What are the different breast reduction techniques?

Breast Reduction Techniques

The primary breast reduction techniques include the inferior pedicle Wise pattern (inverted-T), vertical scar techniques (Lassus/Lejour), periareolar approaches, and superomedial pedicle methods, with the choice depending on breast size, degree of ptosis, and desired scar pattern. 1

Major Technique Categories

Wise Pattern (Inverted-T) Technique

• The Wise pattern with inferior pedicle remains one of the most common techniques for breast reduction, particularly for larger resections and significant ptosis 1
• Creates an anchor-shaped scar with vertical and horizontal components in the inframammary fold 2
• Allows for large volume reductions (up to 1900 gm per breast documented) with reliable nipple-areolar complex (NAC) vascularity 2
• The horizontal inframammary scar is the main aesthetic drawback, though the technique provides predictable, stable results 3

Vertical Scar Techniques

• Vertical mammaplasty eliminates the horizontal submammary scar and has been successfully used in all breast reduction cases since the late 1980s 3
• Uses adjustable markings with an upper pedicle for the areola and central breast reduction with limited skin undermining 3
• The breast shape is created by suturing the gland rather than relying on skin tension 3
• In a series of 192 breasts, vertical technique produced consistently good, stable results with limited scars and few complications requiring reoperation 3
• The vertical approach is particularly effective when combined with liposuction in fatty breasts (50% of large breasts in patients under 50 years and 100% in patients over 50 years) 3

Periareolar and Combined Approaches

• The "owl" incision combines features of large periareolar reduction (Benelli technique) with vertical reduction, either making the horizontal inframammary scar very short or eliminating it completely 2
• Uses a supero-central pedicle with heart-shaped parenchymal resection, maintaining central parenchyma behind the NAC for excellent projection 2
• No skin or parenchymal undermining is required, eliminating the need for drains 2
• In 94 patients over 7 years, this technique achieved excellent projection and shape with minimal visible scars, rare complications, and no conversions to free grafts even in larger resections 2

Superomedial Pedicle Technique

• The superomedial pedicle is one of the two most common pedicles used in breast reduction alongside the inferior pedicle 1
• Provides reliable blood supply to the NAC while allowing significant volume reduction 1

Pedicle Selection and Blood Supply

Common Pedicle Options

• Inferior pedicle: Most traditional, reliable for large reductions, maintains sensation and lactation potential 1
• Superior pedicle: Used in vertical techniques, allows adjustable positioning 3
• Superomedial pedicle: Increasingly popular, provides excellent vascularity and aesthetic outcomes 1
• Supero-central pedicle: Maintains central parenchyma, improves projection, may better preserve NAC sensation and lactation 2

Adjunctive Techniques

Liposuction-Assisted Breast Reduction

• Liposuction can be safely and efficiently used as a complementary procedure before surgical reduction in fatty breasts 3
• Between 100-1000 cc of fat (mean 300 cc) can be suctioned, representing significant volume reduction 3
• Makes modeling of the gland easier and produces breasts with more useful and stable components 3
• Surgical resection is then adjusted to obtain desired breast volume, with complications related to breast weight rather than liposuction itself 3

Multilevel Approach

• The multilevel breast reduction technique recreates breast mound support from the "bottom up" for long-lasting results 4
• Particularly effective in wide ptotic breasts requiring medium-size resections 4
• In 338 consecutive bilateral breast reductions, this vertical scar technique achieved high patient satisfaction with low complication rates: 0.8% hematomas requiring revision, 20% superficial dehiscence, 3.5% superficial infections 4

Unilateral Reduction Considerations

Asymmetry Correction

• For unilateral breast reduction, sculpturing from the undersurface through minimal incisions provides long-lasting symmetry 5
• Traditional techniques performed unilaterally rarely provide lasting symmetry because operated and unoperated breasts react differently to aging, weight changes, and pregnancy 5
• Through a vertical infra-areolar incision, the breast is completely detached from pectoralis fascia and reshaped by discoid resection and/or selective sectoral removal 5
• This approach fully preserves breast anatomy, function, and vascularization while minimizing residual scarring 5

Oncoplastic Applications

Volume Displacement Techniques

• Oncoplastic volume displacement procedures combine generous breast tissue removal with mastopexy techniques to fill surgical defects and avoid significant deformity 6, 7
• These techniques permit removal of larger regions of breast tissue, achieving wider surgical margins while better preserving natural breast shape compared to standard resections 6, 7
• Volume displacement is generally performed during the same operative setting as breast-conserving lumpectomy by the same surgeon 6, 7

Limitations

• The National Comprehensive Cancer Network notes lack of standardization among centers and limited availability at some U.S. medical centers 6, 7
• Possible necessity for subsequent mastectomy if pathologic margins are positive when further breast-conserving attempts are impractical 6

Common Pitfalls and Complications

Risk Factors

• Smoking and obesity increase complication risks for all breast reduction types and are considered relative contraindications 6
• Complications are primarily related to breast weight rather than patient obesity or adjunctive procedures like liposuction 3

Minor Revisions

• In 10% of patients with very large and ptotic breasts, some skin redundancy may require excision at the lower extremity of the scar after several months to improve final results 3
• Superficial dehiscence occurs in approximately 20% of cases but typically resolves without major intervention 4

Safety Profile

• Breast reduction can be safely performed in the outpatient setting in most cases 2
• Enhanced Recovery After Surgery protocols effectively control pain and reduce narcotic use postoperatively 1
• Patient satisfaction after breast reduction surgery is typically high across all techniques 1, 4