What are the criteria for breast reduction surgery?

Criteria for Breast Reduction Surgery

Breast reduction surgery is primarily indicated for patients experiencing significant physical symptoms from macromastia (breast hypertrophy), including chronic pain, skin irritation, postural problems, and functional limitations that impair quality of life, rather than being based solely on breast size or weight thresholds. 1, 2

Primary Indications

Physical Symptoms

• Chronic neck, shoulder, and back pain directly attributable to breast weight is the most common indication 2, 3
• Skin problems including intertrigo (rash), maceration, or chronic infections in the inframammary fold 1, 2
• Postural abnormalities such as increased cervical lordosis, thoracic kyphosis, and disturbed sagittal balance of the vertebral column 4
• Shoulder grooving from bra straps due to excessive breast weight 2, 3
• Functional limitations in physical activities, exercise, or daily living activities 2, 3
• Breathing difficulties related to breast weight 2

Psychological Impact

• Significant psychological distress including poor body image, low self-esteem, and social embarrassment should be documented 1, 3
• Impact on quality of life affecting work, relationships, or social activities 2, 3

Patient Selection Criteria

Appropriate Candidates

• Patients with documented breast-related symptoms that have failed conservative management (proper supportive bras, physical therapy, weight loss if applicable) 1, 2
• Realistic expectations about surgical outcomes, scarring, and recovery 1
• Medical stability with optimization of comorbidities prior to surgery 5
• Non-smokers or willing to quit at least 4-6 weeks before and after surgery 1

Special Considerations by Age

• Younger patients (under 35 years) should have completed breast development and ideally delayed childbearing plans, though this is not an absolute contraindication 5
• Elderly patients (60+ years) are appropriate candidates despite higher comorbidity rates, with studies showing even higher satisfaction rates than younger patients 5
• Age alone is not a contraindication for reduction mammaplasty 5

Body Mass Index Considerations

• Obesity (BMI >30) is associated with higher complication rates but is not an absolute contraindication 2
• Obese patients show particularly significant improvement in breast-related symptoms postoperatively 2
• Weight optimization should be encouraged preoperatively but surgery should not be indefinitely delayed for weight loss alone 1, 2

Quantitative Assessment Tools

Validated Measurement Instruments

• Breast-Related Symptoms Questionnaire (BRSQ) effectively quantifies 13 breast hypertrophy-related symptoms and their frequency 2
• Low preoperative Breast Severity Symptom (BSS) scores (indicating high symptom burden) correlate with considerable surgical benefit 2
• SF-36 Health Survey and Rosenberg Self-esteem Scale document baseline quality of life and psychological status 3
• 15D questionnaire measures health-related quality of life across multiple dimensions 2

Documentation Requirements

• Photographic documentation of breast size, ptosis, and any skin changes 1
• Measurement of breast dimensions and degree of ptosis 1
• Documentation of conservative treatment failures including physical therapy, analgesics, and proper bra fitting 2

Contraindications and Cautions

Absolute Contraindications

• Active breast cancer or suspicious breast lesions requiring workup first 6
• Uncontrolled medical conditions that preclude safe anesthesia 1
• Active smoking without willingness to quit 1
• Unrealistic expectations or body dysmorphic disorder 1

Relative Contraindications

• Plans for near-term pregnancy and breastfeeding should prompt discussion of timing, though not absolute contraindication 1
• Significant obesity may warrant discussion of weight optimization but should not indefinitely delay surgery if symptoms are severe 2
• Poor wound healing conditions (uncontrolled diabetes, immunosuppression) require optimization 1

Oncoplastic Context

Therapeutic Mammoplasty

• Breast reduction techniques can be combined with cancer surgery (therapeutic mammoplasty) to achieve better cosmetic outcomes in patients with large breasts undergoing breast-conserving surgery for cancer 7, 6
• This represents a newer oncoplastic procedure that addresses both cancer treatment and breast size simultaneously 7, 6

Expected Outcomes

Symptom Relief

• Significant improvement in physical symptoms occurs in the vast majority of patients, with mean BSS scores improving from 27 preoperatively to 59 postoperatively 2
• 55 of 59 patients (93%) reported less frequent or non-existent symptoms postoperatively 2
• Vertebral column abnormalities improve with significant decreases in pathologic cervical lordosis and thoracic kyphosis angles 4

Quality of Life

• Health-related quality of life scores improve significantly from 0.889 to 0.930 on the 15D scale 2
• Patient satisfaction is typically very high, with elderly patients showing even higher satisfaction than younger patients 5, 3
• Substantial benefit in physical and psychological health is consistently demonstrated 3

Common Pitfalls to Avoid

• Do not rely solely on breast weight or volume as criteria; symptom burden and functional impact are more important 2
• Do not indefinitely delay surgery for weight loss in obese patients with severe symptoms, as they derive significant benefit 2
• Do not exclude elderly patients based on age alone, as they have excellent outcomes and high satisfaction 5
• Do not proceed without validated symptom assessment tools to document baseline symptoms and predict surgical benefit 2