What are the indications for breast reduction surgery?

Breast Reduction Surgery Indications

Breast reduction surgery is indicated for women with symptomatic macromastia causing physical symptoms (back/neck/shoulder pain, skin irritation, postural problems) or significant psychosocial distress that impairs quality of life, and for oncoplastic reconstruction to achieve symmetry after unilateral breast cancer surgery. 1, 2, 3

Primary Medical Indications

Physical Symptoms

• Chronic musculoskeletal pain including back pain, neck pain, shoulder pain, and postural problems that significantly impair daily function 2, 3
• Skin problems such as intertriginous dermatitis, chronic skin irritation, or recurrent infections in the inframammary fold 2, 3
• Bra strap grooving causing shoulder indentations and discomfort 2, 3
• Functional limitations in physical activity, exercise capacity, or activities of daily living 3

Psychosocial Indications

• Significant body image disturbance and reduced self-esteem directly attributable to breast size 2, 3
• Psychosocial impairment affecting quality of life, social functioning, or emotional well-being 3
• Women with breast hypertrophy demonstrate significantly lower scores on validated quality of life measures (SF-36, mBEQ) compared to matched normal populations 3

Oncoplastic Indications

Cancer-Related Reconstruction

• Contralateral breast reduction for symmetry after unilateral breast cancer surgery is strongly recommended by the American College of Surgeons and NCCN to achieve optimal cosmetic outcomes 1
• Therapeutic mammoplasty combining breast-conserving cancer surgery with reduction techniques in patients with large breasts undergoing lumpectomy 1, 4
• Volume displacement techniques to reduce local volume deficit after tumor excision while maintaining breast shape 1

Patient Selection Criteria

Ideal Candidates

• Symptomatic patients with documented physical complaints or psychosocial distress 2, 3
• Realistic expectations about surgical outcomes, scarring, and recovery 2
• Completed breast development (typically age 18 or older, though exceptions exist for severe symptoms) 2
• Stable weight or commitment to weight management 2

Relative Contraindications Requiring Careful Assessment

• Active smoking increases infection risk 2-fold (RR = 2.0,95% CI = 1.3-3.1) and overall complication rates 5, 6
• Morbid obesity (BMI ≥40), though evidence shows breast reduction can be performed safely in this population with similar complication rates to non-obese patients 7
• Diabetes mellitus significantly increases risk of areolar necrosis 5
• Large resection volumes anticipated (>2000g per breast) correlate with higher rates of delayed wound healing and fat necrosis 5, 6

Absolute Contraindications

• Active breast cancer or suspicious breast lesions requiring complete workup before any elective breast surgery 4
• Pregnancy or active lactation 2
• Unrealistic expectations or body dysmorphic disorder 2
• Medical instability precluding safe anesthesia 2

Important Clinical Predictors

Risk Factors for Complications

• Longer suprasternal notch-to-nipple distance significantly increases infection risk (p < 0.001) and areolar necrosis risk (p < 0.001) 5
• Greater resected specimen weight significantly influences delayed wound healing (p = 0.021) and fat necrosis (p < 0.001) 5
• Presence of stretch marks is an independent risk factor for complications 6
• Surgical technique matters: superior pedicle and free nipple graft techniques show higher complication rates than postero-superior and postero-inferior pedicle techniques 6

Expected Outcomes

Quality of Life Improvements

• Significant improvements occur in all dimensions of breast-related symptoms (BRSQ), breast evaluation (mBEQ), and satisfaction (BREAST-Q) scores at 1 year postoperatively 3
• General health improvements demonstrated in multiple SF-36 dimensions after surgery 3
• Patient satisfaction is typically high following breast reduction surgery 2, 3
• Women with higher preoperative breast volumes and longer sternal notch-to-nipple distances appear more satisfied with cosmetic results postoperatively 3

Common Pitfalls to Avoid

• Do not delay surgery indefinitely in obese patients; evidence shows breast reduction can be performed safely even in morbidly obese patients (BMI ≥40) with similar complication rates 7
• Strongly counsel smoking cessation preoperatively, as smoking doubles infection risk and increases hypertrophic scarring 5, 6
• Consider postponing surgery in active smokers who cannot quit, as this is a modifiable risk factor 6
• Ensure complete cancer workup before proceeding with any breast reduction in patients with suspicious findings 4
• Select appropriate surgical technique based on patient anatomy and vascular supply considerations to minimize complications 6