The boundaries of the breast are commonly considered to be the clavicle cranially, the inframammary fold caudally, the sternum medially, and the lateral/anterior aspect of the latissimus muscle laterally. The tail of Spence extends from the upper outer quadrant into the axilla (FIG 1).

The blood supply to the breast is from perforators from the internal mammary (thoracic) artery and vein, as well as the thoracoacromial and lateral thoracic vessels.

The breast is innervated by the 4th through 6th intercostal nerves.

In females, the areola is usually round and 38 to 40 mm.

Breast ptosis is most commonly graded on the Regnault scale (FIG 2). Grade 0 (no ptosis) indicates that the nipple sits cranially to the IMF. Grade 1 indicates that the nipple sits at the level of the IMF. Grade 2 indicates that the nipple sits caudal to the IMF but not at the caudal-most point of the breast. Grade 3 indicates that the nipple sits at the caudal-most point of the breast. Pseudoptosis is when the nipple sits at or above the IMF, but there is excessive breast tissue below the IMF (this has a characteristic “bottomed out” appearance).

Common, clinically relevant breast measurements include nipple-sternal notch and nipple-IMF distances.

Bra sizes are an imperfect way to gauge breast size (not in the least because most women do not wear the correct size bra). The convention is that the “number” in the breast size is the circumference of the chest wall (measured just caudal to the breast). The “cup” size is indicated by a letter, with each letter’s position in the alphabet indicating the increased number of inches that are measured when the circumference around the breasts is measured (eg, “32B” means that the chest wall circumference is 32 in., and the circumference around the breasts is 34 in.).

Breast hypertrophy is a congenital disorder that frequently is exacerbated by weight gain. Especially in young patients, it can be due to increased end-organ responsiveness to estrogen.

In addition to being socially debilitating in young patients, breast hypertrophy can progress to physical ailments, including “notching” of the shoulders due to the bra straps, neck and upper back pain, and intertriginous infections.

Detailed patient and family history of breast disease is crucial (including benign tumors, malignancy, screening, etc.), and information regarding any prior radiation treatment and the operative reports from any prior breast procedures (most notably partial mastectomy/“lumpectomy” or prior breast reduction) should be obtained.

Factors relevant to lifetime estrogen exposure, such as age at menarche, menopause (if applicable), number of pregnancies, and use of birth control medications, are also important.

Breast-feeding history (including plans for future childrearing) is mandatory.

Nicotine use should be carefully investigated; most surgeons will not perform this elective procedure on anyone who has smoked in the past 2 to 4 weeks.

Personal importance of erogenous breast sensitivity should be discussed, as decreased or complete absence of nipple sensation is a possible consequence.

Symptoms related to breast hypertrophy (should notching, back pain, intertriginous infections, and difficulties with personal hygiene) should be noted.

Physical exam should note any asymmetry between breasts, complete bimanual examination for masses in both breasts and bilateral axillae, and appropriate breast measurements (nipple-sternal notch, nipple-IMF).

In patients who are of an age when standard, surveillance breast imaging is recommended (40-50 years, depending on the recommending agency), and mammography should always be performed prior to any breast reduction procedure. Many surgeons will obtain surveillance imaging prior to reduction regardless of age, though this practice is not formally endorsed.

Weight loss may lead to a small incremental improvement in symptoms but rarely is significant enough to sufficiently alleviate symptoms.

Liposuction is a reasonable approach in a very small subset of patients (namely those with excessive breast volume without ptosis).