Do I need a free nipple graft to get me down to a small size? (Photos)

I would agree with your PS if you want to be that small. Any pedicle approach would lead to a high risk of nipple areolar loss. I can get a similar result with a FNR and a pedicle approach so do not worry. Be aware that you will lose nipple sensitivity, nipple projection, possibly some pigment and ability to breast feed. 

You have very large breast and transfer of your nipple/areola complex may be a problem after reduction regardless of the peddicle used. We were very successful in the past 25 years with large breast reductions using liposuction as a major modality of reduction; breast tissue consists  70-90% of fat tissue and liposuction is excellent way to remove fat from entire breast including lateral breast tail. This procedure does not undermine blood and nerve supply significantly (as much as some other methods) and for that reason transposition of distant areola/nipple seem to be safer. Resection of skin envelope and some redundant tissue from lower pole of the breast will complete reduction. Scar is always concealed underneath the breast. In person evaluation with a board certified plastic surgeon is recommended. Good luck.

The technique I recommend is The Bellesoma Method.  This will reduce and reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage.  The weight of the breast is transferred to the underlying pectoralis major muscle resulting in pain relief without excessive reduction.  Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained.  The goal is to have breasts that are proportionate to your body size.  As others have stated, no one can guarantee a breast size.  B cups vary from manufacturer to manufacturer.  I think your goal photograph is obtainable but not sure that will correspond necessarily to a size B.Best Wishes,Gary Horndeski, M.D.

You're breasts are large, and your nipples are low, but the size of your breasts and position of your nipples does not warrant free nipple grafts. You will have an excellent result with a standard breast reduction. 

Dear Astroaurora,
Breast reduction is best suited for women who wish to decrease the size of their breasts. While there are different techniques used to perform this surgery, I prefer the vertical incision (lollipop pattern) breast reduction technique instead of the anchor scar pattern, which reduces more noticeable scarring than usual. I also use a SAFE liposuction technique to reduce additional fat around the stubborn axilla area and bra line. This way, my patients are achieving beautiful results with minimal incisions which reduces downtime and delivers an overall better breast shape long term.If you are considering breast reduction surgery, you should consult with a board certified plastic surgeon to discuss your options and make sure your surgeon understands your goals. Only after a thorough examination you will get more information and recommendations.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

You are not even close to needing a free nipple graft. Standard relocation of the nipple should not be a problem.Belyeve me you will end up pretty small without removing a lot of tissue. The breasts will seem much larger right after surgery than six months later. A lot of the breast fat will resorb over time and the final result be much smaller than you think. So don’t go too small.

A breast reduction is often a balance between the patient goals and the limits of anatomy. Your surgeon will know what is necessary with regards to weight resection. Anatomic limits are non-negotiable as a certain amount of tissue must be preserved in order to maintain vascular supply to the nipple areolar complex. Free nipple graft may be discussed in cases where the distance the nipple must be transposed is too great (commonly for sternal notch to nipple distance > 40 cm).
Ultimately, you do play a role in the decision making process. The anatomic restrictions are, on the other hand, more rigid. Technically speaking, the larger breast (and greater the ptosis) the more tissue that will need to be preserved in order to maintain vascular supply to the nipple areolar complex. 
With regards to your specific question, free nipple graft is employed in cases of severe ptosis where the distance from sternal notch to nipple approaches or exceeds 40 cm. This is because the amount of tissue needed to preserve the nipple areolar complex at that length is so great as to undermine the benefits of reduction. Based on your measurements, you might still be a candidate for pedicle reduction, however, alteration in pedicle orientation might be in order. 19 cm from fold to nipple might be too large. Basing the pedicle superomedially might be more appropriate (leading to a shorter overall pedicle and a more effective reduction.
As always, discuss your concerns with a board certified plastic surgeon (ABPS).
Donovan Rosas MD
Board Certified by the American Board of Plastic Surgery
Member: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons
RealSelf Top 100
RealSelf Hall of Fame

Hi and welcome to our forum!There are several factors involved in deciding the best modality:2. flap length...the nipple areolar complex is maintained upon its retained attachments to underlying tissues. If flap length is excessive, the nipple-areolar complex may not survive as its blood supply will be compromised2. flap bulk...a longer flap will contain a greater amount of underlying tissue, limiting the amount of reduction possible3. general patient health...if there are health issues, the graft procedure is shorter and safer.The therapeutic advantage of the graft procedure is that a greater amount of breast tissue can be removed to achieve proportionate breast size. The disadvantages are an insensitive nipple-areolar complex and the inability to lactate.You appear to be best served with a free nipple graft if you wish a small size breast.Best wishes...

Thank you for the question and congratulations on your decision to proceed with breast reduction surgery. You may be surprised to know that your goals/requests are not that unusual.   I see several patients every year who wish to achieve as small of a breast appearance outcome, for a variety of personal reasons.
 Generally speaking, it is possible to reduce the breasts size very significantly.   The concern with the amount of tissue removed is related to blood flow to the remaining tissue; if too much tissue is removed in one operation the blood flow to the remaining tissue (including nipple/areola) may be compromised. Part of the tissue that is left in place is called the “pedicle"; this segment of tissue is responsible for delivering the blood supply to the nipple/areola tissue. If the pedicle is made too small (in the effort to reduce the breasts as much as possible) then patient will likely have problems with tissue survival.  Occasionally, a staged procedure is helpful; in others, nipple/areola grafting is helpful.
 In my opinion, successful outcomes with  etc. surgery depend on:
1.  Careful selection of plastic surgeon (and from the surgeon's  standpoint, careful selection of patient).  I would suggest starting with the American Society of Plastic Surgery and/or the Aesthetic Society of Plastic Surgery to obtain a list of well experienced board-certified plastic surgeons. Then, I would suggest you visit a few surgeons whose practices concentrate on aesthetic surgery. ***Ask to see lots of examples of their work and preferably speak/see patients who have had similar procedures done.
2.  Careful communication of goals ( which I will discuss further below).
3.  Skillful execution of procedure ( preoperative, intraopererative, and postoperative patient management).
In my practice, I would ask that you NOT communicate your goals, or evaluate the outcome of the procedure performed, based on cup sizes.  There is simply too much variability when it comes to bra sizes between bra manufacturers and even store employees doing the bra fitting measurements.
 Generally speaking,  for the benefit of patients undergoing breast reduction surgery:  it will be very important to communicate your size goals with your surgeon. Most patients wish to achieve a enough of a reduction to help with their symptoms while remaining proportionate with the remainder of their torso. Again, I suggest that you do not communicate your goals in terms of achieving a specific cup size. For example, a “A or B cup” may mean different things to different people and therefore may be a source of miscommunication.
In my practice, I ask patients to communicate their goals with the help of  computer imaging and/or goal photographs,  as you have done here.  Obviously, the outcome associated with the breast surgery will not necessarily match that of goal photographs perfectly, but they do serve as a better communication tool that subjective terms such as "natural", "proportionate", "flat"… Evaluating goal photographs also allows for a plastic surgeon to determine the consistency of the patient's goals and allows for a discussion of realistic expectations as well.  
***Needless to say, when it comes to achieving patient satisfaction with the outcome of surgery,  it is very important that a patient has consistent goals (fully decided on what she would like to achieve) and a good understanding of realistic expectations (what outcomes can and cannot be achieved). 
 Best wishes with your decision making and for an outcome that you will be very pleased with.

your surgeon was pretty correct. To get down to a B cup, you’d really have to do a nipple graft. If you want to avoid that, I don’t think you could go smaller then a D cup with any traditional pedicle technique because of your length. Now, a D cup on you would be pretty radically different and you’d have a life changing result but it won’t be as small as you’d prefer