SUMMARY          

Assessment of Lassus-lejour technique of breast reduction was done on fifty patients. Results show that inferior dog ear settles well in younger patients, not so in older group. Some dog ears need correction . Also there is scar tenderness and nipple inversion in certain cases which need secondary surgery. In breasts of older people due to laxity of the dermal envelope the settlement of position of the nipple in relation to breast is different. The author also discusses his experience with certain technical manoeuvres.

INTRODUCTION         

The concept of beauty has changed over ages and with culture. And with change of the aspirations towards better aesthetics,  fashions of performing breast surgery has changed. The aim has been towards giving better shape in relation to age as also better scars. The modern trend has been towards minimising scars.

All previous operations as Duformentel, McKissock, Strombeck,Robbins etc. no matter what pedicle they used to supply the nipple ended in inverted T-shaped scar. Mooley however aimed at an oblique single scar  and this proved useful in small reductions.

This was modified to an L-scar technique by Rudolf Myer. Daniel Marchac aimed at reducing the length of horizontal infra mammary scar at the cost of increasing the nipple-areolar circumference.

Lassaus proposed of vertical scar technique in 1987, however the presence of dog-ear initially  seemed to put surgeons off. Lejour combined the techniques of Lassaus  and Marchac to introduce again the vertical scar reduction.

With the advent of evidence that nipple areolar complex is supported and vascularized by central core and blood vessels enter posteriorly (Levet) new techniques of periareolar reduction came about (Carlos). Further modifications combining Marchac and Lejour technique with peri-areolar brought together Benelli's technique.

The modern concept of breast reduction , it is generally agreed that the breast and skin envelope are two different entities and should be handled in their own way.

The author has  tried to critically analyse the Lejour technique of breast reduction of some cases he performed in a span of four years.

MATERIAL

Pre-operative marking were made in the usual way. Midline of the chest, i.e. line from sternal notch to xiphisternum was marked. A point of 11cm from the midline which roughly corresponds to vertical breast axis was marked at the level of infra mammary crease. A point is marked 3-4cm above this point which is roughly the new position of infra mammary fold. On the line of axis of breast a point ranging from 20 to 24cm  was marked from sternal notch and mid-clavicular point , the position of future nipple. A point 9cm from midline at the horizontal level of nipple  is marked to give medial border of the nipple.

Free hand drawing of glandular shape of nipple is drawn with circumference of 14cm , so that each of limbs is 3.5cm and an inferior gap of 6cm for superior dermal pedicle.

Two vertical lines were then marked by displacing/rotating the breast upwards and medially for lateral line and upwards and laterally for medial line. These lines were made to meet superiorly at the inferior points  of  the two ends of the nipple marking and inferiorly at the new infra mammary crease point . Personally I prefer to shape it like an "U" at the inferior portion rather than a "V" , as  it gets rid of excess skin and thereby reduces the dog ear further.

The superior pedicle was marked in usual way. Finally two points on these lines 5cm from inferior point of the nipple is marked denoting the extent of the lateral pillars. I routinely stick to pre-operative markings and never change it throughout operation as any alteration will cause discrepancy in nipple height when dog ear settles.

OPERATIVE TECHNIQUE

The operative technique is similar to Lejour description. All operations were carried out under general anaesthesia with patient at 450 angle with arms abducted on a arm board.

If liposuction is available and breast is reasonably fatty I carry out wet liposuction with tulip canulas. This reduces the blood loss and also helps carving of the breast later. Particular emphasis is taken on axillary tail side and upper quadrants. The central quadrant and superior central part is particularly important especially for big breasts as it will allow the long pedicle of nipple-areolar complex to fold in more easily. However care is taken not to overdo it as this made result in inverted nipple or depressed  nipple if nipple base support is considerably gone.

After de-epithelising the superior pedicle, I usually start at inferior point and start dissecting to the pectoral fascia. The whole breast is lifted on a breast augmentation plane upto the clavicle.

Now I start the dissection with knife or scissors under the skin separating the breast from skin at the lateral triangles upto the inferior point of the pillars.

Incision is made vertically through breast tissue right to the pectoral fascia at region of two pillars  of 5cm length.

Now the lateral breast triangles and central breast is excised holding the whole breast tissue between palm and fingers. The main detachment is from superior part inferior to the nipple-areolar complex.

The de-epithelized superior pedicle is elevated from breast tissue below keeping a thickness of 1-3cm. Now the central breast tissue is reduced depending upon lateral breast pillar support and final volume desired. Care must be taken not to overdo this as loss of this posterior support can cause sinking of nipple-areola.

Hitching up the nipple-areolar complex is a matter of opinion. My general feeling would be not to do it as it can cause undue problems with areolar sinkage in superior pole especially  with long pedicles, rather leaving it to settle where the dermal/breast envelope settles.

The nipple areolar complex is folded and stitched back to new position .The breast pillars are stitched  with 2/0 Vikryl. The continuous intradermal running horizontal mattress stitch taking the inferior pole of breast tissue demarcates clearly the infra-mammary fold and reduces the vertical scar length. Skin can be closed with Prolene or PDS as preferred.

Infra-mammary padding and strapping followed by a bra after 24 -48 hours are done as a routine. Drains were used in all cases.

CLINICAL EVALUATION

RESULTS

Clinical evaluation was carried out on 41 of the 50 patients of breast reduction/mastopexy by Lejour technique carried out by the author. Three other patients replied the questionnaire, but did not attend the interview. Rest 6 patients failed to reply or attend. So for all practical purposes assessment was based on 44 patients.

General Proforma

Clinical evaluation of all 50 cases of Lejour operations which include breast reduction and mastopexy were done by the author and a plastic surgical colleague..

Each of the operated patients was sent a questionnaire. This was filled in by:

 Patient  

It included their views on

1.  Breasts: Equality, shape, size, drop of the breasts. Bra cup  size before and after operation was noted. 

2.  Scar: Pain, thickening and visibility

3.  Position of nipple

4.  Aesthetic contour of nipple areola

5.  Complications: Pain, Wound infection, healing problems etc.

6.  Dog Ear

7.  Fat bulges

8.  Whether they wanted secondary surgery

9.  Nipple sensation

10.Overall satisfaction

11.Indications for surgery

Author and a colleague of his:

Separately assessed each patient with regard to:

1.  Breasts: Equality, shape, size, drop of the breasts. Bra cup  size before and after operation was noted. 

2.  Scar:  Thickening and visibility

3.  Position of nipple

4.  Aesthetic contour of nipple areola

5.  Complications: Pain, Wound infection, healing problems etc.

6.  Dog Ear

7.  Fat bulges

8.  Whether they needed secondary surgery

9.  Nipple sensation

10.Overall satisfaction of the authors

In addition the age of patient and amount of breast tissue removed as well as pre-operative nipple areolar drop from sternal notch was noted.

Indications for surgery

1. Cosmetically large breasts
2. Droopy Breasts
3. Unequal breasts
4. Self-confidence
5. Shoulder Pain

Table 1: Showing indication for breast reduction

Breasts:

The results were based on 44 patients studied (Author and colleague assessed 41 patients, 44 patients replied to questionnaire) :

Table 2: Assessment of  Results of Breast Reduction

STATISTICS

Table 3: Demographic Origin of Patients

Table 4: Age Groups of Patients

Table 5: Overall Statistics

SECONDARY SURGERY  &COMPLICATIONS

Table 6: Secondary Surgery

Table 7: Types of Secondary Surgery

DISCUSSION

As you would see from the findings that Lejour technique is suitable for young girls with mild to moderate breasts. Because of more elasticity of skin the dog ears settle well. Also this would suit those group of patients where vertical movement of the nipples is not significant. However in ladies who are old, elasticity of the skin is less and as such dog ears do not settle. Also where the vertical movement of the nipples is more there is more lax skin to cope inferiorly and in these patients dog ears do not settle.

Liposuction by tulips helps surgery.             

However I do not agree with Lejour on the idea of applying the hitching stitch to pectoral fascia. Not only is an absorbable suture not permanent, but also hitching the breast with a stitch does not give it the tensile strength to hold, in addition can cause  fat necrosis. In addition it definitely contributes to inversion of nipple in long pedicles.          

I feel a U-shaped excision of skin instead of traditional V reduces more of the redundant skin and helps  the dog ears to settle more.            

The disadvantage of the technique is though the dog ear of the skin envelope does settle. However it does not provide the adequate dermal support to maintain the elevation of the breast in long term follow-up. With time  the whole breast migrates inferiorly resulting in the nipple occupying a more superior position in relation to breast mount which migrates inferior to the nipple.. As I have mentioned dermal envelope of the skin is of primary importance in achieving good results. The more heavy the breasts are, the more lax the skin is the more likely distortion of shape in the long . Once that gives way by settling of the dog ears in addition to discrepancy of nipple height the posterior support of nipple-areolar complex was lost which results in the inversion of nipple, .In addition it causes vertical  scar contracture. . Fat necrosis is the most dreaded complication and in one patient this occurred when this breast was operated by a colleague of mine. I do not think the Lejour technique is to blame in this case rather keeping the pedicle too thick (may be the hitching stitch on the breast), resulted in the disaster.

Overall as it is evident from this study Lejour technique of breast reduction is successful in selected patients especially young girls with less sternal notch to nipple distance. I do not think patients above 40 years should have this operation as laxity of the dermal envelope makes the results unpredictable. In older patients where scars settle better than younger people I see no reason why scars in general from inverted T-technique should be less acceptable than vertical scar mammoplasty with its potential problems highlighted.

Moreover in private practice revision surgery on patients causes financial problems. And this should also be taken into account.

                 
ACKNOWLEDGEMENTS

I am grateful to Mr.Malcolm Deane,  Mr.Lance Sully and Miss.F.B.Bailie to allow us to use their patients which I operated on  for my study.

I shall be failing in my duty if I do not thank my colleague Dr.Augustus Cabre L.M.(Barcelona) who took all the pains of assessing these patients with me.

REFERENCES

1.Douformentel c, Mouly R. Mammoplasty by the oblique technique.Ann Chir Plast 1961;6:45-48

2.Georgiade NG, Serafin D,Reikohl E, Georgiade GS.Is there a reduction mammoplasty for "All seasons?" Plast Reconstr Surg 1979;63:765-73

3.Mckissock PK. reduction mammoplasty with a vertical dermal flap.Plastic and Reconstructive Surgery 1972;49:245-52    

4.Pitanguy I.Surgical treatment of breast hypertrophy.Br J Plast Surg 1967;20:78-85

5.Skoog T.A technique of breast reduction; transposition of the nipple on a cutaneous vascular pedicle.Act Chir Scand 1963;126:453-65

6.Strombeck JO.Mammaplasty: report of new technique based on the two pedicle procedure.Br J Plast Surg 1960;13:79-90

7.Wise RJ.A preliminary report on method of planning the mammoplasty.Plasr Reconstrr Surg 1956;17: 367-75

8. Lejour M. Vertical Reduction Mammoplasty and Liposuction (Book and Video)

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