Lejour Breast Reduction Treatment & Management

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

Medical Therapy

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

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Surgical Therapy

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

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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.
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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]

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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.

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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.

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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]

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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.
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