Introduction

Authors: Mia Demant, MD, Magnus Balslev Avnstorp, MD, and Mia Steffensen, MD

Definition

Breast reduction surgery, or reduction mammaplasty, plays a vital role in alleviating physical discomfort and enhancing the quality of life for patients with overly large breasts. Plastic surgeons have a range of techniques at their disposal to tailor breast reduction procedures to individual patient needs – without compromising blood supply to the skin, nipple, and breast parenchyma.

Each reduction technique has its unique combination of skin incision, pedicle planning, and resection pattern. In Denmark, the most common pedicle used is the superomedial, and the most commonly used techniques are:

The Wise Pattern or inverted T-technique: also called Orlando’s technique (1).

Also known as the anchor technique, this approach uses three incisions: around the areola, vertically down to the inframammary fold, and along the fold itself. The resulting shape resembles an inverted “T” or an anchor. The inverted-T technique is suitable for patients with significant ptosis and excess breast tissue. It offers maximal tissue removal and thorough reshaping capabilities.

The vertical scar technique: also called the “Keyhole”-technique or Hall-Findlay’s technique (2).

The vertical technique involves two incisions: a circular one around the areola and a vertical one extending down to the inframammary fold, creating a lollipop shape. This method minimizes scarring compared to the traditional inverted-T technique while allowing for significant tissue removal and reshaping. The vertical technique is ideal for patients with moderate to severe breast ptosis.

Pedicle Techniques: These techniques involve preserving a pedicle of tissue, usually based on the superior or medial aspect of the breast, to maintain blood supply to the nipple-areolar complex. Pedicle techniques are commonly used to prevent loss of nipple sensation and necrosis in cases of severe reduction.

• a. Superior Pedicle: The nipple-areolar complex remains attached to the upper breast tissue, allowing for its repositioning while preserving blood supply.
• b. Medial Pedicle: The nipple-areolar complex is moved medially and upward, based on tissue from the inner breast area.

Liposuction-Assisted Breast Reduction: Liposuction is used to remove excess adipose tissue from the breast, allowing for modest volume reduction and reshaping. This technique is suitable for patients with more fatty tissue and less glandular hypertrophy.

Purpose

To relieve the patient’s physical and psychological difficulties related to her breast size and weight.

Indications for surgery

In Denmark the indications for being a candidate for breast reduction at a public hospital are as following:

• Skin irritations, macerations, intertrigo, and fungal infections under the breasts
• Heavy, pendulous breast (The reduced amount of breast tissue should be at least 400-500 g on each side)
• Neck- and back pain related to the weight of the breasts
• Indentations on the shoulders from bra straps
• Limitations on physical activity due to breast size and weight
• Abnormal ptosis due to age
• Psychological affection due to unwanted attention to the large breasts

Contraindications

• Smoking
• BMI > 25
• Age < 18 years (lower age can sometimes be accepted if the patient’s difficulties are of  significant size)

Pre-operative assessment

• All women ≥ 35 years of age must have normal mammography within the last 6 months
• Any palpable breast lumps must be examined by mammography and ultrasound before surgery
• The skin incision pattern and pedicle (most commonly superiomedial pedicle) is chosen pre-operatively

Risks of reduction surgery

• Necrosis of the NAC
• The ability to breastfeed may be affected
• Decreased skin sensitivity of the NAC and breast
• Hematoma
• Infection

Choosing the appropriate pedicle

The blood supply relies on the chosen pedicle; a superior, medial, inferior, or lateral pedicle for blood vessels and nerves is chosen. The pedicle is de-epithelialized for the preservation of the subdermal blood supply to improve circulation for the NAC. As mentioned, in Denmark surgeons often rely on the superiormedial pedicle. The benefits and drawbacks of various pedicles are presented in Table 1.

Benefits and drawbacks of different pedicle techniques

	Benefits	Drawbacks
Lateral pedicle	Large volume resection possible Breast feeding ability	Limitation of lateral debulking Inferior aesthetic outcome No dual bloodsupply
Inferior pedicle	Increased NAC sensibility Large volume resection possible	High risk of bottoming out No dual blood supply
Superior pedicle	Leaves upper-pole fullness Maintains breast projection	Impairment of NAC sensibility Limited to small resection No dual blood supply
Medial pedicle	Increased NAC sensibility Larger volume resection possible Less risk of bottoming out	No dual blood supply
Superomedial pedicle	Increased NAC sensibility Large volume resection possible Less risk of bottoming out (an appearance of the bottom of the breast tissue bulging downward)	No dual blood supply
Central pedicle	Increased NAC sensibility Large volume resection possible Breast feeding ability Less risk of bottoming out	No dual blood supply

Acknowledgments

Illustrators: Christian Paaskesen, med.stud., Emma Tubæk Nielsen, med.stud.