Gigantomastia is a disabling condition for patients and presents unique challenges to plastic surgeons. Presentation can occur throughout different phases of life, and treatment often begins with nonoperative measures; however, the most effective way to relieve symptoms is surgical breast reduction. Because of the large amount of tissue removed, surgeons can encounter different intraoperative and postoperative complications. By understanding this disease process and these complications, surgeons can attempt to minimize their occurrences. The authors present an overview of the cause, preoperative evaluation, techniques, and outcomes. Additionally, they present outcomes data from their center on 40 patients.
Key points
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Gigantomastia represents extreme hypertrophy of the female breast.
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Although there is no universally accepted definition, the amount of tissue resected during reduction mammaplasty is the most widely used description, with threshold ranges reported between 1000 g and 2000 g per breast.
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Gigantomastia is a complicated problem that presents unique challenges. Understanding the cause of the disease and the necessary preoperative workup will minimize complications from the operation.
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There are multiple surgical approaches for correcting gigantomastia. Although there is not one best approach, many standard approaches can be adapted with an understanding of how to maintain blood supply to the nipple/areolar complex.
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As a general guideline, a pedicle width (when pedicles are used) of at least 8 cm should be maintained with a pedicle length no more than twice that of the width.
Introduction
Gigantomastia is a disabling condition for patients and presents unique challenges to the plastic surgeon. Excessive breast tissue is associated with pain in the back, neck, and shoulders. These patients often have intertrigo and can have derangements in body image perception, quality of life, and physical functioning. To this day, the definition of this condition remains unsettled. There are multiple causes, the most common of which is idiopathic. Presentation can occur throughout different phases of life, and treatment often begins with nonoperative measures; however, the most effective way to relieve symptoms is surgical breast reduction. Because of the large amount of tissue removed, surgeons can encounter different intraoperative and postoperative complications. By understanding this disease process and these complications, surgeons can attempt to minimize their occurrences. The authors present an overview of the cause, preoperative evaluation, techniques, and outcomes. Additionally, they present outcomes data from their center on 40 patients.
Introduction
Gigantomastia is a disabling condition for patients and presents unique challenges to the plastic surgeon. Excessive breast tissue is associated with pain in the back, neck, and shoulders. These patients often have intertrigo and can have derangements in body image perception, quality of life, and physical functioning. To this day, the definition of this condition remains unsettled. There are multiple causes, the most common of which is idiopathic. Presentation can occur throughout different phases of life, and treatment often begins with nonoperative measures; however, the most effective way to relieve symptoms is surgical breast reduction. Because of the large amount of tissue removed, surgeons can encounter different intraoperative and postoperative complications. By understanding this disease process and these complications, surgeons can attempt to minimize their occurrences. The authors present an overview of the cause, preoperative evaluation, techniques, and outcomes. Additionally, they present outcomes data from their center on 40 patients.
Definition
The amount of tissue resected during a reduction mammaplasty is often used as a marker and definition for gigantomastia. However, there is wide disagreement about how much excised tissue weight constitutes gigantomastia, with ranges between 1000 g per breast and as high as 2000 g per breast reported in the literature. Definitions focusing on body mass index (BMI), brassiere size, and breast size also exist. In an attempt to standardize the categorization of gigantomastia, Dancey and colleagues proposed a new classification system based on cause, age, BMI, and pregnancy status ( Table 1 ).
| Group | Characteristics |
|---|---|
| 1a | Idiopathic, spontaneous condition of excessive breast growth in patients with a BMI >30 |
| 1b | Idiopathic, spontaneous condition of excessive breast growth in patients with a BMI <30 |
| 2a | Excessive breast growth related to an imbalance of endogenous hormone production occurring during puberty |
| 2b | Excessive breast growth related to an imbalance of endogenous hormone production occurring during pregnancy |
| 3 | Excessive breast growth induced by a pharmacologic agent |
Another possibly more objective definition from Dafydd and colleagues proposes using excessive breast tissue that contributes 3% or more to patients’ total body weight. For the purposes of the data presented from the authors’ hospital in this article, they chose 1500 g per breast as their benchmark resection weight and definition of gigantomastia.
Causes
There are several different causes for gigantomastia. The most common cause is idiopathic ( Box 1 ). This condition can also be seen in association with pregnancy and puberty. Pregnancy-induced gigantomastia occurs with an incidence of approximately 1 in 65,000 pregnancies. Characteristic features of puberty- and pregnancy-induced gigantomastia include glandular hyperplasia, hyperplasia of the stromal elements, and fibrosis. There are also reports of gigantomastia developing as a result of medication side effects and autoimmune disease.
Idiopathic
Pregnancy induced
Puberty induced
Pharmacologic
Penicillamine
Neothetazone
Cyclosporine
Estrogen
Bucillamine
Autoimmune
Chronic arthritis
Hashimoto thyroiditis
Myasthenia gravis
Psoriasis
Anatomy
Gross ( Fig. 1 )
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There are certain key features that are present in patients with macromastia and gigantomastia . These features include severe ptosis, increased sternal notch to nipple distance, increased nipple to inframammary fold (IMF) distance, increased areolar size, and a broadened base. Understanding the vascular supply to the nipple-areola complex (NAC) is imperative for a safe and effective operation. The NAC is supplied by the internal mammary artery, lateral thoracic artery at the level of the fourth intercostal artery, and the anterior intercostal artery at the level of the midfourth and fifth intercostal spaces.
Fig. 1
( A ) Shows the arterial supply to the breast in an anterior view, and ( B ) shows the blood supply in a cross sectional view.
( From de la Torre J, Davis MR. Anatomy for plastic surgery of the breast. In: Neligan PC, editor. Plastic surgery, vol. 5. Breast, Chapter 1. 3rd edition. Philadelphia: Elsevier, Saunders; 2013. p. 7; with permission.)
Histology
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There are also histologic changes that are present in gigantomastia, which can differ with the varying causes. Idiopathic gigantomastia demonstrates predominantly fibroglandular tissue, lymphocytic infiltration, and venostasis. The hormonal subtype shows stromal, ductal, and glandular hyperplasia with dilatation. In addition, the histology shows collagenous fibrosis, cellular myxoid hyperplasia, ductal proliferation with cystic degeneration, edema, lymphatic dilatation, and fibroadenomas with increased estrogen and progesterone. Interestingly, drug-induced gigantomastia does not show any significant histologic changes.
Evaluation
All women presenting with severe breast hypertrophy require a complete history and physical examination. A thorough weight history should be obtained, including weight loss surgery, lowest/highest/current weight, and how breast size has changed with weight. In addition, history of any breast abnormalities, including masses and/or prior surgeries, should be obtained. Breastfeeding history should be discussed as well as any future plans for breastfeeding, which could be compromised by surgical intervention. Family history of cancer, including breast, ovarian, or colon, should be discussed.
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The physical examination begins with a general inspection of patients and the topography of the breasts, noting any asymmetries, position of the NAC, presence of any chest wall rolls, scars, and quality of skin. A complete breast examination should be performed evaluating any masses, the position and mobility of the IMF, and nipple sensation. Finally anatomic measurements should be performed, which include suprasternal notch to nipple, midclavicle to nipple, nipple to IMF, breast base, and NAC size.
Treatment Options
Conservative management
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Properly fitted brassiere
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Physical therapy
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Weight reduction
Medical management
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Medical management of gigantomastia is based on a limited number of case reports and is grouped in the literature based on cause. Medical management and noninterventional methods often fail and, thus, surgery is required.
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Pregnancy induced
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Bromocriptine, the most commonly used medication for this disease, is a dopamine agonist, which centrally inhibits the release of prolactin and produces a temporary involution of breast tissue during pregnancy. Despite this therapy, most women still require surgical correction after treatment. Other agents that have been tried with pregnancy-induced gigantomastia include androgens, estrogens, progestins, 2 bromine-alpha ergocryptine, prednisone, dexamethasone, hydrochlorothiazide, and furosemide with either marginal or no effects seen.
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Idiopathic and puberty induced
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Tamoxifen, an estrogen receptor antagonist, has been shown to cause regression of breast tissue. Other agents that have been tried include medroxyprogesterone and dydrogesterone.
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Preoperative Counseling
Overview
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A preoperative patient-surgeon counseling session is of the utmost importance . Asymmetry should be discussed with patients. Although each breast may appear similar to patients preoperatively, even small differences in size postoperatively may be observed by patients. The goals of the procedure need to be highlighted during preoperative counseling, and the potential need for free nipple grafting must be discussed.
Goals of reduction mammaplasty in gigantomastia
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Breast volume reduction sufficient to eliminate symptoms
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Elevating the NAC
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Tightening the skin envelope
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Correcting severe asymmetry
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Reshaping the breast mound
Other Preoperative Considerations
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It may be necessary to involve an endocrine specialist, especially in pregnant or pubescent-aged girls. Prior algorithms have been established specifically for the gestational patient population. Of note, reduction mammaplasty for these patients does not reduce the rate of recurrence in subsequent pregnancies. The likelihood of future pregnancy is a key determinant of the type of procedure offered ( Fig. 2 ).
Fig. 2
Treatment algorithm for gestational gigantomastia.
( From Swelstad MR, Swelstad BB, Rao VK, et al. Management of gestational gigantomastia. Plast Reconstr Surg 2006;118(4):845; with permission.)
Surgical Management
Overview
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Surgical management is the most effective treatment of gigantomastia. Although there are several different surgical options, the literature to date only reports small series specific to this patient population and optimal techniques. In cases requiring more than 1000 g per breast resected, surgeons should consider free nipple grafting, although some have argued for a more liberal cutoff at 2000 g per breast. The cutoff should depend on both operator experience and comfort level with the procedure. Additional consideration should be given to high-risk patients. Regardless of surgeon preference, a thorough patient discussion is recommended to discuss the risks, benefits, and alternatives of each proposed procedure. There are many different techniques described, including inferior, superomedial, medial, and bipedicled flaps; the most pertinent topics to address severe breast hypertrophy are described later ( Figs. 3 and 4 ).
Fig. 3
Preoperative photographs demonstrating anteroposterior ( A ), oblique ( B ), and lateral ( C ) views of an 18-year-old patient with gigantomastia.
Fig. 4
Postoperative photographs demonstrating anteroposterior ( A ), oblique ( B ), and lateral ( C ) views 5.5 months after Wise pattern reduction mammaplasty with an inferior pedicle. Excised tissue weights were 1420 g on the left and 1543 g on the right. The patient had a superficial dehiscence along the vertical incision of the right breast. This dehiscence healed by secondary intention with local wound care.Related posts:
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