Breast reduction is a common procedure performed by plastic surgeons for functional or cosmetic improvement of the breast. However, final outcome can be less satisfactory to patients in terms of the size, shape, symmetry, scarring, or wound healing complications. However, good to excellent outcome after breast reduction can be accomplished by plastic surgeons once they have mastered their technique. The medial pedicle vertical breast reduction has been popularized recently. However, the technique is technically more complex, and the results have been less inconsistent with a learning curve. In addition, the technique has been criticized for a residual deformity in the lower pole of the breast and resulted in a high revision rate. In this article, key components for the medial pedicle vertical breast reduction including patient selection and technical refinements are discussed in details. The author describes his philosophy in patient selection, preoperative and intraoperative markings of the breast, and step-by-step surgical procedures with several technical refinements for the medical pedicle vertical breast reduction. In addition, the pearls for achieving an optimal outcome of such a breast reduction are also discussed.