Originally, a breast reduction was considered a functional procedure, meant to reduce breast mass and elevate the nipple position. These goals were achieved by the 1920s [8–10]. Today, expectations are higher and include aesthetic considerations [11]. Patients having breast reduction are concerned about their symptoms, but the majority quite understandably wish to improve their breast appearance as well [11]. Numerous studies document the physical benefits of a breast reduction [11]. Fewer publications evaluate the patient’s perception of the aesthetic result [11]. Patients consistently prefer the aesthetic result and scars of the vertical technique [12–15]. Surgeons [16–18] are aware of the flattening, boxiness, and bottoming-out that can be apparent after breast reduction. These observations have been confirmed with measurements [2, 19].

The surgical approach for a breast reduction plus implants is the same as for an augmentation mastopexy. The procedures are arbitrarily differentiated only by the weight of breast tissue removed. A vertical mammaplasty is performed using a medially based pedicle [16] and intraoperative nipple siting [1–3]. A mosque-dome or keyhole preoperative pattern is not used. Breast implants are inserted subpectorally, although some surgeons may prefer a prepectoral plane. A vertical resection is performed (Fig. 8.3). The nipple/areola site is determined after creation of the new breast mound. An inverted-T modification is used in patients in whom the vertical scar extends below the level of the new inframammary fold (Fig. 8.3).

Surgery is performed on outpatients in a state-licensed ambulatory surgery center using total “SAFE” (spontaneous breathing, avoid gas, face up, extremities mobile) intravenous anesthesia [20]. No muscle relaxation is used so as to preserve the calf muscle pump [21]. Patients are also monitored for venous thromboembolism using ultrasound surveillance as part of a clinical trial in progress [22]. The mean operating time for a vertical breast reduction is 2 h [6]. Simultaneous implant insertion adds only 18 min of operating time , on average [6]. The same synergistic advantages for augmentation mastopexy (compared with either operation performed individually) are available for this combination [1]. Videos demonstrating this combined procedure are available at the Plastic and Reconstructive Surgery Global Open website: http://​journals.​lww.​com/​prsgo/​Pages/​videogallery.​aspx?​videoId=​23&​autoPlay=​true. The videos include preoperative marking, details of the surgery and anesthesia, and follow-up 24 h after surgery.

Breast area, measured on lateral photographs (a surrogate for volume), decreases despite the use of implants [6]. Not surprisingly, the upper pole area is increased to a greater extent than in women who do not receive implants. A vertical breast reduction increases breast projection and upper pole projection even without implants. However, upper pole projection is increased approximately 2 cm when implants are used, compared with <1 cm for women who do not have implants [6].

A vertical reduction, with or without implants, reduces the lower pole area and elevates the lower pole level, reflecting the fact that the lower pole resection is the same regardless of whether implants are used [6]. The lower pole ratio is defined as the lower pole width divided by lower pole length (height) and is an indicator of the boxiness of the lower poles [23]. Values exceeding 2.0 start to appear boxy; values <2.0 appear conical. The overall mean lower pole ratio after a vertical breast reduction is 2.0 cm, with or without implants [6].