Continuing Education Activity
This activity reviews breast reduction surgery and the multiple step approach needed to achieve aesthetically pleasing outcomes. The patient must be familiar with all the potential options, along with the risks and benefits of each. This activity reviews anatomy, preoperative optimization, different pedicle techniques, possible complications and emphasizing the necessity to have a detailed and informed discuss with the patient.
- Identify the anatomy and indications for breast reduction surgery.
- Describe potential complications of breast reduction surgery.
- Describe different techniques of breast reduction surgery.
- Explain the importance of collaboration and communication amongst the interprofessional team to ensure appropriate selection of candidates and the best education of the patient regarding breast reduction surgery.
Breast reduction surgery, also known as reduction mammoplasty, is a procedure to reduce overall breast volume, maintain nipple-areola viability, and achieve a shape that is aesthetically pleasing. Before deciding if a patient is a candidate for this type of procedure, a detailed medical history, including the age of breast development, previous or anticipated pregnancies or breastfeeding, weight change, smoking history, and overall medical status should be obtained. The family history of breast cancer is important as well. Symptoms relating to breast weight such as neck, back, and shoulder pain are documented. Thorough preoperative assessment is essential, including physical examination of size, shape, elasticity, looseness, striae, rashes, bra strap grooving, any asymmetry, masses, and consistency. The position of the nipple-areola complex relative to the inframammary fold is assessed. Measurements are done from the sternal notch to the nipple and nipple to the inframammary fold to assess the degree of vertical correction. It is not uncommon for a patient with severe breast ptosis to present requesting reduction when they require a mastopexy or breast lift. Although reduction mammoplasty and mastopexy are fundamentally different, both operations require similar techniques.  
Anatomy and Physiology
The breast is a subcutaneous structure that originates at the fourth interspace. The breast is held in place by the skin-fascial attachments at the inframammary fold and over the sternum but is not attached to the pectoralis fasia. Skin adherence to the deep fascia at the inferior and medial borders make this area less mobile compared to the lateral and superior breast borders.
The most important aspect of breast reduction anatomy is an understanding of the blood supply and nerve supply to the nipple areolar complex. There are three main sources of blood supply to the breast, and sensory innervation is divided into sections of the breast and the nipple areolar complex.
The internal mammary artery supplies approximately 60% of the breast parenchyma, mainly the medial portion of the breast through medial perforators. The medial breast skin is supplied by the anterior cutaneous divisions of the second through seventh intercostal nerves. The lateral thoracic artery supplies an additional 30% of breast parenchyma, primarily the superior, outer, and lateral portions. The superior portion of the breast sensation is supplied by the supraclavicular nerves formed from the third and fourth branches of the cervical plexus. The anterior and lateral branches of the third, fourth, and fifth posterior intercostal arteries supply the remaining lower outer breast quadrant. Lastly, the nipple is supplied by the overlap between these vascular networks, while sensation is supplied by the lateral cutaneous branch of the fourth intercostal nerve. 
Women inquire about breast reduction for both physical and psychological reasons. The most common indication for breast reduction is relief of physical pain and discomfort associated with heavy, pendulous breasts. Patients will complain of chronic back and neck pain, headaches, shoulder pain, deep bra-strap grooves, and rashes beneath both breasts. The breast can become chronically painful as well. Upper extremity neuropathy and postural changes, along with intertrigo, maceration, irritation, rashes, and other dermatologic manifestations are common. Excessively large breasts can affect daily functioning. This can include difficulty with many forms of exercise and inability to find properly fitting clothes. The psychological impact of hypermastia is significant, and many patients are embarrassed and self-conscious about their size. Reduction mammaplasty can eliminate or decrease these problems in most instances. Breast reduction may also be indicated to correct asymmetry caused by unilateral hyperplasia or to achieve symmetry after unilateral breast reconstruction. 
The patient should meet the usual criteria for undergoing an elective surgical procedure. There is no specific age limit, provided the patient is in reasonable health. Medical conditions, such as diabetes and hypertension, should be controlled. Smokers should be encouraged to quit a couple of weeks before surgery and must be informed of the increased risks of flap necrosis, nipple areolar complex loss, and problems with wound healing. A mammogram should be obtained on those over 40 years of age or with a family history of breast cancer. Any suspicious findings should be addressed by a surgical oncologist before undertaking elective breast reduction. 
The specific reduction technique selected should depend on the patient's physical characteristics, attitude toward scars, along with the surgeon's judgment and experience. The superior pedicle, inferior pedicle, and partial breast amputation with free nipple-areola grafting are three common techniques that effectively meet these goals. The inferior pedicle technique is currently the most widely used approach in reduction mammaplasty. This technique can be used with virtually any size and shape of the breast with a high degree of patient and surgeon satisfaction. The nipple areola complex can be transposed over a considerable distance without loss of the nipple areola sensation or loss of ability to lactate. The technique is also helpful with correction of breast asymmetries and ptosis. 
A variety of superior pedicle techniques has been described. One specific variant is the vertical mammoplasty, which eliminates the need for a horizontal inframammary scar. This is based on the principles of wide skin undermining to promote skin retraction, overcorrection of the lift to produce better long-term results, and liposuction to facilitate breast shaping and tissue removal. This technique is best suited for small to moderate reductions. Not requiring the inframammary incision benefits the patients with a propensity toward hypertrophic scarring or those significantly concerned about the scars. The main disadvantage of this technique is that the final results are not obtained immediately and must deal with the deformed, wrinkled breasts for the first few postoperative months. This is important to understand before surgery.
Amputation with free nipple-areola graft is a rapid and effective reduction mammoplasty technique when patient safety or nipple-areola viability is of concern. This method is chosen when transposition on a pedicle would be too long to be safe. Another indication is in massive reductions where large volumes of glandular tissue are resected allowing no option for a vascular pedicle. Other indications include a high degree of anesthetic risk or previous breast surgery with potentially compromised pedicle vascularity. Major disadvantages are the loss of nipple-areola sensation, inability to breastfeed, and hypopigmentation of the nipple-areola complex. Hypopigmentation occurs because of the loss of some portion of the graft with subsequent secondary healing. 
No matter which technique is selected, during the consultation, the patient and surgeon thoroughly discuss the risks and benefits of the procedure, patients' wishes, and limitations based on her morphologic characteristics. Accurate pre operative marking is important. However, final breast shape and symmetry are achieved intraoperatively. After the initial tissue resection, the breasts are inspected in the upright position and adjustments are made with "tailor-tacking" sutures or staples. Proper determination of the new nipple-areola complex location is essential. Nipple-areola complex malposition is difficult to correct secondarily. Preserve nipple-areola viability by developing a well-perfused pedicle or dermal graft bed. Avoid the tendency to undermine the pedicle. If the pedicle nipple-areola complex viability is questionable at the end of treatment, it should be converted to a free graft.
The patient can be admitted to the hospital overnight if the pain is severe and can not be managed. No laboratory studies are required after surgery. Dressings can be removed the first postoperative day and replaced with clean gauze or a surgical bra. A support bra should be worn day and night for two months after her procedure. If drains are used, the output is carefully recorded and the drains removed when output is less than 30 mL in 24 hours. The patient is permitted to shower on the first postoperative if there are no drains. Otherwise, she must wait until they have been removed. She is instructed to avoid heavy lifting for at least four weeks following surgery. After six to 12 months, mammograms are obtained on all patients older than 40 years of age as new baseline films documenting the radiographic changes of the breast following the operation. 
Complications are common after reduction mammoplasty, but most are minor and do not require additional surgeries. BMI over 30 and smoking are risk factors that increase the risk of complications. As the quantity of breast resection increases, so does the chance of complications. Minor complications that can be seen in the early postoperative period include hematoma, seroma, cellulitis, wound infection, delayed wound healing, and minor wound dehiscence. Major complications that often require surgical intervention are major wound dehiscence, flap necrosis, and nipple areolar necrosis. Once all wounds are well healed, complications involving cosmetic appearance are asymmetry, lack of proper shape, dog ears, under resection, over resection, and unsightly scars. 
Once it has been decided that a patient is a good candidate for reduction mammoplasty, one of the surgical techniques will be selected. The technique chosen needs to result in minimal chance of serious complications such as wound dehiscence, flap necrosis, overelevation of the nipple, and ischemic loss of the nipple. The procedure needs to fulfill the reconstructive goals of weight reduction, attractive appearing breast, and minimal scars. Finally, the procedure needs to successfully reduce the breast, so there is minimal risk of revision. 
Enhancing Healthcare Team Outcomes
Breast reduction is by no means an easy procedure, and even though several techniques have been developed to perform this procedure, each has its own risks and complications. All patients need to be educated about the procedure and potential complications. The downtime can be long and avoiding scars may not always be possible. Recently liposuction has been utilized to elevate the nipple areolar complex, but since the tissue is being removed without being histologically analyzed, the safety of this procedure is being questioned. There is a small risk that a malignancy may be missed with liposuction. Mesh has also been advocated to support the breast parenchyma, but there is a potential risk of an infection and distortion of tissue planes. While minimally invasive procedures offer small scars and rapid recovery, patients should always be informed about the pros and cons of these surgeries. (Level V)