What are the considerations and recommendations for a female patient of reproductive age or older with large breasts and significant discomfort, seeking breast reduction surgery?

Breast Reduction Surgery for Symptomatic Macromastia

For women with large breasts causing significant physical discomfort (back, neck, or shoulder pain), breast reduction surgery is a highly effective treatment that provides substantial relief of symptoms and improvement in quality of life, with patient satisfaction rates typically being very high. 1

Patient Selection and Pre-Operative Assessment

Mandatory Pre-Operative Screening

• Exclude active breast cancer or suspicious lesions before proceeding - this is an absolute contraindication to elective breast reduction 2
• Perform age-appropriate breast cancer screening (mammography) in all candidates, particularly those over 40 years or with risk factors 2
• Rule out extramammary causes of pain including costochondritis, cervical radiculopathy, and cardiac issues if symptoms don't correlate with breast size 3

Special Consideration for High-Risk Patients

If the patient has BRCA1/2 mutations or compelling family history of breast cancer, recommend risk-reduction mastectomy rather than simple breast reduction, as this provides 90% reduction in breast cancer risk 2. Risk-reduction mastectomy should be considered for:

• Women with BRCA1/2, TP53, PTEN, CDH1, or STK11 mutations 4
• Compelling family history of breast cancer 4
• History of LCIS (lobular carcinoma in situ) 4
• Prior thoracic radiation therapy before age 30 4

For these high-risk patients, multidisciplinary consultation including genetics, surgery, and reconstructive surgery is required before proceeding 4

Initial Conservative Management (Trial Before Surgery)

Before proceeding to surgery, document failure of conservative measures:

• Properly fitted supportive bra - essential first-line intervention 3
• Physical therapy with stretching exercises focusing on strengthening upper back muscles and improving posture for 6-12 weeks 3
• NSAIDs (ibuprofen) for symptomatic relief 3
• Ice packs or heating pads for comfort 3
• Regular physical exercise to improve musculoskeletal function 3

If symptoms persist after 6-12 weeks of conservative treatment, referral to physical medicine and rehabilitation or consideration of acupuncture may be attempted before surgery 3

Surgical Technique Selection

Most Common Approaches

The inferior pedicle technique remains the most widely used approach (69% of plastic surgeons), though newer techniques are gaining acceptance 5. The superomedial pedicle (SMP) technique is particularly effective for extremely large breasts (macromastia and gigantomastia) with mean resection weights of 1835g per breast, achieving 90% good aesthetic outcomes with less than 20% long-term complications 6

Key Technical Considerations

• Wise pattern and vertical pattern are the most common skin incision techniques 1
• Inferior and superomedial pedicles are the two most commonly used pedicle designs 1
• For extremely large breasts with very long suprasternal notch-nipple distances (mean 44.13 cm), the SMP technique preserves vascular integrity and sensation of the nipple-areola complex while avoiding the need for free nipple grafts 6

Perioperative Management

Standard Protocols

• Perform 97% of cases under general anesthesia 5
• Use preoperative antibiotics in 93% of cases to reduce infection risk 5, 7
• Implement intraoperative deep venous thrombosis prophylaxis in 92% of cases 5
• Perform 61% of cases on an outpatient basis (over 75% of surgeons' caseload) 5
• Implement Enhanced Recovery After Surgery (ERAS) protocols to effectively control pain and reduce narcotic use postoperatively 1

Thromboembolic Risk Management

For patients on tamoxifen or raloxifene (if being used for breast cancer risk reduction), consider discontinuing prior to elective surgery and resume postoperatively when ambulation is normal 4

Expected Outcomes and Benefits

Symptom Relief

• Relief of pain and discomfort from heavy, pendulous breasts 8
• Improvement in physical symptoms including back, neck, and shoulder pain 1

Quality of Life Improvements

• Increased self-esteem and body image 1
• Improved quality of life 1
• Patient satisfaction after breast reduction surgery is typically high 1
• Normal and pleasing appearance with clothing 8
• Reasonable breast contour without support 8
• Normally sensitive nipples that become erect on stimulation 8

Additional Benefits

• Minimal apparent permanent scarring with modern techniques 8
• Breast size allowing for examination for masses 8
• Ideally intact ducts to nipple (depending on technique) 8

Special Populations

Oncoplastic Considerations

For patients with breast cancer requiring treatment who also have large breasts, therapeutic mammoplasty (oncoplastic breast reduction) can achieve both oncologic and aesthetic goals simultaneously, addressing the unfavorable tumor-to-breast size ratio while providing symptom relief 3, 2

Reproductive Age Women

Discuss potential impact on breastfeeding ability depending on technique chosen, as some approaches better preserve ductal integrity 8

Common Pitfalls to Avoid

• Do not proceed with breast reduction without age-appropriate breast cancer screening - active malignancy must be excluded first 2
• Do not perform simple breast reduction in BRCA1/2 carriers - these patients need risk-reduction mastectomy discussion 2
• Do not skip conservative management trials - document failure of non-surgical approaches for insurance authorization and appropriate patient selection 3
• Do not underestimate DVT risk - implement prophylaxis protocols in all cases 5
• Do not assume all back pain is from breast size - rule out other musculoskeletal and cardiac causes 3