According to the American Society of Aesthetic Plastic Surgeons, 153,087 women underwent breast reduction procedures in 2007, making breast reduction the fifth most common surgical procedure performed by plastic surgeons. This number reflects the high prevalence of macromastia with its associated symptoms, as well as the efficacy of breast reduction surgery to alleviate symptoms and improve physical appearance.
The etiology of macromastia is thought to be related to increased sensitivity to circulating estrogens at the level of the end-organ. Women ranging in age from puberty to old age seek consultation for breast reduction surgery. The presence of macromastia often leads to unfavorable aesthetic appearance, difficulty with clothing, social embarrassment, and decreased self-esteem. Furthermore, it is often associated with multiple somatic symptoms, such as pain and fatigue in the cervical and thoracic spine, poor posture, grooving of the skin and underlying soft tissues of the shoulders, and intertriginous rashes at the inframammary fold (IMF). It has been shown that macromastia exerts a significant impact on the patient’s overall health and quality of life. Medical management focuses on weight loss, adequate support using properly fitted bras with wide straps, nonsteroidal anti-inflammatory drugs, and physical therapy. However, these measures are ineffective in satisfactorily relieving symptoms in most patients. Attempted weight loss was reported to be completely inefficient in more than half and offered partial relief in only 10% of surgical candidates. Furthermore, the presence of macromastia makes it difficult for most patients to participate in exercise programs. Breast reduction surgery has been shown to be an effective means of alleviating symptoms associated with macromastia and in improving the patient’s quality of life. These benefits as well as the improvement in aesthetic appearance make breast reduction both a reconstructive and aesthetic surgical procedure.
Important anatomic considerations include the blood supply, innervation, the lactiferous system as well as the aesthetic considerations regarding breast size and contour.
The breast has a rich blood supply from multiple sources, including perforating branches of the internal mammary artery, the lateral thoracic artery, the thoracodorsal artery, intercostal artery perforators, and the thoracoacromial artery. The blood supply to the nipple-areola complex (NAC) is carried through the glandular breast tissue but also receives contributions from the subdermal plexus of the breast skin. While the early, mostly dermal pedicle, designs relied on the subdermal plexus as the source for NAC perfusion, glandular contribution is now generally considered to be more robust.
The innervation of the breast is based on the underlying dermatomes. The sensation of the NAC (erogenous as well as tactile) is provided for the most part by the anterolateral and anteromedial branches of the fourth intercostal nerve with additional innervation contributed by adjacent dermatomes. Anatomic studies have shown that the fourth intercostal nerve divides into a superficial as well as a deep branch, the latter being situated on top of the pectoralis fascia and reaching the ...