eMedicine Specialties > Plastic Surgery > Breast

Breast Reduction, Amputation

Curtis S F Wong, MD, Clinical Instructor, Department of Family Practice, Division of Surgery, Mercy Medical Center

Updated: Oct 15, 2009

Introduction

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.

Preoperative status of breasts with lateral nipple displacement. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

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.² 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.³

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.

Problem

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.

Etiology

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.

Presentation

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.
• Problems may be a related to hygiene (eg, intertrigo, acne, hidradenitis).
• 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.

Indications

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.

Robbins⁴ suggested this procedure for excisions >1500 mL per breast, and Jackson⁵ 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.

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.

Relevant Anatomy

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 utilized. Circular excisions with purse-string closure techniques are quite effective in minimizing this problem.

Contraindications

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.

Workup

Laboratory Studies

• Perform a complete blood count to ensure anemia (hemoglobin <10 g) or thrombocytopenia are not present. (As blood loss with this procedure should be minimal, the author does not recommend autogenous banking of blood.)
• Provide photographic documentation to the insurance company for authorization and for comparison of before and after photos to help the patient appreciate what has changed.
• Other laboratory tests may be indicated depending on the additional health problems the patient may have or the medications she may be taking. This includes prothrombin time, activated partial thromboplastin time, complete or basic metabolic profiles, and urinalysis. An ECG is performed if indicated by the patient's history or if required by the surgical facility.

Imaging Studies

• Mammogram
  • It is indicated in any patient who is 40 years or older and has not undergone one in the prior 6-9 months. This is in compliance with the guidelines established by the American Cancer Society.
  • The author also considers mammography in patients older than 30 years when they have a strong family history of breast cancer.
  • Mammography (and possibly ultrasound or other imaging studies) is also used in the evaluation of palpable masses noted on physical examination.
  • Postoperative baseline mammograms are obtained approximately 6 months after the surgery or at the discretion of the surgeon. This is to provide a baseline for comparison with future mammograms and document what changes may have occurred following surgical intervention.
• Obtain chest radiographs if indicated by examination findings or the patient's history.

Other Tests

• An ECG is performed if a patient's history warrants. In addition, some surgical facilities have guidelines requiring ECGs at certain patient ages.

Diagnostic Procedures

• Manual lifting of the breasts may result in considerable relief or resolution of symptoms. This is a strong indicator that the procedure will result in relief for the patient.
• Progression of symptoms over the course of the day when upright and wearing a bra also support the probability of a health benefit following reduction surgery.

Histologic Findings

Tissue is sent for pathologic examination to rule out carcinoma or other atypia.

Treatment

Medical Therapy

No medical treatment exists for female breast hypertrophy. However, weight loss may be encouraged if past experience of weight loss led to diminished or alleviated symptoms.

Orthotic devices may assist the patient but usually places more pressure on the shoulders.

Surgical Therapy

Reduction mammaplasty is the only known method of diminishing the size of the breast.

Preoperative status of breasts with lateral nipple displacement. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Preoperative status of breasts, oblique view. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Preoperative Details

McKissock described a very reliable method of marking a patient with the WISE pattern for reduction of very large breasts by free-nipple graft.¹

• In brief, the patient is marked in a sitting position. If the breasts are connected in the midline, a modification of the medial markings is necessary to allow a complete excision.
• The sternal notch and midline are marked. A point is made on the right and left clavicle 7-8 cm away from the sternal notch. When these points are connected, it results in a level line.
• The inframammary folds are marked, and the ink is allowed to dry before releasing the breasts.
• Breast meridian lines are drawn in relation to the current nipple position by connecting the nipple to its respective clavicular mark.
  
  

  

  Marking breast meridians - medial to laterally displaced nipples. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
• Medial or lateral adjustments are made of these meridians until equidistant from the midline and over what is anticipated to be the widest part of the breast.
• An obstetric caliper is used to help transpose the distance from the clavicular marking to the inframammary fold to the front of the breast along the previously drawn meridian.
  
  

  

  Obstetric caliper used to measure distance from clavicle to inframammary fold. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Transposing caliper-measured distance to front of breast along meridian. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
• Other techniques of transposing the inframammary fold to the anterior breast also can be used, eg, the use of the surgeon's finger in the fold. Other techniques may be equally as effective.
• The nipple position, as determined by transposing the clavicle-fold distance to the front of the breast, is now modified by dropping the nipple position 1-2 cm along the meridian line, depending on the anticipated weight of the breast tissue to be removed. If the surgeon ignores this key step, the nipples will be pointing upwards after surgery with excessive lower pole fullness. McKissock describes a "springback" effect on the breast when the weight is removed.¹
  
  

  

  Positioning nipple 1-2 cm below caliper-measured distance to compensate for recoil uplift after amputation of tissues. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
• Confirmatory measurements should now be performed. Measurements from the sternal notch to each nipple should be near equal. Additional near equal measurements include the clavicular-nipple and nipple-midline distances. The nipple position should also appear level on visual inspection.
• The WISE pattern (keyhole template) is then placed over the new nipple position and traced according to the surgeon's preference. This pattern can be rotated to avoid inclusion of the areola skin in the skin flaps.
  
  

  

  Opened keyhole pattern centered around new nipple position. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
• Vertical techniques can also be utilized if the surgeon deems appropriate. This usually involves excision of lateral breast tissue, leaving a thick lateral flap to allow for an adequate excision. The remainder of this discussion is directed toward WISE pattern excisions.
• The spread between the oblique limbs can vary, but pulling the medial breast laterally and the lateral breast medially to see if the vertical lines will meet can simulate closure. If these lines cannot meet, it would be prudent to retrace the pattern with less spread of the oblique limbs to ensure the ability to close the wound.
• The length of the vertical limbs also varies depending on the patient's size and weight of her breasts. This can vary from 5-9 cm, with larger breasts requiring longer vertical limbs. If in doubt, start with a long limb and trim intraoperatively as needed.
• A point is selected laterally to the breast where the breast mound appears to end and blend into the lateral thorax or lateral thoracic roll.
• With the breast held up, this lateral point is drawn downwards medially, perhaps staying a centimeter above the existing inframammary fold.
• This lateral point is also connected to the bottom of the lateral vertical limb with an S-shaped incision, starting almost perpendicular to the previously drawn line.
• This allows more pull laterally, helping to flatten the usually protuberant lateral pole. The patient is then placed supine and the medial lines are drawn, connecting at a point under the medial breast fold.
• View completed pattern markings on the patient.
  
  

  

  Patterns marked. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Pattern marking completed with lateral/medial extensions. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
• If a central connection (nonexistent intermammary distance) exists between breasts, one can refer to Dr. McKissock's monograph Color Atlas of Mammaplasty. This sequence of demonstrative photographs is reprinted with permission from that monograph.¹
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
  

  

  Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  

Intraoperative Details

After induction of general anesthesia, the patient's arms are abducted 90° on padded arm boards and secured with Sof-Rol or Kerlix or a similar technique used to secure extremities.

Appearance of patterns when supine. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

• Sequential compression devices are usually started prior to induction of anesthesia to prevent deep vein thrombosis and potential embolization.
• A Foley catheter is placed at the discretion of the surgeon or anesthesiologist. The chest is prepared and draped in the usual fashion.
• Xylocaine (1%) with epinephrine is injected along the planned incision lines to aid in hemostasis and minimize blood loss. This simple step remarkably reduces bleeding during the procedure.
• A towel clip is used to hold the breast up, and a lap sponge is placed around the base of the breast, similar to commercial breast tourniquets. The nipple is harvested as a full-thickness graft after outlining the nipple-areolar complex with a Padgett nipple marker and stored in a saline sponge.
• The new nipple position (graft site) is then de-epithelialized.
  • The inframammary incision is then made and carried down to the fascia, elevating the breast off the wall, until the inferior aspect of the retained breast flaps is reached. If the decision is to leave an inferiorly based, deepithelialized flap for enhancing projection, this step is performed first, then the transverse incision is made along previous markings and at the cephalad edge of the deepithelialized pyramid. This pyramid is centered under the anticipated vertical closure incision and its width is dependent on the amount of tissue that can be spared and how much projection is desired.
    
    

    

    Inferior pyramid of tissue to be de-epithelialized for improving nipple projection. Image courtesy of Curtis Wong, MD.

    
    
    

    

    Removal of nipple and deepithelialization of graft site (ie, new nipple site). Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

    
    
    

    

    Through the inframammary incision, the breast tissue is dissected off the pectoralis muscle up to the medical and lateral extensions of planned upper incisions. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

    
    
  • If the breasts are so large that leaving the central portion of the keyhole below the nipple graft site would not jeopardize meeting insurance company requirements, this skin can be deepithelialized and even transferred to sub-graft site similar to autoaugmentation techniques described by Ruth Graf, MD. This maneuver also helps with nipple projection.
• Other techniques to help improve breast projection include the following:
  • As mentioned above, Koger suggested a technique that involves preserving an inferior-based (along the inframammary fold) de-epithelialized flap with a tapering, oblique excision of the glandular tissue to the muscle fascia.⁶
  • Another technique was described by Abramson; it involves "a dermal pedicle 9 cm wide at the base that extends superiorly to a point halfway between the inframammary fold and the nipple."⁷ This pedicle then could be trimmed intraoperatively to give the desired nipple projection. A superiorly based dermoglandular flap can also be created by deepithelializing (as opposed to excising) the tissue between the vertical markings of the Wise pattern that is invaginated when the vertical skin edges are reapproximated. An excellent illustration accompanies Abramson's article.⁷
  • McKissock suggested "stair casing" the incision and retaining glandular tissue along the excision line to help with providing breast tissue for projection.¹
    
    

    

    Resection by "staircasing" the breast tissue or beveling away from the skin edges preserves breast tissue that may help with improving nipple projections. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

    
    
  • Fredricks suggested a keel-shaped excision of the keyhole to prevent excess flattening.⁸ Closure is accomplished by liberal irrigation and meticulous hemostasis followed by placement of a drain that is brought out laterally and secured.
• Matarasso has questioned the need for drains.⁹ He compared the complication rate of 50 patients without drains to statistics from previous studies. His conclusion was that routine drainage was unnecessary and should be reconsidered. However, in the author's experience, drains have not increased morbidity. As drainage can be considerable, the author prefers to use drains.
• Traction on the lateral flap provides most of the coverage of the resultant defect. This allows flattening of the lateral pole and diminishes the need for the medial flap to be pulled excessively. Pulling the medial flap laterally in excess results in breasts appearing like "aviator glasses" and lacking the medial fullness of an unoperated breast.
  
  

  

  Plication of graft bed with fine chromic sutures to flatten graft site prior to grafting. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

  
  
• Key sutures are placed using heavy absorbable sutures to reapproximate the skin edges (breast pillars if applicable), then more interrupted, buried, absorbable sutures are placed in the vertical and inframammary fold dermis, burying the knots.
• Closure of the skin is accomplished as per the preference of the surgeon. The nipple-graft sites are prepared by invaginating any protrusions or dog-ears with 5-0 absorbable suture.
  • The site is kept moist until the graft is placed on it. The nipple grafts are defatted, and then placed into the graft sites where they are positioned with interrupted 5-0 Prolene sutures to stretch out the graft. A running peripheral 5-0 Prolene suture is used to approximate skin edges.
  • The graft is covered with a bolster dressing fashioned from Xeroform gauze and oil-moistened cotton balls.
  • The bolster dressing is secured with widely placed 3-0 Prolene horizontal mattress sutures, which are left in place for at least 10 days.
    
    

    

    Appearance after bolster secured with method of surgeons choice. Leave it on for 10-14 days to maximize take of nipple. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

    
    
  • Dressing is then positioned per the surgeon's preference, and the breast is placed into a light brassiere.

Postoperative Details

• The dressings are left in place if there are no problems.
• Drains are removed in 3-4 days if the drainage is less than 30 cc/day. Vertical and fold dressings are changed in the same visit and continued until drainage ceases.
• Vertical sutures are removed after 1 week, and the fold sutures are removed 11-14 days postoperatively. The bolster dressing is also removed at this time. McKissock suggests removal of the bolster dressing after a 2-week period.¹
• Breasts may get wet during showers after the bolster dressings have been removed. The patient should blot the nipple grafts dry until certainty of take.
• The nipple tip is likely to necrose and slough. Topical ointment and gauze is used to dress the nipple until it has healed.

Follow-up

• The patient is seen after 3-4 days for removal of the drain and change of dressing. In addition, vertical sutures/staples are removed, and the wound is steri-stripped.
• The patient returns again after 10-14 days when the bolster dressing, nipple sutures, and inframammary fold sutures are removed.
• She then returns after 3-4 weeks and again after 2 months assuming no complications exist. Photographs are taken at the last visit.
• A baseline mammogram is considered for the following reasons:
  • Strong family history of breast cancer
  • Suggestive lesions in preoperative mammograms
  • Patient requires one because it is time according to American Cancer Society guidelines
• She should continue with breast self-examinations on a regular basis.

Complications

Additional possible complications include asymmetry, contour irregularities, skin or nipple loss, inability to breastfeed, nipple numbness, skin flap necrosis, high-riding nipple (aka bottoming out), over or under resection, wound complications, and poor scarring.

The patient's desired breast size and appearance may not be met with this procedure. Significant weight loss following reduction surgery may lead to diminished breast size to where an augmentation could be considered.

Outcome and Prognosis

Most patients polled postoperatively express considerable relief from their symptoms and satisfaction with the end result.

Many are encouraged to start weight loss programs, which are easier to participate in because of a patient's increased mobility.

There is less risk for "bottoming out" following this technique and better long-term preservation of the desired breast shape.

Full, unrestricted activities may be resumed one month after surgery with the use of a good quality sports bra (assuming there are no surgical complications).

Preoperative photograph of the breasts of patient A. Image courtesy of Curtis Wong, MD.

Postoperative photograph of the breasts of patient A. Image courtesy of Curtis Wong, MD.

Preoperative photograph of the breasts of patient B. Image courtesy of Curtis Wong, MD.

Postoperative photograph of the breasts of patient B. Image courtesy of Curtis Wong, MD.

Future and Controversies

Continuous efforts are being made to find methods, such as the vertical mammaplasty by Lejour, that decrease scars yet produce predictable results.

The vertical pattern has been applied to nipple grafting techniques of breast reduction with satisfactory outcomes.

Theoretically, this technique removes most, if not all of the ductal tissue and should decrease risks for ductal carcinomas.

Multimedia

Media file 1: Preoperative status of breasts with lateral nipple displacement. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 2: Preoperative status of breasts, oblique view. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 3: Marking breast meridians - medial to laterally displaced nipples. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 4: Obstetric caliper used to measure distance from clavicle to inframammary fold. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 5: Transposing caliper-measured distance to front of breast along meridian. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 6: Positioning nipple 1-2 cm below caliper-measured distance to compensate for recoil uplift after amputation of tissues. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 7: Opened keyhole pattern centered around new nipple position. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 8: Intermammary webbing in extremely large breasts. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 9: Patterns marked. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 10: Pattern marking completed with lateral/medial extensions. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 11: Appearance of patterns when supine. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 12: Inferior pyramid of tissue to be de-epithelialized for improving nipple projection. Image courtesy of Curtis Wong, MD.

Media file 13: Removal of nipple and deepithelialization of graft site (ie, new nipple site). Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 14: Through the inframammary incision, the breast tissue is dissected off the pectoralis muscle up to the medical and lateral extensions of planned upper incisions. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 15: Resection by "staircasing" the breast tissue or beveling away from the skin edges preserves breast tissue that may help with improving nipple projections. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 16: Direct closure results in dog ears in the graft bed and at the ends of the incisions; circular excisions of dog ears with purse-string closure dramatically reduces or eliminates dog ear. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 17: Plication of graft bed with fine chromic sutures to flatten graft site prior to grafting. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 18: Appearance after bolster secured with method of surgeons choice. Leave it on for 10-14 days to maximize take of nipple. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 19: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 20: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 21: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 22: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 23: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 24: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 25: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 26: Images 19-26: Sequence of photos to display management of medial webbing in extremely large breasts if incisions need to be carried across midline. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

Media file 27: Preoperative photograph of the breasts of patient A. Image courtesy of Curtis Wong, MD.

Media file 28: Postoperative photograph of the breasts of patient A. Image courtesy of Curtis Wong, MD.

Media file 29: Preoperative photograph of the breasts of patient B. Image courtesy of Curtis Wong, MD.

Media file 30: Postoperative photograph of the breasts of patient B. Image courtesy of Curtis Wong, MD.

References

1. McKissock P. Color Atlas of Mammaplasty. Thieme Medical Publishers;1991:47-78.

2. Hawtof DB, Levine M, Kapetansky DI, Pieper D. Complications of reduction mammaplasty: comparison of nipple-areolar graft and pedicle. Ann Plast Surg. Jul 1989;23(1):3-10. [Medline].

3. American Society of Plastic and Reconstructive Surgeons. Clinical Practice Guidelines for Female Breast Hypertrophy/Breast Reduction. 1993.

4. Robbins TH. Reduction mammaplasty by the Robbins technique. Plast Reconstr Surg. Feb 1987;79(2):308-9. [Medline].

5. Jackson IT, Bayramicli M, Gupta M, Yavuzer R. Importance of the pedicle length measurement in reduction mammaplasty. Plast Reconstr Surg. Aug 1999;104(2):398-400. [Medline].

6. Koger KE, Sunde D, Press BH. Reduction mammaplasty for gigantomastia using inferiorly based pedicle and free nipple transplantation. Ann Plast Surg. Nov 1994;33(5):561-4. [Medline].

7. Abramson DL. Increasing projection in patients undergoing free nipple graft reduction mammoplasty. Aesthetic Plast Surg. Jul-Aug 1999;23(4):282-4. [Medline].

8. Fredricks S. Re: Reduction mammaplasty for gigantomastia using inferiorly based pedicle and free nipple transplantation. Ann Plast Surg. May 1995;34(5):559. [Medline].

9. Matarasso A, Wallach SG, Rankin M. Reevaluating the need for routine drainage in reduction mammaplasty. Plast Reconstr Surg. Nov 1998;102(6):1917-21. [Medline].

10. Bostwick J. Plastic and Reconstructive Breast Surgery. 2^nd ed. Quality Medical Publishing; 2000.

11. Casas LA, Byun MY, Depoli PA, Gradinger GP. Maximizing breast projection after free-nipple-graft reduction mammaplasty. Plast Reconstr Surg. Apr 1 2001;107(4):961-4. [Medline].

12. Farina R, Villano JB. Reduction mammaplasty with free grafting of the nipple and areola. Br J Plast Surg. Oct 1972;25(4):393-8. [Medline].

13. Letterman G, Schurter M. A comparison of modern methods of reduction mammaplasty. South Med J. Oct 1976;69(10):1367-71. [Medline].

14. Netscher D. Mammography and Reduction Mammaplasty. Aesthetic Surg J. 1999;19(6):445.

15. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure?. Ann Plast Surg. Sep 1991;27(3):232-7. [Medline].

Keywords

breast reduction, breast amputation, reduction mammaplasty, nipple graft mammaplasty, amputation mammaplasty, free nipple graft, free nipple transplantation, mammogram, breast flaps, WISE pattern excisions

Contributor Information and Disclosures

Author

Curtis S F Wong, MD, Clinical Instructor, Department of Family Practice, Division of Surgery, Mercy Medical Center
Curtis S F Wong, MD is a member of the following medical societies: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and California Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

James Neal Long, MD, Assistant Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of Alabama at Birmingham and Kirklin Clinics
James Neal Long, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor Saleh M Shenaq, MD, to the development and writing of this article.

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