INTRODUCTION
The vertical scar technique for reduction mammaplasty was first described in 1925 and revisited by Lassus. Madeleine Lejour modified the procedure by eliminating the horizontal scar at the inframammary fold.1–8 Though scarring is not the only consideration in selecting a surgical technique, patients typically find this a particularly concerning outcome of breast reduction.9 The commonly used Wise and other T-scar techniques are associated with a wide and flat breast shape that compromises appearance over the long-term.10 The modified Lejour method may be associated with better aesthetic outcomes.
In the past, severe ptosis and macromastia were considered relative contraindications to the vertical scar technique because the extended pedicle length and nipple transposition distance were thought to risk compromising the blood supply to the nipple-areola complex.10–12 Classic recommendations favored other techniques when removal of > 1 kg of breast tissue or a nipple transposition length > 10 cm was planned.7,11,13,14 More contemporary research suggests that the Lejour method can produce successful outcomes even in patients with gigantomastia and severe ptosis.10,15,16 The Lejour technique is associated with greater patient satisfaction and aesthetically pleasing results without a higher rate of complications compared with inverted-T techniques,8,17 although complications are more frequent with either technique in overweight patients and in those who smoke.18–20 While one study found a higher revision rate in patients managed with vertical scar techniques,17 revision to correct minor skin redundancy should be considered a second-stage procedure rather than a complication.5 There is a common perception that vertical scar techniques, including the Lejour, are more difficult to perform.17,19 In a 2002 survey, 15.5% of board-certified plastic surgeons used a limited incision technique.21
The goal of this study was to assess current technical trends in reduction mammaplasty among board-certified plastic surgeons in the United States and to examine clinical outcomes associated with the Lejour technique for breast reduction among consecutive patients in a single surgeon’s practice.
METHODS
The institutional review board governing research involving human subjects Icahn School of Medicine at Mount Sinai approved the study, and the survey of clinical practice trends among board-certified plastic surgeons was approved by the American Society of Plastic Surgeons (ASPS). We distributed the survey to 2,411 randomly selected, anonymous members, collecting data on the number of years in practice, practice setting, number of breast reductions performed, preferred technique, technique selection criteria, inpatient versus outpatient status, and complications (see appendix, Supplemental Digital Content 1, which displays a survey of clinical practice trends among board-certified plastic surgeons distributed by the ASPS to a cohort of members, https://links.lww.com/PRSGO/A775). Participation was voluntary. Statistical analysis was performed using analysis of variance and Student’s t tests for continuous numerical variables and Chi-square and Fisher’s exact tests for categorical data using JMP statistical software Version 13.2.1 (SAS Institute Inc., Cary, N.C.). Statistical significance was accepted at the 95% confidence level (P ≤ 0.05).
For comparison of outcomes, we reviewed the records of 119 consecutive patients undergoing breast reduction surgery by the principal investigator (M.C.) using the Wise pattern or Lejour technique between January 1997 and December 2006. The following data were extracted: age, height (in inches), weight (pounds), race, breast size (bra and cup size), reduction mammaplasty technique (Wise or Lejour), mass of tissue removed from each breast (grams), pertinent medical and surgical history, medications at the time of the procedure, tobacco usage, diabetes mellitus, relevant operative reports, records of postoperative visits, complications (including hematoma, wound dehiscence, revision, necrosis, infection), and pre- and postoperative photographs (Figs. 1, 2) (Tables 1, 2).
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Fig. 1.: A 53 year-old woman preoperatively (A,B). Same patient 4 months status post bilateral Lejour breast reduction (C,D). In total, 2,000 g removed from each breast.
Fig. 2.: A 49 year-old woman preoperatively (A,B). Same patient 4 months status post bilateral Wise pattern inferior pedicle breast reduction (C,D). In total, 1,200 g removed from each breast.
Table 1.: Patient Demographics
Table 2.: Postoperative Complications following Breast Reduction Surgery
For this series, all breast reduction operations were performed as outpatient procedures using the inferior pedicle Wise pattern, Lejour technique with a superior pedicle and liposuction, or liposuction only under intravenous sedation and tumescent local anesthesia. Postoperative Jackson Pratt drains were maintained for 1 day in all patients undergoing Wise or Lejour reductions.
RESULTS
We received 353 survey responses (14.6%). Of these, 14 were excluded because respondents performed no breast reduction surgery and responses were incomplete in 18. Thirty percentage of practitioners had been in practice over 25 years, and 46% were solo practitioners. Most (74%) performed 1–6 breast reduction procedures monthly, and 92% performed breast reduction as outpatient procedures. Major complication rates below 5% were reported by 79% of operators. A majority (72%) listed the inferior pedicle Wise pattern as the most common technique employed and isolated liposuction as least common. Only 14% reported using the Lejour or modified Lejour technique predominantly, whereas 47% used it as a second choice, and 45% as third-choice technique. Only 33% of respondents reported receiving formal training in the Lejour technique, whereas the majority of respondents based their choice of technique on breast size (77%) and severity of ptosis (64%). Delayed wound healing was reported as the most common complication from all respondents. Insufficient breast reduction was reported more frequently by those who primarily performed Lejour (P = 0.01). This was described by 7 survey participants and more often by those who learned the technique through a course or conference after residency compared with those who received training during full-time residency or fellowship (P = 0.02).
Retrospective chart review identified 119 patients who underwent reduction of 236 breasts during the specified period. The inferior pedicle Wise pattern was used in 14 patients (28 breasts) and Lejour technique in 105 patients (208 breasts) (Figure 1). The Wise technique was performed during the years 1997 and 1998, whereas the Lejour method was employed throughout the entire study period. The technique employed reflects the evolution of the principal investigator’s preference over time.
The mean age of patients was 37 years, and there was no significant difference in age between those in the Wise and Lejour (34 and 38, respectively; P = 0.16). The average body mass index (BMI) was 27 overall, with mean BMI values 32 and 27 for each group, respectively. Among the 119 total patients, 15 were smokers (3 and 12 in each group). None had diabetes. The average mass of tissue removed from each breast was 1,136 g for the entire cohort (range, 170–4,050 g) and for the Wise and Lejour subgroups 1,378 (range, 405–2,600) and 1,104 (range, 170–4,050), respectively (Table 2). Patients undergoing the Wise procedure had higher BMI and greater mass of breast tissue removed than those undergoing the Lejour procedure (both P < 0.05).
Postoperative complications were classified as either major or minor in severity. Minor complications included delayed wound healing ≥ 8 weeks postoperatively and scar revision. Due to the retrospective nature of the chart review, and variation in sensitivity of follow-up care descriptions, 8 weeks was chosen as the threshold period to capture cases of delayed wound healing. Major complications included surgical-site infection and nipple necrosis requiring return to the operating room (Table 1). Four patients suffered major complications after Lejour reductions over the 10-year study period. One, who had multiple sclerosis treated with immunosuppressant medication, developed unilateral infection and nipple necrosis requiring exploration and debridement and suffered complete nipple loss. The other smoked cigarettes despite counseling and developed unilateral infection and nipple necrosis requiring exploration and debridement. A third patient suffered an ankle fracture on the day after surgery, not directly related to the procedure. In another patient, the Jackson Pratt drain fragmented upon removal, requiring return to the operating room for removal; this was also deemed unrelated to the breast reduction technique employed.
The major complication rate for all techniques was 1.74% per breast overall, and 0 and 1.9 for the Wise and Lejour techniques, respectively (P = 0.46). The minor complication rate was 3.7% overall, with individual minor complication rates of 14.3% and 3.4%, respectively (P = 0.01). The minor complication rate of the Wise technique was significantly higher than that of the Lejour technique (P = 0.03).
DISCUSSION
Among the board-certified plastic surgeons performing breast reduction operations who responded to the survey, the Lejour technique was used by the minority, often as a fallback or second-choice technique behind the more often favored Wise method. Relatively few had received formal training in the Lejour procedure during residency training, and a substantial proportion of those performing the procedure incorporated it into the practice after attending a postgraduate course or conference. Nearly half the respondents (49%) listed wound healing as the most frequent complication of breast reduction surgery. Of survey respondents who used the Wise method most often, 22% indicated breakdown at the incisional trifurcation.
A common complication described by survey participants who primarily perform the Lejour technique was insufficient reduction (9%), and this group was statistically more likely to cite this complication than those who primarily perform the Wise technique. This may be due to a misconception that the Lejour technique cannot be used for large reductions. As demonstrated in our case series and by other authors, however, the Lejour can be used for large reductions.10,15,16 Furthermore, this was reported more often by those who obtained training in the Lejour technique in a postgraduate course or conference (P = 0.02), suggesting that training during residency or fellowship may be more effective and emphasizing the value of broad training in all techniques during residency.
Only 14% of those surveyed reported primarily using the Lejour technique. Several factors may contribute to this low percentage. Vertical scar techniques, such as the Lejour, are perceived as more difficult to perform.17,19 The low frequency of Lejour technique usage may also be due to the perception by some surgeons that patient characteristics such as breast size should be considered in identifying appropriate candidates for the Lejour technique. The majority of respondents indicated that choice of technique was based on breast size (77%) and degree of ptosis (64%). Although the survey did not capture precisely how surgeons use this information to guide technique selection, it is likely they limit use of the Lejour method to patients undergoing smaller, less ptotic reductions. Additionally, only 18% of survey respondents listed patient preference as a criterion for technique selection. As patient satisfaction depends largely on postoperative scarring,9 surgeons should consider the Lejour or other limited scar techniques preferentially, even in patients with large breasts.
In the series of procedures performed over a decade by the index operator, the need for minor wound care was common, but classified as a complication only when healing was delayed beyond 8 weeks, as occurred in 2 patients (3 breasts; 1.3%). This overall complication rate is consistent with previous reports and that quoted by survey respondents.14,17,22–24 Four patients in this series suffered major complications after Lejour reductions, though 2 were not directly related to the technique, and the other 2 occurred in patients at elevated risk due to comorbidities. Revisions to correct minor skin redundancy were not considered complications, in keeping with the description by Lejour.5 However, when excisions of redundant tissue were included as minor complications, there was no significance between the Wise and Lejour groups.
There was no statistically significant difference in major complication rates between the 2 techniques, as also reported in prior studies. The Wise technique was associated with a higher minor complication rate compared with the Lejour technique. The 22% incidence of wound complications at the “T” site observed by survey respondents is consistent with previous reports25 and is a concern with the Wise pattern technique. Furthermore, the average amount of breast tissue removed was higher in the Wise technique group, though the amount of tissue removed with the Lejour technique averaged over 1,000 g for each breast with a maximum of 4,050 g. These observations suggest that the Lejour mammaplasty technique can be used regardless of initial breast size, removing as much as 4,050 g from each breast with a low incidence of major complications and no need for free nipple grafting.
This study has several limitations, including the small proportion of surgeons responding to the survey and lack of external validation, and retrospective nature of the case series and uncertain generalizability of the observational data. Though a higher survey response rate would have improved statistical power, the 13.3% rate is high than average for ASPS surveys. Although selection of technique by the principal investigator raises the risk of bias, it reflects evolution of preference over time. Aesthetic outcomes with each technique were not directly compared in either the case series or among the survey respondents. The Lejour technique was used regardless of breast size or degree of ptosis, avoiding the need for a horizontal scar, which can have a negative impact on patient satisfaction.9
CONCLUSIONS
Although according to the survey most board-certified plastic surgeons were not formally trained in the Lejour technique and do not favor it for breast reduction, in the experience of 1 surgeon the method can be successfully employed for patients with very large breasts with no greater risk of complications than the Wise technique. The Lejour technique should be considered a viable alternative for reduction mammaplasty, and training in this technique should be provided during residency training of plastic surgeons.
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