Reﬁnements of the LeJour vertical mammaplasty skin …

Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 471e481

Refinements of the LeJour vertical mammaplastyskin pattern for skin-sparing mastectomy andimmediate breast reconstruction*

J.E. Hunter a, C.M. Malata a,b,*

a Department of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge UniversityHospitals NHS Foundation Trust, Box 186, Hills Road, Cambridge CB2 2QQ, UKb Cambridge Breast Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Box 186, Hills Road, Cambridge CB2 2QQ, UK

Received 9 February 2006; accepted 23 April 2006

KEYWORDSLeJour vertical scarbreast reduction;Skin-sparingmastectomy;Immediate breastreconstruction;Breast ptosis;Macromastia;Mastopexy

Summary Background: Skin-sparing mastectomy (SSM) is a well-established tech-nique for immediate breast reconstruction (IBR). When used for large and/or ptoticbreasts, traditional SSM patterns produce long skin flaps prone to necrosis or ‘T’junction breakdown. The authors have previously demonstrated the applicabilityof the LeJour-type vertical mammaplasty skin pattern to this group of patients.With further experience, indications for this procedure have been widened andthe technique refined.Results: Over five years, 26 immediate breast reconstructions were carried out in19 patients using this technique: three expandable implants, seven LDs, three ped-icled TRAMs, five free TRAMs, seven DIEPs and one SIEA flap. Fourteen patients(74%) had simultaneous contralateral balancing LeJour breast reductions or masto-pexies. The remaining five patients had bilateral mastectomies and reconstructionsusing the vertical mammaplasty skin pattern for both breasts. All flaps were suc-cessful, but there were three cases of minor skin flap necrosis, three of delayedwound healing and two instances of significant post-operative bleeding. Cosmesiswas suboptimal in the prosthetic reconstruction group, necessitating revisionalsurgery.Discussion and conclusions: The vertical mammaplasty skin pattern was success-fully used with a wide range of reconstructions. However, to avoid suboptimal

* Presented at Summer Meeting, British Association of Plastic Surgeons, Dublin, Ireland, 7th July 2004 and at the 40th Congress ofthe European Society for Surgical Research, Konya, Turkey, 27th May 2005.

* Corresponding author. Department of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge University HospitalsNHS Foundation Trust, Box 186, Hills Road, Cambridge CB2 2QQ, UK. Tel.: þ44 1223 586672; fax: þ44 1223 257177.

E-mail address: [email protected] (C.M. Malata).

1748-6815/$-seefrontmatterª2006BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.Allrightsreserved.doi:10.1016/j.bjps.2006.04.028

mailto:[email protected]

472 J.E. Hunter, C.M. Malata

cosmetic results and minimise wound healing problems this technique is notrecommended in heavy smokers, very obese patients, those undergoing prostheticreconstructions or neoadjuvant chemotherapy. The skin resection pattern shouldalso be conservative. The LeJour-type vertical mammaplasty pattern is a viable al-ternative technique for SSM in selected patients, especially those requiring contra-lateral balancing surgery and undergoing autologous tissue reconstruction.ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Pub-lished by Elsevier Ltd. All rights reserved.

Skin-sparing mastectomy1 (SSM) and immediatebreast reconstruction (IBR) are now widely ac-cepted as oncologically safe.2e5 SSM aims to pre-serve as much native breast skin as possible andthus to optimize the cosmetic results of IBR. Thecommon incisions for SSM are the various periareo-lar or racquet designs2,6e15 and the modified Wisepattern.1,3,6,16e19 These designs, however, presentthe ablative and reconstructive surgeons withproblems in very large or significantly ptoticbreasts. These include frequent delayed woundhealing at the ‘T’ junctions and mastectomy skinflap necrosis with the Wise pattern1,3,6,17,18,20,21

while the long (and often thin) flaps produced bythe circular and elliptical incisions account forthe increased incidence of native skin flap necro-sis.1,3,6,17,18,20,21 Access for axillary node dissec-tion or microvascular reconstruction may also bea problem, while injudicious skin retraction mayfurther compromise the vascularity of these longnative skin flaps.3,9

Preliminary results using the vertical mamma-plasty skin pattern,22,23 as an alternative skin-sparing mastectomy design in six patients withlarge or ptotic breasts were recently reported byour group.24 The rationale behind its use in thesepatients was that an inferior ‘T’ junction, theAchilles’ heel of the Wise pattern, would beavoided, the scars minimized and excessivelylong skin flaps prevented, while at the same timeproviding adequate access for the mastectomy,axillary clearance and reconstruction. Clearly, inthose patients requiring contralateral balancingsurgery, greater symmetry could be achieved usingthe same vertical mammaplasty skin pattern onboth the reconstructed and lifted/reduced sides.24

After the initial positive experience, it wasdecided to extend the LeJour skin pattern beyondthe original indications, to include moderatelysized breasts with minimal ptosis, excessively largebreasts with severe ptosis, obese patients and toexpand the range of reconstructions. This paperpresents the refinements of the technique derivedfrom the five-year experience of a single recon-structive surgeon (CMM) with 26 applications of the

LeJour-type vertical mammaplasty skin pattern forSSM and IBR.

Technique, patients and methods

The operative technique used is based on thatdescribed in the preliminary report24 with a fewrefinements. As previously stated the LeJour-typevertical mammaplasty skin pattern is marked outon the mastectomy side in collaboration with theablative surgeon, taking into consideration the lo-cation and nature of the tumour. However, thenew nipple position is now on both breasts located1 cm lower than that predicted by the anteriorprojection of the inframammary fold. The medialand lateral boundaries of the vertical skin resec-tion are determined by pushing the breast laterallyand medially, respectively, to line up with thebreast meridian,23 but marked 1 cm closer to thenipple, thus making the vertical skin resectionnarrower (and the skin flaps longer), than thatpertaining in a classical LeJour mammaplasty.This is important in reducing tension at the sutureline. In contrast, when marking the contralateralbreast, the vertical resection boundaries are notmodified from the traditional LeJour pattern. Asimilar, but less conservative pattern is thenmarked out on the contralateral breast to allowa near symmetrical closure of the skin envelopeon both sides. The mastectomy is then undertakenthrough the vertical skin elliptical incision. Accessfor the axillary clearance and, if indicated, dissec-tion of the internal mammary vessels for free tis-sue transfer is obtained via the same incision.Then the reconstructive flap or prosthesis is placedinto the mastectomy defect and the skin envelopeclosed in a LeJoureLassus pattern. A contralateralLeJour-type breast reduction or mastopexy is thenundertaken, with minimal flap undermining,25,26

and without a hitching suture to the pectoralfascia.23 Nippleeareolar reconstruction is alwaysdeferred to a later date. Twenty-six immediatebreast reconstructions were performed by a singlesurgeon (CMM) using this technique in 19 patients

Refinements of the LeJour vertical mammaplasty skin pattern 473

undergoing SSM and simultaneous contralateralbreast surgery.

Results

The LeJour vertical mammaplasty skin pattern forSSM was used in a wide range of immediate breastreconstructions (Tables 1 and 2) in 19 patientsaged between 36 and 59 years (mean¼ 46.8years). The mastectomy skin and breast resectionmargins were free of tumour and, after an averagefollow-up of 30.9 months (range¼ 4e69 months),none of the patients have developed locoregionalrecurrence. One patient, with a very large tumourneeding chemotherapy to shrink it prior to surgery,has died of distant metastases. The case reportsbelow illustrate the range of reconstructions forwhich the vertical mammaplasty skin pattern wasused.

Significantly large breasts,DIEP flap (case 13)

A 50-year-old non-smoker with a left-sided breastcancer and almost grade 3 ptosis underwentimmediate deep inferior epigastric perforator(DIEP) flap reconstruction and contralateral bal-ancing LeJour reduction (Fig. 1). There were nohealing problems.

Moderately sized breasts with minimalptosis, LD flap and implant (case 8)

A 58-year-old lady with moderately sized breastsand minimal ptosis requested immediate breastreconstruction with a latissimus dorsi (LD) myocu-taneous flap, aiming for the best possible symme-try achievable. A decision was therefore made toundertake a simultaneous contralateral LeJourmastopexy (Fig. 2).

Bilateral mastectomies and free TRAM flapreconstructions (case 17)

A 46-year-old patient had had a left lumpectomyand axillary clearance the previous year for mul-tifocal invasive lobular carcinoma. Due to closeresection margins, she received chemotherapyprior to the completion of mastectomy. Duringthis neoadjuvant chemotherapy, she requesteda right prophylactic mastectomy and bilateralimmediate breast reconstructions. She opted forbilateral free transverse rectus abdominis myocu-taneous (TRAM) flap reconstructions which, in view

of her ptosis (Fig. 3a, b and d), were carried outusing the LeJour vertical mammaplasty skin resec-tion pattern for skin-sparing mastectomy (Fig. 3c,e and f). The delayed wound healing on the sideof the previous lumpectomy required dressingsfor three weeks. She went on to receive post-operative adjuvant radiotherapy for six weeks.

Prosthetic only reconstruction,salvage with LD flaps (case 3)

The 50-year-old patient, used to illustrate theoperative technique in the 2003 paper, had de-veloped bilateral capsular contractures, right im-plant malposition and persistent pain necessitatingsalvage with bilateral LD flaps. The cosmeticresults are now acceptable (Fig. 4) and the patientis relatively symptom-free.

Small ptotic breasts, pedicled TRAMreconstruction (case 4)

This 40-year-old heavy smoker, with small, ptoticbreasts underwent a left mastectomy, right mas-topexy and a pedicled TRAM flap reconstruction.Post-operatively she developed partial necrosis ofthe lateral native skin flap which healed bysecondary intention (Fig. 5). Please note that thenipples were also placed rather too high, a partof the technique which has since been modified.

The post-operative complications are summar-ised in Table 3. Minor skin flap necrosis occurred inthree cases. One was in an obese patient with verythin skin flaps (case 11), one in a recipient of neo-adjuvant chemotherapy (case 12), and one in a41-year-old heavy smoker, who developed inferiorskin flap necrosis (case 4). Three patients devel-oped delayed wound healing requiring dressingchanges for two to three weeks post-operatively.One followed a partial wound dehiscence ina very heavy smoker (case 10). In the second, the‘T’ junction was intentionally left open after freeflap re-exploration for venous congestion to ac-commodate post-operative swelling (case 2). Thethird was a patient who had a large lumpectomyscar prior to the mastectomy (case 17; Fig. 3).

The major problems experienced, however,were in the two prosthetic reconstruction pa-tients. In the first, failure to inflate the expand-able implant resulted in a poor cosmetic outcomenecessitating revisional surgery to excise the mul-tiple persistent skin folds (case 5). The secondpatient (case 3) developed painful capsular con-tractures of her expander reconstructions accom-panied by unilateral malpositioning of the right

y and immediate breast reconstruction

F/U(m)

Mastectomyweight (g)

Contralateralweight

43 731 369 g

is69 730 25 g

ion

69 R e 449;L e 450

N/A

57 360 Skin only

and68 611 151 g

15 576 35.5 g

69 413 Skin only

27 359 Not recorded27 1629 297 g

s 27 673 42 g erecorded

18 954 71 g erecorded

21 758 291 g

31 859 60 g erecorded

14 1002 554 g

5 R¼ 745;L¼ 570

474J.E

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unte

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Table 1 Clinical summary of patients undergoing LeJour vertical mammaplasty skin pattern for skin-sparing mastectom

Case Age Smoker ChemoTx RT Indication Reconstructiontype

Contralateralsurgery

Complications/notes

1 36 NS N N T1N0 grade IIIDC (ERþ)

LDþ style 150expander

Reduction N

2 56 NS Y e post-op Y e post-op T3N1IDC (ERþ)

Free TRAM Mastopexy Re-explored forvenous thrombos

3 46 NS N N ProphylacticBRCA1

Style 150expandersbilaterally

N/A LD revisionsfive years laterfor severe cc andimplant malposit

4 40 S N Y e pre-op T2N0 grade IILC

Pedicled TRAM(surgicallydelayed)

Mastopexy Nipples too high,minor skin flapnecrosis

5 54 NS N N High gradeDCIS

Style 150expander

Mastopexy Pre-op wrinklingand failure to exp

6 33 S Y eneoadjuvant

Ye pre-op T4N1 IDC Pedicled TRAM(surgicallydelayed)

Mastopexy N

7 54 NS N N T1N0 IDC Pedicled TRAM Augmentationmastopexy

N

8 58 NS N N DCIS LDþ implant Mastopexy N9 55 NS Y e post-op Y e post-op T2Nþ (2/19)

grade IIIILC (ER/PRþ)

Free TRAM Reduction Synmastia e notenoughskin to close

10 41 S Y e post-op Y e post-op T3Nþ (9/21)grade IIIDC (ERþ)

Free muscle-sparing TRAM

Reduction Healing problem

11 46 NS Y eneoadjuvant

Y e pre-op T1Nþ (7/24)grade 1 IDC

Autologous LD Reduction Increased BMI,SSM flap necrosis


Y e pre-op T2Nþ (1/20)grade IIILC (ER/PRþ)

DIEP Reduction Minor skinflap necrosis

13 50 NS Y e pre-op T2N1 IDC DIEP Reduction N

14 51 NS N N DCISþ grade IIinvasivefoci after WLE

LDþ implant Reduction N


Y e pre-op Previous WLE,BRCA2 gene;benign

DIEP Lþ SIEA R N/A Returned totheatrefor bleeding


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expandable implant. This culminated in salvagewith LD myocutaneous flaps and anatomical co-hesive gel implants (Fig. 4).

Discussion

Indications (Table 4)

The vertical mammaplasty skin pattern was initiallyused in the immediate autogenous tissue recon-struction of patients with large and/or ptoticbreasts (Table 4).24 It proved to be especially usefulin those who required simultaneous contralateralbalancing mastopexies or reductions. Although atfirst the technique was deemed less suitable forpatients with moderately sized/non-ptotic breasts,it was extended to this group of patients with thespecific aim of improving symmetry to good effect(Fig. 2). It was also successfully applied to patientsundergoing LD flap reconstruction who often havemoderately sized breasts. With these encouragingresults, it was decided to also use this techniquein obese patients, such as those suitable for totallyautologous LD reconstructions. Finally it was uti-lised in all patients requesting the best possiblesymmetry from immediate reconstruction andcontralateral balancing surgery, regardless of thedegree of ptosis and whether or not they wereobese, smokers or recipients of neoadjuvant che-motherapy. Consequently the present report isone of the larger published series on breast reduc-tion patterns for mastectomy and immediatereconstruction.12,16,18,19

The vertical mammaplasty pattern is especiallysuitable for those requiring a balancing contralat-eral breast reduction or mastopexy because itallows adequate control of the post-mastectomyskin envelope thus optimising the cosmetic results.Additionally the application of the vertical skinresection pattern to both breasts improves

Table 2 Reconstructive methods used after SSM

Method No. ofreconstructions

Prosthetic only(McGhan style 150 expandera)

3

Latissimus dorsimyocutaneous flaps

7 (2 totallyautologous)

Pedicled TRAM flaps 3 (2 surgicallydelayed)

Free muscle-sparing TRAM flaps 5DIEP flaps 7SIEA flap 1

a Inamed corp., County Wicklow, Ireland


Figure 1 This 50-year-old patient with very large breasts and almost grade 3 ptosis (a, c and e) had excellent cos-metic results following a DIEP flap reconstruction and contralateral reduction (b, d, f and g).

symmetry. It gave excellent access for the mas-tectomy, axillary dissection and immediate recon-struction and in almost all cases without the needfor extra incisions of the breast or axillary region.

The LeJour-type pattern was also applied tobilateral immediate reconstructions. In our expe-rience these cases are particularly suitable for thisskin-sparing pattern, because symmetry is easierto achieve and excellent cosmetic results can beobtained.18,27 Interestingly, the most recent cases,which have been bilateral reconstructions, havehad problems with significant bleeding and haema-toma formation, necessitating a return to theatre.No flap loss has been incurred, however. Theoccurrence of significant bleeding in bilateralcases is most probably unrelated to the use ofthe vertical mammaplasty pattern.

Patients with significantly ptotic or large breastsare not ideal candidates for prosthetic reconstruc-tion or traditional SSM incisions as describedearlier.24 Therefore a technique which reducesthe length of skin flaps whilst at the same time‘mimicking’ SSM (preserving the skin envelope

and limiting the extent of scarring) is to be pre-ferred, as documented by others.15,18,19 Reductionof the skin envelope is almost always needed in pa-tients with large, ptotic breasts especially if theyrequest simultaneous contralateral balancingsurgery.6,16,28

Because of the significant problems encoun-tered in the prosthetic group, it is strongly recom-mended that this technique should not be used inimplant-only reconstructions. In such cases it ispreferable to use breast reduction patterns whichincorporate a de-epithelialised upper or lower18

breast flap to buttress or ‘waterproof’ orstrengthen the prosthetic pocket, or indeed anLD muscle harvested through the mastectomy inci-sion in place of the de-epithelialised inferior skinflap.29

Caution is also now urged in ‘high risk’ patientssuch as the heavy smokers, the obese and thosereceiving neoadjuvant chemotherapy, because ofthe higher incidence of skin flap necrosis anddelayed wound healing. While delayed woundhealing is a nuisance for the patient, due to


Figure 2 An application of the LeJour technique to combined LD and implant reconstruction with contralateral mas-topexy. Pre-operative appearances (a, c and e). Post-operative appearances before (g) and after (b, d and f) rightnippleeareolar reconstruction.

frequent dressing changes, it was not a majorproblem in autologous tissue reconstructions,17,21

as it did not require revisional surgery or readmis-sion to hospital. However, it can delay thestart of the post-operative adjuvant chemo or

radiotherapy and therefore could potentially dis-advantage the patient oncologically. This has tobe an important consideration in selecting thistechnique and the patient must be counselledaccordingly. Additionally, in immediate prosthetic


Figure 3 This 46-year-old patient with large almost grade 3 ptosic breasts had a left lumpectomy and radiotherapy(a, c and e) prior to bilateral mastectomies and bilateral free muscle-sparing TRAM flaps. There was delayed healingon part of the left vertical suture line. Note the smoothening of the puckered vertical scars with time (b, d, f and g).

Figure 4 Salvage of prosthetic only reconstruction with LD flaps. Prosthetic only reconstruction complicated by cap-sular contracture, implant malposition, and persistent pain (a and c). The tightness was only relieved by the LD flaps(b and d).


Figure 5 Reconstruction of small, but ptotic breasts (a) with a pedicled TRAM flap in a heavy smoker. Note thenecrosis of the native skin flap which healed with dressings only. (b) The nippleeareolae are too high on the breastmounds and too wide.

reconstructions, necrosis of skin flaps, and itsattendant delayed healing, can result in implantexposure, infection, extrusion, or explantation asreported with similar techniques.18

Complications (Table 3)

Using the vertical reduction mammaplasty skinpattern results in relatively shorter skin flaps thanin established SSM techniques, apart from the Wisepattern.1,3,6,17,19 Additionally, they have broaderbases than those in the Wise pattern skin-sparingmastectomies. The incidence of skin flap necrosisshould therefore be lower than the 25% reportedby Skoll and Hudson.19 In this present series of 26reconstructions, three minor cases of mastectomyskin flap necrosis were encountered, and thisseems to be a universal problem in SSM regardlessof type because of the thinness and angulationsof the mastectomy flaps.6,9,14,17,18,28 These pa-tients, however, all had other risk factors for skinflap necrosis, so with more careful patient selec-tion this may have been largely avoided. The Le-Jour skin pattern allowed the formation of twobroad-based flaps, a factor which is said to increasethe resilience of the skin flaps.6,18,19 Another im-portant factor in the viability of the skin flaps istheir thickness as shown by the occurrences of

Table 3 Surgical outcomes

Complication No. of patients

Native skinflap necrosis (minor)

3

Delayed wound healing 3Bleeding

Return to theatre 1Haematoma e no flap compromise 1

Implant-related complicationsFailure to expand 1Salvage with LD 1

delayed wound healing in the patient (case 11) inwhom the flaps needed to be made very thin on on-cological grounds. Even with the modification ofconservative skin resection, described in the ‘Tech-nique, patients and methods’ section, it is oftendifficult to avoid some tension at closure. Thisproblem is not only unique to the LeJour patternbut also occurs in the Wise pattern.6,18

The filling of the breast envelope with autolo-gous tissue instead of prostheses may reduce therisk of necrosis,12,17 and this may account for ourlower incidence of the problem. It certainly allowshealing to occur without endangering the recon-struction as it is made up of vascularised tissue.The major complications necessitating salvage orrevisional surgery were in the implant-only recon-structions. For this reason the technique is to beeschewed in this group.

Refinements (Table 4)

The vertical mammaplasty technique for SSM andIBR has evolved with further experience. Thevertical skin resection margin should be conserva-tive, as illustrated by a 54-year-old patient with

Table 4 Modifications to technique

Patient selection e caution inHeavy smokersVery obese patientsNeoadjuvant chemotherapySynmastia

Technical details� Learning curve for both ablative and

reconstructive teams� Avoid in prosthetic only reconstruction� Conservative vertical skin resection (except if

otherwise dictated oncologically)� Flexibility in design to accommodate tumour� Position nipples slightly lower than predicted

from reduction mammaplasty


synmastia who had a large, superficial tumour inthe inferior part of the left breast (case 9; Fig. 6).On oncological grounds the vertical resection mar-gin had to be wider than usual and extended al-most to the inframammary fold (Fig. 6a and b).Following the right mastopexy, it was impossibleto close the vertical component of the left LeJourSSM pattern directly and therefore an elongatedTRAM flap skin paddle had to be preserved(Fig. 6c). Conservative vertical skin resectionshould also reduce the incidence of skin flap necro-sis as it reduces the degree of tension on closure,one of the factors accounting for its high incidencein the Wise pattern SSM.6,3,17

It was also observed that the nipples have to bepositioned at least 1 cm lower than predicted bystandard breast reduction techniques, to avoid up-turned nippleeareolar complexes, which occurwith post-operative ‘bottoming out’, an unavoid-able occurrence when the LeJour pillars are notapproximated and the flap or breast reductionpedicle is not hitched to the pectoralis muscle.This is well illustrated by one of our early casesin whom the new nipple positions were too high,and the right nippleeareolar complex had beenmade too wide in the attempt to match the contra-lateral skin paddle (case 4, Fig. 5).

Flexibility must be shown in the design of thevertical mammaplasty skin pattern to allow foradequate tumour resection. The pattern maytherefore be positioned lower or higher than inthe standard breast reduction as dictated byoncological considerations. Where a superficial

tumour is located away from the breast meridianthe technique should not be used,24 and if thesame objective is to be achieved, a Wise patternkeyhole reduction pattern 1,17,18 should be em-ployed instead. In common with the Wise patternand B-mammaplasty skin-sparing mastectomytechniques the vertical skin pattern avoids scarringin the upper pole of the breast,15,16,28 thus contrib-uting to improved cosmesis.

The LeJour-type vertical mammaplasty skinpattern can be successfully applied to a varietyof reconstructive techniques following SSM, al-though it is not a panacea for every mastectomypatient. In the suitable patient it offers theablative surgeon more than adequate access forthe mastectomy and axillary clearance and thereconstructive surgeon wide exposure for the re-construction. Additional scars for the axillarydissection are also avoided. The technique wasmost useful for patients with large and/or ptoticbreasts undergoing immediate autogenous tissuereconstruction, including free and pedicledTRAMs, DIEP flaps, SIEA flaps and LDs. The patternis especially suitable for those requiring contralat-eral balancing breast surgery. It can also be used inpatients requesting the best possible cosmesis/symmetry regardless of the grade of ptosis.

Careful patient selection is advised especially insmokers, those with high BMIs and neoadjuvantchemotherapy patients. The skin resection mustbe conservative compared to the normal verticalmammaplasty. This should, however, not compro-mise the oncological resection. The LeJour vertical

Figure 6 A patient with synmastia and a left breast tumour involving the inferior skin (a and b). Appearances followingimmediate muscle-sparing free TRAM flap showing the vertical skin paddle necessitated by tumour resection (c).


mammaplasty skin pattern improves symmetrywithout unduly increasing the wound morbiditybeyond that seen with other SSM incisions.

Acknowledgements

The authors thank Mrs Sue Ramsey, Medical Sec-retary to Mr Malata for organisational support.

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