https://emedicine.medscape.

com/article/1274770-
treatment#d12

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.

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.

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 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 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]