You are in: eMedicine Specialties > Plastic Surgery > BREAST Breast Reduction, LejourArticle Last Updated: Aug 21, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Antonio Espinosa-de-los-Monteros, MD, Staff Physician, Department of Surgery, Division of Plastic Surgery, University of Alabama, Birmingham Coauthor(s): Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics; James F Thornton, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Southwestern Editors: Geoffrey L Robb, MD, Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: breast reduction lejour, Lejour reduction mammaplasty, vertical reduction mammaplasty, short scar breast reduction, Lejour vertical reduction technique, Lassus reduction, mammoplasty, mammaplasty INTRODUCTIONSection 2 of 11
  Breast reduction is one of the most common procedures performed by plastic surgeons in North America, South America, and The weight and size of breasts can be reduced by using various surgical techniques. Two main technical aspects have to be considered when detailing surgical options for reduction mammaplasty. The first one is the pattern in which to incise the skin in order to gain access to the breast parenchyma that will be removed. These skin incisions, and the skin area that is to be excised, ultimately define the location and extent of the final scars. The second aspect to be considered is the segment of breast parenchyma to be left in the patient after the glandular excision is performed. This defines the vascular and nerve supply to the remaining breast (parenchyma, draping skin, and nipple-areola complex), as well as its shape, since each area within the breast has different attributes. History of the ProcedureDiverse methods of skin incision and excision existed in the early reports of breast reduction. Some of them were improvised during the surgery, others were planned based on empiric knowledge, and a few followed complicated geometric calculations. In 1956, Robert Wise published on his experience with a refined pattern that he had previously designed in the form of a key-hole. The Wise pattern has been the workhorse for skin incision for breast reduction for several decades. It leaves an anchor-shaped scar in a periareolar circle, a vertical scar in the midline of the inferior mammary hemisphere, and a curvilinear scar along the inframammary fold that follows the curved shape of the inferior pole of the breast. In 1972, Paul McKissock modified Wise's technique by increasing the length of the vertical limbs of the design to try to compensate for the flat lower pole that was being achieved. It is now recognized that McKissock's technique tends to result in the opposite effect, which is a bottoming-out and is not very well tolerated by patients and surgeons. To date, the Wise pattern remains the most common method of skin excision performed in the The vertical scar incision pattern was originally designed by Claude Lassus in 1964 and reported in 1970, with the particularity that the inferior portion of the vertical scar ended up extending below the inframammary fold. Lassus corrected this by adding a small horizontal scar along the inframammary fold. Later on, he realized that the small horizontal scar ended up migrating up toward the lower hemisphere of the breast. He subsequently redefined his pattern of skin excision until achieving one that left only a vertical scar above the inframammary fold. This is the skin incision that is used in the so-called Lejour technique. The advantages of this type of skin incision are that it does not leave a scar along the inframammary fold and that it leaves no risk of skin edge necrosis at the inferior pole of the breast. (Skin edge necrosis was a risk in the junction of the inverted T incision of the Wise pattern technique). With regard to the pattern of glandular resection, the different techniques performed in breast reduction are denominated by the segment of the breast where the parenchyma is left unresected, which becomes the structure and support of the new breast. This area also contains the vascular pedicle that will supply the breast, including the nipple-areola complex. For these reasons, techniques are denominated superior, superomedial, medial, inferior, lateral, or central pedicles. Bipedicle techniques, which include either superior and inferior or lateral and medial aspects of the breast, are also used. Each technique has advantages and disadvantages. The superior pedicle method (which involves the resection of the medial, lateral, and inferior portions of the breast parenchyma) was originally described by Daniel Weiner in 1973. Initially, it gained more popularity in Europe than in North and Another reason for which this method of parenchyma resection was not widely approved was the thinking that the vascular pedicle may get kinked or compressed while folding the dermoglandular portion of the breast over to inset the areola up on its new location. Currently, good evidence exists supporting the knowledge that the breast is adequately supplied by the superior dermoglandular pedicle that results as a consequence of this pattern of parenchyma resection. For this reason, trends exist in North America and In 1994, Madeleine Lejour reported on 153 reduction mammaplasties using this technique in 79 patients. Later, she updated her experience on 324 reductions performed in 167 patients. Several studies on the use of this technique have been published since. ClinicalPatients with macromastia present to the clinic with enlarged breasts that tend to be ptotic and that cause chest, neck, back and shoulder pain; difficulty performing deep inspirations; and the inability to fit into proper clothing. Patients may show shoulder indentations from the brassiere and inframammary intertrigo. A complete medical history has to be obtained, including age, information on childbearing and breastfeeding, future pregnancy and nursing plans, smoking history, concomitant diseases, history of breast diseases and surgery, family history of breast cancer, medication allergies, and tendency to bleed. Physical examination should focus on body mass index, vital signs, breast masses, inframammary intertrigo, degree of breast enlargement and ptosis, skin lesions, and nipple sensation and discharge. INDICATIONSSection 3 of 11
Reduction mammaplasty is the surgical treatment of macromastia, a condition in which heavy and enlarged breasts may cause chest, neck, back and shoulder pain; inframammary intertrigo; difficulty performing deep inspirations; and the inability to fit into proper clothing. Multiple breast reduction techniques exist. The Lejour technique consists of a vertical reduction based on a superior pedicle and includes breast liposuction and wide lower skin undermining. RELEVANT ANATOMYSection 4 of 11
The breast has an abundant blood supply that consists of perforators from the internal mammary artery (medially and inferiorly), branches from the thoracoacromial and thoracodorsal arteries (superiorly), and branches from the lateral thoracic artery and intercostal perforators (laterally). Also, multiple dermal and subdermal plexus are present, with a rich periareolar plexus. The sensory nerve supply to the breast comes from lateral and anterior cutaneous branches of the second through sixth intercostal nerves. The nipple is supplied primarily by the fourth intercostal nerve, with contributions from the lateral third and fifth intercostal nerves and from the anterior second through fifth cutaneous nerves. CONTRAINDICATIONSSection 5 of 11
Contraindications for reduction mammaplasty include current or recent lactation, presence of unevaluated breast masses or suspicious microcalcifications, increased surgical risk from systemic illnesses, inability to understand the limitations of the procedure, and inability to accept the possible complications of the procedure. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
TREATMENTSection 7 of 11
Medical TherapySome of the symptoms related to macromastia may show some improvement with analgesics, but definitive treatment of macromastia is entirely surgical. Surgical TherapyThe Lejour technique involves a vertical reduction based on a superior pedicle and includes breast liposuction and wide lower skin undermining. Preoperative DetailsBefore the surgery, pictures are taken in different views. The sternal notch–to-nipple distances and the nipple-to–inframammary fold distances are recorded and documented properly. Patients are instructed on the purposes of the procedure, the goals that may be achieved, the expected final size and shape of the breasts, the expected final appearance of the scars, changes in nipple sensations, changes in the ability to breastfeed, and possible complications. Patients are instructed on what to expect during their recovery period and on proper wound care. While the patient is standing, the technique begins by marking the patient with the mosque dome pattern of skin incision and the area that represents the superior dermoglandular pedicle. Markings are placed in the breast midline, the inframammary fold, and the vertical axis of the breast beneath the inframammary fold. The upper edge of the future areola is marked slightly below the level of the inframammary fold, and a semi-circumference no larger than 16 cm is marked. By displacing the breast medially and laterally in relation to its vertical axis, the peripheral limbs are marked, joining together no less than 5 cm above the inframammary fold. The future areolar circumference is marked around the nipple. A minimum of 10 cm of superior pedicle width is marked at the upper border of the future areola and continued in a conical shape down around the marked circumference. Intraoperative DetailsAfter markings are done, patients are placed symmetrically on the operating room table with arms abducted and secured to allow intraoperative placement in a semisitting position. Draping is also performed symmetrically to provide an accurate assessment of postoperative breast symmetry. A dose of prophylactic antibiotic is administered. The breasts are injected with lidocaine and epinephrine, the pedicle epidermis that surrounds the areola is excised, and fat from the breast tissue is suctioned. Next, the medial, lower, and lateral segments of the breast are resected, with undermining of the skin below the lower curved marking. Resected tissue is sent for histopathology inspection, since subclinical foci of cancer can be found in 0.1-0.9% of the specimens. Next, the nipple-areola complex is inset, the parenchymatous pillars are approximated, and the skin is closed. Current evidence suggests that drains can be avoided, since the incidence of collections and wound healing events are the same with or without their use. Postoperative DetailsDressings may vary with surgeon preference and include adhesive strips of tape, liquid skin adhesive, gauzes, pads, tape, and supporting brassieres. Patients are told to ambulate and resume light diet the same day of the surgery. They can shower the day after the surgery but should avoid strenuous physical activity and should wear a sports brassiere. Follow-upRegular visits are scheduled to ensure an adequate outcome and provide early identification and proper care of possible complications. The wrinkles at the bottom of the vertical scar usually fade away in 1-6 months, although some surgical revision of this area might be required. COMPLICATIONSSection 8 of 11
In the original report from Lejour, 153 reduction mammaplasties were performed in 79 patients, with an average liposuction of 300 mL per breast and an average resection of 480 grams per breast with very satisfactory results. Postoperative complications in the form of seroma, wound dehiscence, hematoma, and partial areolar necrosis were seen in 10% of breasts. Lejour later updated her experience on 324 reductions performed in 167 patients, with this complication seen in 7% of breasts. Several studies on the use of this technique have been published since. In general, postoperative complications are seen more commonly in patients with large resections, obesity, history of tobacco use, and young age. Some evidence suggests that wound dehiscence, epidermolysis, fat necrosis, and infection are less common in patients who undergo the Lejour technique than in those who undergo the Wise pattern and inferior pedicle techniques. However, some asymmetry, particularly along the bottom edge, tends to be more common in patients who undergo the Lejour technique; revision rates can be up to 10%. Liposuctioning of the breast has not been shown to increase the rate of local complications. OUTCOME AND PROGNOSISSection 9 of 11
Breast reduction is a successful method for treatment of macromastia. Patients experience an improvement in physical symptoms and health-related quality of life after surgery. Their emotional status tends to improve over time, as less depression and anxiety are evident after surgery. Their ability to perform physical activities also improves. For these reasons, reduction mammaplasty has become a safe and effective technique for treatment of macromastia. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Breast Reduction, Lejour excerpt Article Last Updated: Aug 21, 2007 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
