There are many methods of breast reduction and the method must be tailored to the needs of the patient. Most methods have a number of principles in common including:
• the new nipple position must be marked accurately before surgery
• the nipple must be moved into a new position
• the volume of the gland of the breast is reduced
• the skin envelope is reduced.
The two main techniques are to either remove the nipple as a free skin graft or the leave the nipple attached to a pedicle, or strip, of tissue to preserve its blood supply. Free nipple grafts are usually used in very large breasts or where the patient is not in good health and a rapid operation is needed.
Most commonly the nipple is preserved on a pedicle of tissue which is moved into position with the nipple. The four main methods of breast reduction are:
• horizontal pedicle method, in which the nipple is maintained on a pedicle oriented horizontally
• vertical pedicle method, in which the nipple is maintained on a pedicle oriented vertically. The pedicle can be based inferiorly, or both superiorly and inferiorly.
• lateralizing or B method, in which the nipple is maintained on a pedicle oriented obliquely
• periareolar method, in which nipple is maintained on a central pedicle.
A different approach is to reduce the volume of breast tissue using liposuction. This has the advantage of much less scarring and may be more likely to preserve the ability to breast feed. Both of these are especially important for younger patients. It can be combined with skin tightening or mastopexy, but rarely produces as much tightening as traditional breast reduction.