Background <p>Macromastia, particularly in its severe form—gigantomastia—is characterized by excessive mammary tissue growth and significantly impairs quality of life through physical symptoms, psychological distress and functional limitations. Reduction mammaplasty remains the standard of care, aiming to relieve symptoms while preserving breast function and aesthetics. Several surgical techniques based on vascular pedicles have been developed, including the superomedial and inferior pedicle approaches. However, few studies have compared these techniques in patients requiring large-volume resections.</p> Methods <p>We conducted a systematic review and meta-analysis comparing the inferior and superomedial pedicle techniques in patients with gigantomastia, defined as a resection volume ≥&#xa0;800 grams per breast. Multiple databases were searched for studies published from 2010 onward. Statistical analyses were performed using Review Manager 5.4.1, applying a random-effects model. Primary outcomes included postoperative complications, aesthetic results, and quality of life indicators. Ninety-five percent confidence intervals were calculated using the Mantel–Haenszel method. Heterogeneity was assessed using the I² statistic, and risk of bias in non-randomized studies was evaluated with the Newcastle–Ottawa Scale.</p> Results <p>Eight comparative studies were included. No statistically significant differences were found in the primary outcomes. However, trends favored the superomedial pedicle in most metrics, including overall complication rate, NAC necrosis and NAC sensitivity.</p> Conclusions <p>Both techniques appear to be safe and effective options for patients with severe macromastia. The superomedial pedicle may offer certain advantages in specific outcomes, but current comparative evidence remains limited. Further randomized controlled trials are needed to better inform surgical decision-making in this population.</p> Level of Evidence III <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors &#xa0;<a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>