First, you need to understand the two different types of breast reduction:
- A pedicle reduction is the most common type. In this type of reduction, the nipple is left attached to the underlying breast tissue, and it derives its blood supply from this “pedicle” of tissue. There are many different pedicle designs (inferior, superior medial etc.), but the essential concept to grasp is that the nipple remains attached to the breast.
- A free-nipple reduction is the opposite of a pedicled reduction. In this type of reduction the nipple is actually removed from the breast, and placed back on as a skin graft. In this scenario, the nipple gets nutrition from the underlying wound bed until new blood vessels grow into the graft over a period of a few days.
Both types of breast reduction start the same. Prior to going back to the operating room, the surgeon draws markings on the patient. These markings include the new location of the nipple, where the incisions will be, and some markings for reference (e.g. the midline and the inframmary fold, which is the crease under the breast). These markings are similar for both a pedicle and a free nipple reduction, but are not identical.
Once the surgery actually starts, the two types of breast reduction differ quite a bit. Let’s start with the pedicle reduction first, as that is the most common. The first step in a pedicle reduction is to remove the skin from the pedicle, which is the tissue that the nipple remains attached to. This process of removing skin is called de-epithelializing (the epithelium is the outer layer of skin), and is done because once the nipple is moved up into its new position, skin from the upper part of the breast is draped down over the pedicle. After de-epithelializing the pedicle, the skin that will stay on the breast is separated from the remaining breast tissue. Next, the excess breast tissue between the pedicle and the skin flaps is removed (see image to the right). This is the actual reduction portion of the surgery, and removing this tissue makes room for the pedicle to move up under the skin flaps that were elevated. A new opening is made for the nipple, and the incisions are closed.
A free nipple reduction, in contrast, begins with removal of the nipple. This is set aside to be placed back on the breast at the end of the operation. The excess breast tissue is then removed. In this instance, the tissue is removed from the lower half of the breast. The incisions are brought back together, and the location where the nipple will be placed as a graft is de-epithelialized. This provides a well-vascularized wound bed (meaning it has good blood flow) for the nipple. The nipple graft is held in place with a bolster, which is a padded dressing that holds the graft flat onto the wound bed, ensuring the graft is able to absorb nutrients until new blood vessels grow into it.
At the end of surgery, both a pedicle breast reduction and a free-nipple breast reduction look very similar. The reduced breast is smaller and perkier. The scars track around the nipple, down the front of the breast, and along the inframammary fold; this is commonly known as an anchor shape incision. There are, however, two critical differences:
- Nipple sensation. In a pedicle reduction, the nipples may be more sensitive, less sensitive, or have no changes in sensation. Both numbness and hypersensitivity improve with time. In a free-nipple reduction, however, the nipple is initially completely numb. New nerves will ultimately grow into the graft, but this process takes months to nearly a year, and the new nipple may always have less sensation than before surgery.
- Ability to breast feed. In a pedicle reduction, the lactiferous ducts (the ducts which carry milk from the glands out to the nipple) remain intact. The amount of breast glandular tissue removed may decrease milk supply, but breastfeeding is still possible. But when the nipple is removed from the breast for a free-nipple reduction, all of the ducts are severed, making breast feeding impossible
Do you have any other questions about breast reduction surgery?