Breast Reduction



Breast Reduction


Dennis C. Hammond M.D.

Michael Loffredo M.D.



Grand Rapids, Mich.

From Partners in Plastic Surgery.

Received for publication December 14, 2010; accepted June 29, 2011.

Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31824a2efc





Preoperative Assessment



Physical Examination

The patient is best examined in the standing position, with the arms comfortably at the sides. Any asymmetries in the size of the breasts, the position of the nipple-areola complex, and the level of the inframammary fold are noted. Measurements from the mid clavicle or the sternal notch down to the nipple are obtained, and the distance from the inframammary fold up to the nipple is noted. The latter measurement is important, as it serves as an indicator of the length of the pedicle when an inferior pedicle technique is used. The breast is palpated to assess for any potential masses, and the density of the parenchyma is noted. This is a useful observation to make, as dense fibrous breasts that are often seen in younger women are difficult to dissect, and the tissue remaining after resection often does not mold together as smoothly as a breast with a greater fat content. Finally, an assessment is made as to the estimated amount of breast tissue that will be removed from each side. Accuracy in this determination is helpful in streamlining the insurance preauthorization status. It is also a skill that improves with experience.


Photographic Documentation

Photographic documentation of the patient’s preoperative appearance is a vital part of the preoperative consultation. It is an important part of the patient’s record that can provide perspective if any complications or aesthetic concerns arise postoperatively. Three views of the breast documenting the appearance of the breast from the front and from each side adequately serve to record the patient’s preoperative condition. Supplemental views, including a three-quarters view, a hands-over-head view, and a photograph with the hands lifting the breast to allow the level of the inframammary fold to be seen, can be included for further documentation as needed. Framing the patient from the neck down to just below the level of the breasts with the width extending from just outside each arm will allow the shape, size, and position of the breast to be visualized and yet allow perspective with regard to the rest of the torso to be seen. As with all breast surgery, at no time is it necessary or desirable to include the patient’s face in the photograph.


Insurance Issues

Although breast reduction can occasionally be performed as a self-pay procedure, in the vast majority of instances, some type of insurance is used to pay for or help defray the costs associated with breast reduction. As such, many insurance plans have developed a preauthorization process designed to assess the severity of the patient’s condition and determine whether or not breast reduction would then be indicated. A common thread that applies to many insurance plans relates to documentation of the functional symptoms noted previously. Also, many plans will require what are called “conservative” measures to alleviate the patient’s symptoms, including participation in physical therapy or chiropractic therapy, and a trial of specially fitted support garments. Medical relief
of symptoms with a trial of oral analgesics and/or antiinflammatory drugs is also commonly required. Once these preliminary administrative details have been documented, an estimate as to the weight of tissue to be removed is made based on the surgeon’s previous experience. Typically at this point, a chart is then consulted that references the height and weight of the patient, and either the body surface area or the body mass index is calculated. By adding in the patient’s measurements, a minimum amount of tissue that must be removed to qualify for insurance coverage can then be determined. If the requirements for the symptom complex have been met along with the required (estimated) amount for removal, the procedure can be considered a covered benefit. Some plans offer automatic coverage at this point; others still require a formal letter of preauthorization. Regardless of the details, it is recommended in every circumstance to document the patient’s symptom complex thoroughly and make the best estimate for tissue removal that can be made. This information can prove very useful during the procedure to ensure not only adequate reduction of the breast but also enhanced symmetry in cases of marked breast volume asymmetry.


Operative Strategy

Any procedure designed to reduce the breast must include four cardinal elements. First, a pedicle must be incorporated into the design that preserves the vascularity and innervation to the nipple-areola complex. Second, and closely related to pedicle choice, selected quadrants of the breast must be removed to accomplish the desired volume reduction. This is commonly accomplished by removing tissue from around the perimeter of the pedicle. Third, the excessive skin envelope must be managed in such a way as to minimize scarring as much as possible and yet allow a proportional relationship to be created between the remaining skin and the reduced breast volume. Fourth, an overall aesthetic breast shape must be created either as a function of the overall operative strategy or secondary to defined maneuvers designed to create a specific contour. Any procedure designed to reduce the breast will include these four elements, and analyzing these various and sometimes diverse procedures in this fashion will facilitate a greater understanding of each.


Inverted-T Inferior Pedicle


Pedicle: inferior

Volume reduction: medial, superior, and lateral

Skin pattern: inverted T

Shape: passive

The inverted-T inferior pedicle has been the preferred method of breast reduction around the world over the past 40 years, and it has clearly stood the test of time.710 The blood supply is based on an inferior pedicle, with the redundant tissue being removed from around the upper hemisphere of the pedicle. The excess skin is removed from the lower pole of the breast, including a V-shaped central vertical segment. The resulting scar is that of an inverted T or anchor shape. This has been also commonly referred to as a Wise pattern. Shape is created passively simply as a result of the wrapping of the skin flaps around the inferior pedicle that then settles under the influence of gravity. (See Video, Supplemental Digital Content 1, which highlights the marks and technical features of a standard inferior pedicle inverted-T or Wise pattern breast reduction, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at links.lww.com.easyaccess1.lib.cuhk.edu.hk/PRS/A485.)

The main advantage of the inverted-T inferior pedicle technique is that it can be applied in any circumstance, from simple mastopexy to reduction for gigantomastia (Fig. 1). There is no defined upper limit related to volume for this technique. In extreme instances, the pedicle could be of such length that it outstrips the blood supply. In these circumstances, it is a simple matter to remove the nipple-areola complex, trim the pedicle back to a level of viability, and apply the nipple-areola complex as a skin graft. In contrast to this approach of using the nippleareola complex graft technique only when ischemia to the nipple-areola complex is identified intraoperatively,
some surgeons use this free nipple graft technique as a planned procedure for larger breast reductions deemed to be over a specific amount.1113 Commonly used guidelines for using the free nipple-areola complex graft technique include reductions of over 1500 g from each side.






Video 1. Supplemental Digital Content 1, which highlights the marks and technical features of a standard inferior pedicle inverted-T or Wise pattern breast reduction, is available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at links.lww.com.easyaccess1.lib.cuhk.edu.hk/PRS/A485.






Fig. 1. (Above, left) Preoperative appearance of a 36-year-old woman in preparation for breast reduction using an inverted-T inferior pedicle approach. (Above, right) Preoperative marks. (Below, left) Intraoperative appearance after removal of the excess breast tissue and placement of the inferior/central pedicle into position. (Below, right) Appearance 1 year after removal of 600 g of tissue from the right breast and 650 g of tissue from the left.

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