A thorough history should be performed prior to treatment, identifying physical, functional, and psychological symptoms. It is also important to obtain a detailed past medical and surgical history, reproductive history, family history, social history, and current medications and allergies from the patient.¹

Physical and functional problems associated with macromastia include pain (neck, back, and shoulder), mastodynia, shoulder grooving, intertriginous rashes and/or infections, physical activity restriction, and difficulty fitting into clothing. Patients often suffer from psychological symptoms related to breast size, including feelings of physical unattractiveness and embarrassment in both private and social settings.^2,3

Past medical history should screen for any diseases that would impact the patient’s ability to recover from the reduction mammoplasty, such as heart or lung disease, or impact the viability of the NAC postoperatively, such as collagen vascular diseases.¹ A history of previous benign or malignant breast masses should also be elicited. Obtaining a thorough past surgical history should identify any previous breast or chest wall incisions that may influence planning of either the skin pattern incision or the pedicle to the NAC.¹

Because childbearing can affect the size and shape of a woman’s breasts, the reproductive history of the patient is important to understand and anticipate the effect reduction mammoplasty will have on the future breast.¹ Inquiring about plans for future pregnancies and breastfeeding is important to inform patients of the risks of the procedure. Finally, in patients who have recently given birth and who may be currently breastfeeding, it is important to discuss timing of surgery because it is ideal to delay surgery for at least 1 year after completing either.

Obtaining a thorough family history is important to identify patients at increased risk for breast carcinoma. Younger patients with a family history of breast cancer, in addition to any patient older than the age of 40 years, should undergo a preoperative mammogram in order to identify any suspicious lesions prior to surgery.² Some surgeons routinely obtain a bilateral mammogram in all patients considering reduction mammoplasty.

Smokers are at increased risk of compromise of the blood supply to the NAC and for poor wound healing.¹ Therefore, eliciting a smoking history may alter the timing of surgery. Current recommendations indicate that a period of at least 4 weeks of smoking cessation prior to surgery is ideal for best outcomes.

Macromastia can present at different periods in a woman’s life and therefore surgical timing is important. When present during adolescence, the timing of reduction mammoplasty needs to be balanced with the effects of macromastia on selfesteem and physical activity restriction with ongoing pubertal breast development and potential future childbearing.⁴ In older patients who have encountered recent significant changes in overall weight, it is prudent to delay surgery for at least 1 year until their weight has stabilized, as this can translate into disproportionate changes in breast volume.

A bilateral breast examination should be performed in every patient, including examination of the axillary and supraclavicular lymph node basins. The patient’s height, weight, body mass index, and body surface area, as well as appropriate breast measurements should be taken, including breast width, sternal notch/clavicle to nipple distance, midline inframammary fold to nipple distance, and the dimensions of each areola.² In addition, breast characteristics should be noted including symmetry, upper pole contour and fullness, presence of breast ptosis, skin quality including presence of striae, and breast tissue density (FIG 1).¹

A discussion of patient’s desires and expectations following surgery is essential to avoid dissatisfaction and misunderstandings. In addition, the patient should be informed about possible complications associated with reduction mammoplasty, including changes in nipple sensation, asymmetry, unappealing breast size or shape, scarring, fat necrosis, NAC loss, inability to breastfeed, hematoma, and infection.

The American Cancer Society recommends screening mammograms starting at age 40 years in patients with average risk of developing breast cancer.⁵ These patients, and younger patients at increased risk of breast cancer, should therefore undergo a preoperative mammogram prior to reduction mammoplasty. Many plastic surgeons routinely perform a preoperative screening mammogram in all patients undergoing this procedure.

There are multiple surgical approaches to reduction mammoplasty; however, all must deal with the following four considerations: (1) reduction in the parenchymal volume of the breast, (2) creation of the NAC pedicle, (3) reduction of expendable skin followed by redraping, and (4) repositioning of the NAC.³ This chapter will describe the most commonly practiced Wise pattern (inverted T) technique, which reduces the medial, lateral, and superior breast parenchymal volume and maintains blood supply to the NAC by an inferior pedicle. Other techniques include the superior medial breast reduction,³ short scar periareolar inferior pedicle reduction (SPAIR),¹ and the liposuction breast reduction,⁶ among others.

Advantages to the Wise pattern technique include its reproducibility, popularity, and applicability to a wide range of breast shapes and sizes, whereas disadvantages include longer scars and a tendency toward developing breast ptosis over the long term.