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BACKGROUND Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG). OBJECTIVES We compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty using EP vs. FNG. METHODS A multi-institutional, retrospective study of adult patients with gigantomastia undergoing reduction mammoplasty at two tertiary care centers from 2017-2020 was performed. Gigantomastia was defined as reduction weight >1500 grams per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at one institution used EP technique, while those at the other used FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes. RESULTS Fifty-two patients met inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, p < 0.05), but there were no other differences in surgical or medical complications. There were no differences in baseline BREAST-Q scores between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (p < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (p < 0.05), independent of institution or surgical experience. CONCLUSIONS This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia.