Breast reduction is an extremely common procedure with around 100,000 cases performed annually in the United States. Clasically breast reduction is indicated for women with macromastia, who often complain of associated back, neck, and shoulder pain. These women may also show chronic inframmary intertrigo and excoriations from the bra straps.  

Other reasons women desire the procedure are purely cosmetic  and it is also often employed for simmetry of the contralateral breast following mastectomy and breast reconstruction.

Breast reduction techniques

The goal of breast reduction, or reduction mammoplasty, is to remove excess fat, glandular tissue, and skin to achieve the patient’s desired breast size.

There is a wide variety of breast reduction surgical techniques. The choice depends on the extent of ptosis, breast size and shape, estimated resection volumen and the surgeon's experience.

Reduction mammoplasty technique has two components: skin incision pattern and volume reduction or glandular resection pattern.

With regard to the pattern of skin incision (Fig. 1), in the traditional Wise pattern, or inverted T scar or anchor scar, a key-hole incision leaves a periareolar scar, a vertical  scar in the midline of the inferior mammary hemisphere, and a curvilinear scar along the inframammary fold.

With the pupose of shortening and hiding the scar, newer vertical scar techniques feature a vertical incision alone leaving only a periareolar scar and a vertical scar along the midline of the lower hemisphere of the breast. The resulting scar has a lollopop-shaped appearance. Use of the vertical incision decreases scarring and distortion of the inframmary fold. 

Finally, periareolar technique is used in small to moderate reductions.

With regard to the pattern of glandular resection (Fig. 2), the different techniques used in breast reduction are identified by the segment of the breast that is left unresected, which becomes the structure and support of the new breast. This "pedicle" also contains the vascular supply of the breast mound, including the nipple-areola complex. The pedicle can be derived from tissue in any direction relative to the NAC.  Various techniques include superior, superomedial, medial, inferior, lateral and central pedicles.

Wise skin incisión pattern with inferior pedicle technique (Fig. 3) has become the standard to which all other variations are compared and is the most commonly performed breast reduction procedure. This technique utilizes a key-hole incision and an inferior pedicle for blood supply to the nipple areola complex. Excess breast tissue is removed medially, laterally, and superiorly. When the incisions are closed the patient is left with a classic anchor incision. This technique does have its limitations and resulting breasts tend to have long scars, long term boxy shape and lack of breast projection.  It also has advantages including good circulation, good sensation and possibility of breast feeding.

The superior dermoglandular pedicle method (which involves the resection of the medial, lateral, and inferior portions of the breast parenchyma) is the pattern of resection used in the Lejour technique (Fig. 3). The vertical scar incision pattern is the skin incision that is used and the NAC and pedicle are repositioned superiorly as breast tissue is removed. Suture suspension of the pedicle to pectoralis muscle fascia and total breast liposuction are also performed. Its advantages are that it preserves the area that is less prone to undergo further ptosis secondary to downward pulling action of gravity, as well as maintaining fullness in the upper pole of the breast while allowing for small, medium, and large resections.