Large, pendulous breasts, where much of the parenchyma is below the inframammary fold, require a different approach when considering a reduction procedure. This involves markings, anticipation of anatomic changes with reduction of weight and volume, and handling of the nipple-areola complex as a full-thickness skin graft.
Criteria of what constitutes a breast of this caliber vary among surgeons. McKissock suggested considering amputation mammaplasty for excisions of greater than a kilogram and/or where vertical pedicle lengths exceeded 35 cm.  These are only guidelines, and the final decision about the technique is made between the surgeon and patient.
As many techniques are available, the procedure can be tailored to the patient's desires in terms of shape and size. The patient needs to accept the inability to breastfeed and loss of nipple sensation following this technique. Reduction procedures can provide resolution of the functional and aesthetic problems associated with hypertrophic breasts.
Hawtof, in a retrospective study of 54 patients, revealed that none of the 19 patients who underwent grafting procedures had any complication.  In comparison, 6 of 35 patients who underwent pedicle procedures developed complications such as skin loss, dehiscence, nipple loss, or infection.
Amputation reduction procedures are associated with a high level of satisfaction, long-term preservation of shape, and resolution of symptoms.
History of the Procedure
Historically, the treatment of female breast hypertrophy has been surgical; the first technique was used over 100 years ago. 
In 1921, Thorek described the first deliberate attempt to transplant the nipple for cosmetic reasons.
Hormonal manipulations are ineffective, and weight reduction, while having a direct effect on breast size, does not change body proportion or breast position and has not been shown to consistently relieve the symptoms of breast hypertrophy.
According to the American Society of Plastic Surgeons (ASPS), the terms female breast hypertrophy or macromastia describe an increase in the volume and weight of breast tissue in excess of the normal proportion. This is usually symmetric, but on occasion can be unilateral, such as in a postmastectomy patient or in a patient with benign juvenile hypertrophy. Excessive hypertrophy results in a disproportionate breast to body size.
Many females are genetically destined to have large breasts. This often is aggravated with pregnancy or weight gain. In addition, iatrogenic causes include asymmetry following a mastectomy.
Rarely, a young patient may experience virginal mammary hypertrophy resulting in massive breast hypertrophy and a high recurrence rate following a reduction-type procedure.
Women with macromastia or hypertrophy often present in a classic manner. They have larger than average, ptotic, dense breasts. Often, the patient is overweight with a wide chest and rolls of pannus over the abdomen.
The physician should inquire about previous breast trauma, spinal or neck injuries, and whether symptoms were absent when the patient weighed less. The presence of any of these indicates a more thorough evaluation may be needed. Weight loss prior to surgery may help improve a patient's problems and lead to a better surgical result.
Symptoms can be a result of muscle strains and postural changes causing headaches, backache, neck pain, shoulder pain, and nerve paresthesias.
Complaints may be related to breast weight, brassiere support resulting in shoulder grooving and ulceration, and breast pains.
Of lesser concern to insurance companies are problems related to the restrictions large breasts place on an individual with regard to her participation in sports and exercise, and the social stigma leading to embarrassment, sexual harassment, and feelings of sexual inadequacy.
Finally, clothing may never fit right, necessitating custom-made clothes or alterations.
Shortness of breath is not considered secondary to macromastia. However, the sensation of difficulty breathing when supine is quite common.
Breast reduction surgery is indicated in any female who has voiced the aforementioned complaints and is free of complicating issues such as breast trauma, neck or back injury, or a history of resolution of symptoms with lower weight. In addition, improvement of symptoms by manual lifting of the breast suggests a successful outcome. In addition, a history of feeling better upon awakening and the subsequent progression of symptoms over the course of the day support the diagnosis of symptomatic macromastia.
Robbins  suggested this procedure for excisions greater than 1500 mL per breast, and Jackson  suggests that free nipple graft procedures are not indicated in these patients. This author feels that inferior pedicle techniques lead to long-term bottoming out and that the patient should make the final decision when presented the numerous options available.
With the technique described here, the patient must accept the inability to breastfeed and the loss of nipple sensation. In theory, this technique can remove a considerable amount of the mammary ducts and could be beneficial in helping diminish the risk of subsequent breast cancer. Free nipple grafting can be used in any situation in which nipple viability is questioned and the patient accepts the loss of sensation and inability to breast feed.
With the proliferation and improvements with superior/medial pedicles, these techniques can always be attempted prior to resorting to a free nipple graft (due to obvious poor perfusion). The author now attempts this unless a nipple graft technique is obviously necessary (ie, extreme skin laxity or nipple excessively far from desired new position).
Insurance companies often dictate minimum weight excisions for coverage of breast reduction procedures; these requirements need to be met if the patient plans to use insurance to pay for the procedure.
Since the nipple is being transferred as a full-thickness graft, vascular insufficiency is not really a problem. Nerves to the nipple areolar complex are transected during harvesting of the nipple areolar complex. Incisions should not extend below the existing inframammary fold.
Dog ears are very common laterally if an anchor (WISE) pattern is used. Circular excisions with purse-string closure techniques are quite effective in minimizing this problem.
Breast shape varies among patients, but knowing and understanding the anatomy of the breast ensures safe surgical planning. For more information about the relevant anatomy, see Breast Anatomy.
Reduction mammaplasty is contraindicated in any female with suggestive or suspicious mammographic findings. Until those findings are resolved to the satisfaction of her treating physician, surgery should be delayed.
Surgery is also contraindicated if the patient is not willing to accept a smaller breast and the potential risks and complications that may result.
If nipple sensation is essential to a patient's intimacy and satisfaction, this surgery should not be performed.
The scars that normally result from this procedure also must be accepted completely without reservation.
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