 The importance of proportion in the human figure is something more than aesthetic. It affects physical well-being and comfort, as well as personality, social activity, professional, and economic achievement. Reduction mammoplasty, particularly in active young women, such as those serving in the armed forces, can relieve the discomfort and the psychological pressure imposed by hypertrophy of the breasts. This patient is 23 years old and a musician assigned to the woman's Army Corps band. She plays the trumpet and baritone horn and is also a vocalist. Her breasts had been excessively large since pubertal development was complete. She has had no pregnancies and no history of hormone therapy. Her physical complaints were heaviness of the breasts, a sense of dragging on the shoulders, pain from cutting of her brazier straps, and local discomfort in the breasts just before and during her menstrual periods. Her arms, shoulders, and neck ached and felt excessively tired after playing in the marching band because her breasts made it necessary to hold the baritone horn at an awkward distance. She had never been able to buy a properly fitted swimsuit, and because of self-consciousness, she seldom wore sweaters. The patient wore a 36D brazier, which fit fairly well and provided as good support as she had been able to obtain. The shoulder straps were kept as tight as possible to achieve good support, resulting in painful cutting into her shoulders by the straps. Her posture is round-shouldered and somewhat lordotic. This postural abnormality is the cause of some of the complaints of pain in the upper neck and back in many patients. Without the brazier, the posture and heaviness of the breasts are more readily apparent. The grooves of the shoulders are visible, although they are less marked in this young patient than in older and more obese women. There was no evidence of sub-memory intertrigo, but the patient did report some irritation in the summertime. The Strombeck technique utilizes a pattern worked out by Dr. Robert J. Wise, based on a 34B brazier. A single pattern is suitable for almost all patients, although Strombeck has described a modified pattern for very large breasts. The first mark is made at the sternal notch. The midpoints of the clavicles are located and marked. For greater visibility in the film, a commercial marker is used in place of the usual indelible, brilliant green. Pre-operative marking is done with the patient in an upright position, either seated erect or standing. This avoids the distortion which occurs with shift of position of the breasts when reclining. The axis of each breast is marked by dropping a line from the midpoint of the clavicle through the nipple. The inframamory fold is marked, exercising care not to extend the line too far medially. The new nipple site is chosen on the mammary axis at a point 21 centimeters from the clavicle. The measurements used are those reported in 1955 by Penn. In women with very large or fatty breasts, this should be increased by one or two centimeters, as recently recommended by Strombeck. The pattern is placed on the breast and oriented to the axis at the new nipple site. While the pattern is asymmetrical in the shape of the cup, the portion used to outline the incisions is very nearly symmetrical. The distance from the mid-clavicular point to the nipple site is the same as the distance between sternal notch and nipple, and corresponds to the distance between the two nipples. It is not necessary to reverse the pattern when marking the other breast. The line across the base of the pattern will determine the height of the reconstructed breast. Its length is a critical distance, and if too long, will give the nipple a star-gazing appearance. The medial end of the pattern marking is now joined directly to the end of the inframamory fold. If necessary, a slight offset can be incorporated laterally to lengthen the lateral pedicle. This avoids a dog ear laterally and allows closure without tension. After marking is completed, the important points are scratched to provide reorientation if necessary during the surgery. The pattern is gas-sterilized, and available in the operating room should it be necessary to renew the markings at that time. The actual surgery is accomplished under general anesthesia, with the patient in the supine position. The semi-recomment or sitting position is unnecessary with the Strombeck technique, because the new shape of the breasts has been determined by marking the skin flaps pre-operatively. Using a standard medicine glass, a circular pattern five centimeters in diameter is marked around the nipple without stretching the skin. The cardinal points should be marked to facilitate proper suturing of the areola. Superficial circumcision of the areola is the first incision. Superficial incisions are made to mark the ink lines. This is desirable in case the original markings become faded before surgery is completed. The epidermis is excised freehand, leaving the dermis intact. The area marked for the new nipple site must be incised completely as deep as the pectoral fascia. Although the skin markings are the same for all cases, the amount and location of the tissues removed have a significant effect on the final shape and size of the breast. It is important that the base of the excised cone not extend too far superiorly or medially, and that enough tissue be removed laterally. Since this patient is a vocalist with a dance band, as well as an instrumentalist, a more modest resection is planned. That would be appropriate, for example, for a championship golfer or a non-commissioned officer in charge of whack recruits. A plug is then excised. The upper horizontal incision is made and carried down to the pectoral fascia. This is seen more clearly from below. This leaves the areola portion of the breast in the center of a narrow double-pedical flap like a basket handle. It will move freely, but circulation is perfect. When the pedicle is short, back cuts are made through the dermis to allow easier movement of the areola to its new location. The reshaping of the breast begins with three key sutures. Without undermining the skin, the lower corners of the two skin flaps are sutured. The first suture taken in the areola approximates it to the highest point of the hole previously prepared by removal of the core of breast tissue. The upper corners of the skin flaps are joined. The breast has now been reshaped. The lower flap of tissue to be removed is incised along the breast axis to the submammary fold. This tissue has been retained up to this point to demonstrate its availability for additional bulk. If the technique is used in cases of smaller tonic breasts, the second breast is marked and surgery begins. This is a clear demonstration of the technique by which the skin is removed from the dermal pedicle. The three key sutures are used to pull the pedicle flaps together. In this patient, 490 grams removed from each breast. Using the pattern and techniques developed by Strombeck. Reduction mammoplasty can be carried out in a single operation, even when the breasts are very large. The pre-operative markings give an exactitude that results in nearly identical conical shapes with the areola correctly placed. Surgery is followed with a supportive dressing to hold the breasts firmly in position. After 48 hours, the drains are removed. The incisions examined and a new dressing applied. The patient is now ambulatory. The dressing technique is essentially the same as that used immediately after surgery. With the addition of collodion strips to reinforce the suture lines. Some of the sutures are removed on the sixth day and the remainder two to four days later. The patient's original brassiere is used to secure the dressing after the sixth day. This gives the breasts the necessary support from below and provides additional patient comfort. Civilian defendants who live within commuting distance are discharged from the hospital at this time. After three months, the patient returns for follow-up examination. The results for the patient have been quite satisfactory. Surgically too, the operation was successful. The new size and contour are correct and the incisions are well healed. There has been no necrosis and the cosmetic result is satisfactory. After a year, this patient returned to Walter Reed for final examination. Redistribution of the breast tissue has occurred. But by keeping the suture line short below the areola, the nipples retain their position at the apex of the breast. It should be noted that in patients with olive skin tones or deeper natural coloring, scars will tend to remain more apparent because of pigmentation. In addition to a good cosmetic result, the patient is now able to perform her military assignments with greater ease and less physical strain and finds her personal life happier as well. She has commented, for example, that she can now buy and wear ready-made dresses of almost any style without feeling self-conscious. The disabling effects of breast hypertrophy can be readily and safely eliminated by this strong back technique.