Modifications to the Lejour mastopexy allow treatment of a wide variety of breast problems
In the early 1990s, Madeleine Lejour, MD, PhD, of Belgium, described a technique for mastopexy and reduction mammaplasty that was based on the Lassus mammaplasty of the 1960s.1 The technique is characterized by:
a superior pedicle;
a short vertical scar that does not extend below the inframammary fold;
freehand preoperative markings; and
a reliance on sculpting the breast parenchyma rather than the skin envelope to control the final breast shape.
Since that time, numerous modifications have been described,2–4 and Lejour has published reviews of her technique.5,6 Proponents of the technique point to the more natural-appearing breast shape and improved scar quality compared to the more common inferior pedicle and Wise-pattern techniques.
However, certain difficulties are peculiar to the operation. They include the time needed to master the freehand markings, the difficulty of insetting the superiorly based pedicle in certain circumstances, and a limit to the amount of breast tissue that can be removed. Despite these drawbacks, my comfort level with the procedure has increased since I began using it as a mainstay for breast reduction, breast lift, and augmentation mastopexy in 2001.
I have also found it to be an extremely flexible procedure that is capable of treating a wide variety of breast problems. I will describe modifications of the original technique that may be useful for surgeons who currently use it. I will also describe some extended applications of the technique, such as its use with implants and on very long breasts.
Insetting the Pedicle
The problem of tension on the superior pedicle can make insetting the nipple–areolar complex (NARC) difficult. Tension can deform the nipple into a triangular shape, contribute to widened scarring at the superior portion of the areolar closure, and cause the nipple to assume an eccentric position within the areola. This problem is most pronounced in the mastopexy technique during fixation of the central pedicle to the pectoralis fascia.
This problem may also be encountered when the NARC needs to be elevated more than 5 cm, or if the areola is to be significantly downsized. I have found several quite helpful steps for alleviating these problems.
The NARC and pedicle can be pre-inset with a staple at the 12 o’clock position before reflecting the medial pedicle of tissue beneath the breast, and before suturing the medial and lateral pillars. This maneuver is simple, safe, and reversible. It is particularly helpful when an implant or sizer is being used in an augmentation–mastopexy.
If that maneuver is not entirely successful, then the dermal component of the pedicle inferior to the NARC can be divided. I avoid dividing any breast parenchyma during this maneuver. After inset, if there is still significant tension, the lateral aspects of the dermis can be further incised superiorly up the vertical skin closure.
The last two steps require the surgeon’s judgment as to how tissue viability will be affected. After inset, the areola can be undermined by a few millimeters to help a deformed nipple “sit” in place. Retruing the dermis of the breast skin to a perfect circle using a “cookie cutter” may be needed after this maneuver.
Aligning for Resection and Plication
The dimensions and volume of resection during all mammaplasty techniques are important because the operation must be repeated in a symmetrical manner on the other side. During removal of breast parenchyma, especially from a fatty breast, it is easy to stray off a true line of resection. I wanted to find a way to help standardize both the resection and the resuspension of the tissue.
Before resecting the central component of tissue, I place a 0 polyglactin suture in the parenchyma just below the 6 o’clock position of the nipple and make the appropriate markings (Figure 1). The assistant holds this suture with a hemostat during resection and also during suturing of the medial and lateral pillars. This simple step greatly aids the symmetric removal of tissue and nicely aligns the pillars of tissue for plication. This suture also holds the breast in the desired conical shape.
Lejour with an Implant
The Lejour technique is well-suited for use with an implant. Patients with postinvolutional changes, excess skin, and loss of upper-pole fullness are good candidates (Figure 2).
The first step in this procedure is to carefully assess the skin envelope and estimate the amount of skin resection that will be needed. The standard vertical markings may result in an unnecessarily tight closure, or worse. Therefore, I err on the conservative side when marking the vertical skin-resection lines.
The “neck” of the resection—the confluence of the vertical closure and the base of the NARC—is especially prone to tightness. The shape of the “mosque dome” that will form the new inset point of the NARC must, therefore, be made narrower. Making conservative markings and then using a tissue scissors on excess skin after implant placement and NARC inset spares the surgeon anxious moments upon closure.
Performing the mastopexy–augmentation technique requires the enlargement of the subglandular pocket to accommodate an implant. During this procedure, I am careful to preserve the medial pectoral perforating vessels.
I prefer gel implants because they assume the shape of the pocket more readily. A small gel implant in the 200-mL range is often all that is needed to provide upper-pole fullness.
Saline implants, however, are preferred in patients with asymmetry because of the many fill volumes and base diameters that are available. As with any augmentation–mastopexy, my preference is to use the smallest implant possible to fill the new skin envelope. I explain to patients that a heavier implant increases the risk of scar widening, recurrent ptosis, and healing problems.
The Lejour technique can also be used for very long breasts (Figure 3, page 32). Patients who do not require a large amount of central breast resection are good candidates. After de-epithelializing the pedicle and developing the medial and lateral skin flaps, I resect the necessary volume of tissue and inset the NARC. The pedicle on a very long breast will fold into an S shape, or it can be folded along its length.
After insetting the pedicle and NARC, I use staples to loosely close the vertical skin flaps and then check to be sure that the arterial and venous drainage of the NARC is adequate. A small T-shaped excision of tissue may be needed if a large fold of skin remains beneath the breast. I have found that defatting this skin will often result in good adherence and definition of the new inframammary fold. The remaining skin can easily be excised under local anesthesia after 3 months. I routinely use closed suction drains on breasts that have large amounts of excess skin.
Weight-loss patients, especially those who have undergone bariatric surgery, are being seen more commonly in plastic surgery practices, and they often seek correction of breast ptosis and loss of volume. The deformities seen in this group are often much more complex than those in non-weight-loss patients. The skin envelope is usually exceedingly relaxed, and the skin may be quite thin and atrophic. The presence of medialized and asymmetric nipples, and lateral axillary skin rolls, further complicate management (Figure 4, page 32).
The Lejour technique is well-suited to address these concerns due to the flexibility of the markings. The medialized nipples can be addressed by making the “mosque dome” markings for the new NARC position according to standard guidelines. (The suprasternal notch-to-nipple distance along the meridian of the breast should be about 20 cm, depending on the patient’s physique. The anterior projection of the inframammary fold can also be used.)
The vertical skin resection must then be tailored to include the existing NARC. The resection should end just above the inframammary fold at points equidistant from the midline. The resulting scar may be oriented diagonally, but it should still retain the characteristic “lollipop” configuration.
My preoperative disclosure for breast surgery in weight-loss patients is the same as for all body-contouring procedures in this group. I specifically inform them that the correction of their breast problems will not be complete, and that the chance for early recurrence of ptosis is higher. I explain that it may be necessary to perform these procedures in stages.
I have observed early recurrences of ptosis in weight-loss patients that I have corrected by re-excising an ellipse of vertical skin and then plicating the implant capsule externally without exposing the implant itself. This can often be done under local anesthesia.
Large Breasts and Liposuction
Using the Lejour or any other short-scar technique on very large breasts (more than 1000 g of tissue per side) is the most challenging application of the procedure for me. Resecting the larger tissue specimens can theoretically be done en bloc, although I usually do it in several stages.
Removing these large amounts of tissue also makes symmetry more difficult. After removing more than 700 g, I am almost always left with a significant amount of excess skin at the inferior pole that I choose to resect, resulting in a T-shaped closure. This procedure in no way undermines the other benefits of the superior pedicle technique. Younger patients with more elastic skin have a much higher chance of smoothing out this excess skin.
Whereas liposuction can be a valuable adjunct for removing fat from very large breasts, I have found that it is difficult to use in most younger patients who have a large parenchymal component of breast tissue. In my experience, using liposuction causes excessive trauma to the breast and contributes to postoperative edema. The presence of tumescent fluid within the breast also causes some distortion of the tissues and makes the use of electrocautery less efficient. For these reasons, I rarely incorporate liposuction into the procedure, and I never use ultrasonic liposuction on the breast.
Lejour-lift complications include hema-toma, skin loss, nipple–areolar necrosis, and se-roma. Minor se-quelae include delayed healing, poor scarring, breast asymmetry, and nipple–areolar irregularities. My incidences of major and minor complications are similar to those reported in the literature, but they are most closely tied to patient risk factors. Current or former smokers, individuals more than 40 years old, obese patients, and those with thin or atrophic skin have a higher rate of complications.
As with any breast surgery, patient selection is critical. I begin this process by assessing the skin envelope, parenchyma, and measurements to determine whether the patient is a candidate for a breast lift.
Most importantly, I show the patient numerous examples of postoperative results, along with the full spectrum of scarring. I try to match postoperative results and scarring to the patient’s breast morphology and skin type.
I provide a full written risk-disclosure sheet at the time of the initial consultation and meet with all patients a second time before surgery. I make sure that they understand that permanent scarring goes along with improved breast shape. The most satisfied patients are those who understand the likely outcome of the procedure and the possible complications, and are prepared for the gradual changes in breast shape before the final result.
Overall, I have found that the Lejour mammaplasty is a remarkably adaptable procedure that can treat a wide range of breast conditions. The challenges of the freehand marking technique, intraoperative decision-making, and time needed for the breast shape to evolve are, in my experience, worth overcoming to achieve the final results. PSP
John LoMonaco, MD, FACS, is board-certified in general and plastic surgery, and is a member of the American Society of Plastic Surgeons. His private practice in Houston focuses mainly on breast and body-contouring surgery. He can be reached at (713) 526-5550 or via his Web site, www.drlomonaco.com.
1. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg. 1994;94: 100–114.
2. Lejour M. Pedicle modification of the Lejour vertical scar reduction mammaplasty. Plast Reconstr Surg. 1998;101:1149–1150.
3. Van Thienen CE. Areolar vertical approach (AVA) mammaplasty: Lejour’s technique evolution. Clin Plast Surg. 2002;29:365–377.
4. Berthe JV, Massaut J, Greuse M, Coessens B, De Mey A. The vertical mammaplasty: A reappraisal of the technique and its complications. Plast Reconstr Surg. 2003;111:2192–2199; discussion, 2200–2202.
5. Lejour M. Vertical mammaplasty: Early complications after 250 personal consecutive cases. Plast Reconstr Surg. 1999;104:764–770.
6. Lejour M. Vertical mammaplasty: Update and appraisal of late results. Plast Reconstr Surg. 1999;104:771–781; discussion, 782–784.