Reduction mammoplasty is a surgical procedure used to treat female breast hypertrophy (i.e., macromastia or gigantomastia). The surgery involves the excision of a portion of the breast, including the skin and underlying glandular tissue, to reduce the size, shape, and weight of mammary tissue. Macromastia is defined as a marked, abnormally excessive, pendulous enlargement of one or both breasts. This condition may result in pain of the shoulder, neck, or back, nerve compression of the arms, and recurrent intertrigo in the mammary folds. Reduction mammoplasty can also be performed to alleviate symptoms for a rare condition called gigantomastia. To date, there is no universally acceptable definition for gigantomastia and the exact cause of gigantomastia has not yet been determined; however, it is characterized by excessive breast growth that may occur spontaneously, during puberty, pregnancy, or while taking certain medication. Although reduction mammoplasty may be done at any age, it is usually performed when breast development is complete. In select cases (e.g., when the breasts are not too large and the skin has good elasticity), liposuction has been used as a sole method of treatment to reduce the overall breast size. However, in most cases, only fat, not glandular breast tissue, can be successfully removed by liposuction.
Schnur et al. (1991) developed a sliding scale based on a survey response from plastic surgeons who recorded the height, weight, and amount of breast tissue removed from each breast during reduction mammoplasty. The surgeons were also asked if the procedures were performed for cosmetic or medically necessary reasons. The data were used to create a chart relating the body surface area and the cut-off weight of breast tissue removed. The Schnur scale (abbreviated in the Guidelines section) allows a rough estimate of the minimal amount of soft tissue to be removed to justify surgery to alleviate symptoms based on body surface area.
Kerrigan et al. (2002) published the results of the Breast Reduction: Assessment of Value and Outcomes (BRAVO) study, a registry of 179 women undergoing reduction mammoplasty. The participating women were asked to complete questionnaires addressing quality of life and physical symptoms both before and after surgery. The physical symptom evaluation focused on the number of symptoms that were specific to breast hypertrophy such as back pain, rashes, bra strap grooves, neck pain, shoulder pain, numbness, and arm pain. In addition, the weight and volume of resected breast tissue was documented. The results were compared to a control group of individuals with either breast hypertrophy or normal size breasts who were recruited from the general population. The authors proposed that the presence of at least two physical symptoms should be appropriate for determining medical necessity for breast reduction.
The authors reported that while 71.6% of the hypertrophic control group reported zero or one symptom, only 12.4% of the surgical candidates reported zero or one symptom. This observation was difficult to evaluate because the study did not report how surgical candidacy was determined. The authors also reported that none of the traditional criteria for determining medical necessity for breast reduction surgery (e.g., height, weight, body mass index, bra cup size, or weight of resected tissue) had a statistically significant relationship with postsurgical symptom improvement. The authors concluded that the determination of medical necessity should be based on the individual's report of symptoms rather than more objectively measured criteria, such as estimated weight of excised breast tissue.
Iwuagwu et al. (2006) reported on 73 individuals randomly assigned to reduction mammoplasty within 6 weeks or after a 6-month waiting period to assess lung function. All individuals had symptoms related to macromastia. Postoperative lung function correlated with the weight of breast tissue removed, but there were no significant improvements in any lung function parameters for the mammoplasty group compared with the control group.
In 2008, a randomized controlled trial by Sabino Neto et al. assessed functional capacity of 100 individuals. Subjects were randomly assigned to reduction mammoplasty or waiting list control. At the onset of study and 6 months later, individuals were assessed for function capacity using the Roland-Morris Disability Questionnaire (0=best performance, 24=worst performance) and for pain using a visual analog scale (VAS). The reduction mammoplasty group showed improvement in functional status, with an average score of 5.9 preoperatively to 1.2 within 6 months postoperatively (P<0.001 for pre-post comparison within the mammoplasty group) versus an unchanged average score of 6.2 in control group on the first and second evaluations. Subjects in the reduction mammoplasty group also reported decrease in pain in the lower back region on the VAS from an average of 5.7 preoperatively to 1.3 postoperatively (P<0.001 for pre-post comparison within the mammoplasty group) versus VAS average score in the control group of 6.0 and 5.3 on the first and second evaluations, respectively (no significant change).
Also in 2008, Saariniemi et al. reported on quality of life (QOL) and pain in 82 individuals who were randomly assigned to reduction mammoplasty or a nonoperative group and evaluated at baseline and 6 months later. At 6 months, the authors reported that the mammoplasty group had significant improvement in QOL as measured by Physical Component Summary score of the 36-Item Short-Form Health Survey (SF-36; change, +9.7 vs + 0.7, P<0.001), the Utility Index score (SF-6D; change, +17.5 vs +0.6), the index score of QOL (SF-15D; change, +8.6 vs +0.06, P<0.001), and SF-36 Mental Component Summary score (change, +7.8 vs -1.0, P<0.002). The authors also reported improvements in breast-related symptoms, as reported by the Finnish Breast-Associated Symptoms questionnaire score and the Finnish Pain questionnaire score (−47.9 vs −3.5, P<0.001; 21.5 vs −1.0, P<0.001; respectively).
Thibaudeau et al. (2010) conducted a systematic review to evaluate breastfeeding after reduction mammoplasty. After a review of literature from 1950 through 2008, reviewers concluded that reduction mammoplasty does not reduce the ability to breastfeed. In women who had reduction mammoplasty, breastfeeding rates were comparable in the first month postpartum to rates in the general population in North America.
Chen et al. (2011) reported on a review of claims data to compare complication rates after breast surgery in 2403 obese and 5597 nonobese individuals. Of these individuals, breast reduction was performed in 1939 (80.7%) in the study group and 3569 (63.8%) in the control group. Obese individuals had significantly more claims for complications within 30 days after breast reduction surgery (14.6%) than nonobese individuals (1.7%; P<0.001). Complications included inflammation, infection, pain, and seroma/hematoma development.
Shermak et al. (2011) also reported on a review of claims data comparing complication rates by age after breast reduction surgery in 1192 individuals. Infection occurred more frequently in individuals older than 50 years of age (odds ratio [OR], 2.7; P=0.003). Additionally, women older than 50 years experienced more wound healing problems (OR, 1.6; P=0.09) and reoperative wound debridement (OR, 5.1; P=0.07).
In 2022 and 2021, the American Society of Plastic Surgeons (ASPS) issued practice guidelines and a companion document on criteria for third-party payers for reduction mammoplasty, respectively. The ASPS found that level I evidence has shown reduction mammoplasty is effective in treating symptomatic breast hypertrophy, which “is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions.” The ASPS also indicated the volume or weight of breast tissue resection should not be criteria for reduction mammoplasty. If two or more symptoms are present all or most of the time, reduction mammaplasty is appropriate.
A 2012 systematic review of studies by Singh and Losken reported on outcomes after reduction mammoplasty and found reduction mammoplasty improved functional outcomes including pain, breathing, sleep and headaches; the authors also reported on psychological outcomes and reported improvements in self-esteem, sexual function, and QOL in addition to less anxiety and depression.
A systematic review by Thibaudeau et al. was conducted in 2010 to evaluate breastfeeding after reduction mammoplasty. The authors reviewed literature from 1950 through 2008 and concluded that reduction mammoplasty does not reduce the ability to breastfeed. The authors reported similar rates of breastfeeding in women who had reduction mammoplasty in the first month postpartum to the general population in North America.
In 2016, Beraldo et al. assessed the sexual function and depression outcomes among individuals with breast hypertrophy undergoing reduction mammoplasty in a randomized trial of 60 individuals. At 6 months, the authors reported higher Female Sexual Function Index scores in the reduction mammoplasty group versus the no surgery group (27.5 vs 22.5, P<0.001) and lower levels of depression as measured by the Beck Depression Inventory in the reduction mammoplasty group versus the no surgery group (7.2 vs 13.7, P=0.01).
In 2016, Hernanz et al. reported on a descriptive cohort study of 37 consecutive obese patients who underwent reduction mammoplasty for symptomatic macromastia, along with 37 age-matched women hospitalized for short-stay surgical procedures. In the preoperative state, SF-36 physical health component subscore was significantly lower for patients with symptomatic macromastia (40) than for age-matched controls (53; P<0.001), with differences in five of the eight subscales. At 18 months postprocedure, there was no significant difference in any SF-36 subscores except the body pain subscale between patients who had undergone reduction mammoplasty and age-matched controls.
Overall, reduction mammoplasty in appropriately selected individuals is associated with improvements in several health outcomes. However, the criteria for medically necessary reduction mammoplasty are not well addressed in current professional literature. Therefore, patient selection criteria cannot rely solely on an evidence-based approach. Relevant studies indicate that functional limitations related to breast hypertrophy are improved following reduction mammoplasty. Volume or weight of the potential breast tissue resection should be combined with other concurrent symptoms to determine the appropriateness of reduction mammoplasty for an individual.
Current literature suggests that a baseline mammogram should be performed before the mammoplasty because mammographic findings after this surgery are predictable. Having a baseline reading prevents unnecessary biopsies and assists with diagnosing lesions unrelated to the procedure.
