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Coll. Antropol. 36 (2012) 2: 657–668
Original scientific paper
Current Trends in Breast Reduction
Zdravko Roje1, @eljka Roje2, Milan Milo{evi}3, Josip Varvodi}4and Marko Mance5
1University of Split, Split University Hospital Center, Division for Plastic Surgery and Burns, Department of Surgery, Split,
Croatia
2University of Zagreb, Dubrava University Hospital, Department of Surgery, Zagreb, Croatia
3University of Zagreb, School of Medicine, Andrija [tampar School of Public Health, Zagreb, Croatia
4University of Zagreb, Dubrava University Hospital, Department of Surgery, Zagreb, Croatia
5Ministry of Justice and Public Administration, Zagreb, Croatia
ABSTRACT
Results of our study describe the long term effects of reduction mammaplasty. Many women with excessively small or
large breasts have an altered personal self-image and often suffer from low self-esteem and other psychological stresses.
This procedure is designed to reduce and reshape large breasts, and since the size, shape, and symmetry of a woman’s
breasts can have a profound effect on her mental and physical well-being it is important to observe the patient’s long-term
outcome. Currently, breast reduction surgery is safe, effective and beneficial to the patient. In Croatia, reduction mam-
moplasty is often excluded from the general health care plan. The distinction between »reconstructive« versus »cosmetic«
breast surgery is very well defined by the American Society of Plastic Surgeons Board of Directors. Unfortunately, the
Croatian Health Society has yet to standardize such a distinction. There is an imperative need for evidence-based selec-
tion criteria. We retrospectively analyzed data of 59 female patients suffering from symptomatic macromastia who un-
derwent reduction mammaplasty over a 16 year period (1995 until 2011). Our aim was to compare and contrast the vari-
ous techniques available for reduction mammaplasty and to determine, based on patient outcome and satisfaction, which
technique is most suited for each patient. The results of our study generally reinforce the observation that reduction
mammaplasty significantly provides improvements in health status, long-term quality of life, postsurgical breast ap-
pearance and significantly decrease physical symptoms of pain. A number of 59 consecutive cases were initially treated
with the four different breast reduction techniques: inverted-T scat or Wisa pattern breast reduction, vertical reduction
mammaplasty, simplified vertical reduction mammaplasty, inferior pedicle and free nipple graft techniques. The aver-
age clinical follow-up period was 6-months, and included 48 patients. The statistical analysis of the postoperative pa-
tient complications revealed a significant positive relationship in regards to smoking. The majority of these complica-
tions were wound related, with no significant relationship between patient complications and variables such as age,
BMI, ASA score, resection weight of breast parenchyma, nipple elevation, duration of surgery, and type of pedicle. The
higher number of complication correlated with a lower volume of parenchyma resection (rho=–0.321). Overall satisfac-
tion with the new breast size (79%), appearance of the postoperative scars (87%), overall cosmetic outcome score (91%),
overall outcome (100%), psychosocial outcome (46%), sexual outcome (85%), physical outcome (88%), satisfaction with
preoperative information data (92%), and finally satisfaction with overall care process (96%) was calculated. As ex-
pected, the physical symptoms disappeared or were minimized in 88% of patients. Each method of breast reduction has
its advantages and disadvantages. The surgeon should evaluate each patient’s desires on the basis of her physical pre-
sentation. Breast reduction surgery increases the overall personal and social health; not only for the patient, but for their
family and friends as well. It is an imperative that every surgeon is aware of this, in order to provide the highest level of
care and quality to their patients.
Key words: breast hypetrophy, breast reduction surgery, operative techniques, outcome results, patient satisfaction,
and quality of life
657
Received for publication January 13, 2012
Introduction
Breast reduction or reduction mammalasty is an op-
eration designed to reduce and reshape large breasts.
This surgical procedure has become well perfected with
respect to safety and predictable aesthetic results1. Since
the size, shape, and symmetry of a woman’s breasts can
have a profound effect on her mental and physical well-
-being, it is imperative that the surgeon is aware of this
and approaches every surgery seriously and with care.
Many women with excessively small or large breasts
have an altered personal self-image and often suffer from
low self-esteem and other psychological stresses. In addi-
tion, women whose breasts are abnormally large, in pro-
portion to their body structure, are frequently limited in
their choice of clothing and lifestyle. A women’s breast
size also affects her mood, behavior, and career choice,
personal and professional life in many different ways2.
Many women3seek medical consultation for the sur-
gical relief of the symptoms associated with breast hyper-
trophy. Discomfort associated with large beast can in-
clude symptoms which present as: painful bra strap
grooves, ulceration from bra straps cutting into shoul-
ders, chronic rash of the inframammary fold (IMF), up-
per and lower back pain, neck and shoulder pain, pare-
sthesis of the arms and hands, headaches, painful kypho-
sis, and breast tenderness. They also have difficulty per-
forming various physical exercises and daily activities;
participating in sports or simply finding well-fitting bras
or clothes4. Currently, there are no definite guidelines
which define the exact size at which breast enlargement
becomes pathologic. The definition of symptomatic bre-
ast hypertrophy should focus on the degree of sympto-
matology and not necessarily the degree of breast hyper-
trophy. After breast reduction surgery, patients enjoy a
totally new positive outlook towards life and pursue ac-
tivities that were previously difficult or impossible. Bre-
ast reduction surgery significantly contributes to a wo-
man’s quality of life, positively influencing her psycholog-
ical and physical attitude5.
The history of breast reduction techniques primarily
involves the need for a reliable method to transpose the
nipple-areola complex (NAC) without complete amputa-
tion and subsequent grafting. While most of the opera-
tions performed in the late 1800s and early 1900s were to
correct ptosis, various types of skin and glandular exci-
sions were also performed. These procedures were used
to suspend the breast into a higher position on the chest
wall without true NAC transposition. Wise6in 1956 de-
scribed a pattern for preoperative breast marking which
allow for the accurate and reproducible resection of the
parenchymal tissue with minimally associated complica-
tions and satisfactory breast form. This technique re-
mains popular among surgeons today. Strombeck7in
1960 described a horizontal dermal bi-pedicle flap for
nipple transposition in which the innervations to the
NAC through lateral attachments are maintained. After-
wards, this technique was altered and perfected by many
who developed a variation of this horizontal dermal
bi-pedicle flap. McKissock8described vertical bi-pedicle
flap, Weiner9a superior based flap, Orlando and Guth-
rier10 a superomedially based flap, while Courtiss11 and
Georgiade12 used inferiorly based flaps in their proce-
dures. Numerous reports during the last two decades
have documented the efficiency of the inverted-T scar
methods6. The advantages of this technique include its
applicability to the wide spectrum of breast sizes and
shapes, its ability to match the contra-lateral breast pre-
cisely and its relatively high postoperative predictability.
The largest concern regarding the use of this technique
is the possibility of the long-term loss of shape and »bot-
toming out« of the breast. The final shape of the breast
ultimately depends on the initial skin envelope design
and the new location of the NAC. These two factors de-
termine the volume of resection and ultimately, the sha-
pe of the breast. The internal medial and superior fixa-
tion sutures of the inferior pedicle may assist in shaping
the breast mount, although bottoming out usually occurs
from inadequate glandular resection and the reliance on
a fairly tight lower poll closure to maintain projection.
This unfortunately can lead to scar widening.
The vertical reducing mammoplasty technique has
been increasing in popularity as a method to reduce the
length of the cutaneous scars13. This technique, descri-
bed by Lassus14 and further developed by Lejour15 has
gradually become a more accepted alternative to the tra-
ditional inverted-T scar methods6. Key features of the
vertical-scar technique include skin excision in only one
direction; this enables a reduction in scar burden, central
vertical glandular excision and contributes to the im-
proved postoperative shape by narrowing the breast whi-
le maximizing its projection. Unfortunately, this method
is probably best suited for patients with moderate hyper-
trophy who require a reduction of less than 800 grams.
Larger volume reductions are also possible with this
method although they usually require secondary revi-
sions of excess redundant skin from the base of the verti-
cal scar. The difficulty of moving the NAC over greater
distances has been solved by a modification of the pedicle
design. A lateral or medial pedicle allows the NAC to be
transposed superiorly with greater ease16. Recently, cur-
rent trends in the development of breast reduction sur-
gery include minor refinements in the classic inverted-T
scar technique with the increased use of the vertical scar
reduction mammaplasty technique17. The identification
and the description of the common, basic principles re-
sponsible for the success of all modern reduction tech-
niques must include the importance of the breast blood
supply and the unique relationship between the glandu-
lar tissues with the skin envelope13.
Once the diagnosis of a breast deformity is made, a
4-step surgical approach is used for the breast reduction.
The first step includes the reduction of breast paren-
chyma and the adjustment of the skin envelope. Sec-
ondly, the amputation of the base of the breast is per-
formedin the aim to improve the proportion between the
breast and body profile. The third step involves the de-
velopment of the medial and lateral flap (or wings) to im-
prove breast contour. Lastly, correctly positioning the
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
658
NAC is crucial using the various pedicle techniques such
as the superior, inferior, or lateral pedicle flap to achieve
favorable results. The benefits of the latter, which in-
clude reduced scar burden and improved long-term pro-
jection of the new breast is a more attractive technique,
although this method itself has proved to be somewhat
intuitive and more challenging to the surgeon1. Recent
techniques have involved the use of suction lipectomy, ei-
ther alone or combined with surgical excision of the glan-
dular tissue19. Reduction mammoplasty by either sur-
gery or liposuction proportionately reshapes the enlarged,
sagging breasts of a patient with macromastia or gigan-
tomastia. Which specific reduction mammaplasty proce-
dure to be performed is determined by the volume of
breast parenchyma needed to be resected from each
breast and the degree of breast ptosis present’s. The inci-
sion pattern and the skin-envelope tissue area to be re-
moved determine the location and the size of the surgical
scars. The final shape and contour of the reduced breast
is determined by the remaining breast tissue and it is im-
perative that the skin and glandular tissue pedicle main-
tains proper innervations and blood supply13. Unfortu-
nately, a flat breast deformity with inadequate breast
projection may result following breast mammaplasty due
to the lack of centrally located breast parenchyma. Most
authors recommend placing the nipple 18–23 cm from
the suprasternal notch. This distance will result in the
nipple being placed at or very slightly above the IMF
level. One of the most challenging obstacles following
surgery is the correction of a nipple that was placed too
high. Regardless of the flap orientation the nipple will
have adequate circulation as long as the pedicle is not
subjected to excessive crowding, folding or torsion19. The
development of large, deformed breasts usually occurs
postpartum, after gaining weight, at menopause, and
may occur at any age. Macromastia is the consequence of
adipose tissue hypertrophy (over-development), rather
than mild gland hypertrophy. Macromastia can be mani-
fest as a unilateral or bilateral condition, occurring in
combination with sagging or breast ptosis. This is deter-
mined by the degree of nipple descent below the IMF. Un-
fortunately, many women have a genetic predisposition
for developing large breasts and this can be potentiated
by pregnancy, weight gain or both. There also iatrogenic
conditions such as post mastectomy and post lumpecto-
my asymmetry that could contribute to the development
of large breasts. Although the exact pathophysiology of
breast hypertrophy is unknown, this condition is thou-
ght to be the result of an abnormal response to circulat-
ing estrogens20. Hypermastia typically begins with the
hormonal changes associated with puberty and preg-
nancy. Contrary to popular belief, the breast enlarge-
ment primarily consists of expanding fibrous and fat tis-
sues, while the glandular elements remain quite small20.
Ductal hyperplasia may also play a role in the etiology of
breast hypertrophy21. The main reason for this condition
is the increased sensitivity of mammary tissue to estro-
gen although Kupfer and Dingman22 also suggest a famil-
iar pattern to this disease. Hormonal suppression has
been found to be ineffective in the management of gi-
gantomastia and currently, the mainstay of treatment is
radical surgery which can include free nipple grafting in
order to obtain an adequate reduction23. The recurrence
of gigantomastia, a recognized risk particularly among
pregnant women often warrens a secondary operation. A
female’s breast size in relation to her physical proportion
may have a profound effect on the musculoskeletal sys-
tem. Such patients frequently complain of neck and
shoulder discomfort, headaches, back pain, persisting
rashes, a heavy anterior chest, and occasionally pares-
thesis predominately on the ulnar side of the arm and
hands. Breast reduction surgery is contraindicated if the
patient is lactating, has recently ceased lactating, or if
her breast contains unevaluated tissue substrate with
unidentified micro-calcifications. Other surgical contra-
indications include systemic illness and any patient who
is unable to understand the operative limitations and
possible complications associated with breast surgery.
There are many different surgical methods available
to the surgeon. The inferior pedicle, anchor or Wisa pat-
tern inverted -T scar methods are the most commonly
performed breast reduction operative techniques in the
United States for the previous two decades13. Inverted-T
scar reduction methods are extremely versatile since
both the skin envelope and glandular volume can be re-
duced in a single fashion with great precision. Generally,
the inferior pedicle (central mound) insures a blood sup-
ply from an inferior, centrally based attachment to the
chest. These skin pedicles maintain the innervations and
vascular viability of the NAC, which produces a reduced
sensitive breast while maintaining functionand lactation
capability24. The condition for conventional T scar breast
reduction can safely be extended to cases of more severe
macromastia without resorting to free nipple-graft tech-
niques. The advantages of this technique include the
ability of preserving nipple sensation and avoiding depi-
gmentation or incomplete take of nipple and areolar
grafts. Certain, disadvantages include a longer operative
time, larger final breast sizes, and a potential complica-
tion resulting from having to fold a longer inferior pe-
dicle. The drawbacks of these techniques include an ex-
tensive scar pattern, the propensity for hypertrophic scar
formation, and poor long-term shape, have encouraged
the development of alternative techniques, such as verti-
cal reduction mammoplasty and pure circumareolar me-
thods. The breast reduction performed with the vertical
scar technique usually produces a well projected new
breast with short incision scars and NAC elevated by
means of a pedicle (superior, medial, lateral) that main-
tains the biologic and functional capacity of the NAC. De-
spite its advantages, this method is more intuitive and
inherently less precise than the inverted -T scar methods
due to the central and posterior nature of the glandular
resection during the procedure. Even in experienced
hands, the vertical scar method is probably best suited to
patients with moderate hypertrophy requiring a reduc-
tion of no more than 800 g. Large volume reductions are
also possible with this method but they tend to require
secondary revisions to excise redundant skin at the base
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
659
of the vertical scar13. Periareolar techniques accomplish
breast reduction and reshaping via an incision around
the areola alone. The most common difficulty with pe-
riareolar surgery has been found to be a flattening of the
breast shape with a loss of nipple/areola projection with
widening of the scars and the areolas. Benelli’s »round
block« technique25 in which a permanent pursestring su-
ture is placed may help prevent the scar and areola
spread. The horizontal scar method best applies to a pa-
tient whose over-sized breasts are too large for the verti-
cal incision technique. The potential disadvantage is the
possibility of developing box-shaped breast with tick inci-
sion scars, especially at the IMF7. The free nipple graft
technique transposes the NAC as a tissue graft without a
blood supply, without skin and glandular pedicle. The
therapeutic advantage to this is that a greater volume of
the breast tissue can be resected which produces a pro-
portional breast. Certain disadvantages include a breast
without a sensitive NAC or without lactation capability.
This method is reserved for a patient with the high risk
of tissue ischemia, a diabetic patient, a smoker, a patient
with over-sized breasts that have an approximate NAC to
IMF measure of 20 cm, or a patient with macromastia
who requires the extensive resection of the breast ti-
ssue26. Liposuction-only methods reduce breast tissue
and are usually applied to patients who have over sized
breasts requiring the removal of a medium volume of
breast tissue. It is also used for patients who cannot be
under extended general anesthesia. Many plastic sur-
geons believe that fat tissue should neither be suctioned
from nor added to breast tissue because of oncologic
concerns27. Reduction mammaplasty in adolescents is
also a very demanding procedure and concerns about
hormone-induced hypermastia, possible sensory alter-
ations, difficulties with breastfeeding, interference with
mammography, and other changes created by reduction
surgery compel many plastic surgeons to delay reduction
mammaplasty until the patient is at least 20 years of age.
Younger women considering reduction mammaplasty
should be thoroughly informed about the potential com-
plications of surgery (breast ptosis and a change in bre-
ast shape after pregnancy). McMahan and colleagues28
investigated 48 women who have had reduction mamma-
plasty as teenagers (mean age of surgery was 17, 8 years).
Overall, 94% of patients were satisfied with the results of
their surgery. The most common complaint was the presen-
ce of prominent scars (60%), and sensory deficits (35%).
It has been shown that patients who undergo breast re-
duction surgery have a lower risk of developing breast
cancer29. Although routine histological analysis of tissue
samples is still required, due to the possibility of the
presence of asymptomatic breast cancer. In 27.500 wo-
men in Ontario, Canada who had reduction mammapla-
sty, 0.06% (95% confidence interval 0.03% to 0.09%) was
found to have invasive carcinoma5. The decrease in de-
tection of occult cancer in breast reduction specimens in
recent years has been explained by the advancement of
early cancer detection, improvements in patient educa-
tion, a younger group population undergoing surgery,
and more detailed preoperative screening procedures5.
Materials and Methods
A retrospective cohort study of 59 patients suffering
from symptomatic macromastia underwent bilateral re-
duction mammaplasty in our Department for Plastic
Surgery and Burns over a 16 year period (1995 until
2011). The vast majority of our cases were operated in
our hospital while three cases were treated in an outpa-
tient clinic. Seven patients had gigantomastiaand they
have been documented to have the following characteris-
tics: distance from nipple to sternal notch longer than 32
cm and more than 1000g of breast tissue was resected per
breast.The demographic information collected included
age, number of patients, weight, health status, body
mass index (BMI or Quetelet’s index which analyzed re-
lationship between height and weight), the patient’s
medical history, presence of co-morbidity, preoperative
anesthesia – ASA I-III status, sternal notch to nipple and
sternal notch to IMF measurements, total parenchyma
removed, and smoking habits. The long-term results of
reduction mammaplasty from 48 patients were obtained
after a follow-up period of 6 months. The possibility of
nipple-areola necrosis as well as other tissue necrosis or
the appearance of an infection post operatively was ana-
lyzed separately. Preoperatively, every patient was given
an intravenous antibiotic (Cephalosporin-Ketocef 1.5 g)
over three days as well as deep venous thrombosis pro-
phylaxis with low molecular heparin administered sub-
cutaneously-Fraxyparin 0.6 IU or Clexan 0.6 IU. Specific
surgical data that was collected included the surgical
technique used, the amount of parenchyma resection
(weight), the length of operation, and pathohistological
analysis of the breast tissue samples. Any complications
encountered were documented as either minor or major.
Potential minor complication include seroma formation,
hematoma, the soft tissue infection, dog-ear requiring re-
vision, changes in nipple sensation, and small incisional
breakdown or delayed healing of less than 2 cm. Major
complication included large incisional breakdown or de-
layed healing of greater than 2 cm, nipple-areola necro-
sis, loss of nipple sensation, deep vein thrombosis, pul-
monary embolism, myocardial infarction, or death.
Patient data was collected by reviewing previous med-
ical records up to at least six months following surgery.
48 patients were interviewed and asked questions re-
lated to specific areas: result and outcome satisfaction,
psychosocial outcome, sexual outcome, physical outcome,
and their overall satisfaction with the procedure30. In our
study, the method selection included four types of the
breast reduction techniques. The first is a vertical bi-
pedicle technique by McKissock8which is based on Wisa
keyhole pattern for preoperative marking6. The second is
the inverted-T scar breast reduction with central or infe-
rior pedicles, the third is the vertical scar techniques by
Lejour15 and Ruth Graf’s inferior central-glandular te-
chnique31. The fourth technique used was the free nip-
ple-graft technique26. Unfortunately, it is very difficult to
accurately compare the results for those different reduc-
tion mammaplasty methods, even when the same opera-
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
660
tion is performed by the same surgeon, as was in our co-
hort study.
Preoperative marking (inverted-T, Wisa pattern, ver-
tical scar technique, inferior central-glandular techni-
que, and free nipple graft technique) was performed with
the patient in a standing position. A cooling blanket and
intravenous antibiotics were applied prior to surgery.
During the procedure, the creation of an adequate breast
pedicles and skin envelop was first completed followed by
the excision of the breast parenchyma, by knife or ele-
ctrocautery. Final closure was achieved with a combina-
tion of interrupted 2–0, 3–0 and 4–0 intradermal Vicryl
sutures followed by running 3–0 and 4–0 Monocril or
PDS sutures. Drains were installed in all cases. Follow-
ing drain removal, the patient was additionally fitted
with a soft, supportive bra for the next three or four
weeks.
Statistics
Due to the small size and Kolmogorov-Smirnov test,
only non-parametric test were used in our statistical
analysis. The Chi-square test with Yates correction for
small samples was used in the categorical data analysis.
Quantitative data was analyzed with Mann-Whitney U
test. The Spearman correlation coefficient was calcu-
lated between total parenchyma removed and the num-
ber of complications observed. Binary logistic regression
model was used to assess the impact of several different
clinical predictors in the possibility of the patients pre-
senting with any complications. All P values below 0.05
were considered significant. Statistical software STA-
TISTICA version 10.0 was used in the data analysis.
Results
Fifty-nine consecutive cases of inverted-T scar tech-
nique or Wisa pattern breast reduction, vertical reduc-
tion mammaplasty, simplified vertical reduction mam-
maplasty, inferior pedicle technique, or free nipple graft
were evaluated. It was observed that 58 cases involved
bilateral reduction whereas one case was unilateral due
to congenital Poland syndrome asymmetry. Representa-
tive cases are illustrated in Figures 1 to 3. The mean pa-
tient age was found to be 47 years (range, 24 to 74) and
the majority of the patients in our sample group were be-
tween the ages of 26 to 35 years (39%). Body mass distri-
bution was separated into 5 groups, with the majority
having a BMI between 31 and 35 (39%) (Table1). The av-
erage presurgical distances measured from sternal notch
to the nipple was 28 cm (range, 21 to 41 cm) (Table 4). It
was found that thirteen patients smoked (22%). A pa-
tient’s ASA score was distributed into 3 groups with 48
(81%) found to be in group ASA I (Table 1). The average
clinical follow-up period was 6-months, and included 48
patients (81%) (Table 9). The total average parenchymal
resection volume was found to be 1057 g (range, 360 to
2060 g) (Table 5), although the most common resection
weight was between 1001 and 1500 g (58%) (Table1). The
average duration of breast reduction surgery was 111
minutes, with a range between 56 and 160 minutes (Ta-
ble 5). The finally pathohistological analysis of the breast
tissue samples not found any positive result of the breast
cancer in the sample material. The most common type of
breast reduction surgery performed was the pedicle tech-
nique. This technique uses a variety of related designs in
which the goal is to raise the nipple-areola into a higher
position while leaving these tissues attached to a portion
of the underlying breast tissue (Table 7). It was observed
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
661
Fig. 1. Inverted T-scar technique (Vertical bi-pedicle technique).
Fig. 2. Inferior pedicle techique (Inferior-central dermoglandu-
lar pedicle technique).
Fig. 3. Vertical reduction mammaplasty (Supero-medial dermo-
glandular pedicle technique).
that out of the 59 patients in our study, minor complica-
tions occurred in 27 (45.8%) patients. Specific minor
complications included 9 seromas (15.3%), 3 hematomas
(5.1%), 4 soft tissue infection (6.8%), 3 patients with
dog-ears which required revision (5.1), 5 delayed healing
wound <2cm (8.5%), and 3 cases presented with hyper-
trophic scaring (5.1%). It is important to recognize that
all of the patients received prophylactic doses of antibiotic
(Cephalosporin-Ketocef 1.5 g) which began preopera-
tively and continued postoperative over a course of two
days. Also, deep venous thrombosis prophylaxis with low
molecular weight heparin was administered subcutane-
ously-Fraxyparin 0.6 IU or Clexan 0.6 IU. Nine major
complications (15.3%) occurred during this study. It was
found that only 3 patients had delayed healing wound
which was greater than 2 cm in length (5.1%). NAC ne-
crosis occurred in 3 cases (3.4%), two of which were
smokers and/or diabetics while one had a complication
with the NAC blood supply. Fat necrosis occurred in 1 pa-
tient who was diabetic and one pulmonary embolism was
seen in a previously healthy patient. This was diagnosed
7 days after an uncomplicated 1250 g breast reduction. A
therapeutic dose of 30 million IU of Heparin, divided into
6 doses was administering in the ICU. One patient post-
operatively suffered from an acute myocardial infarction
and one developed a DVT. Both patients were treated in
the ICU (Table 2). The c2analyses of postoperative pa-
tient complications revealed a significant positive rela-
tionship in regards to smoking (p=0.003). The majority
of these complications were wound related and it was
found that there was not a significant relationship be-
tween patient complications and variables such as age,
BMI, ASA score, resection weight of breast tissue, sterna
notch to nipple distance, nipple elevation, duration of
surgery, and type of pedicle (Table 3). Logistic regression
analyses showed that the main clinical predictors for an
increased risk of developing complications were smoking
(p=0.008; OR 61.92), lower volume of removed paren-
chyma (p=0.007; OR 0.98), and a longer duration of the
operation (p=0.019; OR 1.05) (Table 6). Spearmen’s rho
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
662
TABLE 1
DESCRIPTIVE STATISTICS OF INVESTIGATED SAMPLE
REGARDING SOCIO-DEMOGRAPHIC AND CLINICAL
PARAMETERS
N%
Smoking No 46 78.0
Yes 13 22.0
Follow-up No 11 18.6
Yes 48 81.4
Age (groups) <25 5 8.5
26–35 20 33.9
36–45 23 39.0
46–55 8 13.6
>56 3 5.1
BMI (groups)* <25 5 8.5
26–30 15 25.4
31–35 37 62.7
36–40 1 1.7
>40 1 1.7
ASA score † 1 48 81.4
2 8 13.6
335.1
Sterna notch to nip-
ple distance
(groups)
20–25 5 8.5
26–30 42 71.2
31–35 9 15.3
36–40 2 3.4
>40 1 1.7
Nipple elevation 5–7 cm 49 83.1
8–10 cm 6 10.2
9–15 cm 4 6.8
Total parenchyma
removed
<500 g 5 8.5
500–1000 g 13 22.0
1001–1500 g 34 57.6
1501–2000 g 5 8.5
>2000 g 2 3.4
Type of pedicle Vertical bi-pedicle 43 72.9
Superomedial pedicle 6 10.2
Inferior pedicle 6 10.2
Free nipple graft 4 6.8
Duration of
surgery
<60 min 1 1.7
61–90 min 4 6.8
91–120 min 41 69.5
>120 min 13 22.0
* BMI, body mass index (kg/m2)
† ASA score, American Association of Anesthesiologist score
TABLE 2
DESCRIPTIVE STATISTICS OF MAJOR AND MINOR
COMPLICATIONS
N%
Minor
complications
Without 30 50.8
Decreased sensation 2 3.3
Serom 9 15.3
Hematom 3 5.1
Infection 4 6.8
Dogear 3 5.1
Delay healing <2cm 5 8.5
Hypertrophic scars 3 5.1
Major
complications
Without 46 77.9
Diminished nipple sensation 4 6.7
Delay healing >2cm 3 5.1
Nipple areolar necrosis 2 3.4
Fat necrosis 1 1.7
Pulmonary embolism 1 1.7
Infarct 1 1.7
DVT 1 1.7
DVT, Deep vein thromboses
correlation coefficient was calculated between the total
volume of resected parenchyma and the number of ob-
served complications. The higher number of complica-
tions correlated with a lower volume of parenchyma
resected (rho=–0.321, p=0.013). The outcome analyses
of 59 patients undergoing reduction mammaplasty have
shown significant improvements in six groups of stan-
dardized outcome measures. After a 6 month patient fol-
low-up, an analysis of 48 patients was performed (Table
8). It was found that the breast reduction surgery was
particularly effective in increasing patient self-esteem,
correcting specific macromastia or symptomatology, and
improving the patient’s overall health by increasing their
quality of life (both physical and psychosocial).
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
663
TABLE 3
DIFFERENCES BETWEEN PATIENTS WHO HAD ANY COMPLICATIONS AND WITHOUT COMPLICATIONS: c2TEST
Any complications (minor and major)
p
No
N=26
Yes
N=33
N%N%
Smoking No 25 96.2 21 63.6 0.003
Yes 1 3.8 12 36.4
Age (groups) £25 0 0.0 5 15.2
0.137
26–35 8 30.8 12 36.4
36–45 14 53.8 9 27.3
46–55 3 11.5 5 15.2
³56 13.826.1
BMI (groups) £25 1 3.8 4 12.1
0.211
26–30 9 34.6 6 18.2
31–35 14 53.8 23 69.7
36–40 1 3.8 0 0.0
³40 13.800.0
ASA score 1 22 84.6 26 78.8
0.3942 2 7.7 6 18.2
3 2 7.7 1 3.0
Sterna notch to nipple
distance (groups)
20–25 1 3.8 4 12.1
0.698
26–30 20 76.9 22 66.7
31–35 4 15.4 5 15.2
36–40 1 3.8 1 3.0
>40 0 0.0 1 3.0
Nipple elevation 5–7 cm 23 88.5 26 78.8
0.1838–10 cm 3 11.5 3 9.1
9–15 cm 0 0.0 4 12.1
Total parenchyma
removed
£500g 1 3.8 4 12.1
0.408
500–1000g 5 19.2 8 24.2
1001–1500g 15 57.7 19 57.6
1501–2000g 4 15.4 1 3.0
³2000g 13.813.0
Type of pedicle Vertical bi-pedicle 20 76.9 23 69.7
0.868
Superomedial pedicle 2 7.7 4 12.1
Inferior pedicle 2 7.7 4 12.1
Free nipple graft 2 7.7 2 6.1
Duration of surgery £60 min 00.013.0
0.082
61–90 min 2 7.7 2 6.1
91–120 min 22 84.6 19 57.6
³120 min 2 7.7 11 33.3
Discussion
Currently, breast reduction surgery is safe, effective
and beneficial to the patient. In Croatia, reduction mam-
maplasty is often excluded from the general health care
plan. The distinction between »reconstructive« versus
»cosmetic« breast surgery is very well defined by the
American Society of Plastic Surgeons Board of Dire-
ctors32. Unfortunately, the Croatian Health Society has
yet to standardize such a distinction. There is an impera-
tive need for an evidence-based selection criteria’s. Liter-
ature that has examined and contrasted BMI levels has
concluded that most patients with macromastia received
beneficial physical and psychological results from bilat-
eral breast reduction regardless of BMI level33. Many au-
thors have demonstrated that weight loss alone does not
relieve the symptoms of macromastia34. Recent studies
addressing this issue have shown a positive correlation
between obesity and the benefit from bilateral breast re-
duction. It was concluded that obese patients had the
largest benefit from bilateral breast reduction, which im-
proved their overall lung function, physical condition,
quality of life, sexual outcome, overall care process, and
psychosocial status3,5. It is also well documented that
some women develop negative psychosocial behavioral
patterns after breast reduction. Lastly, the female breast
has powerful symbolic significance and is a vital part of
femininity, sexuality and nurturing, while reduction mam-
maplasty is an operation that cuts, scars, changes and de-
sensitizes this a part of a women’s body3. Therefore great
patient care and screening is necessary for every patient
considering undergoing this procedure. A prospective
study from Canada by O’Bleneset al.5was conducted in
an aim to determine whether the beneficial effects of re-
duction mammaplasty are maintained over a long period
of time and to determine whether reduction mammapla-
sty facilitates weight loss in an overweight patient. In
this long-term prospective study of 57 patients undergo-
ing reduction mammplasty, they have showed significant
improvements in all three of their standardized outcome
measures 6 and 21.5 months post-surgery. Stable im-
provements in self-reported self-esteem, specific macro-
mastia symptomatology, and health-related quality of life
were shown after this procedure. Particularly effective
was the improvement of the physical quality of life and
the overall well-being of the patient. It was found that af-
ter 2 years, overweight patients were found to have sig-
nificant weight loss and a change in BMI, with an in-
creased ability to participate in sports and recreation.
Our long-term outcome study provided evidence that re-
duction mammaplasty is an effective method for the re-
duction or alleviation of both physical and psychological
symptoms associated with macromastia. It is imperative
that the overall personal and social benefits provided by
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
664
TABLE 4
DIFFERENCES IN SURGICAL DATA COLLECTION BETWEEN COMPLICATIONS GROUP: MANN-WHITNEY U TEST
Any
complications NMinMax Percentiles p
25th 50th (Median) 75th
Age (years) No 26 32 73 43.00 48.50 53.25 0.271
Yes 33 24 74 36.50 45.00 53.00
Sterna notch to nipple
distance (cm)
No 26 24 36 26.75 27.00 28.25 0.462
Yes 33 21 41 26.50 28.00 29.00
Nipple elevation (cm) No 26 5 9 5.00 6.00 7.00 0.943
Yes 33 5 13 5.00 6.00 7.00
Total parenchyma
removed (grams)
No 26 420 2060 985.00 1140.00 1371.25 0.009
Yes 33 329 2050 755.00 1029.00 1090.00
Duration of surgery
(min)
No 26 69 140 100.00 109.00 115.75 0.587
Yes 33 56 160 99.00 109.00 132.50
TABLE 5
SURGICAL DATA COLLECTION REGARDING WHOLE SAMPLE (N=59)
Minimum Maximum Percentiles
25th 50th (Median) 75th
Age (years) 24.00 74.00 41.00 47.00 53.00
Sterna notch to nipple distance (cm) 21.00 41.00 27.00 28.00 29.00
Nipple elevation (cm) 5.00 13.00 5.00 6.00 7.00
Total parenchyma removed(grams) 329.00 2060.00 870.00 1050.00 1210.00
Duration of surgery (min) 56.00 160.00 100.00 109.00 120.00
this surgery, not only for the patient, but for their family
and friend’s be acknowledged. It is thus crucial that the
medical community, patient population and the national
Heath Care Insurance clinically and financially support
this procedure.
During the past two decades multiple studies have an-
alyzed and compared various techniques of breast redu-
ction16. Most of them concluded that the inferiorly based
dermal flap procedure was the most beneficial in regards
to NAC position and was most beneficial at maintaining
nipple sensation. When vertical bi-pedicle flaps were used,
their postoperative nipple to IMF distance tended to
stretch with time, resulting in nipples that were too high
on the breast mound. Each procedure must be adapted to
the personal need and desires of the patient. The in-
verted-T scar technique may still be the best choice for
patients with large breasts or in patients who have un-
dergone massive weight loss with a considerable amount
of excess skin. The vertical approaches use the new
shape of the breast parenchyma to contour the remain-
ing skin. Increased closure tension is unnecessary as it
can lead to wound healing difficulties. It is crucial in
both the inverted-T and vertical approaches to properly
mark the new nipple position. A nipple that is too high is
difficult or impossible to correct and can be very detri-
mental to the patient. The nipple should be positioned
near or at the level of the IMF, and with the vertical ap-
proach this position should be somewhat lower to accom-
modate the increased projection. The IMF can rise with
some of the vertical techniques but tends to drop be-
neath the horizontal scar with the inverted-T scar me-
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
665
TABLE 7
COMPARISON OF OUR FOUR TECHNIQUES FOR BREAST REDUCTION*
Variables Inverted T-scar Vertical RM Inferior pedicle Free nipple graft
Marking pattern Similar to Wisa pattern
without extension
Wisa pattern without
extension
Wisa pattern Wisa pattern
Pedicle design
Glandular resection
Vertical bi-pedicle
Separate from skin
design
Medial dermoglandular
Skin pattern plus lat.
and med. curve-put
Inferior dermoglandular
Follows skin pattern
Superior dermal
Follows skin pattern
Insertion of pedicle
Breast shaping
Variable: easy to difficult
Suture of medial and
lateral pillars
Easy
Suture of medial
and lateral pillars
Easy
No glandular sutures
Easy
Suture of medial and lat-
eral pillars
Skin undermining
Liposuction
Extensive
Breast volume
and contouring
None
Breast volume
and contouring
None
Contouring only
None
Breast volume and con-
touring
Operative time 2–3 hours 2–3 hours 3–4 hours 2–3 hours
Scaring Racquet shaped Racquet shaped Anchor shape Anchor shape
Recovery 2–4 weeks 2–4 weeks 3–6 weeks 2–4 weeks
Shape Occasional
»bottoming out«
Occasional
»bottoming out«
Frequent
»bottoming out«
Occasional
»bottoming out«
Scar length
(excluding areola)
25–35 cm 12–15 cm 25–35 cm 15–20 cm
* Based on the article: HIDALGO DA, ELLIOT F, PALUMBO S, CASA L, HAMMOND D. Current trends in breast reduction, Plast
ReconstrSurg, 104 (1999) 806.
TABLE 6
LOGISTIC REGRESSION MODEL FOR HAVING ANY COMPLICATION
Predictors p OR 95 CI for OR
Lower Upper
Smoking 0.008 61.92 2.94 1302.59
Age (years) 0.599 0.98 0.90 1.07
BMI (groups) 0.482 1.48 0.50 4.39
ASA score 0.371 0.46 0.08 2.55
Sterna notch to nipple distance (cm) 0.670 0.95 0.75 1.20
Nipple elevation (cm) 0.517 1.16 0.73 1.84
Total parenchyma removed (grams) 0.007 0.98 0.97 0.99
Duration of surgery (min) 0.019 1.05 1.01 1.10
thod. With the wide range of techniques and the avail-
ability of pre/post-operative liposuction, the choice of
which procedure to undertake can be difficult, especially
since the patient population can range from teenagers to
postmenopausal women.
In this study, 17 (28.8%) patients have been found to
be without any form of complication, 29 (49.2%) patients
have minor complications while 13 (22.1%) have major
complications, postoperatively. Various literatures has
documented that the most common complications which
appeared after breast reduction surgery usually included
seroma, hematoma, infection, fat necroses, dog-ear, hy-
pertrophic scars, diminished nipple sensation, stitch ab-
scesses, and delayed healing5. These findings are similar
with our analysis of non-specific minor and major com-
plications after breast reduction surgery. Non-paramet-
ric Sperman’s rho test which was made between the total
parenchyma resection volume and the number of ob-
served complications showed that a higher number of
complications positively correlated with an increased re-
section weight. Patients with macromastia often report
subjective poor or limited sensation on the nipple areola
complex35. Therefore, two hypotheses were proposed.
Firstly, the decreased sensation could result from neuro-
praxia of the sensory nerve fibers secondary to traction
caused by the heavy breast tissue while secondly tissue
expansion of the nipple-areola by the voluminous breast
parenchyma causes a decrease in the number of nerve fi-
bers per surface area and hence decreased sensory per-
ception. There seems to be general agreement that be-
fore surgery, the large breast is less sensitive than the
small breast in response to pressure testing in the NAC36.
This change in NAC sensation after breast reduction is
variable depending on the pattern of operative technique
used and the preoperative distribution of the patient’s
sensory nerves. In a study conducted by Gonzaleet al.37,a
positive correlation between preoperative breast volume
and the corresponding amount of tissue removed at sur-
gery had a direct implication on the loss of nipple areola
sensibility. In our study, it was observed that patients
with the higher parenchyma volume removed have a de-
creased sensation in NAC. After a period of time, post-
surgical breast pain was also a frequent complaint, re-
ported by 50% of patients. Breast pain has been docu-
mented to interfere with sexual activity, reported by 48%
of patients, exercise (36%), social activity (13%), and em-
ployment (6%). Postsurgical breast neurogenic pain must
be differentiated and regarded separately from infec-
tious, neoplastic, or wound-related origin, as these late
surgical complications can be avoided as stated by evi-
dence-based studies for antibiotics, oncologic techniques,
and appropriate tissue modeling35.
The results of our study generally reinforce the obser-
vation that reduction mammoplasty significantly pro-
vides increased improvements in health status, long-
-term quality of life, and postsurgical breast pain. Patients
with breast hypertrophy often experience a various num-
ber of physical symptoms (including intertrigo, painful
bra strap grooves, upper and lower back pain, shoulder
pain, neck pain, arm pain, numbness or pain in the
hands, breast pain, and headaches), as well as psycho-
social difficulty4. Reduction mammaplasty also reduces
neck, back, and shoulder discomfort in all patients and it
was found that pain was totally eliminated in 25% of
sampled patients37. Symptom’s improvement after bre-
ast reduction surgery was independent of patient height-
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
666
TABLE 8
SATISFACTION SURVIVE CHART: DATA FROM 48 PATIENTS,
AFTER 6-MOUNTS FOLLOW-UP
Satisfaction with overall outcome of the new breast Number
Are you satisfied with the new breast size?
Yes 2 2
Quite 16
No 10
Are you satisfied with appearance of the postoperative scars?
Yes 4 2
No 6
How is your overall cosmetic outcome score (from 1 to 10
points score)?
Bad (1–6 points) 4
Good (7–8 points) 8
Excellent (9–10 points) 36
Satisfied with overall outcome
Would you recommend it to anybody who is interest in?
Yes 4 8
No 0
Psychosocial outcome
Have psychosocial symptoms which you have been suffering
from disappeared?
Yes 3 2
Only a little 6
No 10
Sexual outcome
Have you sexual life improved?
Yes 4 1
No 7
Physical outcome
Have physical symptoms which you have been suffering from
disappeared?
Yes 3 7
Only a little 5
No 6
Satisfaction with overall care process
Do you consider that you have received complete preoperative
information data about the surgical procedure?
Yes 4 4
No 4
Are you satisfied with overall care provided?
Yes 4 6
No 2
-to-weight ratios. This casts doubt on weight loss as an
effective therapy for macromastia38. A large number of
patients usually reported complete postoperative resolu-
tion of the three main symptom groups: arm pain, head-
aches, and general pain.
Our results indicate that patients responded with a
high level of satisfaction following reduction mamma-
plasty. Overall satisfaction with the new breast size (79%),
appearance of the postoperative scars (87%), overall cos-
metic outcome score (91%), overall outcome (100%), psy-
chosocial outcome (46%), sexual outcome (85%), physical
outcome (88%), satisfaction with preoperative informa-
tion data (92%), and finally satisfaction with overall care
process (96%) was observed. As expected, the physical
symptoms disappeared or were minimized in 88% of pa-
tients.
Conclusions
Each method of breast reduction surgery has its ad-
vantages and disadvantages. The surgeon should evalu-
ate each patient’s desires on the basis of her physical pre-
sentation. Every patient is unique and therefore there is
not a single technique which satisfies every patient.
Therefore, each surgeon should be confident with the
several surgical techniques available. Breast reduction
surgery increases the overall personal and social health;
not only for the patient, but for their family and friends
as well. It is imperative that every surgeon be aware of
this, in order to provide the highest level of care and
quality to their patients. The Croatian Health Society
should standardize national criteria for breast reduction
mammaplasty which are based on the evidence-based
criteria’s32,33.
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Z. Roje
University of Split, Split University Hospital Center, Division for Plastic Surgery and Burns, Department of Surgery,
Split, Croatia, [oltanska 1, 21000 Split, Croatia
e-mail: zdroje@kbsplit.h
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
667
SUVREMENI TRENDOVI KOD REDUKCIJE DOJKE
SA@ETAK
Rezultati na{e studije pokazuju kasne u~inke kod redukcije tkiva dojki. Mnoge `ene koje imaju neobi~no male grudi
ili one s velikom grudima imaju promijenjen osobni imid`, i obi~no trpe zbog osje}aja manje vrijednosti, kao i zbog
drugih psiholo{kih stresova. Operacija redukcije dojke je dizajnirana za smanjenje i oblikovanje dojke. Dugoro~no pra-
}enje post operacijskih rezultata lije~enja je potrebno zbog toga {to veli~ina, oblik i simetrija dojki mo`e znakovito
utjecati na mentalno i psihi~ko zdravlje `ene koja ima velike dojke. Op}enito govore}i, danas su operacije za redukciju
dojki sigurne i djelotvorne, te imaju veliku u~inkovito{}u. Redukcija dojki u Hrvatskoj jo{ nije na listi zahvata koji idu
na teret HZZO (Zakon o obaveznom zdravstvenom osiguranju), ve} se svaki slu~aj razmatra pojedina~no i pojedina~no
se daje odobrenje za zahvat na teret HZZO. Ina~e je razlika izme|u rekonstrukcijske i estetske korekcije dojki najbolje
definirana od strane Ameri~kog udru`enja za plasti~nu kirurgiju. Stoga u Hrvatskoj u najskorije vrijeme treba napra-
viti standardizaciju tih zahvata prema kriterijima medicine dokaza. U ~lanku smo retrospektivno analizirali 59 `ena
koje su bile podvrgnute redukciji dojki zbog sindroma makromastije, koje smo operirali izme|u 1995. i 2011. godine. Na
temelju analize kona~nog ishoda lije~enja i zadovoljstva pacijenta `eljeli smo utvrditi operacijsku tehniku koja je najpri-
hvatljivija za odre|eni tip makromastije. Rezultati studije su pokazali da redukcija dojki znakovito pridonosi pobolj-
{anju sveukupnog zdravstvenog statusa, kvaliteti `ivljenja i smanjenju bolova. Ukupno je lije~eno 59 `ena, kod kojih
smo primijenili 4 razli~ite operacijske tehnike: Invertnu-T tehniku ili Wisa shemu za redukciju dojke, vertikalnu reduk-
ciju, pojednostavljenju vertikalnu tehniku, tehniku s bazom re`nja prema dolje i slobodni presadak bradavice. Uobi-
~ajeno postoperacijsko pra}enje je trajalo 6 mjesecu i uklju~ilo je 48 pacijentica. Statisti~ka obrada podataka je utvrdila
direktnu povezanost broja komplikacija s pu{enjem. Ve}ina komplikacija je bila povezana s cijeljenjem rane, a {to se ti~e
drugih varijabli utvrdili smo da je ve}i broj komplikacija vezan za starosnu dob, indeks tjelesne mase, preoperacijsku
anesteziolo{ku procjenu rizika operacije, te`inu odstranjenog tkiva dojke, visinu na koju je podignuta bradavica, traja-
nje operacije i tip peteljke na kojoj se premje{ta tkivo dojke. Ve}i broj komplikacija je bio u direktnoj vezi s te`inom
reseciranog tkiva dojke (rho=–0,321). Krajnje zadovoljstvo pacijentice s veli~inom dojke je iznosilo 79%, a izgledom
postoperacisjkog o`iljka 87%. Ukupni kozmetski skor je bio 91%, ukupni ishod operacije 100%, psihosocijalni ishod
46%, seksualno zadovoljstvo 85%, psihi~ko zadovoljstvo 88%, zadovoljstvo s prijeoperacijskim informacijama o redukciji
dojki 92%, i kona~no zadovoljstvo s cijelom procedurom je bilo 96%. Svaka operacijska metoda ima svoje prednosti i
mane. Kirurg mora posebno analizirati svaki pojedina~ni slu~aj i za svaki slu~aj mora odabrati operaciju koja je najpri-
mjerenija. I kona~no, operacije redukcije dojki mo`e znakovito unaprijediti osobni i socijalni status `ene, kao i njezine
porodice.
Z. Roje et al.: Current Trends in Breast Reduction, Coll. Antropol. 36 (2012) 2: 657–668
668