Lejour Breast Reduction 

Updated: Feb 23, 2016
Author: Antonio Espinosa-de-los-Monteros, MD; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

Breast reduction is one of the most common procedures performed by plastic surgeons in North America, South America, and Europe.[1] Breast reduction is the surgical treatment of macromastia, a condition that is defined by the presence of enlarged and heavy breasts.

The weight and size of the breast can be reduced using various surgical techniques. Two main technical aspects have to be considered when detailing surgical options for reduction mammaplasty. One aspect is the pattern of the skin incision/excision used to gain access to the breast parenchyma to be removed. These skin incisions, and the skin area that is to be excised, ultimately describe the location and length of the final scars. The second aspect to be considered is the area/pedicle of breast parenchyma to be left in the patient after the glandular excision is complete. The pedicle selected by the surgeon will have a discrete vascular and nerve supply and is very important in determining final breast shape, since each pedicle technique has known and differing strengths and weaknesses. See the images below.

Preoperative view, Lejour reduction mammaplasty. Preoperative view, Lejour reduction mammaplasty.
Postoperative view, 400-g Lejour reduction perform Postoperative view, 400-g Lejour reduction performed by Dr Glynn Bolitho, San Diego, Calif.

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.[2] 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.[3] 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 purposes of shortening and hiding the 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 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.[4] Lassus corrected this by adding a small horizontal scar along the inframammary fold.[5] 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.[6] This is the skin incision that is used in the technique described by Lejour.

The advantages of this pattern of skin incision are that it leaves no scar along the inframammary fold and it reduces the risk of skin edge necrosis at the inferior aspect of the closure, where tension is greatest and skin flap vascular inflow occurs over the longest distance from its source. (Skin edge necrosis was a particular risk at the junction of the inverted T incision of the Wise pattern technique).

With regard to the pattern of glandular resection, the different techniques used in breast reduction are identified by the segment of the breast that is left unresected, which becomes the structure and support of the new breast. This "pedicle" also contains the vascular supply that will nourish the breast mound, including the nipple-areola complex. Various techniques include superior, superomedial, medial, inferior, lateral and central pedicles. Bipedicle techniques, which include either superior and inferior or lateral and medial aspects of the breast, are also used.

For information on other breast reduction techniques, see Medscape Reference articles Central Pedicle Breast Reduction, Inferior Pedicle Breast Reduction, Moufarrège Total Posterior Pedicle Breast Reduction, Simplified Vertical Breast Reduction, Superior Pedicle Breast Reduction, and Vertical Bipedicle Breast Reduction.

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.[7] 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.[8] This is the pattern of resection 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.[9] Later, she updated her experience on 324 reductions performed in 167 patients.[10] 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. It can be performed in patients who require small or large reductions, even in patients who have gigantomastia (excess of breast tissue of more than 1000 g per side).[11]

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.

Breast shape varies among patients, but knowing and understanding the anatomy of the breast ensures safe surgical planning. For more information about the relevant anatomy, see Breast Anatomy.

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.

 

Workup

Laboratory Studies

See the list below:

  • Standard preoperative laboratory studies are performed based on age and concomitant morbidities.

Imaging Studies

See the list below:

  • Preoperative mammogram is recommended for patients aged 40 years and older to screen for masses and calcifications that may require further evaluation.

 

Treatment

Medical Therapy

Some of the symptoms related to macromastia may show some improvement with analgesics, but definitive treatment of macromastia is entirely surgical.

Surgical Therapy

The Lejour technique involves a vertical reduction based on a superior pedicle and includes breast liposuction and wide lower skin undermining.

Preoperative Details

Before 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. See the image below.

Preoperative markings that demonstrate superior pe Preoperative markings that demonstrate superior periareolar pedicle and inferior skin/parenchymal resection margins.

Intraoperative Details

After 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. (In a meta-analysis based on three randomized, controlled trials, Shortt et al found that wound infections were reduced by 75% when preoperative antibiotics were used before breast reduction surgery.[12] )

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.[13, 14, 15] See the image below.

Demonstration of partial inset of superior pedicle Demonstration of partial inset of superior pedicle and development of breast mound from medial and lateral pillars.

Next, the nipple-areola complex is inset, the parenchymatous pillars are approximated, and the skin is closed. The original technique does not result in horizontal scars, but some newer modifications include the use of small horizontal scars along the inframammary fold in order to avoid redundant skin, particularly in larger breasts.[16] See the image below.

Immediate postoperative appearance, demonstrating Immediate postoperative appearance, demonstrating exaggerated upper pole fullness, downward pointing nipple, and bunched skin on the lower pole of the breast.

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.[17]  Evidence, albeit limited, from a literature review by Khan et al not only indicated that wound drainage after reduction mammoplasty provides no significant benefit but also that it may lead to a significantly longer hospital stay.[18]

Postoperative Details

Dressings 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. This can be maintained for 3 months.

Follow-up

Regular 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.

Complications

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.[9] 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.[10]

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.[19, 20] 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. Decreased sensitivity is seen in 10% of patients, while total loss of sensitivity occurs in 1%.[11]

Outcome and Prognosis

Breast reduction is a successful method for treatment of macromastia.[21] Patients experience an improvement in physical symptoms and health-related quality of life after surgery.[22, 23] Their emotional status tends to improve over time, as less depression and anxiety are evident after surgery.[24] Their ability to perform physical activities also improves. Breastfeeding does not become hampered.[25] Patients with gigantomastia (resections >1000 g per side) tend to reduce an average of 3 cup sizes.[26] For these reasons, reduction mammaplasty has become a safe and effective technique for treatment of macromastia.[27] See the images below.

Preoperative view, Lejour reduction mammaplasty. Preoperative view, Lejour reduction mammaplasty.
Preoperative view, lateral, Lejour reduction mamma Preoperative view, lateral, Lejour reduction mammaplasty.
Postoperative view, 400-g Lejour reduction perform Postoperative view, 400-g Lejour reduction performed by Dr Glynn Bolitho, San Diego, Calif.
Postoperative view, lateral, Lejour reduction mamm Postoperative view, lateral, Lejour reduction mammaplasty.