{"paper_id":"1dcdd4ee-85e0-407b-bb51-2e905964f5db","body_text":"Long-term changes of shape following breast reduction surgery: A retrospective single center study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-term changes of shape following breast reduction surgery: A retrospective single center study Niks Gulbis, Doha Obed, Nadjib Dastagir, Frederik Schlottmann, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9041908/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Introduction: Breast hypertrophy, characterized by abnormal breast enlargement, often leads to chronic neck and back pain. Breast-reduction mammoplasty is commonly performed to alleviate these symptoms and improve breast appearance. Proper preoperative measurements are crucial for satisfactory long-term results. This study aimed to investigate long-term postoperative changes in breast morphology following breast reduction mammoplasty. Material and Methods: We retrospectively analyzed 122 patients who underwent breast reduction mammoplasty at Hannover Medical School between 2011 and 2021. Various pedicle techniques were used, and changes in breast shape and contour were measured from pre- and postoperative photographs using Image J software. Results: A total of 122 female patients (244 breasts) were included. The average postoperative nipple to inframammary fold (N-IF) distance on the right side changed from 142 mm to 72 mm (P<0.0001) at >3 months, 72 mm to 80 mm at 3-6 months, and 80 mm to 85 mm at >1 year. Significant changes in breast shape were observed at all periods (P<0.0001), except between >3 months vs. 3-6 months and 3-6 months vs. >1 year. The mean increase in N-IF distance at >1 year follow-up was 16 mm on the right and 14 mm on the left. The sulcus jugularis to nipple (SN-N) distance increased by 12 mm on the right and 6 mm on the left. The clavicle to nipple (C-NL) distance increased by 16 mm on the right and 14 mm on the left. Conclusions: This study demonstrates satisfactory and stable long-term changes in breast shape post-mammoplasty, aiding surgeons in planning and advising patients on expected outcomes. Breast reduction short vertical scar bottoming-out Long-term breast shape changes Breast surgery Figures Figure 1 Figure 2 1. Introduction Breast hypertrophy is a condition marked by disproportionate breast tissue growth, typically beginning during puberty. It can result in excessive breast weight, exceeding 1.5 kg per breast (macromastia) or even more than 2 kg per breast (gigantomastia) [ 1 ]. Heavy and pendulous breasts often cause chronic pain in the neck/back area and discomfort for many patients. While patients usually request breast reduction mammoplasty to relieve pain and discomfort, they also hope the procedure will improve the appearance of their breasts. Many causes of gross enlargement have been proposed, including increased sensitivity to hormones (estrogen, progesterone, and prolactin), growth factors, drugs (such as penicillamine and antiretrovirals), and obesity [2]. As with all aesthetic procedures, the surgeon and the patient must define the goal of therapy jointly during the consultation. In addition to the patient’s wishes, pre-operative conditions such as preexisting asymmetry, type of skin condition, and tendency to excessive scarring must be taken into account. Detailed information about the realistic result that can be achieved postoperatively is essential to minimize the risk of a surgical result that may be successful for the surgeon but not beneficial for the patient [3]. Before undertaking breast reduction mammoplasty, the surgeon should document several measurements. Poor preoperative planning can lead to unsatisfactory long-term results. It is essential that the breasts be appropriately marked with the patient in the standing position, indicating the planned incision pattern. Four operative key elements in breast reduction surgery should be considered [ 4 ]: The design must incorporate a pedicle that preserves the vascularity and innervation to the nipple-areola complex (NAC). The excess breast tissue is removed to accomplish the desired volume reduction. The excess skin envelope must be reduced. The result should be attractive with the nipple on top of a conical breast with good projection and attractive shape. Reduction mammoplasty is one of the most commonly performed operations by plastic surgeons. To ensure good long-term results following breast reduction surgery, the laws of gravity must be respected. Thus, preoperative planning and measurements remain integral for ensuring a high patient satisfaction rate following breast reduction. Although several techniques have been reported for breast lift and breast reduction, most plastic surgeons favor the inverted-T technique [5]. The objective of this retrospective study was to investigate the long-term changes in breast morphology following breast reduction mammoplasty. This study was conducted at a single center and included 122 patients who underwent breast reduction surgery over a period of 10 years. The aim of this study was to provide a comprehensive follow-up of the postoperative outcomes of the procedure over an extended period. 2. Materials and methods 2.1 Data collection All patients who underwent breast reduction mammoplasty between 2011 and 2021 at the Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery of Hannover Medical School were included in the study. Patients who underwent reduction mammoplasty for congenital breast asymmetry or oncoplastic procedures related to oncologic surgery, as well as male patients, were excluded. Patients who were lost to postoperative follow-up were also excluded. We conducted a retrospective cohort analysis of the included patients and their surgical reports, with a focus on morphological changes. These changes included distances such as the distance between the clavicle and nipple, the distance between the sternal notch and nipple, the distance between the two areolas, and the distance between the inframammary fold and nipple. Measurements were taken at various intervals, including preoperative, postoperative, 3–6 months, and over 1 year. Breast evaluations included standardized distances such as N-IF (distance between the nipple and inframammary fold), SN-N (distance between the sulcus jugularis and nipple), and C-NL (distance between the clavicle and nipple). These measurements were obtained using a high-resolution digital camera (Panasonic Model No. DMC-FZ300) and analyzed using image processing software (Image J Version 1.54d), which allowed for measurements accurate to the smallest pixel (Fig. 1). A standardized protocol for taking photographs (e.g., consistent lighting, distance, angle, and patient positioning) were taken of each patient, including a frontal view with the patient standing comfortably upright with arms at their sides and angular views (lateral and obliques). Also, calibration objects were included in photographs to ensure scale accuracy. 4 of the patients was measured both ways (photographs and direct clinical measurements) to analyzing the correlation and differences between the two sets of measurements. An official consent of using the photos and taking part in the study was signed by every patient. Patients' body mass index (BMI) and age were collected from medical charts and reports. The intraclass correlation coefficient (ICC) and Bland-Altman plots were used to determine the agreement between each pair of measurements. Figure 1. a-b preoperative measurements, c-e postoperative measurements (C-NL: distance between clavicle and nipple, SN-N: distance between sulcus jugularis and nipple, N-IF: distance between nipple and inframammary fold, AIM: distance between two areolas) 2.2 Statistical analysis Descriptive statistics were reported as numbers and percentages or as mean, standard deviation and range of data. A two-way ANOVA was used to determine if there were changes in the breast shape during different times of follow-up. A p-value < 0.05 was considered statistically significant. All analyses were performed using Microsoft® Excel Version 16.47.1 and Prism Version 9.0.2 (134). 3. Results 3.1 Preoperative assessment measurements In this study, 122 female patients (comprising 244 breasts) were included. The patients' ages ranged from 20 to 77 years, with a mean age of 43.1 years. The mean BMI of the patients was 27.1 kg/m², with a range from 19.1 to 35.9 kg/m². The average preoperative SN-N (sternal notch-nipple) distance measured 289 mm (SD ± 40.4) on the right side and 295 mm (SD ± 40.9) on the left side. Similarly, the average preoperative N-IF (nipple-inferior fold) distance on the right side was 142 mm (SD ± 26.4), and on the left side, it was 143 mm (SD ± 26.4). Finally, the average preoperative CNL (clavicle-nipple) distance on the right side was 281 mm (SD ± 41.3), while on the left side, it measured 279 mm (SD ± 40.8). 3.2 Postoperative assessment measurements Descriptive statistics and mean measurements are presented in Table 1. The following average distances were found: When comparing the changes in breast shape during different periods, all exhibited statistical significance (P < 0.0001). The results revealed a mean increase of 16 (± 9) mm and 14 (± 10) mm in the distance between the nipple and inframammary fold (N-IF) on the right and left sides, respectively. Additionally, there was a mean increase of 9 (± 12) mm and 9 (± 14) mm in the distance between the sulcus jugularis and nipple (SN-N) on the right and left sides, respectively. Furthermore, the distance between the clavicle and nipple (C-NL) demonstrated a more substantial increase, with a mean increase of 26 (± 30) mm and 24 (± 29) mm on the right and left sides, respectively, signifying a significant alteration in breast shape following breast reduction mammoplasty surgery. When examining these numbers in percentages, we observe that the mean increase of N-IF is 23% on the right side and 20% on the left side. The mean increase of SN-N is 5% on the right side and 4% on the left side. The mean increase of C-NL is 11% on both sides. No significant differences were found between the measurements obtained using image processing software and those taken with a measuring tape. The values for these measurements are presented in Table 3. All measurements were performed by the same individual. The Bland-Altman Test confirmed that all measurements of the right and left breasts before and after the operation fell within acceptable levels of agreement according to the measurement area. In this study, we investigated the outcomes of breast reduction surgery using various pedicle methods, including craniomedial, superior, inferior, superolateral, and medial pedicles. Our research encompassed a total of 122 breast reduction procedures, with the following distribution of pedicles: 71 craniomedial, 21 superior pedicles, 20 inferior pedicles, 4 superolateral, and 4 medial pedicles. The average weight of the resected breast tissue was determined to be 580 g. On the right side 586 g (± 350; range: 97-2240g) and on the left side 575 g (± 351; range: 90-2270g). This value represents the central tendency of the amount of breast tissue removed during the surgical procedure and offers insight into the extent of the reduction achieved. Table 2. Mean Values for the distance between nipple and inframammary fold 4. Discussion Despite the increasing popularity and relative frequency of breast reduction surgery performed, the long-term effects of breast reduction surgery on the shape of the breast remains sparsely documented within the medical literature. While some studies have sought to compare and contrast various surgical techniques employed in this procedure, these inquiries have rarely involved a sufficiently large patient cohort to provide a definitive answer. Given the importance of this surgical intervention for many women seeking to alleviate chronic pain and discomfort, as well as the desire to achieve optimal aesthetic outcomes, a thorough understanding of its long-term effects is essential. To that end, recent studies have sought to examine the impact of breast reduction surgery on the shape of the breast over an extended period of time. While these studies are still in their early stages, preliminary findings suggest that breast reduction surgery can have a profound and enduring impact on breast shape, particularly when performed with attention to detail and meticulous surgical technique. As such, extensive research of the long-term effects of breast reduction surgery is needed, in order to ensure that patients are provided with the highest possible quality of care and treatment outcomes. Transitioning from the discussion of our research on breast reduction surgery's impact on breast shape, it's essential to recognize that the landscape of this procedure varies significantly across different countries. In high-income nations like the United States, the emphasis often lies on cosmetic aspirations and achieving an aesthetically pleasing breast size and contour. Conversely, lower-income countries often prioritize breast reduction surgery for functional purposes, such as pain relief and improved physical function. Moreover, the techniques employed for the surgery exhibit noteworthy diversity, with inferior pedicle being popular in the West and superomedial pedicle being preferred in Asian countries. These regional disparities underscore the profound influence of cultural and individual factors in shaping both the demand for and outcomes of breast reduction surgery. [6] Patients with breast hypertrophy usually seek help from plastic surgeons to reach a better quality of life, to reduce chronic pain in the neck/back region and also to have less social and sexual embarrassment in their daily life. Many patients report improved quality-of-life following breast reduction surgery which is frequently reflected by an increase in physical activities and the ability to wear appropriate clothing. [7] Consequently, this results in an increase in self-esteem and in the reduction of physical and emotional discomfort. Various studies in the medical literature demonstrate the effectiveness of breast reduction for the improvement of psychological, functional and aesthetic well-being. [8] Sapino et al. compered the results between inferior vs. superomedial pedicle in breast reduction. [9]. A total of 58 patients were included in the study. In line with our study results, Sapino et al. found a mean increase of the SN-N distance after 6 months of 13 mm and N-IF distance of 16 mm. These results are similar to our findings. This also shows that poor preoperative planning and inadequate consultation of the patient can lead to poor long-term results and satisfactory rate of the patient. Zehm et al. compared the long-term inferior pole length between superior and inferior pedicle breast reduction techniques [ 10 ]. They also found that the N-IF distance elongates about 3.3-cm after the superior pedicle Pitanguy technique, and a 3.9 cm mean after the inferior pedicle technique. Superomedial pedicle (SMP) reduction mammoplasties have also shown lower pole elongation to a certain extent [11]. There is still controversy about which method delivers better results. Authors do not always agree on the greater tendency of the inferior pedicle to extend over time, especially in gigantomastias. In the study of Kemaloglu et al., inferior pedicle mammoplasties were not associated with significantly bigger bottoming out when compared to the superomedial pedicle technique. In patients with gigantomastia, bottoming out occurred in both groups with time. [12] In this study, we evaluated five different methods of pedicles used in breast reduction surgery, namely craniomedial, superior, inferior, superolateral, and medial pedicles. Our sample consisted of 71 craniomedial pedicles, 21 superior pedicles, 20 inferior pedicles, 4 superolateral pedicles, and 4 medial pedicles. The purpose of this discussion is to analyze the outcomes and potential advantages or disadvantages associated with each pedicle technique. Craniomedial pedicles were the most frequently employed technique in our study, comprising the majority of cases (71 out of 122 pedicles). This method has been widely adopted due to its reliability and versatility. The craniomedial pedicle offers adequate blood supply to the nippleareola complex (NAC) and allows for repositioning and reshaping of the breast. The high number of cases utilizing this technique in our study suggests that it is a preferred choice among surgeons. [13] Superior pedicles, although representing a smaller portion of our sample (21 pedicles), have gained popularity in recent years. This technique preserves the superior blood supply to the NAC, which is crucial for maintaining nipple viability. The superior pedicle offers advantages such as better nipple projection and a decreased risk of NAC necrosis. However, it may not be suitable for patients with significant ptosis or large breast volumes, as it may result in less optimal breast reshaping. [13] Inferior pedicles, comprising 20 cases in our study, have long been a reliable option for breast reduction surgery. The inferior pedicle technique provides excellent blood supply and allows for adequate reduction of breast volume. It is particularly useful for patients with significant ptosis or those requiring a substantial reduction in breast size. However, it may result in a longer scar and a less favorable breast shape compared to other pedicle techniques. [13] Superolateral and medial pedicles were less frequently utilized in our study, with 4 cases each. The superolateral pedicle technique is suitable for patients requiring a substantial reduction in upper pole fullness or patients with lateral breast ptosis. It provides adequate blood supply but may be associated with a higher risk of nipple malposition or loss of nipple projection. The medial pedicle technique, on the other hand, is useful for patients with large breasts who desire preservation of the medial breast tissue. It maintains the blood supply to the NAC but may result in a less natural breast shape. [13] In conclusion, our study demonstrated that breast reduction surgery utilizing different pedicle techniques can yield satisfactory outcomes. In our study we saw no statistically significant correlation between elongation of the N-IF and the choice of the pedicle. Further studies and long-term follow-ups are warranted to assess the efficacy and safety of these techniques in larger cohorts of patients. Building upon our exploration of key findings, an essential aspect of our study deserving attention is the median value of resected breast tissue, which stands at 580g, shedding light on the extent of reduction achieved during the surgical procedure. The amount of breast tissue removed in breast reduction surgery is a critical factor in achieving the desired cosmetic outcome and alleviating symptoms associated with large breasts, such as back pain, neck pain, and shoulder grooving. The median value of 580g indicates a significant reduction in breast size, which is likely to contribute to improved physical and psychological well-being in the patients. [14] In our study on breast reduction surgery, we thoroughly investigated the relationship between the weight of resected breast tissue and the increase in the inframammary distance postoperatively. Surprisingly, our findings revealed no significant correlation between these two variables. Despite the considerable reduction in breast tissue weight achieved during the surgical procedure, we did not observe a proportional increase in the inframammary distance in our patient cohort. Furthermore, we also saw no significant correlation between BMI of the patient and the elongation of N-IF. In our study, we have harnessed an innovative approach to assess changes in breast shape following breast reduction surgery, utilizing Image J, a sophisticated software program renowned for its ability to make precise measurements from high-resolution photographs. This method has empowered us to amass a substantial dataset from a diverse patient cohort, eliminating the need for extensive physical follow-ups, which can be both resource-intensive and time-consuming. One of the key advantages of this approach is its precision, as measurements can be taken down to the smallest pixel, making it possible to achieve a level of accuracy that surpasses that of conventional methods, such as using a measuring tape. To increase the reliability of the measurements analyzed using image processing software we invited a group of patients for a checkup (> 12 Months) and did the measurements with both methods (image processing software and using a measuring tape). Also, a standardized protocol for taking photographs (e.g., consistent lighting, distance, angle, and patient positioning) was created and calibration objects were included in photographs to ensure scale accuracy. It is also important to note that all of the measurements taken in our study were performed by the same person, to reduce the human factor mistakes and degree of variability into our results. Nevertheless, we have taken great care to minimize such effects, and the consistency of our findings suggests that this potential limitation has not significantly impacted the validity of our results. In conclusion, the use of Image J software has provided us with a valuable tool for exploring the long-term effects of breast reduction surgery on breast shape, enabling us to gather precise and reliable data from a large patient cohort. While some limitations exist, such as the potential for 2D images to produce inaccurate measurements, we are optimistic that further advances in technology will continue to enhance the accuracy and utility of this approach, leading to even more robust and insightful findings in the future. In the present study, some limitations must be taken into account. Firstly, we compered the measurement results with conventional manual measurement methods with a small group of 4 patients. The number of patients should be increased to increase the reliability of the measurements done with Image J. However, the advantage of using a program like Image J is that it allowed us to study a large group of patients without the need for physical follow-up, which can be very time-consuming. Moreover, measuring with this method could be more precise than conventional methods since it allowed for measurements up to the smallest pixel. Another limitation of the study is that all of the measurements were done by the same person, which could have introduced potential bias. However, this also ensured that the measurements were done consistently and eliminated inter-observer variability. Based on the findings of our study and the observed relationship between inframammary incision length and the risk of bottoming out complications in breast reduction surgery, we propose that surgeons should consider a shorter length of the inframammary distance during breast reduction surgery. Our study suggests that shorter distance may be associated with a decreased risk of bottoming out complications. In our clinic the standard distance for N-IF is 5,5–6,5 cm. By creating a shorter incision, the lower breast tissue can be better supported, leading to improved long-term outcomes. Furthermore, a postoperative patient evaluation should be conducted to gather information about their satisfaction with the postoperative results and the relief of physical discomfort. This would provide insight into the patients' subjective experiences and could help to inform future clinical decision-making. Overall, while the present study provides valuable insights into the long-term changes in breast shape after breast reduction surgery, further research is needed to address these limitations and expand our understanding in this field. Declarations Declaration of AI and AI-assisted technologies in the writing process? During the preparation of this work the author used Chat GPT in order to improve readability and language. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Funding: None Conflicts of interest: The authors declare that they have no competing interests. Ethical approval:This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for this study was obtained from the Ethics Committee of Hannover Medical School (Medizinische Hochschule Hannover, Germany). All participants provided written informed consent to participate in the study and for the use of clinical photographs for scientific publication. Reference number (No.10056_BO_K_2025). Clinical trial number: not applicable. References V. Chetty, E. Ndobe Macromastia and gigantomastia: efficacy of the superomedial pedicle pattern for breast reduction surgery SAJS, 54 (4) (2016), pp. 46-50 [ISSN 2078-5151] Neligan PC. Plastic surgery; 6-volume set, 3rd ed. Ed. Saunders, 2012. ISBN-13: 978– 1437717334 and ISBN-10: 1437717330. Praxis der Plastischen Chirurgie: Plastisch-rekonstruktive Operationen - Plastischästhetische Operationen - Handchirurgie – Verbrennungschirurgie von Peter M. Vogt 23.9.2011 XXXIV, 869 S. Mit 950 S. 1000 Abb.. Neligan PC. Plastic surgery; 6-volume set, 3rd ed. Ed. Saunders, 2012. ISBN-13: 978– 1437717334 and ISBN-10: 1437717330. L.R. Bouwer, J.J. van der Biezen, C.A. Spronk, B. van der Lei Vertical scar versus the inverted-T scar reduction mammaplasty: a 10-year follow-up J. Plast. Reconstr. Aesthetic Surg., 65 (10) (2012), pp. 1298-1304 Qiao Q, Zhon G, Ling Y: Breast volume measurement in young Chinese women and clinical applications. Aesthetic Plast Surg. 1997, 21:362-368. 10.1007/s002669900139 Swanson E: A measurement system for evaluation of shape changes and proportions after cosmetic breast surgery. Plast Reconstr Surg. 2012, 129:982-92. 10.1097/ PRS.0b013e3182442290 Rogliani M, Gentile P, Labardi L, et al.Improvement of physical and psychological symptoms after breast reduction. J Plast Reconstr Aesthet Surg 2009;62:1647-9. 10.1016/ j.bjps.2008.06.067 Sapino G, Haselbach D, Watfa W, Baudoin J, Martineau J, Guillier D, di Summa PG. Evaluation of long-term breast shape in inferior versus superomedial pedicle reduction mammoplasty: a comparative study. Gland Surg. 2021 Mar;10(3):1018-1028. doi: 10.21037/ gs-20-440. Erratum in: Gland Surg. 2021 May;10(5):1840. PMID: 33842246; PMCID: PMC8033061. Zehm, S., Puelzl, P., Wechselberger, G. et al. Inferior Pole Length and Long-term Aesthetic Outcome after Superior and Inferior Pedicled Reduction Mammaplasty. Aesth Plast Surg 36, 1128–1133 (2012). https://doi.org/10.1007/s00266-012-9938-6 Altuntaş, Z.K., Kamburoğlu, H.O., Yavuz, N. et al. Long-Term Changes in Nipple-Areolar Complex Position and Inferior Pole Length in Superomedial Pedicle Inverted ‘T’ Scar Reduction Mammaplasty. Aesth Plast Surg 39, 325–330 (2015). https://doi.org/10.1007/ s00266-015-0470-3 Kemaloğlu, Cemal Alper MD; Özocak, Hakan MD. Comparative Outcomes of Inferior Pedicle and Superomedial Pedicle Technique With Wise Pattern Reduction in Gigantomastic Patients. Annals of Plastic Surgery: March 2018 - Volume 80 - Issue 3 - p 217-222 doi: 10.1097/SAP.0000000000001231 Bishop H. Atlas of Breast Surgery. Ann R Coll Surg Engl. 2007 Apr;89(3):331. doi: 10.1308/003588407X179080c. PMCID: PMC1964704. Michael S. Sabel, Essentials of Breast Surgery 2009 doi: 10.1016 B978-0-323-03758-7.X0001-4 Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Apr, 2026 Reviews received at journal 09 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers invited by journal 30 Mar, 2026 Editor assigned by journal 11 Mar, 2026 Submission checks completed at journal 11 Mar, 2026 First submitted to journal 05 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9041908\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":614739189,\"identity\":\"107e5d6e-9c24-4746-a931-378524659d6c\",\"order_by\":0,\"name\":\"Niks Gulbis\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYDACZjYQaZHAxsB8AMiQkCFWiwRQC1sCiMFDhDVQLQwMPAYgFmEt5uxsyR+/tknk8fGf+fzqRo0FDwP74aMb8GmxbGY7Ji3bJlHMJpG7zTrnGNBhPGlpN/BpMTjM3sYs2SaR2CbBu804hw2oRYLHjJCW5s9gLfxnnhnn/CNKC9sByY8gLQw5zI9z24jTkibNcA7klzQz5tw+CR42gn45f8z4448ymzz5/sOPP+d8q5PjZz98DK8WEGCGxgWbBJgkpBwEGH9AtX4gRvUoGAWjYBSMPAAAb7FA3BvH7dwAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Hannover Medical School\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Niks\",\"middleName\":\"\",\"lastName\":\"Gulbis\",\"suffix\":\"\"},{\"id\":614739190,\"identity\":\"227f6b1d-788c-4661-a347-008bab057e53\",\"order_by\":1,\"name\":\"Doha Obed\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hannover Medical School\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Doha\",\"middleName\":\"\",\"lastName\":\"Obed\",\"suffix\":\"\"},{\"id\":614739191,\"identity\":\"b0b9e1ba-f4c3-4853-85c4-f639cf2d3453\",\"order_by\":2,\"name\":\"Nadjib Dastagir\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hannover Medical School\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Nadjib\",\"middleName\":\"\",\"lastName\":\"Dastagir\",\"suffix\":\"\"},{\"id\":614739192,\"identity\":\"f2c261f3-e8c1-484a-bdb4-2527449353b0\",\"order_by\":3,\"name\":\"Frederik Schlottmann\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hannover Medical School\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Frederik\",\"middleName\":\"\",\"lastName\":\"Schlottmann\",\"suffix\":\"\"},{\"id\":614739193,\"identity\":\"f08c8be6-a6a1-482a-81b2-d659a7c93fbf\",\"order_by\":4,\"name\":\"Peter M. Vogt\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hannover Medical School\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Peter\",\"middleName\":\"M.\",\"lastName\":\"Vogt\",\"suffix\":\"\"},{\"id\":614739194,\"identity\":\"60caa411-5dcd-4c9a-a0f0-5716d65d925b\",\"order_by\":5,\"name\":\"Khaled Dastagir\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hannover Medical School\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Khaled\",\"middleName\":\"\",\"lastName\":\"Dastagir\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-05 15:25:50\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9041908/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9041908/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":106094093,\"identity\":\"8dc1d6c2-2486-4d9d-a1f1-aa2b4abc1a7c\",\"added_by\":\"auto\",\"created_at\":\"2026-04-03 11:40:57\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1510603,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSee image above for figure legend\\u0026nbsp;\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9041908/v1/7850be0377cc274a03ac6251.png\"},{\"id\":105984802,\"identity\":\"ddea2b8c-54d6-4c2a-864b-78eeabf424db\",\"added_by\":\"auto\",\"created_at\":\"2026-04-02 07:18:11\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":3361746,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSee image above for figure legend\\u0026nbsp;\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9041908/v1/5df8862406224e32ad4d0946.png\"},{\"id\":106095778,\"identity\":\"e8215260-b4ad-4e66-91d3-7e5f0ac9d110\",\"added_by\":\"auto\",\"created_at\":\"2026-04-03 11:51:02\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":9727059,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9041908/v1/5314c391-5e20-4d16-8cf1-89ad87748643.pdf\"},{\"id\":105984800,\"identity\":\"05a8f1b4-7ccd-4ddb-8115-e4f167e8c2f8\",\"added_by\":\"auto\",\"created_at\":\"2026-04-02 07:18:11\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":101934,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Tables.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9041908/v1/5a17d2216e39dfa0b8883d29.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003eLong-term changes of shape following breast reduction surgery: A retrospective single center study\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"1. Introduction\",\"content\":\"\\u003cp\\u003eBreast hypertrophy is a condition marked by disproportionate breast tissue growth, typically beginning during puberty. It can result in excessive breast weight, exceeding 1.5 kg per breast (macromastia) or even more than 2 kg per breast (gigantomastia) [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Heavy and pendulous breasts often cause chronic pain in the neck/back area and discomfort for many patients. While patients usually request breast reduction mammoplasty to relieve pain and discomfort, they also hope the procedure will improve the appearance of their breasts. Many causes of gross enlargement have been proposed, including increased sensitivity to hormones (estrogen, progesterone, and prolactin), growth factors, drugs (such as penicillamine and antiretrovirals), and obesity [2].\\u003c/p\\u003e \\u003cp\\u003eAs with all aesthetic procedures, the surgeon and the patient must define the goal of therapy jointly during the consultation. In addition to the patient\\u0026rsquo;s wishes, pre-operative conditions such as preexisting asymmetry, type of skin condition, and tendency to excessive scarring must be taken into account. Detailed information about the realistic result that can be achieved postoperatively is essential to minimize the risk of a surgical result that may be successful for the surgeon but not beneficial for the patient [3].\\u003c/p\\u003e \\u003cp\\u003eBefore undertaking breast reduction mammoplasty, the surgeon should document several measurements. Poor preoperative planning can lead to unsatisfactory long-term results. It is essential that the breasts be appropriately marked with the patient in the standing position, indicating the planned incision pattern. Four operative key elements in breast reduction surgery should be considered [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eThe design must incorporate a pedicle that preserves the vascularity and innervation to the nipple-areola complex (NAC).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eThe excess breast tissue is removed to accomplish the desired volume reduction.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eThe excess skin envelope must be reduced.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eThe result should be attractive with the nipple on top of a conical breast with good projection and attractive shape.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eReduction mammoplasty is one of the most commonly performed operations by plastic surgeons. To ensure good long-term results following breast reduction surgery, the laws of gravity must be respected. Thus, preoperative planning and measurements remain integral for ensuring a high patient satisfaction rate following breast reduction. Although several techniques have been reported for breast lift and breast reduction, most plastic surgeons favor the inverted-T technique [5]. The objective of this retrospective study was to investigate the long-term changes in breast morphology following breast reduction mammoplasty. This study was conducted at a single center and included 122 patients who underwent breast reduction surgery over a period of 10 years. The aim of this study was to provide a comprehensive follow-up of the postoperative outcomes of the procedure over an extended period.\\u003c/p\\u003e\"},{\"header\":\"2. Materials and methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.1 Data collection\\u003c/h2\\u003e \\u003cp\\u003eAll patients who underwent breast reduction mammoplasty between 2011 and 2021 at the Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery of Hannover Medical School were included in the study. Patients who underwent reduction mammoplasty for congenital breast asymmetry or oncoplastic procedures related to oncologic surgery, as well as male patients, were excluded. Patients who were lost to postoperative follow-up were also excluded. We conducted a retrospective cohort analysis of the included patients and their surgical reports, with a focus on morphological changes. These changes included distances such as the distance between the clavicle and nipple, the distance between the sternal notch and nipple, the distance between the two areolas, and the distance between the inframammary fold and nipple. Measurements were taken at various intervals, including preoperative, postoperative, 3\\u0026ndash;6 months, and over 1 year. Breast evaluations included standardized distances such as N-IF (distance between the nipple and inframammary fold), SN-N (distance between the sulcus jugularis and nipple), and C-NL (distance between the clavicle and nipple). These measurements were obtained using a high-resolution digital camera (Panasonic Model No. DMC-FZ300) and analyzed using image processing software (Image J Version 1.54d), which allowed for measurements accurate to the smallest pixel (Fig.\\u0026nbsp;1). A standardized protocol for taking photographs (e.g., consistent lighting, distance, angle, and patient positioning) were taken of each patient, including a frontal view with the patient standing comfortably upright with arms at their sides and angular views (lateral and obliques). Also, calibration objects were included in photographs to ensure scale accuracy. 4 of the patients was measured both ways (photographs and direct clinical measurements) to analyzing the correlation and differences between the two sets of measurements. An official consent of using the photos and taking part in the study was signed by every patient. Patients' body mass index (BMI) and age were collected from medical charts and reports. The intraclass correlation coefficient (ICC) and Bland-Altman plots were used to determine the agreement between each pair of measurements.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003eFigure 1. a-b preoperative measurements, c-e postoperative measurements (C-NL: distance between clavicle and nipple, SN-N: distance between sulcus jugularis and nipple, N-IF: distance between nipple and inframammary fold, AIM: distance between two areolas)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.2 Statistical analysis\\u003c/h2\\u003e \\u003cp\\u003eDescriptive statistics were reported as numbers and percentages or as mean, standard deviation and range of data. A two-way ANOVA was used to determine if there were changes in the breast shape during different times of follow-up. A p-value\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 was considered statistically significant. All analyses were performed using Microsoft\\u0026reg; Excel Version 16.47.1 and Prism Version 9.0.2 (134).\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"3. Results\",\"content\":\"\\u003cdiv id=\\\"Sec6\\\"\\u003e\\n \\u003ch2\\u003e3.1 Preoperative assessment measurements\\u003c/h2\\u003e\\n \\u003cp\\u003eIn this study, 122 female patients (comprising 244 breasts) were included. The patients\\u0026apos; ages ranged from 20 to 77 years, with a mean age of 43.1 years. The mean BMI of the patients was 27.1 kg/m\\u0026sup2;, with a range from 19.1 to 35.9 kg/m\\u0026sup2;. The average preoperative SN-N (sternal notch-nipple) distance measured 289 mm (SD\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;40.4) on the right side and 295 mm (SD\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;40.9) on the left side. Similarly, the average preoperative N-IF (nipple-inferior fold) distance on the right side was 142 mm (SD\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;26.4), and on the left side, it was 143 mm (SD\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;26.4). Finally, the average preoperative CNL (clavicle-nipple) distance on the right side was 281 mm (SD\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;41.3), while on the left side, it measured 279 mm (SD\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;40.8).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec7\\\"\\u003e\\n \\u003ch2\\u003e3.2 Postoperative assessment measurements\\u003c/h2\\u003e\\n \\u003cdiv\\u003e\\u0026nbsp;Descriptive statistics and mean measurements are presented in Table 1. The following average distances were found:\\u003c/div\\u003e\\n \\u003cp\\u003eWhen comparing the changes in breast shape during different periods, all exhibited statistical significance (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001). The results revealed a mean increase of 16 (\\u0026plusmn;\\u0026thinsp;9) mm and 14 (\\u0026plusmn;\\u0026thinsp;10) mm in the distance between the nipple and inframammary fold (N-IF) on the right and left sides, respectively. Additionally, there was a mean increase of 9 (\\u0026plusmn;\\u0026thinsp;12) mm and 9 (\\u0026plusmn;\\u0026thinsp;14) mm in the distance between the sulcus jugularis and nipple (SN-N) on the right and left sides, respectively.\\u003c/p\\u003e\\n \\u003cp\\u003eFurthermore, the distance between the clavicle and nipple (C-NL) demonstrated a more substantial increase, with a mean increase of 26 (\\u0026plusmn;\\u0026thinsp;30) mm and 24 (\\u0026plusmn;\\u0026thinsp;29) mm on the right and left sides, respectively, signifying a significant alteration in breast shape following breast reduction mammoplasty surgery. When examining these numbers in percentages, we observe that the mean increase of N-IF is 23% on the right side and 20% on the left side. The mean increase of SN-N is 5% on the right side and 4% on the left side. The mean increase of C-NL is 11% on both sides. No significant differences were found between the measurements obtained using image processing software and those taken with a measuring tape. The values for these measurements are presented in Table 3. All measurements were performed by the same individual. The Bland-Altman Test confirmed that all measurements of the right and left breasts before and after the operation fell within acceptable levels of agreement according to the measurement area.\\u003c/p\\u003e\\n \\u003cp\\u003eIn this study, we investigated the outcomes of breast reduction surgery using various pedicle methods, including craniomedial, superior, inferior, superolateral, and medial pedicles. Our research encompassed a total of 122 breast reduction procedures, with the following distribution of pedicles:\\u003c/p\\u003e\\n \\u003cp\\u003e71 craniomedial, 21 superior pedicles, 20 inferior pedicles, 4 superolateral, and 4 medial pedicles. The average weight of the resected breast tissue was determined to be 580 g. On the right side 586 g (\\u0026plusmn;\\u0026thinsp;350; range: 97-2240g) and on the left side 575 g (\\u0026plusmn;\\u0026thinsp;351; range: 90-2270g). This value represents the central tendency of the amount of breast tissue removed during the surgical procedure and offers insight into the extent of the reduction achieved.\\u003c/p\\u003e\\n \\u003cp\\u003eTable 2. Mean Values for the distance between nipple and inframammary fold\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003eDespite the increasing popularity and relative frequency of breast reduction surgery performed, the long-term effects of breast reduction surgery on the shape of the breast remains sparsely documented within the medical literature. While some studies have sought to compare and contrast various surgical techniques employed in this procedure, these inquiries have rarely involved a sufficiently large patient cohort to provide a definitive answer. Given the importance of this surgical intervention for many women seeking to alleviate chronic pain and discomfort, as well as the desire to achieve optimal aesthetic outcomes, a thorough understanding of its long-term effects is essential. To that end, recent studies have sought to examine the impact of breast reduction surgery on the shape of the breast over an extended period of time. While these studies are still in their early stages, preliminary findings suggest that breast reduction surgery can have a profound and enduring impact on breast shape, particularly when performed with attention to detail and meticulous surgical technique. As such, extensive research of the long-term effects of breast reduction surgery is needed, in order to ensure that patients are provided with the highest possible quality of care and treatment outcomes.\\u003c/p\\u003e \\u003cp\\u003eTransitioning from the discussion of our research on breast reduction surgery's impact on breast shape, it's essential to recognize that the landscape of this procedure varies significantly across different countries. In high-income nations like the United States, the emphasis often lies on cosmetic aspirations and achieving an aesthetically pleasing breast size and contour. Conversely, lower-income countries often prioritize breast reduction surgery for functional purposes, such as pain relief and improved physical function. Moreover, the techniques employed for the surgery exhibit noteworthy diversity, with inferior pedicle being popular in the West and superomedial pedicle being preferred in Asian countries. These regional disparities underscore the profound influence of cultural and individual factors in shaping both the demand for and outcomes of breast reduction surgery. [6]\\u003c/p\\u003e \\u003cp\\u003ePatients with breast hypertrophy usually seek help from plastic surgeons to reach a better quality of life, to reduce chronic pain in the neck/back region and also to have less social and sexual embarrassment in their daily life. Many patients report improved quality-of-life following breast reduction surgery which is frequently reflected by an increase in physical activities and the ability to wear appropriate clothing. [7] Consequently, this results in an increase in self-esteem and in the reduction of physical and emotional discomfort. Various studies in the medical literature demonstrate the effectiveness of breast reduction for the improvement of psychological, functional and aesthetic well-being. [8]\\u003c/p\\u003e \\u003cp\\u003eSapino et al. compered the results between inferior vs. superomedial pedicle in breast reduction. [9]. A total of 58 patients were included in the study. In line with our study results, Sapino et al. found a mean increase of the SN-N distance after 6 months of 13 mm and N-IF distance of 16 mm. These results are similar to our findings. This also shows that poor preoperative planning and inadequate consultation of the patient can lead to poor long-term results and satisfactory rate of the patient. Zehm et al. compared the long-term inferior pole length between superior and inferior pedicle breast reduction techniques [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. They also found that the N-IF distance elongates about 3.3-cm after the superior pedicle Pitanguy technique, and a 3.9 cm mean after the inferior pedicle technique. Superomedial pedicle (SMP) reduction mammoplasties have also shown lower pole elongation to a certain extent [11].\\u003c/p\\u003e \\u003cp\\u003eThere is still controversy about which method delivers better results. Authors do not always agree on the greater tendency of the inferior pedicle to extend over time, especially in gigantomastias. In the study of Kemaloglu et al., inferior pedicle mammoplasties were not associated with significantly bigger bottoming out when compared to the superomedial pedicle technique. In patients with gigantomastia, bottoming out occurred in both groups with time. [12]\\u003c/p\\u003e \\u003cp\\u003eIn this study, we evaluated five different methods of pedicles used in breast reduction surgery, namely craniomedial, superior, inferior, superolateral, and medial pedicles. Our sample consisted of 71 craniomedial pedicles, 21 superior pedicles, 20 inferior pedicles, 4 superolateral pedicles, and 4 medial pedicles. The purpose of this discussion is to analyze the outcomes and potential advantages or disadvantages associated with each pedicle technique.\\u003c/p\\u003e \\u003cp\\u003eCraniomedial pedicles were the most frequently employed technique in our study, comprising the majority of cases (71 out of 122 pedicles). This method has been widely adopted due to its reliability and versatility. The craniomedial pedicle offers adequate blood supply to the nippleareola complex (NAC) and allows for repositioning and reshaping of the breast. The high number of cases utilizing this technique in our study suggests that it is a preferred choice among surgeons.\\u003c/p\\u003e \\u003cp\\u003e[13]\\u003c/p\\u003e \\u003cp\\u003eSuperior pedicles, although representing a smaller portion of our sample (21 pedicles), have gained popularity in recent years. This technique preserves the superior blood supply to the NAC, which is crucial for maintaining nipple viability. The superior pedicle offers advantages such as better nipple projection and a decreased risk of NAC necrosis. However, it may not be suitable for patients with significant ptosis or large breast volumes, as it may result in less optimal breast reshaping. [13]\\u003c/p\\u003e \\u003cp\\u003eInferior pedicles, comprising 20 cases in our study, have long been a reliable option for breast reduction surgery. The inferior pedicle technique provides excellent blood supply and allows for adequate reduction of breast volume. It is particularly useful for patients with significant ptosis or those requiring a substantial reduction in breast size. However, it may result in a longer scar and a less favorable breast shape compared to other pedicle techniques. [13]\\u003c/p\\u003e \\u003cp\\u003eSuperolateral and medial pedicles were less frequently utilized in our study, with 4 cases each. The superolateral pedicle technique is suitable for patients requiring a substantial reduction in upper pole fullness or patients with lateral breast ptosis. It provides adequate blood supply but may be associated with a higher risk of nipple malposition or loss of nipple projection. The medial pedicle technique, on the other hand, is useful for patients with large breasts who desire preservation of the medial breast tissue. It maintains the blood supply to the NAC but may result in a less natural breast shape. [13]\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, our study demonstrated that breast reduction surgery utilizing different pedicle techniques can yield satisfactory outcomes. In our study we saw no statistically significant correlation between elongation of the N-IF and the choice of the pedicle. Further studies and long-term follow-ups are warranted to assess the efficacy and safety of these techniques in larger cohorts of patients.\\u003c/p\\u003e \\u003cp\\u003eBuilding upon our exploration of key findings, an essential aspect of our study deserving attention is the median value of resected breast tissue, which stands at 580g, shedding light on the extent of reduction achieved during the surgical procedure. The amount of breast tissue removed in breast reduction surgery is a critical factor in achieving the desired cosmetic outcome and alleviating symptoms associated with large breasts, such as back pain, neck pain, and shoulder grooving. The median value of 580g indicates a significant reduction in breast size, which is likely to contribute to improved physical and psychological well-being in the patients. [14] In our study on breast reduction surgery, we thoroughly investigated the relationship between the weight of resected breast tissue and the increase in the inframammary distance postoperatively. Surprisingly, our findings revealed no significant correlation between these two variables. Despite the considerable reduction in breast tissue weight achieved during the surgical procedure, we did not observe a proportional increase in the inframammary distance in our patient cohort. Furthermore, we also saw no significant correlation between BMI of the patient and the elongation of N-IF.\\u003c/p\\u003e \\u003cp\\u003eIn our study, we have harnessed an innovative approach to assess changes in breast shape following breast reduction surgery, utilizing Image J, a sophisticated software program renowned for its ability to make precise measurements from high-resolution photographs. This method has empowered us to amass a substantial dataset from a diverse patient cohort, eliminating the need for extensive physical follow-ups, which can be both resource-intensive and time-consuming. One of the key advantages of this approach is its precision, as measurements can be taken down to the smallest pixel, making it possible to achieve a level of accuracy that surpasses that of conventional methods, such as using a measuring tape. To increase the reliability of the measurements analyzed using image processing software we invited a group of patients for a checkup (\\u0026gt;\\u0026thinsp;12 Months) and did the measurements with both methods (image processing software and using a measuring tape). Also, a standardized protocol for taking photographs (e.g., consistent lighting, distance, angle, and patient positioning) was created and calibration objects were included in photographs to ensure scale accuracy.\\u003c/p\\u003e \\u003cp\\u003eIt is also important to note that all of the measurements taken in our study were performed by the same person, to reduce the human factor mistakes and degree of variability into our results. Nevertheless, we have taken great care to minimize such effects, and the consistency of our findings suggests that this potential limitation has not significantly impacted the validity of our results. In conclusion, the use of Image J software has provided us with a valuable tool for exploring the long-term effects of breast reduction surgery on breast shape, enabling us to gather precise and reliable data from a large patient cohort. While some limitations exist, such as the potential for 2D images to produce inaccurate measurements, we are optimistic that further advances in technology will continue to enhance the accuracy and utility of this approach, leading to even more robust and insightful findings in the future.\\u003c/p\\u003e \\u003cp\\u003eIn the present study, some limitations must be taken into account. Firstly, we compered the measurement results with conventional manual measurement methods with a small group of 4 patients. The number of patients should be increased to increase the reliability of the measurements done with Image J. However, the advantage of using a program like Image J is that it allowed us to study a large group of patients without the need for physical follow-up, which can be very time-consuming. Moreover, measuring with this method could be more precise than conventional methods since it allowed for measurements up to the smallest pixel. Another limitation of the study is that all of the measurements were done by the same person, which could have introduced potential bias. However, this also ensured that the measurements were done consistently and eliminated inter-observer variability.\\u003c/p\\u003e \\u003cp\\u003eBased on the findings of our study and the observed relationship between inframammary incision length and the risk of bottoming out complications in breast reduction surgery, we propose that surgeons should consider a shorter length of the inframammary distance during breast reduction surgery. Our study suggests that shorter distance may be associated with a decreased risk of bottoming out complications. In our clinic the standard distance for N-IF is 5,5\\u0026ndash;6,5 cm. By creating a shorter incision, the lower breast tissue can be better supported, leading to improved long-term outcomes.\\u003c/p\\u003e \\u003cp\\u003eFurthermore, a postoperative patient evaluation should be conducted to gather information about their satisfaction with the postoperative results and the relief of physical discomfort. This would provide insight into the patients' subjective experiences and could help to inform future clinical decision-making. Overall, while the present study provides valuable insights into the long-term changes in breast shape after breast reduction surgery, further research is needed to address these limitations and expand our understanding in this field.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eDeclaration of AI and AI-assisted technologies in the writing process?\\u003c/p\\u003e\\n\\u003cp\\u003eDuring the preparation of this work the author used Chat GPT in order to improve readability and language. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Funding: None\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Conflicts of interest: The authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Ethical approval:This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for this study was obtained from the Ethics Committee of Hannover Medical School (Medizinische Hochschule Hannover, Germany). All participants provided written informed consent to participate in the study and for the use of clinical photographs for scientific publication. Reference number (No.10056_BO_K_2025).\\u003c/p\\u003e\\n\\u003cp\\u003eClinical trial number: not applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eV. Chetty, E. Ndobe Macromastia and gigantomastia: efficacy of the superomedial pedicle pattern for breast reduction surgery SAJS, 54 (4) (2016), pp. 46-50 [ISSN 2078-5151]\\u003c/li\\u003e\\n\\u003cli\\u003eNeligan PC. Plastic surgery; 6-volume set, 3rd ed. Ed. Saunders, 2012. ISBN-13: 978\\u0026ndash; 1437717334 and ISBN-10: 1437717330. \\u003c/li\\u003e\\n\\u003cli\\u003ePraxis der Plastischen Chirurgie: Plastisch-rekonstruktive Operationen - Plastisch\\u0026auml;sthetische Operationen - Handchirurgie \\u0026ndash; Verbrennungschirurgie von Peter M. Vogt 23.9.2011 XXXIV, 869 S. Mit 950 S. 1000 Abb.. \\u003c/li\\u003e\\n\\u003cli\\u003eNeligan PC. Plastic surgery; 6-volume set, 3rd ed. Ed. Saunders, 2012. ISBN-13: 978\\u0026ndash; 1437717334 and ISBN-10: 1437717330. \\u003c/li\\u003e\\n\\u003cli\\u003eL.R. Bouwer, J.J. van der Biezen, C.A. Spronk, B. van der Lei Vertical scar versus the inverted-T scar reduction mammaplasty: a 10-year follow-up J. Plast. Reconstr. Aesthetic Surg., 65 (10) (2012), pp. 1298-1304 \\u003c/li\\u003e\\n\\u003cli\\u003eQiao Q, Zhon G, Ling Y: Breast volume measurement in young Chinese women and clinical applications. Aesthetic Plast Surg. 1997, 21:362-368. 10.1007/s002669900139 \\u003c/li\\u003e\\n\\u003cli\\u003eSwanson E: A measurement system for evaluation of shape changes and proportions after cosmetic breast surgery. Plast Reconstr Surg. 2012, 129:982-92. 10.1097/ PRS.0b013e3182442290 \\u003c/li\\u003e\\n\\u003cli\\u003eRogliani M, Gentile P, Labardi L, et al.Improvement of physical and psychological symptoms after breast reduction. J Plast Reconstr Aesthet Surg 2009;62:1647-9. 10.1016/ j.bjps.2008.06.067 \\u003c/li\\u003e\\n\\u003cli\\u003eSapino G, Haselbach D, Watfa W, Baudoin J, Martineau J, Guillier D, di Summa PG. Evaluation of long-term breast shape in inferior versus superomedial pedicle reduction mammoplasty: a comparative study. Gland Surg. 2021 Mar;10(3):1018-1028. doi: 10.21037/ gs-20-440. Erratum in: Gland Surg. 2021 May;10(5):1840. PMID: 33842246; PMCID: PMC8033061. \\u003c/li\\u003e\\n\\u003cli\\u003eZehm, S., Puelzl, P., Wechselberger, G. et al. Inferior Pole Length and Long-term Aesthetic Outcome after Superior and Inferior Pedicled Reduction Mammaplasty. Aesth Plast Surg 36, 1128\\u0026ndash;1133 (2012). https://doi.org/10.1007/s00266-012-9938-6 \\u003c/li\\u003e\\n\\u003cli\\u003eAltuntaş, Z.K., Kamburoğlu, H.O., Yavuz, N. et al. Long-Term Changes in Nipple-Areolar Complex Position and Inferior Pole Length in Superomedial Pedicle Inverted \\u0026lsquo;T\\u0026rsquo; Scar Reduction Mammaplasty. Aesth Plast Surg 39, 325\\u0026ndash;330 (2015). https://doi.org/10.1007/ s00266-015-0470-3 \\u003c/li\\u003e\\n\\u003cli\\u003eKemaloğlu, Cemal Alper MD; \\u0026Ouml;zocak, Hakan MD. Comparative Outcomes of Inferior Pedicle and Superomedial Pedicle Technique With Wise Pattern Reduction in Gigantomastic Patients. Annals of Plastic Surgery: March 2018 - Volume 80 - Issue 3 - p 217-222 doi: 10.1097/SAP.0000000000001231 \\u003c/li\\u003e\\n\\u003cli\\u003eBishop H. Atlas of Breast Surgery. Ann R Coll Surg Engl. 2007 Apr;89(3):331. doi: 10.1308/003588407X179080c. PMCID: PMC1964704. \\u003c/li\\u003e\\n\\u003cli\\u003eMichael S. Sabel, Essentials of Breast Surgery 2009 doi: 10.1016 B978-0-323-03758-7.X0001-4\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTables are available in the Supplementary Files section.\\u003c/p\\u003e\\n\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"european-journal-of-plastic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ejps\",\"sideBox\":\"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)\",\"snPcode\":\"238\",\"submissionUrl\":\"https://submission.nature.com/new-submission/238/3\",\"title\":\"European Journal of Plastic Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Breast reduction, short vertical scar, bottoming-out, Long-term breast shape changes, Breast surgery\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9041908/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9041908/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eIntroduction: \\u003c/strong\\u003eBreast hypertrophy, characterized by abnormal breast enlargement, often leads to chronic neck and back pain. Breast-reduction mammoplasty is commonly performed to alleviate these symptoms and improve breast appearance. Proper preoperative measurements are crucial for satisfactory long-term results. This study aimed to investigate long-term postoperative changes in breast morphology following breast reduction mammoplasty.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMaterial and Methods: \\u003c/strong\\u003eWe retrospectively analyzed 122 patients who underwent breast reduction mammoplasty at Hannover Medical School between 2011 and 2021. Various pedicle techniques were used, and changes in breast shape and contour were measured from pre- and postoperative photographs using Image J software.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eA total of 122 female patients (244 breasts) were included. The average postoperative nipple to inframammary fold (N-IF) distance on the right side changed from 142 mm to 72 mm (P\\u0026lt;0.0001) at \\u0026gt;3 months, 72 mm to 80 mm at 3-6 months, and 80 mm to 85 mm at \\u0026gt;1 year. Significant changes in breast shape were observed at all periods (P\\u0026lt;0.0001), except between \\u0026gt;3 months vs. 3-6 months and 3-6 months vs. \\u0026gt;1 year. The mean increase in N-IF distance at \\u0026gt;1 year follow-up was 16 mm on the right and 14 mm on the left. The sulcus jugularis to nipple (SN-N) distance increased by 12 mm on the right and 6 mm on the left. The clavicle to nipple (C-NL) distance increased by 16 mm on the right and 14 mm on the left.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions: \\u003c/strong\\u003eThis study demonstrates satisfactory and stable long-term changes in breast shape post-mammoplasty, aiding surgeons in planning and advising patients on expected outcomes.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Long-term changes of shape following breast reduction surgery: A retrospective single center study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-02 07:18:07\",\"doi\":\"10.21203/rs.3.rs-9041908/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-04-11T14:25:18+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-09T11:12:32+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"309734091820527718170760719691726781843\",\"date\":\"2026-04-02T10:32:13+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-03-30T16:22:01+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-03-11T05:28:01+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-03-11T05:27:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"European Journal of Plastic Surgery\",\"date\":\"2026-03-05T15:18:30+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"european-journal-of-plastic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ejps\",\"sideBox\":\"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)\",\"snPcode\":\"238\",\"submissionUrl\":\"https://submission.nature.com/new-submission/238/3\",\"title\":\"European Journal of Plastic Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"46699383-a229-4c79-9816-2a055c3e573f\",\"owner\":[],\"postedDate\":\"April 2nd, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-12T18:24:15+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-04-02 07:18:07\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9041908\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9041908\",\"identity\":\"rs-9041908\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}