Clinical UM Guideline

This document addresses reduction mammaplasty (plastic surgery of the breast intended to reduce volume by excision of tissue and often to improve shape and position) and does not apply to reconstructive procedures performed after surgery for breast cancer or other clinical indications, including removal of implants.

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Note: This document does not address reduction mammaplasty done prior to mastectomy for breast cancer treatment or breast cancer risk-reduction. For these indications, please refer to:

• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures.

Note: For other information related to breast procedures, refer to:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• CG-SURG-88 Mastectomy for Gynecomastia
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment, AND the procedure can be reasonably expected to improve the functional impairment.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

Medically Necessary:

Reduction mammaplasty is considered medically necessary when either of the following criteria (I or II) are met:

I.  Individuals meeting BOTH of the following criteria (A and B):

1. Presence of one or more of the following:
   1. A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is clearly related to the excess weight of the breast tissue and there has been at least 3 months of adequate conservative treatment with one or more of the following: special support garments (for example, special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
   2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy; or
   3. Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least 3 months of adequate conservative treatment.
      and
2. The preoperative evaluation by the surgeon concludes that an appropriate amount of breast tissue, from at least one breast, will be removed, based upon body surface area or total mass to be removed and that there is a reasonable prognosis of symptomatic relief. The request for surgery must include: the individual’s height and weight; the size and shape of the breast(s) causing symptoms; the anticipated amount of breast tissue to be removed. Pictures may be requested to document medical necessity.

Note: Medical records from the primary care physician and other providers (for example, physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request may also be required.

The appropriate amounts (in grams) of breast tissue must be anticipated for removal from at least one breast, which is based on the individual’s total body surface area (BSA) in meters squared. See Appendix for a table relating BSA values to the minimum amount (weight) of breast tissue to be removed per breast.

Note: To calculate body surface area, see: https://www.calculator.net/body-surface-area-calculator.html. Please use the Du Bois formula, with BSA represented in meters squared.

or

II.  Individuals, regardless of BSA, who are anticipated to have at least 1 kg. of breast tissue removed from each breast and who meet any of  the following criteria:

1. Presence of one or more of the following:
   1. A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is clearly related to the excess weight of the breast tissue and there has been at least 3 months of adequate conservative treatment with one or more of the following: special support garments (for example, special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
   2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy; or
   3. Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least 3 months of adequate conservative treatment.

Note: Medical records from the primary care physician and other providers (for example, physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request may also be required.

Not Medically Necessary:

Breast reduction surgery is considered not medically necessary when the criteria above are not met.

The use of liposuction to perform breast reduction is considered not medically necessary.

Cosmetic and Not Medically Necessary:

Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion.

This document describes clinical studies and expert recommendations, and explains when breast reduction surgery is clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Reduction mammaplasty (breast reduction surgery) removes extra breast tissue, fat, and skin to reduce breast size and weight. It is used for people with very large breasts that cause health problems such as back, neck, or shoulder pain, skin irritation under the breast, or nerve symptoms such as tingling or numbness. The goal is to improve daily function and reduce pain when other treatments such as supportive bras, medicines (such as nonsteroidal anti-inflammatory drugs or NSAIDs), or physical therapy have not helped. The amount of tissue removed is based on body size or a set minimum weight. Surgery may improve quality of life, but it also has risks such as wound healing problems, infection, or need for more surgery. Liposuction alone, which removes only fat, has not been shown to improve health outcomes for this condition.

What the Studies Show

Breast reduction surgery works by decreasing the weight of the breasts, which can reduce strain on the back, neck, and shoulders and improve skin conditions under the breast. Studies, including randomized trials and long-term follow-up research, show that people often have less pain and better physical function after surgery.

Most studies find the surgery is generally safe, but complications can happen. Potential issues include slow wound healing, minor infections, or fluid buildup. Larger studies show major complications are uncommon, and no deaths were reported. Risk may be higher in people with higher body weight, older age, a history of smoking, or other health conditions.

Studies on liposuction alone are limited and mostly low quality. These studies do not clearly show that liposuction alone for breast reduction surgery improves health problems caused by large breasts. Better studies are needed to know if liposuction alone improves health.

When is Reduction Mammaplasty Clinically Appropriate?

Reduction mammaplasty may be appropriate in these situations:

• The person has ongoing upper back, neck, or shoulder pain that affects daily life or work; and the pain is clearly linked to breast weight; and symptoms have not improved after at least 3 months of treatments such as supportive bras, NSAIDs, physical therapy, or similar care; or
• The person has severe skin irritation under the breast or shoulder grooves with skin breakdown that have not improved with standard treatment; or
• The person has nerve symptoms (such as tingling or numbness in the arms or hands) linked to breast size that have not improved after at least 3 months of treatment; and
• The surgeon expects that removing a certain amount of breast tissue will likely relieve symptoms, based on body size or a minimum amount of tissue (for example, about 1 kilogram per breast in some cases).

Additional medical records and measurements are usually needed to confirm the need for surgery.

When is this not Clinically Appropriate?

Reduction mammaplasty is not clinically appropriate when the criteria above are not met.

Liposuction alone is not clinically appropriate because studies have not shown that it improves the symptoms caused by large breasts.

Breast reduction is also not clinically appropriate when done only to improve appearance, such as for posture concerns, uneven breast size, sagging, clothing fit issues, or changes in the nipple area. In these cases, the procedure does not treat a medical problem.

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

When services are also Not Medically Necessary:
For the following procedure and diagnosis codes

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above for situations designated in the Clinical Indications section as cosmetic and not medically necessary.

Summary

Reduction mammaplasty is an effective treatment for symptomatic macromastia when conservative therapies fail. It can relieve pain, intertrigo, and functional impairment. Evidence from prospective studies, randomized trials, and meta-analyses consistently demonstrates significant improvements in pain, physical function, and quality of life (QOL) following surgery, with durable long-term benefit. While the precise relationship between resection weight and symptom relief is variable, objective measures such as body surface area-based thresholds (for example, Schnur scale) provide a standardized method to identify individuals likely to experience improvement of health after the procedure, thereby distinguishing medically necessary procedures from cosmetic procedures.

Professional society guidance supports reduction mammaplasty as clinically effective for symptomatic individuals. The American Society of Plastic Surgeons (ASPS, 2021 and 2022) recognizes the procedure’s effectiveness in reducing symptoms and improving QOL, while policy criteria incorporating symptom burden and minimum tissue resection requirements align with commonly used clinical tools for appropriate candidate selection. The American College of Obstetricians and Gynecologists (ACOG, 2017) recommends individualized decision-making in adolescents based on symptom severity and maturity. Overall, reduction mammaplasty is supported as medically necessary when clinical symptoms and objective resection criteria are met, whereas liposuction alone has not demonstrated improved health outcomes and is not considered medically necessary.

Discussion

Breast reduction surgery involves removal of skin, fat and breast tissue to reduce breast mass. Liposuction removes only fatty tissue. When symptoms exist and cannot be alleviated by conservative methods (examples include pain medication, physical therapy, and skin ointments or powders), surgical intervention to reduce the size of the breasts may be indicated. Breast reduction surgery is performed when excess breast mass and weight cause medical problems such as submammary intertrigo (an inflammatory condition causing redness, burning, itching, skin disintegration and cracking underneath the breast), back, neck and shoulder pain, or thoracic outlet syndrome, which can lead to pain and loss of feeling in the arms or hands. Removal of excess breast tissue results in a decrease in breast mass and weight with the goal of relieving symptoms. In the absence of symptoms or associated conditions, breast reduction may be performed for cosmetic purposes to enhance appearance.

Studies have found that breast reduction can lead to symptom relief. Collins and colleagues (2002) conducted a prospective, controlled study designed to evaluate the efficacy of breast reduction in alleviating symptoms of macromastia by comparing baseline and postoperative health status. Standard outcome instruments were utilized in the study and consisted of the SF-36, the EuroQol, the Multidimensional Body-Self Relations Questionnaire (MBSRQ), and the McGill Pain Questionnaire (MPQ). The study involved 179 individuals with matched preoperative and postoperative data sets, 96 controls, and 88 hypertrophy controls. The women were mainly Caucasian, middle-aged, well-educated, and employed. Data from completed questionnaires were gathered preoperatively and at approximately 6 to 9 months post-surgery. Outcomes demonstrated that participants preoperatively had lower scores (p<0.05) in all health domains of the SF-36 and in the mental and physical component summary scores. After surgery, the same group of participants measured higher than national norms in seven of eight health domains. Preoperative pain scores measured with a Pain Rating Index (PRI) score from the MPQ were reported to be 26.6, and after surgery pain was stated to be lower with a score of 11.7. Study limitations included a lack of randomization and the possibility that women may have overstated their symptoms or lack of effectiveness of nonsurgical treatments. In addition, the study was not designed to determine a threshold for weight of tissue to be removed to produce symptom relief, and there was no comparison of resection weight and extent of symptom relief.

Saariniemi and colleagues (2008) reported on a study assessing QOL and pain in 82 women randomized to either reduction mammaplasty or a nonoperative group. Evaluations were performed at the onset of the study and 6 months later. The authors reported that the mammaplasty group had significant improvements in QOL as measured by the physical summary score of the Short Form (SF)-36 QOL questionnaire (change of +9.7 vs. +0.7, p<0.0001), the utility index score (SF-6D) (+17.5 vs. +0.6), the index score of quality of life (SF-15D) (+8.6 vs. +0.06, p<0.0001), and the SF-36 mental summary score (+7.8 vs. -1.0, p<0.002). There were also improvements in breast-related symptoms as measured by the Finnish Breast-Associated Symptoms questionnaire score (-7.9 vs. -3.5, p<0.0001) and the Finnish Pain Questionnaire score (-21.5 vs. -1.0, p<0.0001). This study was limited by a small sample size and lack of long-term follow-up.

In a prospective, longitudinal study, Nuzzi and colleagues (2017) evaluated the effects of reduction mammaplasty on the QOL. The criteria for the mammaplasty group included female individuals ages 12-21 with symptomatic bilateral macromastia and no previous history of breast surgery. The researchers compared results in individuals who had reduction mammaplasty (n=102) with a healthy control group that had no history of breast complaints (n=84). Macromastia was evaluated using a symptom profile, physical exam, and modified Schnur criteria. Participants completed four self-administered validated surveys: the Short-Form 36v2 (SF-36), the Rosenberg Self-Esteem Scale (RSES), the BRSQ, and the Eating Attitudes Test-26 (EAT-26). The surveys were completed at baseline, 6 months, 1 year, 3 years, and 5 years. After surgery, the mammaplasty group had significant score improvements in several domains, including physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health (p<0.001). At 6 months, the mammaplasty group scored similarly to or better than the control group on the surveys, and the benefits continued at the 5 year follow-up. The researchers found that age and weight did not significantly affect the results.

Lin and colleagues (2021) published a meta-analysis of data from seven RCTs with a total of 285 participants comparing reduction mammaplasty with a control intervention for the treatment of breast hypertrophy, and reporting pain, physical function or psychological function. A pooled analysis of data from four studies found a statistically significant reduction in pain in the reduction mammaplasty compared with control group (standardized mean difference [SMD], -1.29; 95% confidence interval [CI], -1.63 to -0.96; p<0.00001). A pooled analysis of five studies found significantly greater improvement in physical function status after reduction mammaplasty versus control (SMD, 0.97; 95% CI, 0.69 to 1.25; p<0.0001). Data from three studies were suitable for the pooled analysis of psychological function. In this analysis, reduction mammaplasty had a significantly greater effect on psychological functioning compared with control (SMD, -0.79; 95% CI, -1.07 to -0.52; p<0.0001).

Amount of Tissue

The amount of breast tissue needed to achieve adequate symptomatic relief is not well understood. The limited medical literature addressing this question is largely based on estimating the amount to be removed based on body surface. One such approach is referred to as the Schnur scale. Schnur and colleagues (1991) reported the results of two surveys sent to 220 randomly selected, board certified plastic surgeons who performed reduction mammaplasties. A total of 92 plastic surgeons returned survey data of 600 women on whom reduction mammaplasty had been performed. Data obtained from the first survey included the height and weight of the individual, as well as the amount of breast tissue removed from each breast. The second survey resulted in an estimate of percentages of women who sought a reduction mammaplasty for purely cosmetic reasons, for purely medical reasons, and for mixed reasons. Based on the results obtained, the authors concluded that if the removed breast tissue weight was greater than the 22^nd percentile, a woman’s motivation for the surgery was medical, and if the removed breast tissue weight was less than the 5^th percentile, the procedure was sought for cosmetic reasons. Those women whose removed breast tissue weight was between the 5^th and the 22^nd percentile reportedly had mixed reasons for requesting the procedure. In a subsequent outcome study, based on questionnaire responses from women who had undergone reduction mammaplasty, Schnur and colleagues (1997) reported that in properly selected individuals, reduction mammaplasty is a safe and effective procedure for relieving or improving symptoms related to symptomatic macromastia. Because breasts are paired organs, bilateral breast reduction mammaplasty may be considered appropriate if the amount of breast tissue anticipated for removal from at least one breast meets the minimum amount (weight) per the Schnur scale and all other criteria are met.

Other scales related to amount of breast tissue include the Galveston, Appel, and Descamps scales. These scales are methods to estimate resection weight; they do not attempt to differentiate between medical and cosmetic breast reduction procedures. Descamps (2008) evaluated data from 214 individuals with macromastia who had undergone breast reductions. The investigators conducted regression analyses using breast weight as the dependent variable and sternal notch to nipple distance, nipple to inframammary crease distance, age and body mass index (BMI) as independent variables. Using regression analysis, the following formula for predicting resection weight was established: Breast weight = 5.4 (notch-to-nipple distance) + 60.66 (nipple to inframammary crease distance) - 1239.64.

Appel (2010) evaluated data on 348 individuals who underwent breast reduction; mean resection weight was 833g. Using multiple linear regression, the following formula to predict resection weight is as follows: 40 (sternal notch-to-nipple distance) + 24.7 (inframammary fold-to-nipple distance) + 17.7 (BMI) - 1443. The investigators noted the strongest correlation when all 3 of the above parameters were incorporated into the regression model.

Boukovalas and colleagues (2019) described the development of the Galveston scale and compared it to other scales, including the Schnur scale. The study was a retrospective analysis of data on 314 individuals who underwent reduction mammaplasty at a single institution. Individuals were divided into 2 groups, A and B; data from Group A (n=184) were used to develop the Galveston scale, and data from Group B (130) were used to validate the scale. The average breast tissue resection weight was 953g in Group A and 907g in Group B. Data on individuals in Group A were analyzed to identify independent predictors of resection weight. In multiple regression analysis, sternal notch-to-nipple distance, nipple-to-inframammary fold distance, BMI and age were independent predictors, and these were incorporated into the Galveston scale. The formula for the amount of tissue to remove was: 68.03 x nipple-to-inframammary fold distance + 40.33 x sternal notch to-nipple distance + 31.75 x BMI - 4.27 x age - 2461.1. The authors then conducted regression models to evaluate the ability of each of the scales to predict actual resected values. They reported the statistic, R², which is a measure of regression model “fit”, the ability of the predictive scale to measure the actual resected amount of breast tissue. The adjusted R² values were 0.43 for the Schnur Scale, 0.66 for the Descamps Scale, 0.70 for the Appel Scale and 0.73 for the Galveston scale. In a similar analysis using data from Group B, adjusted R² values were 0.28 for the Schnur Scale, 0.68 for the Descamps scale, 0.69 for the Appel Scale and 0.71 for the Galveston scale.

In a retrospective review of data from 579 individuals who underwent bilateral reduction mammaplasty, Wampler (2019) compared the accuracy of surgeons’ resection estimates using clinical estimation with the actual resected weight. As a group, the 7 surgeons in the sample had a median error of 105 grams per breast between the presurgical estimate of resection weight and the actual resection weight. Overestimation occurred for 55.7% of breasts and underestimation with 40.4% of breasts. The positive predictive value (PPV) of the surgeons’ resection estimate being at least 500g was 91.2% and the negative predictive value (NPV) was 82.9%. The PPV of an estimate that was greater than the Schnur requirement was 86.6% and the NPV was 64.0%. In 19.2% of breasts, the surgeons’ estimate of resected weight was less than the Schnur requirement. When comparing the surgeons’ estimates with estimates derived from the Descamps and Appel formulas for 579 individuals, all of the 3 methods were moderately correlated with true resection weight. Correlation was 0.62 for surgeons’ estimates, 0.64 for the Descamps estimate and 0.70 for the Appel estimate. The surgeons’ estimates were less than the Schnur requirement for 19.2% of breasts, compared with 18.4% of breasts with the Descamps formula and 20.2% of breasts with the Appel formula.

A 2022 retrospective cohort analysis by Yan and colleagues reported on 154 individuals who had bilateral reduction mammaplasty. The study included female individuals with a clinical diagnosis of macromastia. The study eligibility criteria did not include a requirement for symptoms or functional impairment due to the macromastia, and the issue of whether or not the surgery was primarily cosmetic in nature was not discussed. The Schnur scale explained 38% of the variability in the actual resection weight. In contrast, the Appel, Descamps and Galveston scales predicted 64%, 57% and 67%, respectively, of the variability in the resection weight. For resection weights of 500 g or more, differences between the estimated and actual resection weights were -211.4 g for the Schnur scale, -17.5 g for the Appel scale, -9.6 for the Descamps scale and -99.2g for the Galveston scale.

Gonzalez and colleagues (2012) reported on 178 women who had breast reduction surgery primarily for symptomatic macromastia. The Breast Q questionnaire was completed once after surgery, and retrospective chart reviews were also completed to assess individual outcomes and determine whether any correlation exists between outcomes and size or amount of breast tissue removed. Most of the women responded to the surgery satisfactorily with a mean response on the Breast Q questionnaire of 2.8 (2, somewhat agree; 3, definitely agree). The mean BMI reported was 28.3 kg/m and correlated significantly with the amount of breast tissue removed (p<0.0001). The mean combined total amount of breast tissue removed was 1221 g but did not correlate significantly with QOL responses (p=0.57).

In 2015, Strong and Hall-Findlay reported results of a custom-designed questionnaire given to women at routine follow-up appointments, asking them to rate their preoperative and postoperative symptoms related to macromastia. All participants had a reduction mammaplasty performed by the senior author of this paper, and the same surgical technique was used for all. Of an initial 661 eligible participants, a total of 410 remained in the study after excluding questionnaires that were incomplete, had answers provided in an incorrect format, or were returned too early. A Schnur sliding scale percentile had been calculated for all participants. The participants/questionnaires were divided into six groups based on the amount of tissue resected per breast. Information received was examined for a trend that would link a higher amount of tissue resected to a greater change in symptoms. Only participants who had reported the particular symptom prior to surgery were included in this analysis. There was no statistically significant trend across the groups related to breast pain, shoulder grooves, rashes under the breast, headache, exercise intolerance, or lack of self-esteem. Statistically significant results were reported for symptoms related to back pain, neck pain and poor posture suggesting a potential relationship between greater amounts of tissue resected and increased symptom improvement. However, after post hoc tests were performed, there was no statistically significant difference reported between the groups for these three symptoms. The authors concluded their study demonstrated that for reduction mammaplasty “patients can experience significant symptomatic relief even when less than 250 g of tissue is resected from each breast.” There were significant limitations of this study including the retrospective nature that relied on “patient recollection of preoperative symptoms” and the dependence upon one specific surgeon’s techniques.

The American Society of Plastic Surgeons (ASPS, 2021) issued an updated document on criteria for third-party payers. This document states: “Based on the thorough evidence review leading to the strong recommendation in the revised clinical practice guideline, it is clear that reduction mammaplasty is extremely effective at reducing hypertrophy related symptoms and improving postoperative quality of life”.

In 2022, the ASPS published an updated clinical practice guideline on reduction mammaplasty that included the following recommendation: “The work group recommends that postmenarche female patients presenting with breast hypertrophy should be offered reduction mammaplasty surgery as first-line therapy over nonoperative therapy based solely on the presence of multiple symptoms rather than resection weight”. The document did not further specify the type or number of symptoms that would need to be present. No randomized or other prospective controlled trials were cited that compared outcomes in women wanting to have a relatively small amount of tissue removed (e.g., less than 1 kg) who were managed with conservative therapy versus reduction mammaplasty.

Age

A 2017 committee opinion from ACOG addresses breast reduction surgery in adolescents. The opinion was reaffirmed in 2024. ACOG did not issue specific recommendations on age and breast reduction surgery, but the document states:

Recommendations for timing of surgery including postponing surgery until breast maturity is reached, waiting until there is stability in cup size over 6 months, and waiting until the age of 18 years. Although there is no one consensus on timing, it may reasonably be determined by the severity of symptoms. An assessment of the adolescent’s emotional, physiologic, and physical maturity is recommended…

In 2021, Hudson and colleagues published a systematic review of studies on breastfeeding and complications associated with breast reduction, with the aim of applying conclusions to conducting the procedure in adolescents. The authors identified 23 single-arm studies on female individuals less than 25 years old who underwent bilateral breast reduction, and reported post-surgery breastfeeding or surgery-related complications. In the studies, the mean age at the time of surgery ranged from 16 to 21 years, and all studies included at least some individuals younger than 18 years old. Complication rates were reported in 17 (74%) studies. The overall rate of any complication was 27.3%, and the rate of major complications was 4.2%. A total of 17.8% of individuals reported noticeable breast regrowth postoperatively and 2.7% underwent a second revision reduction mammaplasty. Eight studies (35%) reported breastfeeding outcomes. In a pooled analysis of these studies, 35.1% of individuals in the studies became pregnant and, of the women who attempted breastfeeding, 55.1% were successful and 39% experienced difficulties.

Complications

Older observational studies demonstrate that reduction mammaplasty is generally safe but associated with a range of mostly minor complications, with risk influenced by individual and procedural factors. Early data from the BRAVO study (Cunningham, 2005) reported higher overall complication rates (43%), most commonly delayed wound healing, though findings were limited by small sample size and inconsistent reporting. Larger, retrospective analyses (Gust, 2013; Manahan, 2015) reported lower overall complication rates and confirmed that higher BMI is a consistent risk factor for surgical site complications, including infection and wound issue. Additional contributors included older age, smoking, and comorbidities. Across studies, major complications were uncommon, no mortality was reported, and reduction mammaplasty was considered a safe procedure, though careful surgical candidate selection and counseling regarding risk factors remain important.

In a systematic review and meta-analysis, Myung and colleagues (2017) evaluated the relationship between obesity and surgery complications after reduction mammaplasty. The analyzed surgical complications included infection, delayed wound healing, wound dehiscence, hematoma, seroma, and tissue necrosis. The review included 26 mostly retrospective studies. The researchers compared outcomes for obese (n=3752) and non-obese (n=3152) individuals and found that surgical complication rates were collectively higher in the obese group (relative risk [RR], 1.45; 95% CI, 1.21 to 1.75), with skin and fat necrosis especially prevalent (RR, 2.01; 95% CI, 1.54 to 2.63). In addition, the researchers found that the risk of surgical complications gradually increases with the severity of obesity. They concluded that risks associated with obesity are not higher for reduction mammaplasty when compared to other types of surgeries, but "every surgeon should consider the risks and benefits of reduction mammaplasty carefully during patient selection and should appropriately plan the surgery."

Payton (2022) evaluated complications in 277 women who underwent bilateral mammaplasty between 2014 and 2018. The mean age was 35.7 years; mean BMI was 30.2 and mean length of follow-up was 133 days. The authors found that the rate of minor complications (defined as superficial wounds, non-operative hematomas or seromas, minor fat necrosis, and superficial infections or cellulitis) was 49.3%. The most common minor complication was superficial wounds (42.1%). The rate of major complications (defined as “emergent intervention in the operating room for hematoma, wounds requiring sharp debridement, infection requiring drainage or intravenous antibiotics, and symptomatic or large fat necrosis”) was 4.3%. There were no reported deaths. Eight (3%) of individuals required reoperation within 30 days and 11 (4%) of individuals had unexpected admissions to the hospital for postoperative complications (i.e. expanding hematoma or infected seroma) or medical management. Thirty-three (11.9%) individuals had wounds that required more than 2 months to heal. In multivariate analysis, age, BMI, and resection weight were not significant predictors of major complications. When controlling for age and resection weight, BMI was a significant predictor of wounds requiring greater than 2 months to heal.

Liposuction

The use of liposuction, either as a primary technique or adjunct to reduction mammaplasty, has not been demonstrated to improve health outcomes. While case series have been reported, no randomized or controlled trials have compared liposuction to standard reduction mammaplasty, and the procedure has not been established as a standard of care. A 2024 systematic review (Kadhum) of seven studies (n=652) found that liposuction-only breast reduction may result in moderate volume reduction, improved personal satisfaction, and low complication rates, particularly in individuals with mild to moderate macromastia. Although some studies reported improvement in functional symptoms such as back, neck, and shoulder pain and intertrigo, these outcomes were primarily based on subjective measures, and the review did not clearly distinguish or compare functional versus cosmetic indications. The evidence base is limited by low methodological quality, as all included studies were case series (mostly retrospective) with small sample sizes, heterogeneous outcome reporting, and high risk of selection and reporting bias, limiting conclusions regarding clinical effectiveness for medically necessary indications (Abboud, 2020; Ederer, 2025; Habbema, 2009; Sadove, 2005).

Body mass index (BMI): Measure calculated as body weight in kilograms divided by height in meters squared (kg/m²) and represents one of the most commonly used anthropometric measures to assess total body adiposity. Standard BMI categories for adults in North America, Europe, and most regions are:

• underweight (< 18.5 kg/m²),
• normal weight (18.5-24.9 kg/m²),
• overweight (25.0-29.9 kg/m²), and
• obesity (≥ 30.0 kg/m²).

Obesity is further stratified into class I (30.0-34.9 kg/m²), class II (35.0-39.9 kg/m²), and class III (≥40.0 kg/m²). Some classifications extend to class IV (≥50 kg/m²) and class V (≥60 kg/m²). BMI may overestimate adiposity in muscular individuals and underestimate it in frail or elderly persons. Lower BMI cutoffs are recommended for Asian populations (overweight ≥ 23 kg/m², obesity ≥ 25-28 kg/m² depending on the specific population) due to greater adiposity and comorbidity risk at lower BMI levels.

Breast Hypertrophy: see Macromastia.

Intertrigo: An inflammatory skin condition occurring in opposing skin folds (for example, beneath pendulous breasts), characterized by redness, irritation, and itching; it may be complicated by secondary infection or skin breakdown.

Macromastia: Excessive growth of breast tissue in one or both breasts, representing a benign condition that can cause significant physical symptoms including breast, shoulder, back, and neck pain, poor posture, infections, and loss of nipple sensation. Quantitatively, macromastia has been defined as breast volumes above 1250 ml (95th percentile) for individuals with a normal BMI (18.5-24.9 kg/m^²).

Reduction mammaplasty (also spelled reduction mammoplasty): A surgical treatment for symptomatic breast hypertrophy that involves reducing breast volume, reshaping the parenchyma, repositioning the nipple-areola complex, and resecting redundant skin. The goals of the procedure are to reduce breast volume, create an aesthetically stable shape over time, maintain blood supply and innervation to the nipple-areolar complex, and minimize visible scarring.

Submammary (inframammary) region: The anatomical area beneath the breast, with the inframammary fold (IMF) serving as the inferior anatomic border of the breast where it meets the chest wall. The inframammary fold is a defining element in the shape and structure of the female breast and represents an essential aesthetic landmark in breast surgery.

Thoracic outlet syndrome: A condition caused by compression of nerves and/or blood vessels in the thoracic outlet (the space between the neck and shoulder), which may result in pain, numbness, or weakness in the arm.

Peer Reviewed Publications:

1. Abboud MH, El Hajj HN, Abboud NM. No-scar breast reduction utilizing power-assisted liposuction mammaplasty, loops, and lipofilling. Aesthet Surg J. 2021; 41(5):563-565.
2. Appel JZ, Wendel JJ, Zellner EG, et al. Association between preoperative measurements and resection weight in patients undergoing reduction mammaplasty. Ann Plast Surg. 2010; 64(5):512-515.
3. Boukovalas S, Padilla PL, Spratt H, et al. Redefining the role of resection weight prediction in reduction mammoplasty and breaking the “One-Scale-Fits-All” paradigm. Plast Reconstr Surg 2019; 144 (1):18e-27e.
4. Chao JD, Memmel HC, Redding JF, et al. Reduction mammaplasty is a functional operation, improving quality of life in symptomatic women: a prospective, single-center breast reduction outcome study. Plast Reconstr Surg. 2002; 110(7):1644-1652.
5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. 2002; 109(5):1556-1566.
6. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005; 115(6):1597-1604.
7. Descamps MJL, Landau AG, Lazarus D, et al. A formula determining resection weights for reduction mammaplasty. Plast Reconstr Surg. 2008; 121(2):397-400.
8. Di Giuseppe A. Breast reduction with ultrasound-assisted lipectomy. Plast Reconstr Surg. 2003; 112(1):71-82.
9. Drohan AE, Quan ML, Birdsell DC, et al. Breast cancer after reduction mammoplasty: a population-based analysis of incidence, treatment and screening patterns. Ann Surg Open. 2023; 4(3):e322.
10. Ederer IA, Najaf Zadeh S, Walber J, et al. Power-assisted liposuction of the superomedial pedicle in primary wise-pattern reduction mammoplasties. J Clin Med. 2025; 14(13):4475.
11. Flegal KM, Kit BK, Graubard BI. Body mass index categories in observational studies of weight and risk of death. Am J Epidemiol. 2014; 180(3):288-296.
12. Fryzek JP, Ye W, Nyrén O, et al. A nationwide epidemiologic study of breast cancer incidence following breast reduction surgery in a large cohort of Swedish women. Breast Cancer Res Treat. 2006; 97(2):131-134.
13. Glatt BS, Sarwer DB, O’Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg. 1999; 103(1):76-82.
14. Gonzalez MA, Glickman LT, Aladegbami B, Simpson RL. Quality of life after breast reduction surgery: a 10-year retrospective analysis using the Breast Q questionnaire: does breast size matter? Ann Plast Surg. 2012; 69(4):361-363.
15. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg. 2001; 108(4):1006-1010.
16. Gust MJ, Smetona JT, Persing JS, et al. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J. 2013; 33(8):1140-1147.
17. Habbema L. Breast reduction using liposuction with tumescent local anesthesia and powered cannulas. Dermatol Surg. 2009; 35(1):41-50; discussion 50-52.
18. Hudson AS, Morzycki AD, Guilfoyle R. Reduction mammaplasty for macromastia in adolescents: a systematic review and pooled analysis. Plast Reconstr Surg. 2021; 148(1):31-43.
19. Kadhum M, Symonette C, Khan W, Javed MU. Liposuction-only breast reduction: a systematic review of outcomes. Aesthetic Plast Surg. 2024; 48(17):3351-3361.
20. Kaminer MS, Tan MH, Hsu TS. Limited breast reduction by liposuction. Skin Therapy Lett. 2002; 7(10):6-8.
21. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002; 22(3):208-217.
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26. Matarasso A. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 2000; 105(7):2604-2607.
27. Matarasso SL. Liposuction of chest and back. Dermatol Clin. 1999; 17(4):799-804.
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Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Obstetricians and Gynecologists. Committee Opinion No. 686: Breast and Labial Surgery in Adolescents. Obstet Gynecol. 2017;129(1):e17-e19. Reaffirmed 2024.
2. American Society of Plastic Surgeons. Reduction mammaplasty recommended criteria for third-party payer coverage from the American Society of Plastic Surgeons (ASPS). Updated and Reaffirmed 2021. Available at: https://www.plasticsurgery.org/documents/Health-Policy/Reimbursement/insurance-2021-reduction-mammaplasty.pdf. Accessed on April 5, 2026.
3. Perdikis G, Dillingham C, Boukovalas S et al. American Society of Plastic Surgeons evidence-based clinical practice guideline revision: reduction mammaplasty. Plast Reconstr Surg. 2022;149(3):392e-409e.

1. American Academy of Orthopaedic Surgeons. Thoracic Outlet Syndrome. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/thoracic-outlet-syndrome/. Accessed on April 5, 2026.

Liposuction Assisted Breast Reduction
Mammaplasty
Mammoplasty
Power-Assisted Liposuction
Reduction Mammaplasty

Minimum Weight of Breast Tissue Removed, per Breast, as a Function of Body Surface Area
Schnur Sliding Scale

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