# Breast Reduction and Mastopexy

## Introduction
Breast reduction (reduction mammaplasty) is one of the most common and satisfying plastic surgery procedures. Addresses physical symptoms (neck/back pain, shoulder grooving, intertrigo, bra strap pain) and aesthetic concerns. Mastopexy (breast lift) addresses ptosis without significant volume reduction. Techniques overlap substantially; the key difference is the amount of tissue removed. Functional breast reduction is often covered by insurance (documentation of symptoms, weight of tissue removed).

## Anatomy Review
Blood supply to the NAC is critical for pedicle selection: **Internal mammary perforators**: medial supply. **Lateral thoracic artery**: lateral supply. **Intercostal perforators (4th-6th)**: posterior/inferior supply.

**Thoracoacromial artery**: superior supply through pectoralis. NAC viability depends on maintaining at least one reliable pedicle. Sensation: 4th lateral intercostal nerve (primary sensory to NAC).

## Classification of Breast Ptosis (Regnault)

| Grade | Description | Nipple Position Relative to IMF |
|-------|-------------|-------------------------------|
| Normal | No ptosis | Above IMF; adequate lower pole |
| Grade I (Minor) | Mild ptosis | At the level of the IMF |
| Grade II (Moderate) | Moderate ptosis | Below IMF but above lower pole |
| Grade III (Severe) | Severe ptosis | At lowest contour, pointing downward |
| Pseudoptosis | Lower pole ptosis | Above IMF (but lower pole hypotrophic/ptotic) |
| Glandular ptosis | Gland descent | Normal nipple position but gland below IMF |

**Normal**: nipple above the IMF; adequate lower pole volume. **Grade I (Minor ptosis)**: nipple at the level of the IMF. **Grade II (Moderate ptosis)**: nipple below the IMF but above the lower pole. **Grade III (Severe ptosis)**: nipple at the lowest contour of the breast, pointing downward.

**Pseudoptosis**: nipple above the IMF but lower pole is hypotrophic and ptotic (common after pregnancy/lactation). **Glandular ptosis**: nipple position is normal but gland is ptotic below the IMF.

## Preoperative Assessment
History: symptoms (pain, rash, numbness, difficulty exercising), desire for breastfeeding, weight stability, family history of breast cancer. Physical exam: breast measurements (SN-N, N-IMF, base width), nipple position relative to IMF, degree of ptosis, skin quality, asymmetry. Mammography/imaging per age-appropriate screening guidelines before surgery. Photography (standardized views).

Documentation for insurance: symptom duration, failed conservative measures (bras, physical therapy, NSAIDs), minimum tissue removal requirements (varies by insurer, often 300-500g per breast or Schnur sliding scale).

## Pedicle Options

| Pedicle | Blood Supply | Best For | Limitation |
|---------|-------------|----------|------------|
| Superior | Thoracoacromial perforators | Moderate reductions | Unreliable if SN-N >40 cm |
| Inferior | Intercostal perforators (4th-6th), IMA perforators | Large reductions | Bottoming out; boxy shape |
| Superior-medial | Combined superior + medial | Large reductions with good shape | Technically demanding |
| Central mound/Posterior | Direct posterior intercostal perforators | Gigantomastia (>2000g/breast) | Less common technique |
| Free nipple graft | N/A (graft) | Massive reductions, SN-N >40 cm | Loss of sensation, projection, breastfeeding |

### Superior Pedicle
Blood supply from thoracoacromial perforators through the pectoralis. Good for moderate reductions; limits on length of pedicle. NAC transposed on a superiorly based dermoglandular pedicle. Less reliable for very large reductions or long pedicle distances (SN-N >40 cm).

### Inferior Pedicle
Most commonly used pedicle in North America. Blood supply from intercostal perforators (4th-6th) and internal mammary perforators. Reliable for large reductions; long pedicle length tolerated. Combined with the Wise (inverted-T) pattern most commonly. **Disadvantages**: tendency for "bottoming out" (pseudoptosis recurrence), boxy shape.

### Superior-Medial Pedicle
Gaining popularity; combines superior and medial blood supply. Reliable NAC perfusion; allows significant volume reduction. Better upper pole fullness and projection than inferior pedicle. Good shape maintenance over time. Can be combined with Wise pattern or vertical pattern.

### Central Mound/Posterior Pedicle
Based on posterior intercostal perforators directly from the chest wall. Allows massive reductions (>2000g per breast). Very reliable blood supply through short, direct posterior perforators. Technique: breast parenchyma resected peripherally, central core preserved on chest wall. Less common; used for gigantomastia.

### Lateral Pedicle
Based on lateral thoracic artery. Less commonly used; may be combined with vertical scar technique. Useful when medial tissue is inadequate.

### Free Nipple Graft
NAC removed, defatted, and applied as a full-thickness skin graft. Indicated for: massive reductions, very long SN-N distance (>40 cm), high-risk patients for pedicle viability. **Advantages**: safely accommodates any volume reduction. **Disadvantages**: loss of NAC sensation and projection, inability to breastfeed, color mismatch, graft failure risk.

## Skin Pattern (Scar) Options

### Wise Pattern (Inverted-T/Anchor)
Most common pattern overall. Three scars: periareolar, vertical, horizontal (in the IMF). Provides maximum skin excision and reshaping control. Best for large reductions and severe ptosis.

**Keyhole** marking: upper margin at new nipple position, medial and lateral limbs converge at the IMF. **Disadvantage**: longest scar; T-junction complications.

### Vertical (Lollipop)
Periareolar scar + vertical scar only (no horizontal/IMF scar). Popularized by Lejour, Hall-Findlay. Relies on skin redraping and internal shaping sutures. Better long-term shape (skin contraction molds the breast).

Skin bunching inferiorly at closure (resolves over 3-6 months). Best for moderate reductions (<800g per breast) and mastopexy. Shorter scar than Wise pattern.

### Periareolar (Circumareolar/Donut)
Scar confined to the areolar margin. Limited skin removal; limited lifting capacity. Best for mild ptosis with minimal skin excess. Risk of widened scar, areolar spreading, flat breast shape.

Often combined with internal mastopexy sutures (purse-string, go-through). Benelli technique: circumareolar with round-block internal suture.

### Short Scar (J-Scar/L-Scar)
Modified Wise pattern with shortened or eliminated horizontal scar on one side. Compromises between vertical-only and full Wise pattern.

<image>Illustration showing four breast reduction/mastopexy scar patterns on anterior views of the female chest. Panel A: Wise pattern (inverted-T/anchor) showing periareolar, vertical, and horizontal inframammary fold scars. Panel B: Vertical (lollipop) pattern showing periareolar and vertical scars only. Panel C: Periareolar (donut/circumareolar) pattern with scar limited to the areolar circumference. Panel D: Short scar pattern with periareolar, vertical, and abbreviated horizontal scar. Each panel shows the preoperative markings (skin to be excised in shaded areas) on the left breast and the postoperative scar result on the right breast.</image>

## Surgical Technique (Inferior Pedicle, Wise Pattern — Example)

### Marking
Patient upright; mark breast meridian, IMF, new nipple position (at the level of the IMF, typically 21-23 cm from SN). Wise pattern keyhole: superior limb width 6-8 cm (new areolar opening), medial and lateral limbs 7-9 cm. Limbs meet at the IMF; verify with patient seated.

### Steps
1. Deepithelialize the pedicle (inferior dermoglandular tissue left intact)
2. Incise the skin along the marked pattern
3. Resect breast tissue from the superior, medial, and lateral aspects (weigh specimens)
4. Shape the remaining breast on the inferior pedicle
5. Transpose the NAC to its new position through the keyhole opening
6. Close the vertical limbs and horizontal limb (tailor-tack approach for final skin adjustment)
7. Layered closure; drains optional 8. Specimen sent to pathology (occult malignancy found in 0.1-1%)

## Mastopexy-Specific Considerations
Minimal tissue removal; focus on reshaping and repositioning. Auto-augmentation techniques: inferior or medial pedicle tissue folded and sutured to create upper pole fullness. Mastopexy with augmentation: combined implant placement and lift; higher complication rate than either alone (competing forces: implant expands envelope while mastopexy tightens it). Staged approach may be safer: mastopexy first, augmentation second.

## Breastfeeding After Reduction
Depends on pedicle type and amount of tissue removed. Inferior and superior pedicles maintain ductal connections to NAC in many patients. Free nipple graft severs all connections; breastfeeding impossible. Counsel all patients that breastfeeding ability may be reduced but is possible in many cases (especially with pedicle techniques).

## Complications
Hematoma (1-2%). Infection (1-3%). Wound dehiscence (especially at T-junction in Wise pattern). Fat necrosis.

NAC partial or total necrosis (rare with well-designed pedicle, <1%). Seroma. Asymmetry (most common reason for revision). Altered NAC sensation (temporary in most; permanent in 10-15%).

Dog ears (lateral/medial excess tissue). Inability to breastfeed. Recurrent hypertrophy (especially in young patients, weight gain). DVT/PE (rare; prophylaxis standard). Occult carcinoma in specimen (0.1-1%): always send tissue to pathology.

## Clinical Pearls
The superior-medial pedicle with Wise pattern is gaining favor over the traditional inferior pedicle because it provides better shape maintenance, upper pole fullness, and reduced pseudoptosis over time. Always send resected tissue to pathology; occult malignancy is found in approximately 0.4-1% of reduction specimens. The vertical technique (Hall-Findlay) produces superior long-term breast shape but requires comfort with initial postoperative skin bunching; patients should be counseled that the final shape takes 3-6 months to settle.

In mastopexy-augmentation, the tension between the implant expanding the envelope and the mastopexy tightening it creates competing forces; this combination has the highest revision rate of any breast procedure — consider staged procedures for safety. For gigantomastia (>2000g reduction per breast), the free nipple graft technique is safest; attempting to maintain a pedicle over such a long distance risks NAC necrosis. Measure twice, cut once: meticulous preoperative marking with the patient upright is the single most important factor in achieving symmetric results.

## References
- Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr Surg. 2015;136(4):531e-544e.
- Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr Surg. 1999;103(3):890-901.
- Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle reduction mammaplasty: clinical experience and technical refinements. Ann Plast Surg. 2000;44(3):235-243.
- Regnault P. Breast ptosis: definition and treatment. Clin Plast Surg. 1976;3(2):193-203.
- Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991;27(3):232-237.
- Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast Reconstr Surg. 1999;104(3):771-781.