Before entering the operating room, the surgeon will ask you to sit upright and draw surgical markings. These markings will outline the location for the incisions later during surgery. The drawings typically take the form of an anchor — encircling the areola and extending above the areola to the new location of the nipple. The markings also extend down vertically below the nipple and horizontally following the natural curve of the crease beneath your breast.
An incision is made along the surgical markings. Flaps are created on either side of the breast and the excess skin, fat, and glandular tissues are removed. In most cases, the nipples are moved higher up on the breast, but remain attached to the nerves and blood vessels. In some instances, where the breasts are particularly heavy, the nipples may need to be grafted to a new location. In such cases, the nipples are separated from the underlying tissues and you will lose sensation in the nipple and areola.
After surgery, the flaps of skin are re-attached around and beneath the breast, then pulled to the front of the breast and sutured in place around the nipple. The reduction of breast tissue reduces the weight of the breast and the restructuring of the skin reshapes it.
When the procedure is finished, there are stitches around the areola and nipple area, in a vertical line extending from the nipple, and horizontally under the breast. Some surgical techniques can avoid the horizontal scar altogether. Occasionally, liposuction alone can be used to reduce breast size when only fat needs to be removed, leaving minimal scars.