per breast). breast reduction surgery has two technical aspects: (i) the skin-incision pattern and the skin- and glandular-tissue excision technique applied for access to and removal of breast parenchyma tissue. the incision pattern and the area of skin-envelope tissue to be removed determine the locales and the lengths of the surgical scars; (ii) the final shape and contour of the reduced breast are determined by the area of the tissues remaining in the breast, and that the skin- and glandular-tissue pedicle has a proper supply of nerves and blood vessels (arterial and venous) that ensure its tissue viability. the specific reduction mammoplasty procedure is determined by the volume of breast tissues (glandular, adipose, skin) to be resected (cut and removed) from each breast, and the degree of breast ptosis present: pseudoptosis (sagging of the inferior pole of the breast; the nipple is at or above the inframammary fold); grade i: mild ptosis (the nipple is below the imf, but above the lower pole of the breast); grade ii: moderate ptosis (the nipple is below the imf; yet some lower-pole breast tissue hangs lower than the nipple); grade iii: severe ptosis (the nipple is far below the imf; no breast tissue is below the nipple). the full, corrective outcome of the surgical re-establishment of a bodily proportionate bust becomes evident at 6-months to 1-year post-operative, during which period the reduced and lifted breast tissues settle upon and into the chest. the post-operative convalescence is weeks long, depending upon the corrections performed; and some women might experience painful breast-enlargement during the first post-operative menstruation. contraindications breast reduction surgery cannot be performed if the woman is lactating, or has recently ceased lactating; if her breasts contain unevaluated tissue masses, or unidentified microcalcifications; if she has a systemic illness; if she is unable to understand the technical limitations of the plastic surgery; and her inability to accept the possible medical complications of the procedure. additionally, recent research has indicated that mammograms should not be done with any increased frequency in patients undergoing breast surgery, including breast augmentation, mastopexy, and breast reduction. i. inferior pedicle technique (anchor pattern, inverted-t incision, wise pattern) the inferior pedicle (central mound) features a blood vessel supply (arterial and venous) for the nac from an inferior, centrally-based attachment to the chest wall. the skin pedicle maintains the innervation and vascular viability of the nac, which produces a reduced, sensitive breast with full lactational capability and function. the volume and size reduction of hypertrophied breasts is performed with a periareolar incision to the nac, which then extends downwards, following the natural curve of the breast hemisphere. after cutting and removing the requisite quantities of tissue (glandular, adipose, skin), the nac is transposed higher upon the breast hemisphere; thereby the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the woman's person. nonetheless, breast-reduction with an inferior pedicle, occasionally produces breasts that appear squared; yet, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia. ii. vertical scar technique (lollipop incision) the breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incision scars and a nac elevated by means of a pedicle (superior, medial, lateral) that maintains the biologic and functional viability of the nac. the increased projection of the reduced bust is achieved by medially gathering the folds of the skin-envelope and suturing the inner and outer portions of the remaining breast gland to provide a support pillar, and upward projection of the nac . the vertical-scar reduction mammoplasty is best suited for removing small areas of the skin envelope and small volumes of internal tissues (glandular, adipose) from the lateral and the inferior portions of the breast hemisphere; thus the short incision scars. iii. horizontal scar technique the breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (imf) and a nac pedicle. to elevate the nac, the technique usually employs either an inferior pedicle or an inferior-lateral pedicle, and features no vertical incision (like the anchor pattern). the horizontal-scar technique best applies to the woman whose oversized breasts are too large for a vertical-incision technique (e.g. the lollipop pattern); and it has two therapeutic advantages: no vertical incision-scar to the breast hemisphere, and better healing of the periareolar scar of the transposed nac. the potential disadvantages are box-shaped breasts with thick (hypertrophied) incision scars, especially at the inframammary fold. iv. free nipple-graft technique the breast reduction performed with the free nipple-graft technique transposes the nac as a tissue graft without a blood supply, without a skin and glandular pedicle. the therapeutic advantage is the greater volume of breast tissues (glandular, adipose, skin) that can be resected to produce a proportionate breast. the therapeutic disadvantage is a breast without a sensitive nac, and without lactational capability. the medically indicated candidates are: the woman whose health presents a high risk of ischemia (localized tissue anemia) of the nac, which might cause tissue necrosis; the diabetic woman; the woman who is a tobacco smoker; the woman whose oversized breasts have an approximate nac-to-imf measure of 20 cm; and the woman who has macromastia, requiring much resecting of the breast tissues. v. liposuction-only technique (lipectomy) the breast reduction performed with the liposuction-only technique usually applies to the woman whose oversized breasts require the removal of a medium volume of internal tissue; and to the woman whose health precludes her being under the extended anaesthesia usual to surgical breast-reduction operations. the ideal lipectomy candidate is the woman whose low-density breasts are principally composed of adipose tissue, have a relatively elastic skin envelope, and manifest mild ptosis. the therapeutic advantages of the liposuction-only technique are the small incision-scars required for access to the breast interior, hence, a shorter post-operative healing period for the incision scars; the therapeutic disadvantage is limited breast-reduction volumes. surgical techniques pre-operative matters the medical treatment records for the reduction mammoplasty are established with pre-operative, multi-perspective photographs of the oversized breasts, the sternal-notch–to-nipple distances, and the nipple-to–inframammary-fold distances. the woman is instructed about the purposes of the breast reduction surgery, the achievable corrections, the expected final size, shape, and contour of the reduced breasts, the expected final appearance of the breast reduction scars; possible changes in the sensation of the nac, possible changes in her breast-feeding capability, and possible medical complications. the woman also is instructed about post-operative matters such as convalescence and the proper care of the surgical wounds to the breasts. incision-plan delineation: to the breasts of the standing patient, the plastic surgeon delineates the mosque dome skin-incision plan, and the area representing the superior pedicle (composed of skin and glandular tissues), the breast midline, the inframammary fold (imf), and the vertical axis of the breast, beneath the imf. the upper edge of the (future) nac is marked slightly below the imf-level, and a semicircle of 16-cm maximum diameter. in relation to the vertical axis, the mosque dome incision plan displaces the breast to the middle and to the side; the peripheral limbs of the incision plan are marked so that they approximate (join) at no less than 5-cm above the inframammary fold. the circumference of the (future) nac is delineated around the nipple, and a superior pedicle (10-cm wide minimum) is delineated at the upper-border of the future nac circumference; the incision-plan delineation continues down as a cone, and around the marked circumference. operative technique the patient is laid supine upon the operating table so that the surgeon can later raise them to a sitting position that will allow visual comparison of the drape of the breasts, and an accurate assessment of the post-operative symmetry of the reduced and lifted bust. afterwards, the pedicle epidermis surrounding the nac is cut, and adipose tissue is liposuctioned from the breast. the medial, lower, and lateral segments of the breast are resected (cut and removed), by undermining the skin below the lower curved line. then, the nac is transposed higher upon the breast hemisphere. the pillars of parenchymal tissue are approximated (joined), and the skin envelope is sutured. there is no evidence to support using drains during breast reduction surgery. notes biological: the resected tissue is submitted to histopathologic examination, because sub-clinical breast cancer foci occur in 0.1–0.9 per cent of the tissue specimens. technical: the original lejour technique incision plan had no horizontal limbs, and so did not produce horizontal scars; however, contemporary variants, such as the modified lejour technique, employ small, horizontal incisions along the inframammary fold, in order to avoid redundant skin folds, especially in the reduction of very oversized breasts. post-operative matters the woman is instructed to resume her normal life activities, and to eat a light diet, post-operative, on the day of the breast reduction surgery; to resume washing in a shower at 1-day post-operative; to avoid strenuous physical activity, and to wear a sports brassière; the convalescence regimen is for 3-months post-operative. she is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within 1–6 months post-operative; yet some cases might require surgical revision of the vertical scar. scheduled follow-up consultations ensure a satisfactory outcome to the breast reduction surgery, and facilitate the early identification and management of medical complications. there is limited evidence in showing wound drains have no significant benefit after reduction mammoplasty. complications the post-operative complications occurred included seroma, wound dehiscence, hematoma; whereas partial nac necrosis occurred in 10 per cent of the reduced breasts; yet, after refinement of the lejour technique, the study vertical mammaplasty: early complications after 250 personal consecutive cases (1999), reported a reduced incidence rate of 7.0 per cent in the 324 breast reductions performed in 167 patients. moreover, the incidence of such post-operative complications is greater among the women whose breasts required large-volume resection of the parenchyma; in women who were obese; in women who were tobacco smokers; and in young women. furthermore, wound dehiscence, epidermolysis, adipose tissue necrosis, and infection occur less among women who undergo lejour-technique breast reduction, than among women who undergo a periareolar, anchor pattern breast-reduction, or an inferior-pedicle breast reduction. nonetheless, bottom-edge asymmetry occurs more among lejour-technique patients; the revision surgery rates can be up to 10 per cent. moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased nac sensitivity occurs in 10 per cent of the women; and total nac insensitivity occurs in 1.0 per cent of women. liposuction-only technique the reliability of the lipectomy procedure was confirmed in two studies. the first, tumescent technique, tumescent anesthesia & microcannular liposuction (2000) reported that tumescent liposuction is a reliable reduction mammoplasty procedure, which yields consistent results of size, appearance, and texture of the reduced-volume breasts. the second study by daniel lanzer, breast reduction with liposuction (2002), about a 250-woman cohort, reported that the application of tumescent liposuction, as the sole reduction-mammoplasty procedure, yielded consistent results wherein none of the patients had loose breast-skin envelopes, irregular breast-shape, permanent loss of sensation (either glandular, dermal, or of the nac), scars, tissue necrosis, or infection. after fat cells are suctioned away via liposuction, it was quoted in the obesity journal that overall body fat generally returned to the same level as before treatment. this is despite maintaining the previous diet and exercise regimen. while the fat returned somewhat to the treated area, most of the increased fat occurred in the abdominal area. visceral fat - the fat surrounding the internal organs - increased, and this condition has been linked to life-shortening diseases such as diabetes, stroke, and heart attack. indications the reduction of oversized breasts by liposuction only (lipectomy) is indicated when a minor-to-moderate volume-reduction is required, and there is no breast ptosis to correct. however, in a 2001 study of 250 patients, nipple and breast elevation of between 3 cm and 15 cm was reported. further indications for lipectomy are presented by: (i) the woman who requires a large-volume reduction, and wants un-scarred, sensate breasts, yet will accept a degree of ptosis; (ii) the woman who requires a secondary mammoplasty to correct an asymmetric breast, by up to one brassière cup-size; and (iii) the girl affected by virginal breast hypertrophy, as a temporary procedure performed before the conclusion of her thelarche (the pubertal breast-growth phase), given the hypertrophy's