breast reduction breast reduction reduction mammoplasty (also breast reduction and reduction mammaplasty) is the plastic surgery procedure for reducing the size of large breasts. in a breast reduction surgery for re-establishing a functional bust that is proportionate to the woman's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (nac), to ensure the functional sensitivity and lactational capability of the breasts. the indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the woman's self-image, and of her mental health. breast reductionbreast reduction: the correction of macromastia and severe breast ptosis; pre-operative aspects (left); post-operative aspects (right).icd-9-cm85.3medlineplus007405 in corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied to mastopexy (breast lift). presentation the woman with macromastia presents heavy, enlarged breasts that sag and cause her chronic pains to the head, neck, shoulders, and back; an oversized bust also causes her secondary health problems, such as poor blood circulation, impaired breathing (inability to fill the lungs with air); chafing of the skin of the chest and the lower breast (inframammary intertrigo); brassière-strap indentations to the shoulders; and the improper fit of clothes. in the woman affected by gigantomastia (>1,000 gm overweight per breast), the average breast-volume reduction diminished her oversized bust by three brassière cup-sizes. the surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations that a bodily disproportionate bust imposes upon a woman; thereby it improves her physical and mental health. afterwards, the woman's ability to comfortably perform physical activities previously impeded by oversized breasts improves her emotional health (self-esteem) by reducing anxiety and lessening psychological depression. medical history the medical history records the woman's age, the number of children she has borne, her breast-feeding practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. additional to the personal medical information, are her history of tobacco smoking and concomitant diseases, breast-surgery and breast-disease histories, family history of breast cancer, and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness. the physical examination records and establishes the accurate measures of the woman's body mass index, vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of breast ptosis, the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the nipple–areola complex (nac), and discharges from the nipple. also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassière strap from the breast weight, kyphosis (excessive, backwards curvature of the thoracic region of the spinal column), skin irritation, and skin rash affecting the breast crease (imf). cause a woman develops large breasts usually during thelarche (the pubertal breast-development stage), but large breasts can also develop postpartum, after gaining weight, at menopause, and at any age. whereas macromastia usually develops in consequence to the hypertrophy (overdevelopment) of adipose fat, rather than to milk-gland hypertrophy. moreover, many women are genetically predisposed to developing large breasts, the size and weight of which often are increased either by pregnancy or by weight gain, or by both conditions; there also exist iatrogenic (physician-caused) conditions such as post–mastectomy and post–lumpectomy asymmetry. nonetheless, it is statistically rare for a young woman to experience virginal mammary hypertrophy that results in massive, oversized breasts, and recurrent breast hypertrophy. the abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the overdevelopment of the milk glands or of the adipose tissue, or by a combination of both occurrences of hypertrophy. the resultant breast-volume increases can range from the mild (<300 gm) to the moderate (ca. 300–800 gm) to the severe (>800 gm). macromastia can be manifested either as a unilateral condition or as a bilateral condition (single-breasted enlargement or double-breasted enlargement) that can occur in combination with sagging, breast ptosis that is determined by the degree to which the nipple has descended below the inframammary fold (imf). medical breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy; yet a weight-reduction regimen for the over-weight woman can alleviate some of the excessive size and volume of her abnormally enlarged breasts. physical therapy provides some relief for neck, back, or shoulder pain. skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chafing, infection, and bleeding. surgical the traditional surgical techniques for breast reduction remodel the breast mound using a skin and glandular (breast tissue) pedicle (inferior, superior, central), and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; yet it produces long surgical scars upon the breast hemisphere. in response, l. benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar – around the nac, where the dark-to-light skin-color transition hides the surgical scar. anatomy of the breast the procedure a reduction mammoplasty to re-size enlarged breasts and to correct breast ptosis resects (cuts and removes) excess tissues (glandular, adipose, skin), overstretched suspensory ligaments, and transposes the nac higher upon the breast hemisphere. during puberty, the breast grows in consequence to the influences of the hormones estrogen and progesterone; as a mammary gland the breast is composed of lobules of glandular tissue, each of which is drained by a lactiferous duct that empties to the nipple. most of the volume (ca. 90%) and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules – except during pregnancy and lactation, when breast milk constitutes most of the breast volume. composition surgically, the breast is an apocrine gland overlaying the chest – attached at the nipple and suspended with ligaments from the chest – which is integral to the skin, the body integument of the woman. the dimensions and weight of the breasts vary with her age and habitus (body build and physical constitution); hence small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750–1,000 gm. anatomically, the breast topography and the hemispheric locale of the nac are particular to each woman; thus, the desirable, average measurements are a 21–23 cm sternal distance (nipple to sternum-bone notch), and a 5–7 cm inferior-limb distance (nac to imf). blood supply and innervation the arterial blood supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery (from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries. drainage of venous blood from the breast is by the superficial vein system under the dermis, and by the deep vein system parallel to the artery system. the primary lymph drainage system is the retromammary lymph plexus in the pectoral fascia. sensation in the breast is established by the peripheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerves, and thoracic spinal nerve 4 (t4 nerve) innervates and supplies sensation to the nac. surgical anatomy of the mammary gland for reduction mammoplasty correction: chest wallpectoralis muscleslobulesnippleareolamilk ductfatty tissueskin envelope mechanical structures of the breast in realizing the breast-reduction corrections, the plastic surgeon takes anatomic and histologic account of the biomechanical, load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility (poisson's ratio of ~0.5). rib cage. the 2nd, 3rd, 4th, 5th, and 6th ribs of the thoracic cage are the structural supports for the mammary glands. chest muscles. the breasts overlay the pectoralis major muscle, the pectoralis minor muscle, and the intercostal muscles (between the ribs), and can extend to and cover a portion of the (front) anterior serratus muscle (attached to the ribs, the rib muscles, and the shoulder blade), and to the rectus abdominis muscle (a long, flat muscle extending up the torso, from pubic bone to rib cage). the body posture of the woman exerts physical stresses upon the pectoralis major muscles and the pectoralis minor muscles, which cause the weight of the breasts to induce static and dynamic shear forces (when standing and when walking), compression forces (when lying supine), and tension forces (when kneeling on four limbs). pectoralis fascia. the pectoralis major muscle is covered with a thin superficial membrane, the pectoral fascia, which has many prolongations intercalated among its fasciculi (fascicles); at the midline, it is attached to the front of the sternum, above it is attached to the clavicle (collar bone), while laterally and below, it is continuous with the fascia. suspensory ligaments. the subcutaneous layer of adipose tissue in the breast is traversed with thin suspensory ligaments (cooper's ligaments) that extend obliquely to the skin surface, and from the skin to the deep pectoral fascia. the structural stability provided by the cooper's ligaments derives from its closely packed bundles of collagen fibers oriented in parallel; the principal, ligament-component cell is the fibroblast, interspersed throughout the parallel collagen-fiber bundles of the shoulder, axilla, and thorax ligaments. glandular tissue. as a mammary gland, the breast comprises lobules (milk glands at each lobe-tip) and the lactiferous ducts (milk passages), which widen to form an ampulla (sac) at the nipple. adipose tissue. the fat tissue of the breast is composed of lipidic fluid (60–85% weight) that is 90–99 per cent triglycerides, free fatty acids, diglycerides, cholesterol phospholipids, and minute quantities of cholesterol esters, and monoglycerides; the other components are water (5–30% weight) and protein (2–3% weight). fatty tissue. in biology, adipose tissue (/ˈædəˌpoʊs/), or body fat or fat depot or just fat, is loose connective tissue composed of adipocytes. it is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. adipose tissue is derived from lipoblasts. its main role is to store energy in the form of lipids, although it also cushions and insulates the body. far from hormonally inert, adipose tissue has in recent years been recognized as a major endocrine organ, as it produces hormones such as leptin, resistin, and the cytokine tnfα. moreover, adipose tissue can affect other organ systems of the body and may lead to disease. obesity or being overweight in humans and most animals does not depend on body weight but on the amount of body fat – to be specific, adipose tissue. two types of adipose tissue exist: white adipose tissue (wat) and brown adipose tissue (bat). the formation of adipose tissue appears to be controlled in part by the adipose gene. adipose tissue was first identified by the swiss naturalist conrad gessner in 1551. the skin envelope. the breast skin is in three layers: (i) the epidermis, (ii) the dermis, and (iii) the hypodermis. the epidermis is 50–100 μm thick, and is composed of a stratum corneum of flat keratin cells, that is 10–20 μm thick; it protects the underlying viable epidermis, which is composed of keratinizing epithelial cells. the dermis is mostly collagen and elastin fibers embedded to a viscous water and glycoprotein medium. the fibers of the upper dermis ("papillary dermis") are thinner than the fibers of the deep dermis, thus the skin envelope is 1–3 mm thick. the thickness of the hypodermis (adipocyte cells) varies from woman to woman, and body part. the skin of the nipple and areola is further composed of a modified and specialized myoepithelium that is responsible for contraction in response to stimuli. surgical procedures breast reduction: the pre-operative (l.) and post-operative (r.) aspects of the correction of macromastia and breast ptosis in a young woman. reduction mammoplasty: the keyhole incision plan for correcting macromastia; the sagging, hypertrophied breast (l.), the surgical reduction procedure (c.), the reduced, elevated breast (r.). breast reduction: foremost is the tissue viability of the nac; it also hides a periareolar scar in the skin-color transition at the areolar periphery. reduction mammoplasty: the vertical scar technique (lollipop incision) and the inferior pedicle flap technique (anchor incision) also are applicable to breast lift surgery. general reduction mammoplasty, either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a woman affected either with macromastia (>500 gm increase per breast) or with gigantomastia (>1,000 gm increase