Abstract
Background
Severe breast hypertrophy presents a significant surgical challenge, especially in high body mass index (BMI) patients, due to the risks of poor projection, wound complications, and nipple-areolar complex (NAC) necrosis. This study evaluates a refined technique combining free NAC grafting with dual fascial fixation and minimal suture stabilization to optimize outcomes in this high-risk population.Methods
We retrospectively reviewed patients with severe breast hypertrophy who underwent reduction mammaplasty using the described technique between 2019 and 2023. Surgical indication for free NAC grafting was based on the presence of Grade 3 ptosis with required NAC elevation exceeding 8 cm and BMI ≥29 kg/m², reflecting the high-risk nature of the cohort for NAC ischemia with pedicled techniques. The technique involved Wise pattern resection, dual fixation of medial and lateral pedicles to the superficial fascia, subdermal inverting sutures, and four-point fixation of a full-thickness free NAC graft. Postoperative outcomes were assessed clinically and photographically, focusing on breast projection, NAC survival, scar quality, and patient satisfaction.Results
All 42 patients (mean age 42.2 years, mean BMI 35.5 kg/m²) had no total NAC graft loss and maintained satisfactory breast projection and shape. The mean resection weight per breast was approximately 1135 g (range: 560-1710 g); the minimum value (560 g) represented the smaller breast of an asymmetric patient whose contralateral resection was 1470 g. Minor complications included focal areolar hypopigmentation in 2 patients and minor marginal necrosis in 4 cases (9.5%), all managed conservatively. Despite loss of lactation function and erogenous sensitivity, all patients reported high satisfaction with the aesthetic outcomes.Conclusion
Reduction mammaplasty using a refined free nipple-areolar complex grafting approach with dual fascial fixation and minimal suture stabilization represents a reliable and reproducible option for managing severe breast hypertrophy in high body mass index patients. When applied within a standardized operative framework and individualized patient selection, this technique allows for consistent breast projection, durable contour, and high patient satisfaction with a low complication profile.