Indications for breast reduction, regardless of the technique is used, include (a) self-identification of problems, (b) referral from another health care provider, and (c) issues of symmetry related to a lumpectomy or mastectomy for contralateral breast cancer.

Because of the wide dissemination of knowledge facilitated by the proliferation of health-related websites, prospective patients are often able to self-diagnose the cause of the stereotypical symptom cluster of macromastia. By surfing plastic surgeons’ websites, a woman seeking breast reduction will often have gained a reasonable fund of knowledge regarding the benefits that breast reduction may offer. She is likely to become well educated about the range of techniques being offered, the likely functional and cosmetic outcomes, and the expected aesthetic shape. It is, of course, the in-person surgical consultation with an appropriately trained and credentialed plastic surgeon that can help to confirm the diagnosis, clarify the patient’s do-it-yourself understanding, and correct any misinformation that the woman may have received. Some women are free of physical symptoms and seek breast reduction solely for aesthetic purposes, yet all women want an aesthetically proportioned breast shape delivered along with volumetric reduction.

Other women are referred for a plastic surgery consultation from their primary care physician, gynecologist, chiropractor, or spine specialist for conditions such as symptoms of back pain, neck pain, shoulder grooves, breast pain, intertrigo in the inframammary folds (IMFs), inability to exercise or participate in sports, or inability to fit into clothes. Most have failed some attempt at conservative management, such as physical therapy, exercise, weight loss, massage, or nonsteroidal anti-inflammatory drugs (NSAIDs). Attempts at weight loss are a “catch-22”: Inability to exercise because of neck, back, and shoulder pain impedes their ability to lose weight, and thus the macromastia persists. Since the underlying problem of large, pendulous breasts remains uncorrected, it does seem illogical that conservative measures would suffice: Such women would have to undergo lifelong physical therapy or lifelong NSAIDs and be at risk for their adverse renal and gastric effects (1,2).

Given the high incidence of breast cancer in North American women, many patients undergo a lumpectomy followed by radiation therapy. This leads to fibrosis, breast volume loss, and contraction of the breast. Alternatively, if a woman has had a unilateral mastectomy followed by reconstruction (autologous or prosthetic based) that tends to have less ptosis and is smaller because of limitations in donor-site availability, the normal, unoperated breast will continue to age and have more ptosis and be larger. Hence, women may seek a unilateral breast reduction to match a side that has been treated for cancer.

A detailed history is obtained to ensure that the patient is suitable for surgery from medico-surgico-psychosocial perspective. A notable family history of breast cancer should be worked up for genetic susceptibility (BRCA testing). This may precipitate bilateral mastectomy and immediate reconstruction instead of bilateral breast reduction. Mammograms are obtained as necessary to bring them up to date with current guidelines for baseline mammography and screening for breast cancer. American Cancer Society guidelines recommend a baseline mammogram at age 40 years and annually thereafter for women of average risk. Any detected anomalies should be referred to a breast oncologic surgeon to ascertain need for biopsy, imaging, or deferring of surgery to observe any suspicious radiographic abnormalities over time.

During the consultation process, measurements are undertaken for both the medical record and for third-party payer coverage criteria documentation. Typically, height, weight, sternal notch-to-nipple distance, and nipple-to-IMF distance are recorded bilaterally, and discrepancies in IMF and nipple-areolar complex (NAC) positions are pointed out to the patient. The degree of ptosis (none, mild, moderate, or severe) is assessed. During the focused breast exam, the breasts are screened for masses or nodules, axillary lymphadenopathy is checked, and the skin is examined for ulcerations, erosions, or postinflammatory hyperpigmentation. Nipple discharge is ruled out, and NAC size is noted (small, average, or dilated). Standard-view photography of the patient is done.

Lalonde breast sizers or a water displacement technique can be used to estimate the volume in each breast (3). With newer digital imaging technologies, it may be possible to estimate the volume from stereophotography.

Current bra size is elicited, and the desired cup size is discussed with the patient. Patients do not always understand the bra sizing system, and some request going from a 38DD to a 32B, for instance. The band size usually will not change (unless axillary liposuction is also done) since this reflects the underbust chest circumference. Ranges for volume resection that correlate with each one-cup-size reduction are from 200 to 350 cc, with little consensus. Some heavy-set women request a small breast cup size and should be counseled about choosing a cup size that is proportional to their overall body habitus. Lastly, cup size serves as a lay parlance discussion tool only. Cup sizes vary significantly by bra manufacturer, and these are not medical measurements. They serve as general guideposts to facilitate dialogue about a woman’s desired target size.

The volume to be resected in each side, which may be different based on preexisting asymmetries, is estimated. Broad generalizations suggest that approximately 200 to 350 g is required for each one-cup-size change, and that each 1 cm of
asymmetry in NAC position between the breasts accounts for 100 g of breast volume asymmetry. Most insurance companies establish volume requirements of breast tissue to be resected to reimburse for the procedure. While there are many variations, some third-party payers require 500 g of resection at least. Other companies use a nomogram based on height and weight to determine how much breast tissue needs to be removed to be eligible for reimbursement.

Preauthorization from insurance companies is sought with a copy of the consultation and the foregoing measurements, photographs of the torso in frontal and lateral views, and International Statistical Classification of Diseases and Related Health Problems-9 (ICD-9) and Current Procedural Terminology (CPT) codes. The ICD-9 codes frequently used in conjunction with breast reduction symptomatology are 611.1 (breast hypertrophy), 611.71 (breast pain), 692.9 (intertrigo), 724.8 (symptoms referable to back), 724.1 (back pain), 723.1 (neck pain), 723.9 (shoulder pain), 738.3 (shoulder grooves), and 709.0 (dyschromia). The CPT code is 19318-50. (Breast reduction preformed unilaterally to correct asymmetry with a reconstructed postmastectomy breast is covered by insurance without regard to size and volume criteria, as mandated by the Women’s Health and Cancer Rights Act of 1998.)

When coverage for breast reduction is denied, an appeal letter may be considered, reminding the payer that recent scientific literature and evidence-based studies published in peer-reviewed journals strongly support the position that women undergoing reduction mammaplasty for symptomatic breast hypertrophy experience significant improvement in their preoperative signs and symptoms. Managed care organizations rate outcome or cost-effectiveness analyses as the most important factor in determining reduction mammaplasty coverage policies (4).

The plastic surgeon’s office can often facilitate the appeal process, but the ultimate responsibility rests with the patient. The objective, ethical, and honest account of the patient’s health care problem is captured in the office consultation note prepared by the physician, and a copy may be provided directly to the patient, supplemented with photographs. The patient may be encouraged to contact her payer or employer directly about her dissatisfaction. Some women will pay for services out of pocket in the face of denial and/or use their flexible health savings accounts to fund the surgery.

After a thorough medical history and physical exam, the patient is screened for outpatient surgery. Smoking or second-hand smoke exposure must be stopped for 6 to 8 weeks prior to surgery. Nicotine exposure via gum or patch is also eliminated. A newer, non–nicotine-containing medication, varenicline, may be initiated. Patients should additionally remain free of tobacco smoke and nicotine for the postoperative healing period of at least 6 weeks. Weight loss, if indicated, is desirable to get closer to ideal body weight, but this is frequently unrealistic, as discussed earlier.

Preoperative testing is directed by medical history, physical findings, and age per anesthesia criteria. Young, healthy women may not need any testing except for a history and physical examination. Those with medical illnesses may need a complete blood count, electrolytes, liver function tests, pulmonary function tests, chest x-ray, and/or electrocardiogram. Those with a significant cardiopulmonary history should be cleared by their internist or cardiologist.

The patient is instructed to stop medications that predispose to a bleeding diathesis, such as NSAIDs, aspirin, salicylic acids, and over-the-counter medications that may contain these ingredients. Herbal medications and vitamin supplements, especially in large doses, are also eliminated. In particular, vitamin E, gingko biloba, St. John’s wort, and garlic are to be discontinued.

Estrogenic medications such as oral contraceptive pills (OCPs) and postmenopausal hormone replacement therapy should be discontinued to lower the risk of deep vein thromboses (DVTs) and venous thromboembolism (VTE) associated with surgery. Patients on OCPs should practice an alternate form of contraception in the preoperative and postoperative interval because OCPs (even when not discontinued) may have decreased effectiveness due to metabolism of other medications during the episode of surgical care.

During the consultation, the patient and her significant others are educated regarding the risks and benefits of breast reduction surgery, as well as the alternative techniques available such as (a) no surgery and attempt at weight loss, (b) breast liposuction, (c) periareolar incision, (d) a vertical pattern or short-scar procedure, (e) a transverse scar (Passot) procedure, or (f) Wise-pattern breast reduction.

Having no surgery and seeking reduction in breast size through exercise and weight loss is also a possibility, especially if the patient can achieve a weight loss to get to a normal body mass index (BMI). She may then be reevaluated at some future date to see whether she still needs a breast reduction or only a mastopexy. Breast liposuction may be successful in decreasing one or two cup sizes for some women with moderate hypertrophy without mild to moderate ptosis and should be considered. Liposuction does not address NAC ptosis and may worsen it. Periareolar techniques may have a role in mild hypertrophy but remain technically challenging and unpredictable. Vertical or short-scar reduction has the advantage of eliminating the transverse IMF scar; however, this has a 15% to 20% revision rate with possible future or intraoperative conversion to a Wise pattern or J or L scar. These breast reductions do not achieve their optimal shape right away and do so over time. This is less likely to have bottoming out or parenchymal maldistribution (pseudoptosis). The transverse scar technique is typically used with a superomedial or superior pedicle and/or with free nipple graft. However, the inferior pedicle reduction technique can be used with the transverse scar.

The Wise skin pattern is most commonly associated with the inferior pedicle breast reduction technique. This incision pattern can be used, however, with superior or superomedial pedicle techniques, as well as with free nipple grafts. Nevertheless, the Wise or inverted-T scar technique is most commonly associated with the inferior pedicle technique. The inferior pedicle breast reduction in combination with the anchor T incision remains the most popular method of breast reduction and is the most predictable (5). Approximately 75% of plastic surgeons in the United States use this technique, and approximately 50% of surgeons use this technique exclusively. It is the most versatile and has a straightforward learning curve. It bears emphasizing that pedicle and skin pattern can be chosen independently of each other in most, but not all, scenarios.

The written informed consent is a supplement to the patient education process that occurs during the consultation. It should cover the risks including, but not limited to, infection, bleeding, hematoma, seroma, wound dehiscence, delayed healing, poor healing, and swelling. The patient is told about the potential for scarring, such as keloids, hypertrophic scar, hypopigmentation or hyperpigmentation, and dark or pink, itchy, or tender scars, which may be visible outside or through garments. Adverse sequelae include asymmetry, numbness, stiffness, pain, chronic pain, or anxiety and/or depression related to changes in body image. The patient is informed of the chance for further unplanned surgery with its additional risks, financial responsibilities, and time required for surgery and recuperation. Potential hospitalization may not be covered by insurance, since most reduction mammaplasties are done as outpatient cases at ambulatory surgery centers.

Urine pregnancy tests are recommended. If the woman is pregnant, she could be exposed to medications and anesthetics that cause birth defects or miscarriages.

There is the potential, but fortunately extremely rarely, for blood transfusion with major surgery and the accompanying risks including bacterial and viral infection (e.g., HIV, hepatitis) and transfusion reaction. There may be partial or total flap and tissue loss, fat necrosis, and loss of skin or of the NAC. Incomplete relief or no relief of the symptoms (e.g., back pain, neck pain) may occur, or the patient may be dissatisfied with the results of the surgery. No guarantee can be made of fitting into a particular clothes size or bra cup size or to match a digital simulation. Any surgery of the breasts leads to scars, both internal and external, and hence may hinder cancer surveillance and detection efforts. Magnetic resonance imaging may be required instead of mammograms for follow-up of calcifications from surgery.

Those patients who travel a great distance to a particularly well regarded surgeon may incur higher risks associated with traveling soon after surgery (e.g., flying, driving) such as DVTs or pulmonary embolisms from immobility in a confined car or airplane.

Comorbidities must be addressed in the informed-consent process as well. For instance, obesity and diabetes (controlled or uncontrolled) may contribute to poor healing and raise the rates of infection. After discussing best-case, worst-case, and average outcomes and scenarios and looking at representative photographs/diagrams, the patient and her family should feel comfortable that they grasp the likely benefits and potential for untoward events. They must understand the diagnosis, medical necessity versus elective nature of the surgery, goals of the procedure, pain management, expected time course of recovery and management of complications should they arise, and warning signs and symptoms of complications. Patients are provided sufficient time to consider the procedure in depth and should demonstrate their comprehension by being able to relate the information back to the surgeon and voice their understanding of the procedure in plain, lay language.

One contraindication is recent postpartum state in which breast size is still changing and has not reached an equilibrium plateau from involution. Active lactation is similarly a contraindication to breast reduction.

Age must be considered as well. With earlier and earlier age of thelarche and menarche in Western women, teen-aged girls are encountered with greater frequency with symptoms of macromastia, some of which is related to higher obesity rates in teens. The decision must be tailored to the physical findings, expected future growth, maturity level, and willingness to accept the potential for a repeat reduction mammaplasty in the future. There are no absolute age-related criteria, and the decision to operate is multifactorial.

Prior irradiation for breast conservation therapy (BCT) after lumpectomy is not a contraindication but should be given due consideration, as it may precipitate the need to alter the surgical plans. If an inferocentral lumpectomy has been performed, then the vascularity for an inferior pedicle reduction may not exist, and the plan should be changed in favor of an alternate pedicle. Radiation, independent of the lumpectomy site, will lead to slight modification of the surgical plans. For instance, the skin brassiere is not undermined widely, and, in general, more conservative markings are used.