Scientific Forum

Special Topic

Breast Reduction Techniques and

Outcomes: A Meta-analysis

Stephen P. Daane, MDa; and W. Bradford Rockwell, MDb

Background: Although sequelae such as visible scarring often are an expected result
of reduction mammaplasty, successful aesthetic outcomes depend on the surgeon’s
thorough understanding of the available techniques.
Objective: A literature review was undertaken to compare published outcome data for
the five classical reduction mammaplasty techniques as described by Pitanguy, Skoog,
McKissock, Goldwyn, and LeJour.
Methods: Complication rates, patient satisfaction, and symptom relief are reviewed.
Management of common pitfalls is discussed.
Results: Reported complication rates range from 6.5% to 22% for reduction
mammaplasty, whereas reported patient satisfaction rates range from 80% to 95%.
Reported rates of symptom improvement range from 70% to 100%, with a dramatic
improvement in psychological well-being.
Conclusion: It is hoped that an understanding of the principles and caveats published by
the originators of these five techniques will promote enhanced skill in performing reduc-
tion mammaplasty.

B
ased on patient satisfaction, breast reduction is one of the most successful opera-
tions performed by plastic surgeons. It allows women greater comfort during
physical activity, relieves weight-bearing pain in the neck, shoulders, and back,
and may improve a woman’s self-esteem. Although the exact pathophysiology of breast
hypertrophy is unknown, the condition is believed to be the product of abnormal end- From Manhattan Eye, Ear & Throat
Hospital, New York University, NYa;
organ response to estrogen. More than 68,000 breast reductions are performed in the
and the Plastic Surgery Division,
United States each year,1 with more than 100 techniques described in the literature. University of Utah Health Sciences
Center, Salt Lake City, UT.b

A History of the Techniques Accepted for publication March 24,

1999.
Breast reductions have been performed for hundreds of years; the original procedures Reprint requests: W. Bradford
were breast amputations. In 1922, Thorek2 reported on free nipple-areola grafts with Rockwell, MD, Plastic Surgery
Division, University of Utah Medical
reduction. This safe, rapid procedure provides an acceptable cosmetic result and has a Center, Salt Lake City, UT 84132.
low complication rate in older and high-risk patients, as well as in patients with very
Copyright © 1999 by The American
pendulous breasts or those undergoing a resection of 2000 g or more.3 Lexer,4 in 1912, Society for Aesthetic Plastic
and von Kraske,5 in 1923, developed the first de-epithelialized nipple-areolar pedicle Surgery, Inc.

techniques. In 1928, Biesenberger6 reported on the parenchymal pedicle technique, 1084-0761/99/$8.00 + 0

which involved wide undermining of skin flaps and resection of the lateral quadrants. 70/1/100635

AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 1999 293

 Scientific Forum
Figure 1. The Biesenberger parenchymal pedicle technique6 involved
wide undermining of skin flaps and resection of the lateral breast quad-
rants. The breast was re-formed with lateral-superior rotation.
Although this technique carried a high incidence of skin necrosis due to
wide undermining of the flaps, it remained the most popular breast
reduction method for almost 30 years.
Figure 2. The Wise keyhole pattern, based on brassiere patterns from
Frederick’s of Hollywood, is the basic design used in most breast reduc-
tion procedures today. A wire keyhole pattern is available commercial-
ly.79 A, Strombeck technique, B, Skoog technique, C, McKissock
technique, D, Pitanguy technique, and E, inferior pedicle technique.
The breast was re-formed with lateral-superior rotation
(Figure 1). Although the Biesenberger technique resulted
in a high incidence of skin and nipple necrosis, it
remained the most popular breast reduction method for
almost 30 years. In 1956, Wise7 ushered in the modern
era of breast reduction by creating the “keyhole” pattern
and emphasized the importance of preoperative marking.
He used brassiere patterns from Frederick’s of
Hollywood to develop his incisions. The Wise keyhole
pattern is the basic design used in most breast reduction
procedures today (Figure 2).
McKissock8 reported the vertical bipedicle dermoglandu-
lar technique in 1972, which until recently was the most
frequently performed breast reduction procedure in the
294 AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST
Figure 3. McKissock technique. The vertical bipedicle technique is
commonly used because of a low rate of nipple necrosis and repro-
ducibly good results. McKissock8,80 believed that use of the narrowest
angle possible between the limbs of the Wise keyhole pattern and the
addition of the “lazy-S” closure helped to avoid the boxy breast. These
maneuvers constrict the skin envelope of the breast medially and lateral-
ly while retaining a relative excess of skin centrally, contributing to a
desired “conical” shape. After medial and lateral dermoglandular trian-
gles are resected, additional tissue is resected from beneath the vertical
flap, converting it to a bipedicled “bucket handle.” The flap is thin
superiorly and thick below, with a stout inferior base maintained on the
thoracic wall and inframammary dermis. The nipple is elevated to its
final location by folding the flap. A vertical pedicle length of up to 50
cm has been used by McKissock.81
Figure 4. Pitanguy technique. Glandular resection is performed in a
“keel-like” fashion while elevating the new nipple site at point A with a
Kocher clamp. The “keel” can be thought of as a disk of breast tissue
with a triangular pyramid superimposed on top of it. “Pillars” of the
medial and lateral breast flaps are invaginated with sutures to create a
conical shape for the breast. Pitanguy continues to make use of a plaster
cast after surgery.82
United States (Figure 3). Other techniques include the
horizontal dermal pedicle technique,9 the superior/hori-
zontal dermoglandular technique10 (Figure 4), the superi-
or dermal pedicle technique11 (Figure 5), the inferior
dermoglandular pedicle technique12-15 (Figure 6), and the
vertical mammaplasty technique with liposuction16
(Figure 7). Recently, surgeons have attempted variants of
these techniques in search of a “short-scar” reduction
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Figure 6. The inferior pedicle technique, which was reported on by sev-

eral authors independently,12-15 was developed in an attempt to main-
tain nipple sensitivity and to preserve lactation after breast reduction.
The inferior borders of the medial and lateral skin flaps are drawn
straight so that their combined length is 1 to 2 cm longer than the infra-
mammary incision. The base of the inferior dermal pedicle is marked 1
Figure 5. Skoog technique. Skoog11 was the first to describe transposi- cm above the inframammary fold so that the final scar is not irritated by
tion of the nipple on a vascularized dermal pedicle without underlying a brassiere. Five cm is most commonly chosen for the Wise keyhole
glandular tissue. Skoog believed that an inferior resection diminished pattern limbs. A 3:1 pedicle length/width ratio is recommended; the
the possibility of future breast ptosis. The dermal pedicle flap usually width of the inferior pedicle typically measures 8 to 10 cm, although
measures 10 to 12 cm in length, encircling the areola by at least 1.5 cm Georgiade et al83 emphasize the importance of leaving wider “pyrami-
to preserve the periareolar vascular plexus. A laterally-based flap was dal” attachments to the pectoralis major muscle.
chosen, although the circulation of a medially-based flap is also ade-
quate. The nipple flap is undermined to give a thickness of 0.5 to 1 cm.
A small “back-cut” excision at the superior edge of the flap permits it to
rotate superiorly without compression. Medial and lateral segments of
glandular tissue are sutured to create a “cone” shape for the breast.
Table 1. Symptoms and results of reduction
mammaplasty with Skoog’s method in 149
mammaplasty.17-24 However, the trade-off with short- patients*
scar techniques for large reductions is often a less satis-
Cured or
factory breast shape. For the patient with “minimal
Reason for Patients Mean age improved
hypertrophy,” the periareolar reduction-mastopexy tech- operation (%) (y) (%)
nique of Goes25 yields an excellent aesthetic result,
Headache 2 64 100
although the polyglactine-polyester mesh used by Dr. Psychic reasons 4 37 100
Goes is not available in the United States. This technique Hygienic reasons 13 42 100
is based on the principle that the skin envelope alone Indenting bra straps 41 44 98
does not prevent early ptosis. Cosmetic reasons 41 32 98
Thoracic-lumbar pain 52 38 91
Indications Shoulder-arm pain 50 42 85
Neck pain 31 43 83
Breasts that are out of proportion to the body habitus Mastodynia 6 36 80
may have adverse effects on the musculoskeletal system.
*The average reduction was 1100 g per breast.
Patients are commonly seen with complaints of neck,
back, and shoulder pain or arthritis, postural defects
(kyphosis) from attempting to hide large breasts, and
deep ridges over the shoulders from brassiere straps26
(Table 1). Breast reduction may alleviate intertriginous may participate in exercise programs after breast reduc-
rashes and ulnar paresthesias.27 Psychological problems tion, resulting in improvement of their overall health.
related to body image are believed to be considerable. Goldwyn28 found no improvement in pulmonary func-
Women who gain weight to “hide” their large breasts tion after reduction mammaplasty.

Breast Reduction Techniques and Outcomes: AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 1999 295
A Meta-analysis
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B
Figure 7. Lejour technique. Vertical mammaplasty was originally
developed by Dartigues84 in 1925 for mastopexy and by Lassus85 in
1981 for reduction. It uses an upper pedicle for the nipple-areola com-
plex, and a central breast reduction with lower skin undermining.
Vertical markings are drawn on the inferior breast after pushing the
breast superomedially and superolaterally. The lower marking extends
to just above the inframammary fold. The top of the periareolar “dome
of a mosque” marking is made 2 cm superior to the chosen new nipple
site (the area within the “mosque” is deepithelialized); the total length
of the mosque markings that accommodate the new nipple is 14 to 16
cm. Liposuction is performed in 50% of breasts to make modeling of
the gland easier. The skin is incised and undermined, leaving a 0.5-cm
fat layer under the skin flaps lateral, medial, and inferior to the sub-
mammary fold. Dissection proceeds upward behind the breast. After the
central breast is partially excised, the remaining breast tissue is elevated
by posterior fixation to the chest wall. A, The nipple is transposed on its
superior pedicle, and the anterior breast is plicated to create a “cone,”
which will keep tension off of the skin. B, Vertical skin suturing “gath-
ers” the breast flaps and reduces their vertical length by 6 to 7 cm while
the breast seems to “bulge” in the superior pole. Overcorrection is
believed to produce better late results16; final shape is expected by 2 to 8
weeks after surgery. A significant advantage of this technique is the
absence of a horizontal scar. Lejour34 reports excellent results, although
it is common for other surgeons to report poor results during the
“learning curve.”
Because insurance carriers often use the standard of
500 g of tissue removed per breast as a cutoff point to
determine whether a breast reduction is “reconstructive”
or “cosmetic,” surgeons should carefully document
symptoms, including pain, posture, shoulder grooves,
and intertrigial excoriations that would substantiate the
need for a “medical” reduction. The origins and rationale
296 AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST
A B
Figure 8. Marcus43 classified nipple-areolar circulation into three types:
A, circular (70%), in which the internal mammary artery and lateral
thoracic arteries anastomose in a typical circumareolar ring to supply
the nipple; B, loop (20%), in which the medial and lateral branches
anastomose above and below the nipple, forming a loop; and C, radial
(6%), a tenuous configuration in which a strong anastomotic vascular
supply is lacking.
of the arbitrary standard of 500 g of tissue per breast is
unknown. On the basis of normative values, Schnur et
al29 calculated that a woman of 5 ft 3 in height and
weighing 140 lb would require only 300 g removed from
each breast for “purely medical” reasons, or 200 g
removed per breast for “mixed cosmetic and medical”
reasons. At less than 200 g per breast, the operation
would be considered a purely cosmetic procedure.29
Complication Rates
Table 2 compares the complication rates for the five
classical techniques. In Pitanguy’s30 series, which
included 2822 cases from 1962 to 1987, the superior
dermoglandular pedicle technique had an overall com-
plication rate of 6.5%. Kinell et al26 reported a compli-
cation rate of 17.7% in 149 of Skoog’s patients up to
5 years after the superior dermal pedicle technique was
performed. McKissock31 noted an 18% incidence of
partial nipple loss, dehiscence, and “unsightly” scar-
ring, plus “several” patients with skin infection or
necrosis in a series of 52 patients who underwent
surgery with the vertical bipedicle technique. In a com-
prehensive review of the inferior pedicle dermoglandu-
lar technique, Mandrekas et al32 noted an 11.4%
incidence of complications in 371 patients, whereas
Bolger et al33 reported a 13.6% complication rate in
300 patients after reduction with an inferior pedicle
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Table 2. Complication rates for five classical techniques*

Lejour

With Without
Pitanguy Skoog McKissock Mandrekas Bolger suction suction
(2822 (149 (52 (371 (300 (~85 (~135
patients) patients) patients) patients) patients) patients) patients)
(%) (%) (%) (%) (%) (%) (%)
Glandular necrosis/ — 1.3 >4 5.4 2.0 8.2 1.5
dehiscence
Cutaneous problems/ 3.8 6.9 “Several” 0.3 6.2 11 2.2
delayed healing
Hematoma/seroma 0.4 2.5 — 0.3 1.2 14 9.6
Areolar problems/ 0.9 1.3 6 0.8 — 1.1 0.7
nipple necrosis
“Unsightly”/ 1.4 4.4 ~58* 3.3 — — —
hypertrophic scarring
“Sagging”/ — 1.3 ~50* 0.3 1.5 — —
contour revisions
Altered nipple/ — — ~70* 1.3 2.3 — —
breast sensation
Occult cancer 1.5 — — 0.5 — — —
Pulmonary embolus — — — — 0.4 — —
Total reported by author 6.5 17.7 18 11.4 13.6 22.2
(11.2% of breasts)

*There was standardization in reporting or adjustment for the amount of tissue resected. (Note: frequently the complication rates reported
by the authors do not equal the totals reported in their published articles).

“glandular-only” technique. Interestingly, in the latter Infection

study there were no problems with nipple vascularity in
spite of division of the inferior dermal bridge. Lejour34
reported complications in 11.2% of 417 breasts (a
21.2% complication rate in 220 patients) with the ver-
tical mammaplasty technique.
Hematoma
Strombeck35 reported hematoma in 2.7% of 671
patients; McKissock36 reported hematoma in 2.2% of
360 patients; Kinell et al26 reported hematoma in 2.5%
of 149 of Skoog’s patients; Lejour34 reported hematoma
or seroma in more than 10% of 220 patients; and
Mandrekas et al32 reported a 0.3% incidence of
hematoma in 371 patients undergoing reduction with
the inferior pedicle technique with suction drains.
Drains are usually recommended during the first 24
hours after surgery to prevent hematoma. Preoperative
infiltration of dilute epinephrine has been shown to
reduce blood loss by 50% when compared with the
noninfiltrated side.37
Because breast ducts harbor bacteria (Staphlococcus
aureus and Propionibacterium acnes), breast reductions
are subject to infection at a higher rate than other
“clean” surgical procedures. In a series of 406 patients
who underwent reduction mammaplasty by the inferior
pedicle or Strombeck techniques, infection requiring
antibiotics occurred in 12%.38 Perioperative antibiotics
are routinely used; a study of antibiotic use in 2587 sur-
gical procedures of the breast found that 38% of predict-
ed infections were prevented.39
Nipple or “T” Junction Necrosis
Maliniac’s40 dissection and x-ray injection studies eluci-
dated contributions of the internal mammary, lateral tho-
racic, and intercostal arteries to the breast circulation via
the medial and lateral mammary arteries. Over-reliance
on the de-epithelialized dermal bridge as a vascular struc-
ture in inferior pedicle reductions may lead unwary sur-
geons to over-resect breast parenchyma containing the
more important deep perforators.33 Cooper41 demon-

Breast Reduction Techniques and Outcomes: AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 1999 297
A Meta-analysis
 Scientific Forum
strated a rich subdermal arterial and venous plexus to the
nipple-areolar complex. Aufrict42 noted that complica-
tions arose when either the nipple-areola complex is sep-
arated from its dermal blood supply or when glandular
tissue is separated from its cutaneous blood supply.
Marcus43 classified nipple-areolar circulation into the cir-
cular (70%), loop (20%), and radial (6%) types. The
radial areolar circulation type is a tenuous configuration
in which a strong anastomotic vascular supply is lacking
(Figure 8); patients with this type of nipple-areolar circu-
lation are possibly the ones in whom nipple necrosis
developed even when the operation proceeded well tech-
nically. If the nipple-areola appears blue and engorged,
sutures should be removed to rule out pedicle torsion or
hematoma. If survival is questionable, the nipple may be
removed and replaced as a free graft more inferiorly on
the dermal pedicle. Leeches may also be considered in
cases of severe venous congestion.44 The incidence of skin
dehiscence at the “T” junction was 4.6% in 371 inferior
pedicle breast reductions, which were left to heal by sec-
ondary intention.32 Suturing toward the midline is prac-
ticed to decrease tension centrally at the “T.”
Fat Necrosis
Fat necrosis is more common in larger resections.
Strombeck35 reported a 16% incidence of fat necrosis in
obese patients having resections of more than 1000 g.
However, the incidence of fat necrosis has been reported
as low as 0.8% in 371 patients undergoing an average
resection of 870 g per breast.32 Debridement with saline
solution–soaked wet to dry dressing changes are the time-
honored treatment. Firm nodules may require excision
because they may mimic malignancy.
Asymmetry and the “Boxy” and “Flat” Breast
Asymmetry may develop up to several years after reduc-
tion; unfavorable results in terms of contour and shape
can only be judged after at least 18 months. Patients also
should be counseled regarding the possibility of postpreg-
nancy ptosis. “Bottoming out” may occur as a result of
stretching of the skin beneath the breast, leaving the nip-
ple-areola complex too high, thus requiring inferior skin
resection or a prosthesis. The “boxy” breast may result
from tight midline closure with relative over-resection of
the central breast mass. Horizontal incisions with a
“lazy-S” pattern are designed to constrict the skin enve-
lope of the breast medially and laterally, while retaining a
relative excess of skin centrally and thereby contributing
to a desired “conical” shape.31 Tacking sutures to sus-
pend the inferior pedicle to the chest wall (or choosing a
298 AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST
superior pedicle reduction) may prevent the “flat
breast.”45 Breast projection may also be enhanced by
widening the angle of the limbs of the Wise pattern to
greater than 90 degrees.46
Dog-Ears
Dog-ears resulting from mismatch in the length of the
submammary incision and the medial/lateral breast flaps
can be avoided by triangulating the Wise pattern mark-
ings with a 2-0 silk suture to check for symmetry at the
beginning of the procedure (ie, E–B + C–D should equal
E–D in Figure 4). “Chasing” a dog-ear laterally onto the
chest wall can be avoided by excising redundant skin tis-
sue as tension is exerted medially toward the “T” junc-
tion. Because hypertrophic breasts in obese patients
extend into the axilla without a well-defined anterior
axillary fold, liposuction and excision of subcutaneous
tissue in the lateral upper quadrant with plication to the
chest wall will narrow the base of the reduced breast,
helping to define the anterior axillary fold and enhance
breast projection.
Occult Cancer
Malignant tumors have been found in up to 1.5% of
breast reduction specimens in reported series,47 whereas
lobular carcinoma in situ has been found in up to 8% of
breast reduction specimens in patients more than 40
years of age.48 Carcinomas discovered after breast tissue
is examined by the pathologist cannot be assayed for hor-
monal binding status because fresh, unfixed tissue is
required.49 Therefore a careful breast examination and
preoperative mammography are recommended for
patients 35 years and older and in patients with first-
degree relatives with breast cancer. If carcinoma is found,
an oncologic consultation is necessary because the patient
may require mastectomy. Caution should be exercised
when performing liposuction on a gland highly prone to
cancer, because it is extremely difficult to microscopically
examine the liposuction aspirate. The exact effect of
reduction mammaplasty on the incidence of breast cancer
is unknown. A follow-up study of 1700 patients who
underwent prophylactic mastectomy showed a lower-
than-expected incidence of breast cancer,50 whereas a
recent follow-up on 27,000 patients who underwent
breast reduction in the Canadian health care system
showed a lower incidence of breast cancer than that in
cohorts.51 Mammographic changes after reduction
mammaplasty are predictable; “coarse” calcifications
tend to develop in the second or third year in the periare-
olar and inferior portions of the breast along suture lines.
1999 Volume 19, Number 4
 Scientific Forum
The first postoperative mammogram should be per-
formed 3 to 6 months after surgery as a baseline for
future comparison. The American Cancer Society and
American College of Radiology guidelines then recom-
mend mammography every 2 years from age 40 to 49
and yearly thereafter.
Nipple-Areolar Inversion
Skoog believed that a protuberant nipple could be cre-
ated by transection of the lactiferous ducts, thereby elimi-
nating traction on the nipple. The frequency of nipple
invagination was 6% with Skoog’s technique, compared
to 18% with Strombeck’s horizontal bipedicle
technique.52 Nipple projection can be increased by
supporting the nipple on a dermal “shelf” peripherally.
It is sometimes necessary to reoperate for release of
a scar band or lactiferous duct causing retraction. A
“teardrop” or “comma” nipple seen at the conclusion of
an operation represents a mismatch between the breast
parenchyma and skin envelope. It can be corrected by use
of the “cookie cutter” pattern to resect more periareolar
skin medially and laterally.
Mondor’s Disease
Mondor’s disease is a benign, self-limiting superficial
thrombophlebitis of chest wall veins that can occur 3 to 7
weeks after breast reduction. No treatment is indicated.
Occasionally, a surgical incision may be required to
remove a thrombosed vein for pain or for cosmesis.
Hypertrophic Scarring
Hypertrophic scarring occurs most frequently at the medial
and lateral aspects of the inframammary incision and at
the circumareolar incision. Hypertrophic scars were report-
ed in 3.3% of 371 patients undergoing reduction with
the inferior pedicle technique.32 Steroid injections (triamci-
nolone every 4 to 6 weeks times 3) and Silastic® (Dow
Corning, Midland, Mich) sheeting are helpful; scar revision
may be attempted at 1 year after surgery. The inframam-
mary incision is usually marked slightly higher than antici-
pated, particularly medially and laterally to coincide with
the expected new course of the inframammary fold and
thus hide the scar; this marking is most easily performed
with the patient’s arms elevated. Hypertrophic suture
marks in the circumareolar incision are preventable by
placing everting mattress sutures intradermally (rather than
cutaneously) on the skin side of the incision.11
Nipple Too High
The ideal position of the nipple was deduced in 1955 by
Penn53 from 150 healthy adult women, 20 of whom had
Breast Reduction Techniques and Outcomes: AESTHETIC
A Meta-analysis
“aesthetically perfect breasts.” Penn noted that the
suprasternal notch and nipples form an equilateral trian-
gle, with limbs 21 cm in length. The average nipple-to-
inframammary fold length in these patients was 6.9 cm,
whereas the ideal areolar diameters were measured from
38 to 45 mm. In performing a breast reduction, place-
ment of the nipple at the level of the inframammary fold
is usually performed to create a breast corresponding to
Regnault’s grade 1 ptosis.54 Taking the average of 10
published series, 5 cm has generally been chosen as the
ideal distance for the limbs of the Wise pattern from the
areola to the submammary fold.55 In the standing
patient, the axes of the projecting nipples form a 30° to
45° angle anterior to the midline56; thus preoperative
markings with the patient in a recumbent position may
result in the “headlight deformity,” in which the axes of
the projecting nipples are parallel to each other. The
breast should be supported with one hand as the new
nipple position is marked so that “rebound” skin retrac-
tion after reduction does not bring the nipple higher.
Moving the nipple/areola to a lower position by excising
it always leaves an undesirable scar on the upper breast.
In addition, correcting a high nipple requires shortening
the areola-to-inframammary fold distance. A prosthesis
behind the breast may be required for projection beneath
the nipple.57 In a study by Reus and Mathes,58 22
patients undergoing inferior pedicle breast reduction
were monitored for 4.7 years. There was a gradual
increase in distance from the inframammary fold to the
areola, whereas the clavicle-to-nipple distance did not
lengthen.
Breast Too Small
Careful planning will prevent a resection that is too large.
Women’s brassiere sizes are calculated by subtracting the
chest girth measured under the arms from the breast girth
measured across the nipples. If the breast girth exceeds
the chest girth by 1 in, the cup size is an A; if the differ-
ence is 2 or 3 in, the cup size is B or C. According to
Regnault,59 a general method for calculating the amount
of tissue to resect is 100 g per cup size for a 32- to 34-in
chest; 200 g per cup size for a 36- to 38-in chest; and 300
g per cup size for a 40- to 42-in chest.
Inability to Lactate
Because the lactiferous ducts may be transected to create
cutaneous nipple flaps, the possibility of re-establishing
the lactatory system would seem slight. Strombeck35
reported a 50% to 70% chance of nursing in patients
who had breast reduction by nipple transposition tech-
SURGERY JOURNAL ~ JULY/AUGUST 1999 299
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Table 3. Reasons for litigation among 50 US
patients undergoing breast reduction
Reason Patients
Scars 43
Asymmetry 11
Nipple loss
Complete 2
Partial 6
Nipple sensation 3
Nipples too high 6 tion objectively, 22% had normal sensation, and 8% had
Size
Too small 2 years, objective decreased nipple sensation occurred in
Too large 3 35% of patients; however, the women reported a higher
Inverted nipples 2 degree of sensibility in their breasts. Most breast reduc-
niques, although in a follow-up study of Strombeck’s
patients, Muller60 reported that of 10 patients who
became pregnant, none were able to lactate. “Lactation”
(expressing milk) is different than “breast feeding,”
which is defined as an infant’s ability to express adequate
amounts of milk for nourishment, without supplements,
for at least the first 2 months of life. Sandsmark61 report-
ed that in 49 patients who underwent breast reduction
and who gave birth, 32 could nurse, but milk production
was in no case sufficient for complete infant feeding. In
the event of pregnancy after breast reduction, lactation
may need to be suppressed with stilbestrol to avoid the
development of cysts.
Recurrent Hypertrophy
Recurrent hypertrophy is extremely rare. If it occurs, it is
more common in very young patients (12 to 14 years)
with gigantomastia who require surgery for psychologi-
cally or socially compelling reasons.
Impaired Sensation
The nipple’s sensibility is derived primarily from the lat-
eral cutaneous branch of the fourth intercostal nerve.62
Nerve branches tend to stay close to the deep fascia on
the anterior surface of the pectoralis major muscle, pass-
ing at first through the deepest part of the subcutaneous
tissue and then into the base of the breast.63,64 Common
practice is to dissect above this layer to preserve the nerve
during inferior pedicle reduction. However, the inter-
costal nerve may not be the only nerve supply to the are-
ola, because sensitivity has been reported to return with
virtually any technique. A review of 170 of Lejour’s
patients undergoing vertical reduction revealed only 1
300 AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST
patient with absent sensitivity and 6 patients with
reduced sensitivity after 6 months.65 Preoperative breast
volume and large resections are strongly correlated with
loss of sensitivity. Slezak and Dellon66 noted lower senso-
ry thresholds in the nipple-areola complex of women
with gigantomastia (D-cup or greater) compared with the
same parameters in small-breasted women. McKissock36
reported that at 2 years after surgery in 362 patients who
had undergone breast reduction, 70% had reduced sensa-
no sensation. Courtiss and Goldwyn62 noted that at 2
tions result in some loss of nipple sensation that will
return within 2 years; it is important for the surgeon to
document whether nipple sensation is intact and to dis-
cuss the possibility of diminished sensation with the
patient.
Patient Dissatisfaction
Older patients are generally happier with the results of
breast reduction than younger patients and will generally
accept complications more readily.35 In published series,
patient satisfaction rates range from 80% to 95%, and
symptom relief is reported from 70% to 100%.26,67-72
Kinell et al26 reported a 95% satisfaction rate and relief
from preoperative symptoms ranging from 83% to 100%
in 149 of Skoog’s patients monitored for 5 years (Table
1). Gonzalez et al71 reported that in 33 patients with an
average reduction of 753 g per breast, symptoms were
eliminated or improved in 81% to 100% of patients.
Raispis et al72 reported an improved self-image in 88%
of 177 patients. Seventy-nine percent of these patients
had preoperative neck and back pain, compared with
only 26% after surgery. “Severe” neck pain was relieved
in 81% of patients, and “severe” back pain was relieved
in 78% of patients. Davis69 noted marked resolution of
preoperative complaints of shoulder grooving, neck pain,
and back pain in 406 patients monitored for 4.7 years.
Self-esteem was improved in 88%, and the overall satis-
faction rate was 87%; 93% reported that they would
undergo surgery again. Shoulder, neck, and back pain
were eliminated in 80% to 93% of patients. In a compar-
ison of 172 patients operated on with 6 different tech-
niques, more than 95% of preoperative complaints were
alleviated in all groups of patients.70 In spite of these
favorable reports, in a 20-year review of the malpractice
experience of plastic surgeons by a major US malpractice
insurance carrier, breast reduction ranked second only to
1999 Volume 19, Number 4
 Scientific Forum
breast augmentation (and ahead of rhinoplasty, face lift,
and lipoplasty) for procedures associated with the most
severe malpractice losses.73 Hoffman74 analyzed the
records of 50 cases of reduction mammaplasty involved
in litigation and concluded that hypertrophic scars were
the most frequent cause of lawsuits (Table 3). Postopera-
tive photographs that show a range of results have been
recommended as a helpful communication aid.75
Krysander76 reports equivalent results for breast reduc-
tion performed by those without plastic surgery training.
Conclusion
Breast reduction is designed to reduce the weight of the
breast while improving shape and configuration.
Established techniques for large reductions include opera-
tions that resect central tissue and move peripheral breast
tissue to the center (Pitanguy, Skoog, Lejour), as well as
operations that leave behind a central pedicle (Goldwyn,
McKissock), conceptually similar to an augmentation
mammaplasty.
Inferior pedicle techniques are the most widely used
today because they offer reproducibly good results with a
low incidence of complications. However, the biggest
drawback is the lack of superior pole fullness obtained
with superior pedicle reductions. Although an under-
standing of 2 to 3 techniques allows a surgeon to handle
a full range of problems, Goldwyn77 warned that trying
new procedures without fully understanding the princi-
ples and caveats is detrimental to the development of an
individual surgeon’s experience and skill.
Reported complication rates range from 6.5% to 22%,
whereas reported patient satisfaction rates range from
80% to 95%. Reported rates of symptom improvement
range from 70% to 100%. In published series evaluating
the psychological outcome of breast reduction, Goin and
Goin78 and Glatt86 noted transient body image distur-
bances, but overall they reported a dramatic improve-
ment in psychological well-being. ■
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