Why can't doctors go from D cup to A cup? It bothers me that most breast reductions almost never go small enough.

Good question. Often women with very large breasts are so fed up with them that they even say "I just want them off." The surgeon has two goals, to reduce the breast size adequately but still end up with an attractive breast. It is really not possible to achieve an attractive A cup breast after a breast reduction because the breast base starts off so large the breasts would look very flat, not very pretty. Usually I tell patients that a C-cup is a good goal to remove the weight and still look good. But ultimately it is the patient's decision, and I have taken breasts down to almost flat in women who tell me that is what they want.

Hi.  It basically comes down to blood supply.  For the nipple to be repositioned it needs to be maintained on a block of tissue that we refer to as the pedicle.  That then allows the nipple to be shifted upwards, thus giving a breast lift at the same time as making the breasts smaller.  If that pedicle is too small, then there will be an inadequate and poor blood supply to the nipple which can actually result in the nipple dying (either partially or fully).  As such, the pedicle is designed to try and maximize vascularity or blood supply to the nipple as well as a good nerve supply to the nipple, but also try to reduce the size of the breast to what the patient desires.I would recommend consulting with a board-certified plastic surgeon with good experience in this area to help guide you through this process.Good luck and take care, Dr. Howell

The best way to determine what your breast size should be with respect to your anatomy and give true advice would be an in-person exam with a board certified plastic surgeon who performs hundreds of breast procedures annually. Not only does proportion depend upon the aesthetic balance of your breasts with your shoulders, waist, hips, and buttocks, but also upon your objectives, active lifestyle, soft tissue quality, muscular anatomy, and long-term concerns. There is also a limit to how small you can go due to tissue that needs to be retained for the nipple/areola to maintain a good blood and sensory nerve supply.

thank you for the question.  If insurance is paying for the surgery they probably require a certain minimum amount removed.  As far as how much the breast is reduced it seems to me that there is more of a risk of over reduction.  After surgery the remaining breast tissue will atrophy to a considerable degree so I tend to leave my reductions on the more full side.  In addition to that, they end up looking better.

Dear commelesfrancaises,
Plastic surgeons avoid radical breast reduction due to high chance of nipple necrosis in such cases. 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

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. This amount tends to rise with the distance the nipple must travel from where it is to its planned destination. 
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, it is difficult to predict the size of safe reduction. However, as stated above, there will be limits based on anatomy. With a very large pre-op cup size (D) it is often unrealistic to expect a significantly smaller cup (A) post op. I generally recommend that very large patients temper their expectations along these lines.
It is also important to remember that we deal in weight and volume (which are standardized) whereas "cup size" goals can be extremely variable (depending upon the manufacturer). There is no correlation between cup and grams resected. Much like in augmentation focus not on the cup but on the look and resolution of symptoms.
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
 

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. 
My best advice:  seek consultation with board-certified plastic surgeons who can demonstrate significant experience achieving the types of outcomes you will be pleased with. This careful selection of plastic surgeon will be the most important decision you make.
Before undergoing the breast reduction procedure 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.  I suggest that you do not communicate your goals in terms of achieving a specific cup size. For example, a “A 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 goal photographs.
 
I hope this helps.  Best wishes.

Hello and thank you for your question .  I find that women who go drastically smaller from original size, end up regretting it.  They understandably are tired of having large breasts and want the other extreme , however, they end up looking disproportionately smaller.  You still can ultimately still have smaller breasts if that's what you choose.  

Thanks for writing,The limitations of this operation are the need to keep the nipple and some central breast tissue (which is attached to the nipple) alive. That being said, The breast can be made quite small based on what volume you are starting with. J'espere que ca aide, bonne chanceStephen M. Davis, MD, FACS
Certified: American Board of Plastic Surgery
Member: American Society for Aesthetic Plastic Surgery
Member: American Society of Plastic Surgery
Member: RealSelf Hall of Fame
VERIFIED: Plastic Surgery

It seems like a simple answer, but actually, the reason most breast reductions do not go down to an 'A' cup is due to the breast tissue and anatomy.  The nipple and areola must maintain a proper blood supply, so the surgeon must excise only enough tissue around the nipple and areola (called a pedicle) to preserve it.  This 'pedicle' with the intact blood supply is usually moderately wide and thick which stops us from going down to an 'A' cup.Dr T