What is the procedure for performing breast reduction surgery?

Breast Reduction Surgery Procedure

Breast reduction surgery should be performed using either the Wise pattern or vertical pattern skin incisions with inferior or superomedial pedicle techniques, following oncoplastic principles to ensure optimal cosmetic outcomes while maintaining breast health. 1

Preoperative Planning

• Evaluate the likely cosmetic outcome before surgery, considering the patient's body habitus, breast size, and degree of ptosis 2
• Consider oncoplastic techniques which combine removal of breast tissue with mastopexy techniques to preserve natural shape and appearance 2
• Assess for contraindications including smoking and obesity, which increase risk of complications such as wound healing problems and flap failure 2

Surgical Techniques

Skin Incision Patterns

• Wise pattern (inverted-T): Most commonly used technique, provides good access for tissue removal and reshaping 1, 3
• Vertical pattern: Results in less scarring but may be more technically challenging for larger reductions 1

Pedicle Techniques

• Inferior pedicle: Most commonly used (69% of surgeons), preserves nipple sensation and vascularity 3
• Superomedial pedicle: Alternative approach with good blood supply to the nipple-areola complex 1

Surgical Procedure Steps

1. Marking: With patient in standing position, mark the new nipple position, incision lines, and pedicle 1
2. Anesthesia: General anesthesia is used in 97% of cases, though local anesthesia with IV sedation is possible for selected patients 4, 3
3. De-epithelialization: Preserve the pedicle by de-epithelializing the area while maintaining blood supply 5
4. Tissue Resection: Remove excess breast tissue (typically from inferior and lateral regions) while preserving the pedicle 5
5. Nipple-Areola Repositioning: Transpose the nipple-areola complex on the preserved pedicle to the new position 1
6. Closure: Reshape the breast and close incisions in layers to minimize tension 1
7. Adjunctive Liposuction: Can be used to refine contours, particularly in the lateral breast and axillary region 5

Postoperative Care

• Implement Enhanced Recovery After Surgery (ERAS) protocols to control pain and reduce narcotic use 1
• Monitor for complications including hematoma, seroma, fat necrosis, skin loss, and nipple loss 6
• Schedule follow-up visits to assess healing and cosmetic outcomes 1

Special Considerations

Re-Reduction Procedures

• For patients requiring a second reduction, use a random pattern blood supply to the nipple rather than recreating the primary pedicle 5
• Remove excess tissue where it exists (usually inferiorly and laterally) 5
• Complement the resection with liposuction to elevate a bottomed-out inframammary fold 5
• Avoid horizontal skin excision below the inframammary fold 5

Oncoplastic Considerations

• Volume displacement techniques allow removal of larger regions of breast tissue while preserving natural shape 2
• These techniques can be applied when addressing post-pregnancy breast changes 7
• For significant ptosis, consider combining with mastopexy techniques 7

Potential Complications

• Hematoma and seroma formation 6
• Fat necrosis and skin loss 6
• Nipple-areola complex necrosis (rare with proper technique) 6, 5
• Unsightly or painful scars 6
• Deep venous thrombosis (use prophylaxis intraoperatively) 3

Most complications can be avoided with proper patient selection, appropriate surgical technique, and gentle tissue handling 6. Patient satisfaction after breast reduction surgery is typically high due to improvements in physical symptoms, self-esteem, body image, and quality of life 1.