Introduction
Breast reduction is one of the most common procedures performed by plastic surgeons in North America, South America, and Europe. It is the surgical treatment of macromastia, a condition that comprises the presence of enlarged and heavy breasts.
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 Procedure
Diverse 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 United States, although current trends show surgeons favoring other methods that have been designed with the purpose of leaving a less extensive scar. In South America and Europe, such methods have been very well developed over the years and represent the most common method of skin incision for breast reduction. Among these shorter-scars techniques, the mosque dome pattern of skin incision has gained the greatest acceptance. It eliminates the lower curvilinear scar seen with the use of the Wise pattern, leaving only a periareolar scar and a vertical scar along the midline of the lower hemisphere of the breast. For this reason, the technique has been called vertical scar, and breast reductions using this pattern of skin incision are denominated vertical reduction mammaplasties.
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 South America. It was thought to put at risk the sensation of the nipple-areola complex because of the belief that it transected the lateral branches of the fourth intercostal nerve. The sensory branches to the nipple-areola complex are now known to run deep at the level of the chest wall and perforate superficially through the breast parenchyma to reach to nipple areola complex. For this reason, keeping parenchymatous resections just above the level of the chest wall preserves the nerve supply to the nipple-areola complex and, thus, its sensation.
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 South America toward performing superior pedicle techniques of breast reduction more often than in the past. This is the pattern of parenchymatous excision used in the Lejour technique. Its advantages are that it preserves the area that is less prone to undergo further ptosis secondary to downward pulling action of gravity, as well as maintaining fullness in the upper pole of the breast while allowing for small, medium, and large resections.
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.
Presentation
Patients 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.
Indications
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 Anatomy
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.
Contraindications
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.
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References
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Miller BJ, Morris SF, Sigurdson LL, Bendor-Samuel RL, Brennan M, Davis G, et al. Prospective study of outcomes after reduction mammaplasty. Plast Reconstr Surg. Apr 2005;115(4):1025-31; discussion 1032-3. [Medline].
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Further Reading
Keywords
breast reduction lejour, Lejour reduction mammaplasty, vertical reduction mammaplasty, short scar breast reduction, Lejour vertical reduction technique, Lassus reduction, mammoplasty, mammaplasty
