Breast reduction

Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

Overview
Breast reduction, or reduction mammoplasty, is a surgical procedure which involves the reduction in the size of breasts by excising fat, skin, and glandular tissue; it may also involve a procedure to counteract drooping of the breasts. As with breast augmentation, this procedure is performed most often on women, but may also be performed on men afflicted by gynecomastia.

Candidates
Breast reduction surgery is oriented toward women with large, pendulous breasts, since the weight of their breasts may cause neck, back, shoulder, circulation, or breathing problems. The weight may also cause discomfort as a result of brassiere straps abrading or irritating the skin. Even if physical discomfort is not a problem, some women feel awkward with the enormity of their breasts in proportion to the rest of their relatively smaller bodies. Reduction mammoplasty affords the recipient smaller, lighter, and firmer breasts. The surgeon may also reduce the size of and change the shape of the areola or nipples.

Except in unusual cases, this procedure is performed on individuals with fully-developed breasts. It is not recommended for women who desire to breastfeed, as it can impair the likelihood of breastfeeding success and significantly decrease the volume of breast milk produced because of the surgical disruption to the lactiferous duct system within the breast. However, a number of studies have demonstrated a similar ability to breast feed when breast reduction patients are compared to control groups.

Notable women who are known for receiving breast reductions include Drew Barrymore, Queen Latifah, and Sharon Osbourne.

Techniques
The two most popular techniques in North America are the inferior pedicle and vertical scar techniques. Both of which are more likely to leave both nipple sensitivity and capability to lactate for the patient as compared to other techniques of the past. It is now being studied and debated as to which of the two techniques results in a better quality of life for the patient in the long run. Liposuction has been used along with the other breast reduction procedures for quite some time, but the newer liposuction only technique is now gaining popularity. All of the breast reduction techniques include a breast lift besides the liposuction only method.

The inferior pedicle technique, sometimes also known as a keyhole or Weiss pattern reduction, involves an anchor-shaped incision which circles the areola. The incision extends downward, following the natural curve of the breast. Excess glandular tissue, fat, and skin is removed. Next, the nipple and areola are moved into their new higher position. A drawback of this technique is sometimes "square" looking breasts, but this is a common option for women with the largest, droopiest breasts.
 * Inferior pedicle technique

The vertical scar technique, also known as the SPAIR or short scar breast reduction, is now widely gaining popularity due its minimal scarring and round shape post-surgery. To perform this, a doctor performs what is also known as a "lolipop incision" to the breast, resulting in the least amount of scarring. There are no horizontal incisions, and the scars are less likely to broaden with time, as with the Anchor-shaped technique. This technique keeps its results the best in the long term. The breast is reduced through removal of the lateral and inferior tissues, leaving the upper pole mostly untouched.
 * Vertical scar technique

The free nipple graft technique, a less common procedure, is now typically used only in the most extreme cases of drooping. In this procedure, the areola and nipple are completely removed for relocation and replaced as a skin graft higher on the breast. In these cases, sensation from the areola area will be lost and it is most likely to impair lactation as compared to the two most popular procedures, although some women have been known to successfully produce some amounts of milk.
 * Free nipple graft technique

The liposuction only technique is used for women with breasts that are not quite as large as with the other procedures. For the best outcomes, women who choose this procedure have perkier breasts without a drooping nipple, as the skin itself never moves, but, rather, fat is simply removed from inside of the breast. The result is not as drastic as the other techniques, but it involves a much quicker healing time, less pain, and less money. This is the technique typically used for men.
 * Liposuction only technique

Procedure
Doctors almost always perform breast reductions while the patient is under general anesthesia. During pre-operative visits, the doctor and patient may decide on new (usually higher) positions for the areolas and nipples.

Patients may take a few weeks for initial recovery, however it may take from six months to a year for the body to completely adjust to the new breast size. Some women may experience discomfort during their initial menstruation following the surgery due to the breasts swelling.

Cancer-prevention
Although not advocated as a cancer risk reducing procedure, a woman's risk of subsequently developing breast cancer will be reduced proportionately to the amount of breast tissue left. It is recommended that patients receive new baseline mammograms 6-8 months after breast reduction to accommodate expected radiographic changes and give a new basis to which future imaging studies can be compared.

Risks
Scarring from this procedure may be extensive and permanent. Initially, the scars are lumpy and red, but gradually subside into their final smaller sizes as thin lines. Though permanent, the surgeon can generally make the scars inconspicuous to the point that even low-cut tops may be worn without visible scars. Other common problems include: asymmetry, delayed wound healing, altered nipple sensation, fluid retention in the breast, altered erogenous function, and late changes in shape and recurrent ptosis (drooping.)