In addition to the physical manifestations that can cause a patient to present for evaluation for possible reduction mammaplasty, the psychologic manifestations can also be profound. Specifically in younger patient populations, macromastia can lead to a decrease in self-confidence, particularly in social situations where sexual attention may occur and in athletic settings where the individual is required to wear activewear or swimwear. This is more than just a cosmetic concern; it has the potential to lead to an actual impediment to emotional development in adolescents. Despite this, some insurers will not cover breast reduction surgery in patients under the age of 18 years old. ^{4 ,​ 6} Elective breast surgery in this adolescent population is discussed in detail in Section 7.2.5.

It is important to note that with all of the presenting complaints outlined here, the severity of symptoms does not always correlate with degree of breast hypertrophy. ¹³ Thus, physicians should not discourage patients with relatively mild macromastia from proceeding with surgery if it has been determined that the patient’s complaints are truly due to her breast hypertrophy and not other somatic or psychological pathology.

7.2.2 Medical and Surgical History

Once the chief complaint has been thoroughly addressed, it is important to obtain a complete medical and surgical history, as this can identify early risk factors for surgical complications and initiate the process for surgical optimization. Medications must be reviewed, specifically identifying any current or prolonged history of steroid use, which can negatively impact wound healing; any anticoagulation medications, which can lead to increased risk of intraoperative and postoperative bleeding and hematoma formation; and the use of hormonal birth control or oral estrogens, which can dramatically increase the likelihood of postoperative deep venous thrombosis (DVT) or pulmonary embolus (PE). In cases where these medications are identified, surgeons must work with the primary care and specialty care physicians to determine whether it is safe to discontinue their use temporarily for surgery or whether the risk of doing so outweighs the benefits of this elective procedure.

Several other topics are important factors in the preoperative planning of any breast-related surgery. One is the patient’s individual weight history, including any major weight loss such as in the postbariatric setting, which can have profound impact on the reduction technique employed and the surgical outcome. Additionally, a history of prior soft tissue infections, especially methicillin-resistant Staphylococcus aureus (MRSA) infections, should be identified, as these can increase the risk of future infections, and any intraoperative antibiotic therapy may need to be adjusted accordingly. Finally, a personal or family history of keloids or unfavorable scars should be reviewed. Since reduction mammaplasty requires long incisions and, therefore, results in extensive scars, the risk of scar hypertrophy, hyperpigmentation, or keloid formation should be discussed in the preoperative setting.

7.2.3 Breast History

A detailed breast history is absolutely essential to providing appropriate patient care and preventing potentially unfavorable postoperative complications. Any current or past breast masses should be thoroughly investigated to ensure that malignancy is ruled out. Additionally, any previous breast biopsies, whether benign or malignant; any personal history of breast cancer, with or without surgical treatment; and any family history of breast cancer need to be outlined. The date of the patient’s last mammogram should also be noted, along with the results and any secondary testing performed. In patients who are identified preoperatively as being high-risk for future breast malignancy, it is prudent to discuss with the patient the surgical plan if an occult malignancy is encountered intraoperatively.

Outside of breast cancer, A few other aspects of breast history should be discussed because they can have an impact on surgical planning. Any previous breast surgery, such as a prior augmentation, reduction, or mastopexy, needs to be identified. Additionally, any future plans for pregnancy should be explored, as this can dramatically change the breast volume and degree of ptosis. As such, some physicians recommend that elective breast surgery be deferred until no further childbearing is planned. Deferring surgery also alleviates concerns regarding the ability to breastfeed postoperatively, which is discussed in more detail in Section 7.5.1, Possible Complications.

7.2.4 Comorbidities

After thoroughly evaluating the physical and emotional symptoms and establishing an accurate diagnosis of symptomatic macromastia, the discussion should turn to the topic of comorbidities. Since the only true method for correcting the symptoms associated with breast hypertrophy and ptosis is surgery, which is discussed in detail in Chapter 8, Mastopexy Techniques—Basic Principles, identifying comorbid conditions that could threaten the success of a surgical intervention is essential.

7.2.5 Age

Although most patients who present for evaluation of symptomatic macromastia are 30–40 years of age, there is a small proportion of patients who present well before or after this age seeking surgical intervention for their breast hypertrophy or ptosis. ³ Additional time should be spent in the preoperative setting when considering treatment of macromastia in such younger or older patients, as special consideration needs to be given to ensure proper management.

7.2.6 Postradiation

Evaluating the postradiation patient for elective breast surgery can be a daunting task, since there is a reported complication rate of between 50 and 60% in this population. ^{25 ,​ 26} It has been shown that the amount of radiation is directly proportional to risk for surgical complications such as delayed wound healing, nipple necrosis, and prolonged erythema. ²⁷ Therefore, if surgery is attempted, it is important for the surgeon to be cautious intraoperatively; design flaps with shorter, wider pedicles; and avoid excessive undermining of flaps to give the tissue the best chance for survival. Additionally, the choice of pedicle may need to be based on the previous lumpectomy location, with the understanding that past surgery may have disrupted the normal blood flow, and therefore the lumpectomy site should, if possible, not be included in the pedicle. ²⁷ In the event that a wound complication is encountered in the postoperative setting, physicians may consider ordering hyperbaric oxygen therapy, which has been shown to improve delayed wound healing in the irradiated patient. ²⁸ Overall, as long as patients are educated on the risks of surgery on irradiated tissue, they should not be discouraged from undergoing reduction mammaplasty for symmetry or other cosmetic concerns.

Alternatively, as a way of avoiding additional surgery on irradiated tissue, some patients with a known existing breast malignancy who are undergoing lumpectomy may be offered the option of a simultaneous oncoplastic reduction at the time of mass resection. ²⁹ Not only does this reduce the total number of operations, but it allows the reduction to be performed before any radiation treatment is begun, dramatically reducing the rate of wound healing complications. ³⁰

7.2.7 Psychosocial Factors

Approximately 30% of patients who seek breast reduction surgery have a history of a psychiatric disorder that required some form of treatment. ³¹ Although most disorders are mild forms of anxiety or depression, identifying patients with a psychiatric history is important because patients with depression generally have unrealistic expectations and perceive their surgical outcomes as worse compared to the general population. ⁵ Even when patients do not have a diagnosed condition, those with poor coping mechanisms or poor support systems may not be good candidates for elective surgery. In these cases, surgery may not resolve their emotional distress, and an individual’s dissatisfaction about her breasts may just shift to another part of her body after surgery. ³²

When assessing patients at their initial preoperative appointment, physicians should consider a complex psychiatric history or a history of multiple cosmetic procedures as indicators of a more complex emotional or psychological situation. However, in select cases, studies have shown that reduction mammaplasty may be considered as a possible way to significantly improve depression, anxiety, and low self-esteem in patients whose large breasts are the true source of their emotional distress. ^{31 ,​ 32} In these patients, positive emotional results have shown to last for up to 5 years after surgery. ⁵

7.2.8 Physical Examination

It is important to have a complete understanding of the patient’s preoperative breast aesthetics in order to plan for possible surgical intervention. Elements of the breast that should be examined include the preoperative breast size, the areolar diameter, the NAC position, and degree of nipple ptosis. Breast and nipple ptosis can be assessed by analyzing the NAC in relation to the inframammary fold (IMF). This technique was discussed in an early paper by Regnault in which breast ptosis was grouped into three broad categories. ³³ He describes first-degree, or minor, ptosis as when “the nipple lies at the level of the submammary fold, above the lower contour of the gland and skin brassiere.” Second-degree, or moderate, ptosis occurs when “the nipple lies below the level of the fold but remains above the lower contour of the breast and skin brassiere.” Finally, third-degree, or major, ptosis is found when “the nipple lies below the fold level and at the lower contour of the breast and skin brassiere” (Fig. 7‑1). ^{33 ,​ 34} Additionally, the physician should mention any preexisting asymmetry, for example, differences in shape, volume, or anatomy such as a constricted pole. Assessment of the breast skin should also be completed as part of the physical exam. The skin quality, the amount of skin excess, and the presence of scars that would interfere with pedicle design should all be noted. This is of particular importance for postbariatric patients, who typically have excessive skin laxity and deflated tissue (see Chapter 10). Additionally, the physician must palpate the entirety of the breast for any masses. ¹⁴ Finally, photographs of the patient in the anteroposterior (AP), oblique, and lateral views should be obtained. These images can then be used for the patient’s medical record, for preoperative planning, and for any required insurance documentation.

Some physicians advocate for recording specific breast surface measurements at the time of the preoperative appointment. Standard measurements that are often recorded include the sternal notch–to-nipple distance, the IMF-to-nipple distance, intermammary distance, and chest circumference. Additional measurements that have been proposed include orthogonal surface breast measurement (Fig. 7‑2). The horizontal breast distance is measured from the lateralmost aspect of the breast mound on the chest wall, over the nipple, to the medialmost aspect of the breast mound on the sternum. The vertical breast distance is recorded by measuring from the most cephalad point of the palpable breast tissue, over the nipple, to the IMF (Fig. 7‑3). ³⁵ These measurements can be recorded not just for determination of the preoperative breast size and ptosis, but also to predict reduction mammaplasty resection weights, as discussed in Section 7.4, Preoperative Planning: Resection Weight and Size Goals. ³⁵