MOC-CME

Evidence-Based Medicine: Reduction Mammaplasty

Richard Greco, M.D. Learning Objectives: After reading this article, the participant should be able
Barrett Noone, M.D. to: 1. Understand the multiple reduction mammaplasty techniques available
Savannah, Ga. for patients and describe the advantages and disadvantages associated with
each. 2. Describe the indications for the treatment of macromastia in patients
younger than 18 years. 3. Identify the preoperative indications for breast im-
aging before surgery. 4. Describe the benefits of breast infiltration with local
anesthesia with epinephrine before surgery. 5. Understand the use of deep
venous thrombosis prophylaxis in breast reduction surgery. 6. Describe when
the use of drains is indicated after breast reduction surgery.
Summary: The goal of this Continuing Medical Education module is to sum-
marize key evidence-based data available to plastic surgeons to improve their
care of patients with breast hypertrophy. The authors’ goal is to present the
current controversies regarding their treatment and provide a discussion of the
various options in their care. The article was prepared to accompany practice-
based assessment with ongoing surgical education for the Maintenance of Cer-
tification Program of the American Board of Plastic Surgery. (Plast. Reconstr.
Surg. 139: 230e, 2017.)

I
n 2014, the American Society of Plastic Sur- The reduction mammaplasty Practice Assessment
geons annual statistics demonstrated that in Plastic Surgery module is one of 20 tracer proce-
101,192 breast reduction procedures were dures developed by the American Board of Plastic
performed,1 compared with 104,455 in 2006.2 Surgery for the practicing surgeon to report activi-
The major difference was that the number con- ties to meet the obligations of the Maintenance
sidered reconstructive (covered by insurance) of Certification program. During the reporting
was reduced to 59,883, and 41,309 were consid- periods, 1343 surgeons have reported on breast
ered cosmetic (self-pay).1 The number of patients reduction surgery, and of those, 507 have done so
with enlarged breasts desiring improvement of more than one time, allowing for an evaluation of
shape, size, and symptoms has not changed, but the change of their surgical management behavior
the willingness for insurance to pay for the opera- (Table 1). A limitation of these data is that they
tion has. The satisfaction rate from this procedure include only individual surgeons that are maintain-
continues to remain extremely high; on RealSelf. ing their certification through the Maintenance of
com, the “worth it” rating is 97.5 percent—equal Certification program. In addition, the data are
to the satisfaction of our patients that have had self-reported and not audited, and the questions
a breast augmentation3 (https://docs.google. may be subject to misinterpretation; therefore, the
com/presentation/d/1lCB8HxyGNUs-yVRxK79 data must be evaluated as trends in consideration
q0INSptgRUOIv4nHTYuWcy-s/edit#slide=id. of these restraints. However, the data present an
g5abbcca99_1_207). This demonstrates why incredible opportunity to look into the practice of
patients elect to pay for the relief of symptoms
and improved body image out of their own pocket
when insurance denies them. Disclosure: The authors have no financial interest
This update will continue to use the American to declare in relation to the content of this article.
Board of Plastic Surgery data set for the Mainte-
nance of Certification program to evaluate the
changing trends in practice by our diplomates. Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
From The Georgia Institute for Plastic Surgery. browser to access this content. Clickable links
Received for publication October 27, 2015; accepted June to the material are provided in the HTML
1, 2016. text of this article on the Journal’s website
Copyright © 2016 by the American Society of Plastic Surgeons (www.PRSJournal.com).
DOI: 10.1097/PRS.0000000000002856

230e www.PRSJournal.com
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 139, Number 1 • Reduction Mammaplasty

Table 1. Statistics of Maintenance of Certification on findings from several large studies, and they
Breast Reduction Data: 2014 Data should stop being taught. They also concluded that
Characteristic Value patients younger than 50 years should be evaluated
No. of patients 2010
on an individual basis, taking the patient context into
Hospital inpatient 301 (15%) account, including the patient’s values regarding
Outpatient 1380 (85%) specific benefits and harms of screening procedures.
 Hospital outpatient 1305
 ASC 365 The results of the American Board of Plastic Sur-
 Accredited office facility 39 gery diplomates demonstrated a reduction in pre-
Technique
 Skin pattern operative mammography in all age groups studied
  Wise pattern 1591 (79%) younger than 50 years. Those younger than 35 years
  Vertical with modifications 311 (15.5%)
   Vertical 254 were reduced from 17 percent to 12 percent, those
   J or L vertical 57 younger than 45 years were reduced from 35 per-
  No vertical scar 48 (2.4%) cent to 31 percent, and those younger than 50 years
Pedicle type
 Inferior pedicle 1177 (59%) were reduced from 41 percent to 38 percent.
 Medial pedicle 392 (19.5%) ­However, patients older than 50 years also saw a
 Superior pedicle 267 (13.3%)
 Central mound 105 (5.2%) reduction in screening studies from 79 percent to
71 percent. Evidence supports the concept that the
a cross-section of our entire plastic surgical com- decision to perform a preoperative mammogram
munity, and no other comparable data base exists. should be individualized by the patient’s family
A literature search was performed using history of breast cancer, genetic testing results, evi-
PubMed to obtain the best available evidence dence of mass on examination, and the age of the
on reduction mammaplasty and the treatment individual. Every patient older than 50 years should
of macromastia patients. Search terms included have a recent mammogram, and many believe that
“macromastia” or “reduction mammaplasty” or those older than 40 years should as well.
“breast reduction” individually for all articles pub-
lished from 1995 to the present (2015). Location of Surgery
Health care continues to become more efficient
UPDATE OF TRENDS OF AMERICAN and more ambulatory. In the past, all breast reduc-
BOARD OF PLASTIC SURGERY TRACER tions were performed as an inpatient procedure,
PROGRAM often requiring blood transfusions and prolonged
Screening Mammography hospital stays.8 Modern advances in anesthesia—
including improved equipment, monitoring, train-
Guidelines for screening mammography con-
tinue to be controversial.4–7 The gold standard for ing, evaluation of healthy patients, shorter acting
years was the American Cancer Society’s recommen- narcotics, intravenous propofol, shorter acting inha-
dations of routine breast self-examination, clinical lation gases, and the evolution of perioperative nurs-
breast examination every 2 to 3 years after the age of ing care—have allowed for the development and
20 to 30, and routine screening mammography every performance of safe ambulatory surgery. Economic
year after the age of 40 unless there is a genetic or sig- factors and patient preferences also have stimulated
nificant family history of breast cancer to encourage the impetus to create less invasive procedures and
earlier or more frequent examinations. The Depart- increased the popularity of ambulatory surgery.9
ment of Health and Human Services convened a The American Board of Plastic Surgery tracer
group of independent health experts, the U.S. Pre- data demonstrated a continued shift away from
ventive Services Task Force, to review the present inpatient breast reduction surgery. In 2012, 22 per-
literature and to develop computer-simulated mod- cent of all procedures were performed on an inpa-
els comparing the expected outcomes under many
tient basis; in 2014 it was down to 15 percent. There
different screening scenarios. The Task Force had
four main and controversial conclusions: (1) rou- will always be patients that have significant comor-
tine screening mammograms should begin at age bidities that may require inpatient status (e.g., sleep
50 instead of age 40; (2) routine screening should apnea, massive obesity, permanent pacemaker); in
end at age 74; (3) women should get screening mam- addition, some surgeons may not have access to an
mograms every 2 years instead of every year; and (4) ambulatory facility and must perform their surgical
breast self-examinations have very little value, based procedures on an inpatient basis.

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 Plastic and Reconstructive Surgery • January 2017

Use of Prophylactic Antibiotics The Need for Deep Venous Thrombosis

Although there are contradictory studies Prophylaxis
regarding the need for perioperative antibiotics Plastic surgery is often “elective” and is fre-
for a “clean operation” such as a breast reduction, quently performed on the patient’s skin and soft
the American Society of Plastic Surgeons created a tissues, and therefore is considered to be “safer”
Patient Safety Task Force and reviewed 667 articles than intraabdominal or vascular types of proce-
on the topic of prophylactic antibiotics for breast dures. Deep venous thrombosis prophylaxis is
reduction operations.10 Their conclusions were that often not adequately considered. The finding is
there was not definitive evidence in either direction exemplified by the study performed by the Ameri-
and that one should individualize the risks and ben- can Board of Plastic Surgery in 2007 that demon-
efits to each patient; however, there was adequate strated that 48.7 percent of physicians performing
evidence to suggest that the surgeon should con- face lifts and 60.8 percent of those performing
sider using prophylactic antibiotics in their breast combined procedures used thromboprophylaxis
reduction operations. The American Board of all the time.14 Any treatment requires that the phy-
Plastic Surgery tracer data demonstrated a 98 per- sician considers the risks to the patient without
cent use of intravenous antibiotics within 1 hour of treatment, the underlying health and risk of the
the commencement of the procedure. There are individual patient, the risks to the patient from
patients with multiple antibiotic allergies and oth- the treatment used, and the likelihood of the
ers who may become very ill from the medicines so treatment reducing the patient’s risk of problems
that 100 percent may never be attainable in a risk-to- or creating a new or different problem.
benefit evaluation. In addition, although there are Breast reductions are often performed on
no data regarding the added benefit of antibiotic young, healthy women on an outpatient basis, with
use after the perioperative dose, 58.2 percent of the a relatively short operative time. The expectation
diplomates use additional postoperative antibiotics. is that the patient will be ambulatory later that day
or the next morning. Older, sicker patients with
Use of Epinephrine as a Wetting Agent significant obesity and the lack of mobility are an
The use of a dilute epinephrine wetting agent entirely different patient category and should be
injected along the incision lines before commence- evaluated differently. This topic has been studied
ment of the breast reduction operation has dem- extensively and the strategies for prevention are
onstrated a reduction in the amount of blood loss extensive and are based on the individual patient’s
and the need for transfusions in these patients.11 In comorbidities and the proposed procedure.15–18 In
addition, the amount of pain can be reduced when a review of 17,774 plastic surgery patients, Wes et
the epinephrine is mixed in a carrier of local anes- al. found 46 patients with deep vein thrombosis
thetic and is injected before surgery.12 In 2012, Ker- and 44 with pulmonary emboli, for an overall rate
rigan and Slezak demonstrated in their review of of 0.51 percent. Variables that were correlated
the American Board of Plastic Surgery tracer data with an increase in these complications included
that 49 percent of the studied members did not general anesthesia; male sex; increased obesity;
use the epinephrine injections, 17 percent used it age older than 65 years; truncal contouring; mul-
occasionally, and 34 percent used in the all of their tiple combined procedures; longer operative
cases.13 In our review of the 2014 American Board times; inpatient status; increased length of stay;
of Plastic Surgery data, 59 percent used epineph- and a history of diabetes, hypertension, malnutri-
rine in the majority of their patients and 40 percent tion, and dyspnea.17
rarely used it. This is almost a 25 percent increase in Most breast reductions are performed under
use of this very valid and important improvement in general anesthesia, and there is some risk of deep
patient care. Surgeons often cite the fear of delayed venous thrombosis in all of these patients. Strate-
hematomas when the epinephrine dissipates, but gies that have been found to be effective with little
the review by Kerrigan and Slezak of their 6271 risk to the patient include stopping oral contra-
American Board of Plastic Surgery tracer patients ception or hormone replacement 1 month before
does not support this concern. Only 2.2 percent surgery and for 2 weeks after surgery.15 Preopera-
with injections suffered hematomas, in comparison tive instructions should include the importance
with 1.9 percent in patients without injections. Con- of early postoperative ambulation.15 In addition,
tinued education of the validity of this concept is the use of graduated compression stockings and
necessary for our new generation of plastic surgeons appropriate patient positioning in the operating
to reduce the gap between evidence and practice. room with 5 degrees of flexion at the knee to aid

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 Volume 139, Number 1 • Reduction Mammaplasty

blood return through the popliteal vein should be distress.20–26 Although many insurance companies
used. In addition, intermittent pneumatic com- have generically disallowed breast reduction sur-
pression devices can be placed on the extremities gery on patients younger than 18 years—it has
30 minutes before induction of anesthesia. The been repeatedly shown that appropriate patients
boots help to reduce two of the three underlying in this group will have a dramatic improvement
pathophysiologic components of venous throm- of their symptoms and psychological status after
bosis (Virchow triangle). Venous stasis is reduced reduction mammaplasty surgery. Over 97 percent
by intermittent peak and mean venous velocities of these patients have reported patient satisfac-
in the common femoral vein secondary to the tion,20 and 95.9 percent would choose to have the
sequential intermittent pneumatic compression procedure performed again.21
from the device. In addition, fibrinolytic pathways In a review of the 2014 American Board of Plas-
are targeted through multiple pathways, includ- tic Surgery tracer data, 103 (5.1 percent) of the 2010
ing the release of plasminogen activator inhibi- patients were aged 18 years or younger. The young-
tor-1 and tissue factor pathway inhibitor from the est patient was aged 14 years. Symptomatic adoles-
vascular endothelium.16 Breast reduction opera- cent macromastia patients are not common, but
tions often require large operative incisions and when we meet the appropriate patient, we should
large planes of dissection, and create concerns for be a vigorous patient advocate for our patient work-
a higher risk of hematoma from anticoagulation. ing with their insurance company to help them get
In a study by Lapid et al. using low-molecular- approval for this very effective surgical solution.
weight heparin for chemoprophylaxis, the risk of
postoperative hematoma was on the high side in Options for Surgical Techniques for Macromastia
the breast reduction population (5.1 percent).18 The goals of the patient suffering from large
In high-risk patients and those undergoing breasts are as follows: to have relief of their physi-
multiple procedures, especially abdominoplasties, cal symptoms; to have an improved self-image
consideration as to the use of perioperative che- with regard to the shape, size, harmony, and sym-
moprophylaxis should be considered. The plastic metry of their breasts; for this to be performed in
surgeon should discuss with the patient the risks a safe manner and to not require additional sur-
of hematomas and bleeding versus the potential gery; and to have the best/least scars possible.27
to reduce the incidence of venous thrombosis; the Excellent results can be achieved with one of
use of subcutaneous heparin versus low-molecu- many techniques, and the surgeon must take into
lar-weight heparin; the consideration of postop- account the patient’s morphology, breast size,
erative-only dosing; and, in extremely high-risk degree of nipple transposition and displacement,
patients, the addition of a preoperative dose of body mass index, smoking history, and underlying
chemoprophylaxis. Even when doctors order che- health issues; and the surgeon’s training, experi-
moprophylaxis, occasionally nurses do not admin- ence, and comfort level with specific procedures
ister and often patients refuse them.19 in obtaining their optimal results. In addition,
A review of the American Board of Plastic the patient’s desired postoperative size and will-
Surgery tracer data demonstrates that 450 of 469 ingness to accept specific scars must be taken into
plastic surgeons (96 percent) always used some account.
type of deep venous thrombosis prophylaxis and
458 of 469 (98 percent) usually used it. Only six of Wise Skin Pattern Reduction
469 (1.3 percent) never used it. Pneumatic com- The Wise pattern with an inferior pedicle
pression boots were used in 1940 patients before technique has been the mainstay treatment for
surgery (96.5 percent) and 329 after surgery, and years13,28,29 (Figs. 1 through 3), and is still the most
low-molecular-weight heparin was used in 118 (7.8 commonly performed procedure by our mem-
percent). This is a remarkable change in best prac- bers. The 2014 American Board of Plastic Sur-
tice from the 40 percent (face lifts) to 68.7 percent gery tracer data demonstrate that certified plastic
(combined procedures) in 2007.14 surgeons performed a Wise pattern operation
on 79 percent of their patients, using an inferior
Breast Reductions in Patients Younger Than pedicle on 59 percent of them (Table 1). This is a
18 Years slow shift from 2012 data, where the Wise pattern
The symptoms of macromastia do not know was used in 83 percent and the inferior pedicle
an age limit, and all patients suffer the same was used in 69 percent.13 (See Video, Supplemen-
symptoms—back and neck pain, shoulder groov- tal Digital Content 1, which displays the Wise pat-
ing, shoulder pain, intertrigo, and psychological tern and inferior pedicle technique. This video

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 Plastic and Reconstructive Surgery • January 2017

Fig. 1. Wise pattern breast reduction. (Left) The drawing of the Wise skin pattern is displayed. This can be used with an inferior
pedicle (center) or superior medial (right) technique.

for patients with reductions greater than 1000 g.35

Its basic premise is that patients do not like the
horizontal scar and that avoiding it is essential for
obtaining a better reduction result (http://jour-
nals.lww.com/plasreconsurg/Pages/videogallery.
aspx?videoId=659&autoPlay=true).
The vertical reduction procedure has been
used for over 80 years,36 and the Wise pattern
operation was designed to overcome some of
the shortcomings of the previous short-scar tech-
niques and to obtain a more predictable and
aesthetically pleasing breast.37 The vertical mam-
maplasty has been improved and designed to bet-
ter control the shape of the postoperative breast
Fig. 2. Illustration of an anchor type skin closure of Wise pattern.
with no horizontal scars by Lejour et al.,38 Hall-
Findlay,33 and Lista et al.34 Three-dimensional
analysis of the postoperative breast demonstrated
is available in the “Related Videos” section of the that the final shape of the Wise pattern breast
full-text article on PRSJournal.com or at http:// was evident at 6 months and that of the vertical
links.lww.com/PRS/B938.) reduction at 9 months. In addition, the upper
Superior (13.3 percent) and medial (19.5 pole–to–lower pole ratios were the same for both
percent) pedicles have grown in favor with many techniques at 1 year: 70:30.39 In early experiences,
surgeons, as they are thought to result in more there was a relatively high conversion to a short T
superior fullness and less bottoming out over time. scar to deal with the redundancies or dog-ears.40
Patient satisfaction is very high with each of the In a recent matched cohort study, the complica-
reduction techniques.3 Thoma et al. used a ran- tion and reoperation rates for Wise versus vertical
domized controlled study to compare T-shaped reduction were identical.41
scar reductions to vertical scar reductions and On review of the American Board of Plastic
found no significant difference in complication Surgery tracer data, the 2012 data demonstrated
rate or patients’ objective Health Utilities Index that 12 percent of all reductions were of a vertical
Mark 3 and Breast Related Symptoms Question- pattern; in the 2014 data, 12.7 percent were verti-
naire results.30 cal and 2.8 percent were J or L incisions (15.5 per-
cent total). The shift has not been overwhelming.
Vertical Scar Breast Reduction
The vertical scar has had a recent surge of No Vertical Scar Technique
interest, and many authors are very ardent advo- Although it is believed by surgeons that the
cates of the procedure.31–34 The vertical reduction horizontal scar is the scar that bothers most
procedure has been based on a superior or medial patients, when 66 prospective reduction mam-
blood supply (Figs. 4 and 5), although Hammond maplasty patients were asked to rate line draw-
et al. have devised an inferior pedicle technique ings and postoperative photographs of all three

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 Volume 139, Number 1 • Reduction Mammaplasty

Fig. 3. Wise pattern breast reduction with the inferior pedicle technique. A 32-year-old, 5 foot 2 inch, 163-lb woman with
a 796-g right and 874-g left resection (from G to D size breasts) is shown (left) preoperatively and (right) postoperatively.

Video 1. Supplemental Digital Content 1 displays the Wise pattern

and inferior pedicle technique. This video is available in the “Related
Videos” section of the full-text article on PRSJournal.com or at http://
links.lww.com/PRS/B938.

reduction techniques, the no vertical scar opera- al.44 and Nagy et al.45 (Figs. 6 and 7). The ideal
tion was significantly preferred by the patient.42 patient for this procedure is one with the need for
This technique was brought to our attention by significant nipple transposition. The preoperative
Passot43 and later repopularized by Lalonde et nipple-areola complex lies below the inferior edge

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 Plastic and Reconstructive Surgery • January 2017

Fig. 4. Vertical breast reduction with the superior medial technique. (Left) Skin incision design. (Center) Superior medial pedicle.
(Right) Skin wound closure.

Fig. 5. Vertical breast reduction with the superior medial technique A 39-year-old, 5 foot 2 inch, 180-lb woman with
460 g plus 200 cc liposuction right and 340 g and 200 cc liposuction left resections (from 36 DDD to D size breasts) shown
(left) preoperatively and (right) postoperatively. (Case courtesy of Jamil Ahmad, M.D., University of Toronto.)

of the proposed incision on the no vertical scar on the shape of the new areola, and it significantly
technique. (See Video, Supplemental Digital Con- reduces the healing complications of the inferior-
tent 2, which displays a no vertical scar reduction. T connection on a standard Wise procedure.
This video is available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or Use of Postoperative Drains
at http://links.lww.com/PRS/B939.) In addition to Despite multiple studies,46–48 an Ameri-
removing the vertical limb of the T scar, one does can Society of Plastic Surgeons Evidence-
not have the disfiguring pull of the vertical limb based Clinical Practice Guideline (reduction

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 Volume 139, Number 1 • Reduction Mammaplasty

Fig. 6. No vertical scar technique. (Left) Skin pattern design. (Center) Inferior pedicle and superior flap. (Right) Final skin wound
closure.

Fig. 7. No vertical scar breast reduction technique in a 29-year-old, 5 foot 7 inch, 225-lb woman with 1286-g resection on
the right and 1052-g resection on the left (from DDD to D size breasts).

mammaplasty),10 and a cumulative study per- drains. In 2012, 56 percent of the patients had
formed by the Cochrane Library49 that have dem- postoperative drains used, and in 2014 there was
onstrated that postoperative use of drains has led only a 3 percent change to 53 percent. We do
to no difference in hematoma rates, no difference agree with the American Society of Plastic Sur-
in wound healing complications, greater patient geons Clinical Practice Guideline that in patients
discomfort,47 more economic costs, and a lon- that have liposuction as an adjunct procedure
ger hospital stay,47 there has been no significant in their breast or axilla, “drainage should be left
change in our diplomates’ use of postoperative to the surgeon’s discretion.”10 Understanding

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 Plastic and Reconstructive Surgery • January 2017

Video 2. Supplemental Digital Content 2 displays a no vertical scar

reduction. This video is available in the “Related Videos” section of
the full-text article on PRSJournal.com or at http://links.lww.com/
PRS/B939.

evidence-based medicine should eventually lead Richard Greco, M.D.

to a reduction in the use of postoperative drains The Georgia Institute for Plastic Surgery
in reduction mammaplasty. In the future, the 5361 Reynolds Street
Maintenance of Certification American Board of Savannah, Ga. 31405
[email protected]
Plastic Surgery tracer data may want to consider
how many patients have adjunct liposuction with
their reduction mammaplasties and what per- references
centage of the patients with and without liposuc-
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Documents/news-resources/statistics/2015-statistics/plastic-
surgery-statsitics-full-report.pdf. Accessed September 1, 2015.
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 Volume 139, Number 1 • Reduction Mammaplasty

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