The purpose of bilateral breast reduction surgery is to reduce the size of hypertrophic breasts. Occasionally, unilateral breast reduction is performed to create symmetry with a smaller or reconstructed contralateral breast. The vertical, bipedicle, reduction mammaplasty is one of various techniques employed by some surgeons to reduce breast volume. Any breast reduction technique should prioritize patient safety, demonstrate reproducibility, and maintain breast aesthetics.
History of the Procedure
The bipedicle (full thickness vertical dermal flap) breast reduction, or McKissock reduction mammaplasty, has long been a standard to which other operative methods of breast reduction have been compared. Paul Kendrick McKissock, a California plastic surgeon, published his procedure in the March 1972 issue of Plastic and Reconstructive Surgery.  He initially developed the procedure as a modification of the Strombeck procedure  and refined it during the decade preceding publication. He is credited with making it a safe and reproducible operation. Since that time, his original technique has been modified by many surgeons, but the original principles have remained.
Women with macromastia can develop back and neck pain. The shoulders can become progressively notched from the pressure of the bra straps. The area under the breast can often develop intertrigo, which is characterized by frequent rash and skin breakdown. Frequent headaches may occur. Physical activity can be cumbersome and positioning for sleep may be difficult. Presently, only operative treatment can correct female breast hypertrophy. Breast reduction surgery alleviates the symptoms produced by mammary hypertrophy. The vertical bipedicle reduction mammaplasty can be adapted to the entire range of size and volume encountered in breast hypertrophy.
For information on other breast reduction techniques, see the Breast section of Medscape Reference’s Plastic Surgery journal.
The number of breast reduction procedures performed each year has increased. According to a recent publication by the American Society for Aesthetic Plastic Surgery, breast reduction was the fifth most frequent cosmetic procedure performed in the United States in 2006.  A total of 145,822 patients that underwent this procedure, although no specific information is available as to the specific techniques used in each surgery. 
In a study published in 2004, Rohrich et al reported that the McKissock technique is used by 4.8 percent of US plastic surgeons.  The most common technique is the inferior pedicle technique, used by 44.1 percent of the plastic surgeons surveyed.  The McKissock technique represents the fifth most commonly preferred technique in the United States.
Bilateral breast hypertrophy presents at puberty or soon thereafter. Teenage females with large breasts frequently report that they are subjected to ridicule from their peers. This can represent the psychosocial component of the problem. Some women develop breast hypertrophy during pregnancy that persists even beyond. In extremely rare instances, rapidly progressive unremitting breast enlargement known as virginal breast hypertrophy may occur.
The symptoms of female breast hypertrophy relate to muscular discomfort. Patients report back pain, neck pain, shoulder discomfort, and even headache. Patients report poor posture due to the excessive weight of the breasts. Occasionally, ulnar nerve paresthesia can occur. Poor hygiene in the submammary crease leads to irritations, rashes, and even cutaneous infections.
Shoulder grooves develop over time from the pressure exerted by bra straps. If a bra is not worn, activities and even sleep may be difficult. Women with large breasts frequently report that they cannot participate in sports. Once this affects the patient's activities of daily living, the patient seeks medical attention.
Physical examination confirms the diagnosis of breast hypertrophy and attempts to rule out the possibility of breast cancer. Breast examination is typically performed with the patient in the seated and then recumbent positions. The breasts are assessed for any lumps, masses, scars, skin dimpling, or nipple discharge. The distance from the sternal notch to the nipple is often greater than 21 cm. The position of the nipple-areola complex (NAC) is noted in relation to the rest of the glandular tissue and the inframammary fold (IMF). Body surface area and excess breast tissue weight are estimated.
Secondary skeletal effects are examined by asking the patient to lean forward and examining vertical spinal alignment. Bra strap grooves are assessed for depth and skin breakdown. Intertrigo is assessed by lifting each breast and closely examining the skin for breakdown and rashes. Preoperative photographs to document mammary hypertrophy complete the physical examination.
The treating plastic surgeon may seek the help of a general surgeon for evaluation of breast nodularity or an abnormal mammogram. Consultation with a spine surgeon is recommended to assess the back pain. Orthopedic surgeons may need to assess the patient for shoulder or other musculoskeletal pain.
See the list below:
Muscular pain in the neck, shoulder, and back as a result of mammary hypertrophy
Shoulder grooving from bra straps
Intermittent intertrigo in the submammary region or cleavage area
Alteration of activities of daily living as a result of enlarged breasts
The female breast is a glandular structure that varies in volume and shape. It occupies the area overlying the second to sixth ribs extending from the sternum to the anterior axillary line (see the image below). The center of each nipple-areola complex lies approximately 21 cm from the sternal notch. In women with mammary hypertrophy, that distance is longer and can sometimes reach more than 40 cm.
The arterial supply of the breasts is from the lateral branches of the intercostal arteries, the lateral thoracic artery, and the perforating branches of the internal mammary artery. The nipple receives most of its blood supply from musculocutaneous perforating vessels from the pectoralis major muscle. These vessels travel through the breast tissue and supply the nipple-areola complex. An additional and substantial dermal plexus of arteries also supplies the nipple-areola complex and forms the basis of the vertical bipedicle technique.
The anterior cutaneous branches of the first to seventh intercostal nerves innervate the skin of the medial breast and the lateral cutaneous branches of the second to seventh intercostal nerves the lateral breast. The anterior and lateral cutaneous branches of the fourth intercostal nerve innervate the nipple-areola complex. Additional innervation to this complex is by the cutaneous branches of the third and fifth intercostal nerves.
For more information about the relevant anatomy, see Breast Anatomy.
The main contraindication for breast reduction surgery is the patient's preoperative medical condition. Patients with history of coronary arterial disease, thromboembolic disease, chronic lung disease, and chronic kidney disease are often not good candidates for surgery in general. An evaluation by the patient's primary physician is important in determining whether she is a good candidate. Patients who smoke are encouraged to stop smoking at least 4 weeks before surgery and not smoke for at least 4 weeks after the surgery.
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