Gigantomastia – a classification and review of the literature

Parathyroid hormone-related peptide induced hypercalcemia of pregnancy due to mammary hyperplasia

Maternal Parathyroid Hormone-related Protein (PTHrP) is involved in the placental transport of calcium. Autonomous overproduction of PTHrP is a rare cause of hypercalcemia in pregnancy. Prior cases of PTHrP-induced hypercalcemia in pregnancy have been managed with either dopamine agonists, fetal delivery, termination of pregnancy, or mastectomy. However, PTHrP level normalization following mastectomy has not previously been documented. Herein, we present a 39-year-old female hospitalized at 19 weeks of gestation for acute encephalopathy due to PTHrP induced hypercalcemic crisis (calcium 15.8 mg/dL, PTHrp 46.5 pmol/L [normal 0-3.4]). Mammary hyperplasia resulting in gigantomastia significantly impaired her ability to ambulate and perform activities of daily living. She remained hypercalcemic during hospitalization despite aggressive hydration, calcitonin, and 2 weeks of dopamine agonist treatment. Bisphosphonate therapy was not administered due to pregnancy and potential effects on the fetus. Our patient underwent bilateral mastectomy along with excision of a large axillary mass. The pathology of all three specimens revealed mammary stromal hyperplasia. PTHrP was undetectable on post-op day 2 and calcium normalized by post-op day 3. At discharge, she was able to ambulate independently. To our knowledge, this is the first reported case of PTHrP induced hypercalcemia related to gigantomastia, documenting resolution of hypercalcemia, and PTHrP levels following mastectomy. Mastectomy is a potential option in the second trimester for pregnant patients with PTHrP induced severe hypercalcemia due to gigantomastia, refractory to treatment with dopamine agonist therapy.

Topographic Analysis of the Nipple-Areolar Complex Sensation in Superomedial Pedicle Breast Reduction

BACKGROUND

Surgeons meticulously perform breast reductions, while ensuring vascular integrity of the pedicle and Nipple-Areolar complex (NAC) to prevent any complication. It is crucial to remember that loss of sensation is also substantial complication, mainly due to unique characteristic features of the NAC. This study aimed to compare early and long-term sensory results by performing topographic analysis of NAC sensation after superomedial pedicle breast reduction.

METHODS

A prospective study was conducted by including nonrandomized female patients who underwent breast reduction surgery with wise pattern excision superomedial pedicle technique between January 2019 and June 2022. Semmes-Weinstein Monofilament (SWM) test performed at preoperatively, 3-6 months and 15-18 months postoperatively. NAC complex was divided into four equal quadrants and nipple: superomedial (SM), inferomedial (IM), inferolateral (IL), superolateral (SL) and Nipple (N). Touch-Test® Sensory Evaluator Chart was used to evaluate sensory results.

RESULTS

None of the patients had any loss of sensation during preoperative SWM test. In postoperative 3-6 months, statistically significant differences were observed between N and SL (p = 0.002), SL and IM (p < 0.05), SM and IM (p < 0.05). In postoperative 15-18 months, there was no difference between the quadrants and nipple (p = 0.07). In early and long-term comparisons of the same quadrants, IL less pronounced than other quadrant comparisons (p = 0.034). A statistical difference was observed in overall NAC score (p < 0.05).

CONCLUSIONS

It would be beneficial to inform patients overall NAC sensation in the postoperative may not be as good as preoperative, there might be variations in NAC sensation across different quadrants in early period.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Role of ERα and Aromatase in Juvenile Gigantomastia

CONTEXT

Approximately 150 patients with juvenile gigantomastia have been reported in the literature but the underlying biologic mechanisms remain unknown.

OBJECTIVE

To conduct extensive clinical, biochemical, immunochemical, and genetic studies in 3 patients with juvenile gigantomastia to determine causative biologic factors.

METHODS

We examined clinical effects of estrogen by blockading estrogen synthesis or its action. Breast tissue aromatase expression and activity were quantitated in 1 patient and 5 controls. Other biochemical markers, including estrogen receptor α (ERα), cyclin D1 and E, p-RB, p-MAPK, p-AKT, BCL-2, EGF-R, IGF-IR β, and p-EGFR were assayed by Western blot. Immunohistochemical analyses for aromatase, ERα and β, PgR, Ki67, sulfotransferase, estrone sulfatase, and 17βHD were performed in all 3 patients. The entire genomes of the mother, father, and patient in the 3 families were sequenced.

RESULTS

Blockade of estrogen synthesis or action in patients resulted in demonstrable clinical effects. Biochemical studies on fresh frozen tissue revealed no differences between patients and controls, presumably due to tissue dilution from the large proportion of stroma. However, immunohistochemical analysis of ductal breast cells in the 3 patients revealed a high percent of ERα (64.1% ± 7.8% vs reference women 9.6%, range 2.3-15%); aromatase score of 4 (76%-100% of cells positive vs 30.4% ± 5.6%); PgR (69.5% ± 15.2% vs 6.0%, range 2.7%-11.9%) and Ki67 (23.7% ± 0.54% vs 4.2%). Genetic studies were inconclusive although some intriguing variants were identified.

CONCLUSION

The data implicate an important biologic role for ERα to increase tissue sensitivity to estrogen and aromatase to enhance local tissue production as biologic factors involved in juvenile gigantomastia.

Evaluating Patient-reported Outcomes after Bilateral Reduction Mammoplasty: A Comparison of Reduction Techniques at a University Hospital

Background

Macromastia, defined as the abnormal enlargement of breasts, burdens individuals physically and psychologically, impacting their daily lives beyond aesthetics. Reduction mammoplasty offers relief by restoring proportional breast volume and appropriate contour. Surgical success relies on choosing a suitable individualized operative technique tailored to the patient's presentation and postoperative goals. This study examines postoperative, patient-reported outcomes across different reduction techniques to gauge the impact of reduction technique on overall patient perspective of aesthetic and functional satisfaction.

Methods

A retrospective review identified reduction mammoplasty patients by a single surgeon between 2018 and 2022. Exclusion criteria included augmentation-related or cancer reconstructive procedures. Phone interviews were conducted using a survey adapted from BREAST-Q to assess postoperative outcomes in patients. Data analysis included Pearson chi-square test in STATA 16.1.

Results

Among 155 patients identified, 64 completed the survey. Average postsurgical interval was 24 months postoperative. After stratifying patients by operative technique, there was no significant difference in postoperative satisfaction among the cohorts with regard to nipple and breast appearance, sensation, symmetry, or shape.

Conclusions

This study highlights no significant disparity in perceived aesthetic or functional outcomes among different reduction mammoplasty techniques. Personalized considerations, such as patient factors, surgical expertise, and anatomical specifics, should guide technique selection, emphasizing individualized approaches over presumed superior methods for optimal results.

Superomedial-Posterior Pedicle-Based Reduction Mammaplasty: Evaluation of Effectiveness and BREAST-Q Outcomes of a Rapid and Safer Technique

INTRODUCTION

Breast hypertrophy, a common pathological condition, often requires surgical intervention to alleviate musculoskeletal pain and improve patients' quality of life. Various techniques have been developed for breast reduction, each with its own advantages and complications. The primary aim of this study is to evaluate the efficacy, safety, and patient-reported outcomes of the authors technique: the Superomedial-Posterior Pedicle-Based Reduction Mammaplasty.

MATERIAL AND METHODS

A prospective study was conducted on 912 patients who underwent breast reduction surgery between November 2012 and July 2020. The surgical technique involved preserving all glandular tissue from the areola to the pectoralis major muscle using the superomedial-posterior pedicle. The patients' demographic data, operative details, complications, breast-related quality of life (measured using the Breast-Q questionnaire), and nipple-areola complex sensitivity were analyzed.

RESULTS

The average operative time was 62.12 ± 10.3 minutes. Complications included minor wound dehiscence (4.05%) and hematoma (1.2%), with no cases of nipple-areola complex necrosis. Nipple-areola sensitivity was fully restored in all patients at the 2-year follow-up. Patient satisfaction with the procedure was high with a statistically significant difference observed between pre- and postoperative scores (p < 0.001) of the Breast-Q questionnaire.

CONCLUSION

Authors technique offers reliable vascularization and innervation of the nipple-areola complex and achieves satisfactory aesthetic outcomes. It is associated with shorter operative times compared to other techniques reported in the literature. The Superomedial-Posterior Pedicle-Based Reduction Mammaplasty represents a safe and effective method for breast reduction surgery, providing significant benefits to patients with breast hypertrophy.

LEVEL OF EVIDENCE I

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VIRGINAL RECURRENT GIGANTOMASTIA (BREAST HYPERTROPHY). A CASE REPORT

Virginal gigantomastia (VGM) is a benign disease of the breasts without a clearly established etiology. The treatment of VGM remains a problem. The conservative treatment is not effective while surgery is too traumatic. Most specialists recommend subcutaneous mastectomy with immediate implant reconstruction or reduction mammoplasty. The reduction mammoplasty with adjuvant hormone therapy is a variant of treatment of young patients with a risk of recurrence. We present a case of a patient with VGM who was operated in 2014. Reduction mammoplasty was performed. After 9 years, the patient had a relapse and second surgery, resection of the breasts with reduction mammoplasty. Tissues with cysts, fibrosis, hamartomas, and fibroadenomas were dissected. Histopathology revealed extensive fibrosis with hamartomas and fibroadenomas. The immunohistochemical examination of the breast tissue showed a high level (70%) of estrogen and progesterone receptors expression. We prescribed hormone therapy with tamoxifen 10 mg per day. Dynamic monitoring of the treatment result and control of the disease remission was carried out. Breast-conserving surgery performed in such patients can help alleviate the psychological, social, and physical disorders caused by VGM.

Is Quality of Life After Breast Reduction Influenced by Different Surgery's Technique? A Prospective Study

BACKGROUND

Breast hyperplasia is a condition with a significant impact on the quality of life and psychological well-being of patients. Over time, various surgical techniques have been developed to reduce breast mass, which have proven effective in improving the quality of life of women undergoing the procedure. It is not yet well described how various techniques may influence the improvement in QoL (Quality of Life). The aim of this study is to assess the impact of different techniques on the improvement of quality of life.

MATERIAL AND METHODS

We analyzed the responses to the Breast-Q questionnaire from 95 patients undergoing breast reduction surgery between 2021 and 2023. The questionnaires were completed both before the procedure and during the 6-month follow-up. We assessed the questionnaire responses and overall satisfaction with the results, categorizing the data based on the specific surgical technique used.

RESULTS

A statistically significant improvement in the quality of life was observed in the postoperative period, as well as a remarkable satisfaction with the outcome (mean score of 81 out of 100). We did not detect statistically significant differences in the levels of quality of life and satisfaction with the outcome among the various techniques.

CONCLUSION

The breast reduction surgery procedure continues to prove its ability to significantly improve the quality of life for patients with breast hypertrophy, regardless of the specific surgical technique employed.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Association Between Body Weight and Removed Weight in Women Undergoing Reduction Mammaplasty-A 17-year Retrospective Study of 1777 Breasts

BACKGROUND

Breast hypertrophy causes physical and psychological symptoms. Reduction mammaplasty is a surgical procedure to lessen discomfort. However, there is a dispute about whether the weight of breast resection is related to body weight. This study aims to provide Chinese data and assess the association between body weight and removed weight in women undergoing reduction mammaplasty.

METHODS

Retrospective data were collected from 1777 breasts in a single center in 17 years. Simple linear regression analysis was performed to establish whether removed weight and removed weight ratio (removed weight/body weight) correlated with the body weight. The correlations were then analyzed again after grouping according to the removed weight.

RESULTS

For all breasts included, removed weight or ratio positively correlates with body weight. When the removed weight is more than 1000g, there is no statistically significant correlation between body weight and removed breast weight. When removed per breast weight is more than 600g, there is no correlation between body weight and removed breast weight ratio.

CONCLUSIONS

The correlation between body weight and removed weight or ratio decreased with increasing removed weight. When removed weight >600g, the degree of breast hypertrophy is not related to body shape.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Therapeutic study.

The Immunohistochemical Profile of Mammary Tissue in Women With Macromastia and Its Potential Clinical Implications

Macromastia is an excessive, rapid, or slow growth of breast tissue in 1 or both breasts. While macromastia represents a benign lesion, it may cause breast, shoulder, back, and neck pain, poor posture, infections, and loss of nipple sensation. The pathogenesis of macromastia or hypertrophy of mammary tissue remains poorly understood. The purpose of this study is to investigate the immunohistochemical expression of several hormone receptors that may potentially influence the growth of breast tissue in women with macromastia. Immunohistochemical studies performed on representative sections of breast tissue from 63 patients diagnosed with macromastia included estrogen receptor, progesterone receptor, androgen receptor (AR), prolactin receptor, growth hormone receptor, and vascular endothelial growth factor. The expression of each stain was evaluated separately in the glandular epithelium and adipose tissue and calculated as an H-score. We observed that AR expression in breast glandular and adipose tissue in women with macromastia was significantly lower than benign, nonhypertrophic breast tissue of a control group. Although the analyses were controlled for the age, the fact the mean age and hormonal status differed between the patients and the controls could have affected the results. Additional large studies will be required to further verify this finding and increase the knowledge about the etiology of this condition and then guide pharmacological treatment of juvenile and/or idiopathic gigantomastia.

Mammoplasty Using Modified Superomedial Pedicle Technique in Severely Macromastia and Ptotic Breasts

Mammoplasty is a surgery commonly used for macromastia. Many mammoplasty techniques are described, all with their specific pros and cons. However, the concern to avoid serious complications sometimes takes precedence, and the ideal result cannot be. For macromastia and severely ptotic breasts, usually the free nipple-areolar complex (NAC) mammoplasty technique is implemented. The results, however, may only be completely satisfactory regarding cosmetics. Loss of NAC, poor appearance, flabbiness, flattening, and ptosis are among the disadvantages of this technique. This study aimed to present the results of mammoplasty employing the superomedial pedicle technique without interrupting a macromastia central base with a pedicle length of 8 to 18 cm. According to the literature, many plastic surgeons recommend the free NAC rather than the pedicle technique because of the high complication rates in mammoplasties planned for highly ptotic breasts and macromastia. On the other hand, many free NAC techniques and their modifications with pedicle mammoplasty are described. The general conviction is that a standard method, protocol, or technique good for all patients does not exist. Our results are more acceptable both cosmetically and physiologically. Therefore, the superomedial pedicle technique can be modified to achieve ideal results where free NAC mammoplasty is considered for severe macromastia and ptotic patients. This combined method contributes to the viability of NAC by increasing blood supply to breast tissue and providing an ideal breast appearance.

Extremely rare case of unilateral gigantomastia after hormonal stimulation treated with a modified wise pattern technique: A case report

INTRODUCTION

Gigantomastia, characterized by excessive breast size (usually heavier than 2.5 kg), can result from various causes and significantly affect patients' lives. Surgical intervention is often required, and over time, several techniques have been developed for its treatment. These techniques aim to address the functional and aesthetic concerns associated with gigantomastia, providing relief to patients and improving their quality of life.

PRESENTATION OF THE CASE

A 40-year-old primiparous housewife developed unilateral gigantomastia as a consequence of hormone therapy. To address this, a modified reduction mammoplasty procedure was undertaken, incorporating NAC (Nipple-Areola Complex) grafting. The reduction involved removing 3450 g of tissue, resulting in restored breast symmetry and enabling the patient to reintegrate into normal daily life.

DISCUSSION

Compared to the traditional technique, the introduction of some modifications in the design allowed for the absence of complications such as dehiscence of the scar at the intersection of the T, the failure of the nipple graft attachment, and the maintenance of a conical shape over time, enabling complete symmetrization of the two breasts.

CONCLUSION

The use of a modified version of the Thorek technique allowed for optimal functional and aesthetic restoration even in the case of a significantly disproportionate breast compared to the contralateral one, with no complications.

Is free nipple grafting necessary in patients undergoing reduction mammoplasty for gigantomastia? A systematic review and meta-analysis

BACKGROUND

Gigantomastia is a debilitating condition characterised by an excessive breast tissue growth impacting patients' quality of life. Surgically treatment options include the limited-length pedicle (LP) technique with free nipple grafting (FNG) and the elongated pedicle (EP) technique, which maintains continuity of the nipple-areola complex (NAC). Initially, despite the less satisfactory aesthetic outcome, FNG was preferred to treat hypertrophic breasts requiring resections over 1000 g of parenchymal and adipose tissue, due to concerns about NAC perfusion. Recently, many studies have questioned this indication. The aim of this study was therefore to evaluate the safety of the NAC-carrying EP technique in patients with gigantomastia eventually challenging the need for FNG.

METHODS

A literature search using PubMed and Cochrane databases was performed, including studies describing the outcome of EP technique for resection exceeding 1000 g of breast tissue. Thereby, a meta-analysis was conducted to evaluate the rate of NAC necrosis, whereas a descriptive statistic was applied to assess all other surgery-associated complications.

RESULTS

Twenty-five studies, encompassing 1355 patients (2656 breasts), were included. EP demonstrated an extremely low rate of NAC necrosis. Moreover, the analysis demonstrated a low rate of ischaemia-independent complications and a very high probability of maintaining NAC-sensation equal to the preoperative state.

CONCLUSION

Current evidence indicates that the EP technique should be the preferred surgical method to treat gigantomastia with or without massive ptosis whenever indicated. It has proven to be safe. Furthermore, it yields superior aesthetic and functional outcomes, including breast feeding and preservation of NAC-sensation compared to the LP technique.

Management of Gestational Gigantomastia with Goldilocks Procedure after Mastectomy: A Case Report and Review of Literature

Gestational gigantomastia is characterized by the rapid growth of breasts during pregnancy. The treatment method of gestational gigantomastia is unclear; if the medical treatment is ineffective, surgery is considered. However, sufficient research on which method is best to perform breast reconstruction for the gestational gigantomastia patient has not yet been conducted. Our patient was young and had aesthetic needs; thus, we did not recommend modified radical mastectomy. However, it was difficult for the patient to consider active reconstruction using an implant or autologous tissue because of the expected complications and economic problems. The patient had a thin body shape and very large breasts compared with the trunk. Therefore, breast volume was not significantly required after reconstruction. Additionally, we expected that a considerable portion of skin would remain after mastectomy as a tubular-shaped breast. It was expected that the Goldilocks technique would be sufficient to meet the patient's volume needs. Therefore, we proceeded with total mastectomy and reconstruction using the Goldilocks procedure. No complications were recorded after the operation; most of the patient's discomfort was resolved, and the shape and size of the breasts were satisfactory.

Idiopathic gigantomastia exacerbated during pregnancy. Its relationship with autoimmunity: A case report

Gigantomastia is a rare entity characterized by diffuse and excessive breast enlargement. It mainly occurs during puberty and pregnancy as a consequence of hormonal fluctuations. We report an unusual case of gigantomastia in a 29-year-old woman with a history of personal and familiar autoimmune phenomena. She had autoimmune thyroiditis and several positive autoantibodies, and developed 3 crises of the disease, 1 related to pregnancy (possibly hormone-mediated), and 2 unrelated to pregnancy in which an autoimmune role is raised based in clinical, histological and laboratory findings. Immunological aspects that may be involved in this presentation of the disease are discussed.

Definitions of Abnormal Breast Size and Asymmetry: A Cohort Study of 400 Women

BACKGROUND

Macromastia, micromastia and breast asymmetry have an impact on health and quality of life. However, there is scarce information addressing breast size and asymmetry frequency distribution in reference populations.

OBJECTIVE

The current study aims to identify factors that influence breast size and symmetry and classifies abnormal breast sizes and breast asymmetries in an adult German population.

METHODS

Breast base dimensions, breast volume, symmetry, and other breast anthropometric parameters of 400 German female patients were determined in a retrospective review of the MRI archives at our institution. Professional medical MRI-segmentation software was used for volume measurement.

RESULTS

A total of 400 Patients were retrospectively enrolled. The patients had a mean age of 50 ± 12 years (min: 24; max: 82), mean BMI of 25.0 ± 5.0 (min: 14.7, max: 45.6), and a mean total breast volume of 976 ml (right: 973 ml, min: 64, max: 4777; left: 979 ml, min: 55, max: 4670). The strongest correlation of breast volume was observed with BMI (r = 0.834, p < 0.001), followed by breast base width (r = 0.799, p < 0.001). Smaller breasts have higher breast volume asymmetry ratios (r = - 0.124, p < 0.014). For a BMI between 18.5 and 24.9 kg/m2, micromastia is defined by breast volumes below 250 ml (5th percentile) and macromastia by volumes above 1250 ml (95th percentile). Abnormal breast volume asymmetry (< 5th and > 95th percentile) is equivalent to an absolute difference of approximately 25% relative to the smallest side (bidirectional asymmetry ratio 5th percentile - 19%; 95th percentile 26%).

CONCLUSION

This study provides normative data of German women, as well as selected size-for-BMI percentiles and asymmetry ratio percentiles. The normative data may help to establish transparent and objective coverage criteria for health insurances.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lessons learned in severe axillary gestational gigantomastia

Gestational gigantomastia involving axillary breast tissue can be safely resected during pregnancy; early management is paramount in preventing progression and limiting impact on pregnancy.

Medial Pedicle Wise-pattern Breast Reduction for Gigantomastia: A Single-center Retrospective Review

Gigantomastia causes severe back pain, postural imbalance, intertrigo, and psychosocial disablement. Multiple breast reduction techniques exist. Breast reduction with free nipple graft reconstruction is the preferred treatment. We found that the medial pedicle Wise-pattern (MPWP) technique is an equally safe and effective technique.

Methods

Review of our institution's electronic medical record between February 2020 and February 2023 identified women with gigantomastia who underwent bilateral reduction with more than 1500 g resected in at least one breast. Multinomial logistical regressions were used to identify associations between comorbidities, operative techniques, postoperative complications, and nipple areolar complex function.

Results

Thirty-one patients underwent bilateral reduction mammaplasty. Total bilateral resection weight and average body mass index (BMI) were 3828 g and 40 kg per m2. Common comorbidities were hypertension (38%) and tobacco use (26%). MPWP was used predominantly (65%), followed by inferior pedicle (16%) and superior-medial pedicle (10%). Complications included loss of nipple areolar complex sensation (23%) and wound dehiscence (16%). Reduction technique was not associated with increased surgical complications (odds ratio = 0.75, P = 0.273). Age, excision amount, use of postsurgical drains, and BMI were not associated with increased complications (P = 0.29, P = 0.55, P = 0.74, P = 0.41). Rates of areolar sensation loss were higher in larger BMIs, but this was not statistically significant (P = 0.051).

Conclusions

The MPWP reduction technique is an equally safe and effective treatment of gigantomastia when compared with reduction with free nipple graft reconstruction. There is the added benefit of preserved nipple sensation without increased postoperative complications.

Virginal Breast Hypertrophy: A Case Report

Virginal breast hypertrophy, also known as juvenile macromastia or juvenile gigantomastia, is an uncommon condition characterized by the rapid and excessive growth of breasts in prepubertal or peripubertal girls in the absence of any hormonal or physiological causes. While virginal breast hypertrophy is a rare benign disorder that occurs independent of hormonal stimulation, it can cause a diagnostic challenge to physicians and requires a multidisciplinary team to get it right. It also results in detrimental effects, both physical and psychological, for young girls. We present a case of virginal breast hypertrophy in an 11-year-old Saudi girl, which was successfully managed. This report will contribute to knowledge sharing with healthcare professionals in Saudi Arabia about this rare case. It can also pave roads for further research to understand the underlying mechanisms and to standardize treatment modalities.

Is Preoperative Asymmetry a Predictor of Postoperative Asymmetry in Patients Undergoing Breast Reduction?

Plastic surgeons aim to achieve symmetry in breast surgeries, which is the main determinant of chest aesthetics. The aim of this study was to verify if preoperative breast asymmetry is a predictor of postoperative asymmetry in women undergoing breast reduction. In this prospective study, we enrolled 71 women (the mean age 37 years, SD 10 years) with breast hypertrophy who underwent reduction mammaplasty. We collected clinical data including age, height, weight, weight of the resected tissues, and performed pre and postoperative photographic documentation. The following measurements of both breasts were analyzed: volumes (vol), nipple-sternal notch distance (A-sn), difference between nipples' levels (A-A'), nipple-midline distance (A-ml), difference between inframammary folds levels (IF-IF'), distance between inframammary fold and nipple (IF-A), distance between inframammary fold apex and midline (IF-ml). All measurements were performed preoperatively and 6 months after the surgery and asymmetries of all variables were calculated (asy-vol, A-A', asyA-sn, asyA-ml, IF-IF', asyIF-A, asyIF-ml). Postoperative asymmetry of breast volumes and nipples position was not associated with any of the analyzed clinical variables. Postoperative asymmetry of nipples' level was associated with preoperative asymmetry of IF-ml; however, logistic regression did not detect any preoperative measurement influencing postoperative volume and nipples' level asymmetry. Moreover, we found that preoperative asyIF-ml increased the risk of postoperative volume asymmetry, which is above the average (52 cc) (OR = 2.04). Postoperative breast asymmetry after breast reduction is not related neither to preoperative asymmetries nor clinical variables; however, asymmetry of inframammary fold apex to the midline may be the factor affecting postoperative volumetric asymmetry.

Outcomes of Extended Pedicle Technique vs Free Nipple Graft Reduction Mammoplasty for Patients With Gigantomastia

BACKGROUND

Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG).

OBJECTIVES

The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG.

METHODS

A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes.

RESULTS

Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience.

CONCLUSIONS

This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia.

LEVEL OF EVIDENCE: 4

Repeated recurrence of bilateral gigantomastia after subcutaneous mastectomy caused by tumoral pseudoangiomatous stromal hyperplasia: a case report and review of literature

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign proliferative mesenchymal lesion of the breast with a hormonal-sensitive nature. Various manifestations of PASH, ranging from an incidental microscopic finding in a tissue biopsy to a large palpable mass or bilateral gigantomastia, have been described. For tumoral PASH, surgical excision is indicated for a growing and symptomatic mass with a small chance of recurrence. A recurrence of bilateral gigantomastia after surgical excision or reduction mammoplasty is not common but has been occasionally reported, leading to further mastectomy. Repeated recurrence of bilateral gigantomastia is extremely rare. Herein, we report a case of a 13-year-old girl who presented with the third recurrence of bilateral gigantomastia caused by tumoral PASH, after undergoing bilateral reduction mammoplasty, and later subcutaneous mastectomy. Precocious puberty occurred early in this child at the age of 9 years, which may have been a factor unmasking PASH at this young age. The incomplete removal of the PASH could also have been a recurrence risk in our case as extended masses underneath the pectoralis muscle were later identified on the MRI study. This highlights the advantage of preoperative imaging in cases with a very large tumoral PASH in order to maximize the chance of complete tumor removal.

A Systematic Literature Review of the Clinical Presentation, Management, and Outcome of Gestational Gigantomastia in the 21st Century

BACKGROUND

Gestational gigantomastia (GG) is an uncommon pregnancy condition, and the underlying cause of GG has yet to be determined. Medical management and surgery are two treatment options for GG, and breast reduction or mastectomy with delayed reconstruction is the only available surgical option. We have conducted this systematic review to summarize and critically analyze all the GG data in the literature.

METHODS

The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines were adhered to in reporting this article. A systematic search was conducted in February 2022 for published case reports and case series on GG using the PubMed, MEDLINE, and Cochrane databases. The following keywords were used: macromastia, gestational gigantomastia, and gestational.

RESULTS

A total of 639 articles were searched, and only 66 case reports published between 1962 and 2022 were included. The mean patient's age at presentation was 28.79 years old. The majority of the patients were in their first trimester (n = 23, 47%). The main complaint was rapid bilateral breast enlargement (n = 54, 80.59%). Bromocriptine was the most common medical management used (n = 19/35, 54.28%). Bilateral breast reduction was the most common surgery (n = 24/48, 50%). Most patients had uneventful recovery (n = 40/54, 74.07%).

CONCLUSION

Gigantomastia is a difficult condition, in terms of its management. We have found that surgery is the gold-standard among all the cases reported; while Bromocriptine was the most commonly administered medical therapy. This systematic review provides a guideline for plastic surgeons to better facilitate their care of these patients.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast Fluctuating Asymmetry in Women with Macromastia/Gigantomastia

BACKGROUND

A number of studies have reported breasts have high fluctuating asymmetry (FA:|Right-Left|), suggesting that they contain evolutionary and clinical information (e.g., high FA correlates with breast cancer risk). Here we focus on breast FA in women with a wide range of breast sizes, including participants with macromastia and/or gigantomastia.

MATERIAL AND METHODS

The sample included 65 women (mean age 33.97 ± 12.1 years). Thirty were randomly selected students and/or patients who regarded their breast size as small, normal or average and who had not undergone or intended to have any breast surgery. The remainder (n = 35) were qualified for breast reduction due to macromastia and/or gigantomastia. In all participants we measured/calculated weight, height and BMI, as well as took chest photographs. Breast volumes and nipple areola complex FAs were evaluated in a specifically-designed software.

RESULTS

Breast size significantly positively correlated with breast volume FA in all women (t = 5.17, p < 0.0001) and in women with macromastia/gigantomastia (t = 2.32, p = 0.027). All nipple location FAs correlated positively with breast size.

CONCLUSIONS

In women with different breast sizes, breast size correlates with FA calculated from breast volume and nipple location FAs. In women with macromastia and/or gigantomastia, breasts present higher FA than "normal" breasts. This observation may give a rationale for earlier and more frequent prophylactic breast imaging in women with macromastia and/or gigantomastia.

A case report of prepubescent idiopathic gigantomastia with pseudoangiomatous stromal hyperplasia

INTRODUCTION

This is an interesting case of a prepubescent female diagnosed and treated for gigantomastia, of unknown cause.

PRESENTATION OF CASE

Gigantomastia treated with surgical intervention with the final pathology being that of Pseudoangiomatous stromal hyperplasia.

DISCUSSION

Hormonal manipulation, as a treatment, was considered before surgical intervention. It was discarded as deemed, in accordance to published cases, to be slow and inconsistent and would not allow the breast tissue to regress.

CONCLUSION

We describe our approach and successful surgical management, in such an unusual case, to add our experience to the limited reporting in the literature.

Gigantomastia as a Cause of Pulmonary Hypertension

Reduction mammaplasty is the gold standard treatment for gigantomastia. We report one female patient with juvenile gigantomastia associated with severe pulmonary hypertension where her pulmonary pressure decreased significantly after the surgery, improving her quality of life. A 22-year-old female patient with gigantomastia since 10 years old, tricuspid regurgitation, and pulmonary thromboembolism antecedent was admitted to the emergency department. Her oxygen saturation was 89%. Acute heart failure management was initiated. An echocardiogram reported left ventricle ejection fraction (LVEF) of 70% with severe right heart dilation, contractile dysfunction, and arterial pulmonary pressure (PASP) of 110 mm Hg. A multidisciplinary team considered gigantomastia could generate a restrictive pattern, so a Thorek reduction mammoplasty with Wise pattern was performed. Presurgical measurements were: sternal notch to nipple-areola complex, right 59 cm, left 56 cm. Three days after surgery, the patient could breathe without oxygen support. In the outpatient follow-up, patient referred reduction of her respiratory symptoms and marked improvement in her quality of life. Six months after surgery, a control echocardiogram showed a LVEF of 62% and PASP of 85 mm Hg. Pulmonary hypertension may be present in patients with gigantomastia. Reduction mammoplasty may be a feasible alternative to improve the cardiac signs and symptoms in patients with medical refractory management.

Genetic Factors of Idiopathic Gigantomastia: Clinical Implications of Aromatase and Progesterone Receptor Polymorphisms

The role of estrogen, progesterone, their receptors and aromatase in the development of the breast is well documented. In this study we examined the association of genetic variants of progesterone receptor (PGR) and aromatase (CYP19A1) genes with gigantomastia risk. We conducted a case-control study among 124 women: 60 with gigantomastia and 64 controls. We examined the single nucleotide polymorphisms (SNPs) for CYP19A1 (rs749292 and rs7172156) and PGR (rs1042838). Our results showed that allele G in rs749292 (CYP19A1) increased the risk of gigantomastia, but not significantly (p = 0.09). There is a correlation between rs1042838 (PGR) and waist-to-hip ratio (WHR) in women with gigantomastia-AC genotype correlates with lower WHR and CC with higher WHR. There were no correlations between the onset of gigantomastia, the age of menarche and the length of the menstrual cycle, and rs1042838, rs749292 and rs7172156. We did not find differences in the SNP of PGR (rs1042838) between women with gigantomastia and controls. However, our findings showed more frequent G allele in CYP19A1 (rs749292) in women with gigantomastia.

Effect of Reduction Mammoplasty on Pulmonary Function Tests: A Systematic Review

ABSTRACT

In patients with breast hypertrophy, excessive breast weight applies pressure on the thorax, which may disrupt the normal breathing. The purpose of this study is to evaluate the impact of the breast hypertrophy and reduction mammoplasty on respiratory function. A comprehensive search of 3 databases, PubMed, Ovid, and Scopus databases, was performed. "Mammoplasty" and "respiration or pulmonary function tests" were the keywords used to search for relevant articles. Ten studies involving 280 patients with breast hypertrophy were included in the final review. Seven articles demonstrated an increase in at least 1 pulmonary function test value after the surgery. This systematic review revealed that, preoperatively, pulmonary function test values of the patients are usually in the normal range. Nonetheless, reduction mammoplasty still improves lung function parameters. Additionally, patients with respiratory complaints felt improvement in their symptoms after the surgery. However, future studies are needed, as heterogeneity among studies was observed.

Double-Unit Superomedio-Central (DUS) Pedicle Inverted-T Reduction Mammaplasty in Gigantomastia: A 7-year Single-Center Retrospective Study

Introduction

Reduction mammaplasty in patients with gigantomastia is challenging. The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is the standard technique for reduction mammaplasty in our clinic. The aim of this study was to review our approach in cases with gigantomastia in comparison with the current literature.

Patients and Methods

From 01/2011 to 12/2017, we performed 831 reduction mammaplasties in 630 patients. The Double-Unit  Superomedio-Central  (DUS) pedicle and inverted-T incision was implemented as a standard procedure for gigantomastia. Patient demographics and the outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility, and surgical revision rate were obtained and retrospectively analyzed.

Results

In 37 patients, 55 reduction mammaplasties were performed with more than 1000 g per breast. Mean resection weight was 1311 g on right side and 1289 g on left side. Mean age was 52.5 years, mean body mass index was 32.8 kg/m², mean sternal-notch-to-nipple distance was 38.3 cm. A free NAC graft was necessary in four breasts. Overall complication rate was 14.5%; secondary surgical revision rate was 12.7%. 91% of the patients were “very satisfied” and “satisfied” with the aesthetic result. Nipple sensibility was rated “high” and “medium” in 83%.

Conclusion

The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is very effective to achieve volume reduction and aesthetically pleasing reproducible results with a low complication rate in cases with gigantomastia.

Level of Evidence

Level of Evidence This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02351-y.

Reduction Mammoplasty: A Ten-Year Retrospective Review of the Omega Resection Pattern Technique

Reduction mammoplasty is the gold standard procedure for symptomatic breast hypertrophy and it is also used for contralateral breast symmetrisation following breast cancer surgery. We aim at introducing a new procedure, which uses an omega resection pattern to simplify the inferior pedicle breast resection technique. A retrospective review of all patients who underwent the omega resection reduction mammoplasty at the University Hospital of Basel between 2010 and 2020 was carried out. We collected patient demographics, surgical outcomes, operation time, type and frequency of complications at 12 months follow-up. Outcomes were compared with the most commonly used techniques. Additionally, we assessed if patients’ and clinical characteristics augmented/diminished the complication rate. During the study period, 67 reduction mammaplasties were performed by a senior plastic surgeon (M_age = 42.5, SD_age = 15.6; M_BMI = 27.28, SD_BMI = 3.4; 20% smokers). The average tissue removed was 826 g (ranging from 15 to 2307 g). In 10 breasts (15%) occurred minor complications. No major complications were reported. Operation time (M = 149 min; ranging from 87 to 270 min) was significantly shorter than the inferior, superomedial, and superior pedicle techniques. Univariate Odd Ratios showed that no-smoker status, a BMI in a normal range, resection weight between 500 g to 1500 g, NTN distance < 30 cm, removal of drains one day after the operation, ASA index of 2, inpatient clinic hospitalisation, and not undergoing other concomitant surgical operations were protective factors against the risk to develop complications. The omega resection pattern technique demonstrated to be an effective, safe, and fast mammoplasty reduction procedure for bilateral macromastia and unilateral symmetrizing procedures, even for large breasts, able to be adopted as a new valid alternative to the existing ones.

Idiopathic gigantomastia in a patient on polypharmacy

Gigantomastia is an uncommon benign condition characterized by massive breast enlargement. It is most often due to hormonal imbalance secondary to puberty or pregnancy, or induced by a pharmacological agent but can also be idiopathic. Herein, we report a rare case of idiopathic gigantomastia in a 46-year-old female on antiepileptic multiple-drug therapy who underwent total bilateral mastectomy to relieve associated pain.

Myo-Glandular Flap Breast Reduction: Preventing the Bottoming out Deformity-A Novel Technique

Large, heavy breasts are a common complaint among women causing various functional and aesthetic concerns. The plastic surgery community has offered a variety of surgical techniques to address this condition. Most of these operations developed during the 1970s-1980s cemented their place in history as fundamentals of breast reduction surgery and are still widely taught today. Despite ongoing plastic surgery advances, long-term complications surrounding breast reduction surgery remain a concern, even to experienced surgeons. Its apparent trends have shifted focus over time; from the basics of developing a patient-safe and easily replicable technique, toward developing more refined maneuvers allowing surgeons to reach desired and long-lasting outcomes while preventing known complications. The bottoming out phenomena, lack of nipple areola complex sensitivity, upper pole emptiness with low setting breasts and high revision rates still plague the breast reduction landscape. We present a novel technique involving a pectoralis major-based myo-glandular flap with breast parenchymal suspension to the upper chest wall to combat bottoming out and upper pole emptiness. These procedural elements allow the breasts to attain not only acceptable results, with smaller, round and well-projected breasts, but also to create an active opposing vector to resist the gravitational forces which otherwise pull breast tissue inferiorly creating the bottoming out deformity.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Successful management of diffuse bilateral pseudoangiomatous stromal hyperplasia of the mammary glands by reductive mammoplasty

Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast condition commonly presented as an incidental microscopic finding. However, it can also manifest as a mass-forming lesion (tumorous PASH) or as gigantomastia (diffuse PASH). Most of the previously reported cases are unilateral tumorous PASH treated by mastectomy. In this article, we reported a rare case of diffuse bilateral PASH. A 21-year-old woman presented with a two-year history of bilateral breast enlargement and neck pain. Physical examination revealed asymmetrical bilateral macromastia with profound ptosis. Breast ultrasound demonstrated no cysts or masses in both breasts. The decision was made to perform an inverted T bilateral reductive mammoplasty which was performed successfully through a superior-central pedicle approach. Microscopic examination of the specimens confirmed the diagnosis of PASH without any evidence for malignancy. Nine months postoperatively, the size for both breasts was optimal the patient was satisfied. Recognition and reporting of this rare form of PASH is essential for proper investigation, pathology understanding, risk factors recognition, prognosis assessment and treatment methods selection.

Severe Gestational Gigantomastia: from Mastectomy to Staged Autologous Breast Reconstruction. A Case Report

Gestational gigantomastia (GGM) is a rare condition characterized by a massive overgrowth of breast tissue during pregnancy. Surgical sanction may be required when conservative measures fail. In this study, we report the case of a 29-year-old woman who presented with an evolutive GGM responsible for physical and emotional distress, despite medical treatment. A multidisciplinary decision was made to induce delivery at 32 weeks. In the postdelivery period, the patient developed breast wounds, complicated with septic cardiomyopathy. An emergency bilateral mastectomy was then carried out, together with banking of both nipple-areola complexes. Thereafter, delayed bilateral 2-stage breast reconstruction was started at 12 months with subcutaneous tissue expanders, later on followed by implants removal and autologous reconstruction with bilateral deep inferior epigastric artery perforator flaps and bilateral nipple replantation.

Management of gestational gigantomastia with breast reconstruction after mastectomy: case report and literature review

Gestational gigantomastia (GGM) is a rare complication of pregnancy. The etiology of GGM is yet to be fully established. Treatment methods for GGM include medical therapy and surgery. If medical treatment is unsuccessful, surgery may be required. Currently available surgical interventions are either breast reduction or mastectomy with delayed reconstruction. We report a case of a 25-year-old woman (G1P1) who presented with massive enlargement of both breasts during puerperium. Because of the limited effect of medical therapy, surgical intervention was considered to be the first choice. Bilateral mastectomies with grafting of the nipple–areola complex and immediate bilateral tissue expander implantation were performed. Reconstruction was fully completed 8 months after the initial procedure by replacing tissue expanders with definitive implants. Despite being a benign condition, GGM can turn into a serious problem. GGM can be successfully reconstructed by mastectomy with delayed reconstruction and grafting of the nipple–areola complex.

Superiomedial Pedicle Breast Reduction for Gigantic Breast Hypertrophy: Experience in 341 Breasts and Suggested Safety Modifications

BACKGROUND

Reduction mammoplasty in patients with gigantic breast hypertrophy runs a high risk of complication. Traditionally, inferior pedicle reductions or free nipple grafting techniques have been recommended for gigantic breasts on the basis of measurements and expected resection weights. The superiomedial pedicle (SMP) technique has been less commonly used, due to concerns of vascular inadequacy. This study examines the outcomes of SMP in large reductions and outlines suggested modifications for enhanced safety.

METHODS

This is a retrospective review of all patients who underwent SMP breast reduction in our institution between 2005 and 2016. Included are cases with resection weights greater than 800 g.

RESULTS

A total of 173 patients with 341 breasts were included. Mean sternal notch to nipple (SNN) distance was mean 35.0 ± 6.6 cm (range 23-44.5) on the left and 34.9 ± 6.6 cm (range 18-46) on the right. Mean resection weight was 1152.2 ± 368.6 g (range 810-2926) on the left and 1159.4 ± 326.6 g (range 800-2528) on the right. The total complication rate was 22.7%. Minor complications occurred in 63 (18.6%) breasts. Major complications occurred in 12 (4.1%) breasts. NAC congestion and partial necrosis occurred in 1.8% and total NAC necrosis in 0.9%.

CONCLUSION

The SMP reduction technique is a safe option for gigantic breast reduction with comparable complication rates to other techniques. Preoperative measurements or resection weights are not reliable risk factors alone. High tissue density may be a significant risk factor. High-risk breasts mandate surgical planning and should be tailored to include technical modifications as described.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Gestational gigantomastia with fatal outcome

Gigantomastia is a rare disease defined by an extreme and rapid enlargement of the breast, generally bilateral. The majority of cases are reported in pregnant women. Ninety-eight cases of gestational gigantomastia have been identified in electronic databases, and those with fatal outcomes comprised only 2 cases (2%). Despite its benign nature, it can lead to severe complications and even death. Its etiology has not been fully elucidated, but it has been speculated that a hormonal component may play a role in the pathogenesis. Currently, treatment options are limited, and surgery is gaining importance, but it is often not feasible in low-resource settings. Herein, we describe a case of a 30-year-old HIV-positive female with no relevant past medical history, who died due to the complications of gestational gigantomastia at the Maputo Central Hospital, in Mozambique.

The Nomenclature, Terminology and Lexicon of Breast Surgery: Are We Really Saying the Same Thing?

This study investigated inconsistencies in the use of descriptors in breast surgery and recommends a novel nomenclature that will be adopted and standardized among plastic surgeons. The study used a modified Delphi methodology to first identify redundant descriptors or those with multiple interpretations, and then achieve consensus on ideal recommended nomenclature in breast surgery. The Delphi panel agreed that there was misuse of and lack of a clear definition for several terms, and recommended removal of these subjective terms. Replacement with more anatomic nomenclature was suggested. Stretch deformity, pectoral banding, and implant-gland mismatch were introduced as new terms.

A case of acute onset gigantomastia in a 20-year-old woman

Gigantomastia is an abnormal and rare breast condition characterized by excessive breast tissue growth that can result in physical and psychosocial debilitation. While the etiology is not fully understood, it is postulated that abnormal endogenous hormone stimulation plays a contributory role and often requires mastectomy for definitive treatment. Proliferation of all elements is commonly observed, including glands, ducts, stroma, fat, vessels and skin. Pseudoangiomatous stromal hyperplasia (PASH) is an additional benign breast disease defined microscopically by proliferation of mammary stroma. PASH often clinically presents as an incidental finding while evaluating other benign or malignant lesions, or less commonly as a palpable, well-circumscribed breast mass. Uncommon cases have been reported in which PASH presents as a bilateral, diffuse process. In this case presentation, we report a rare case of a 20-year-old woman presenting with acute onset gigantomastia most likely due to diffuse PASH.

Body size measurements, digit ratio (2D:4D) and oestrogen and progesterone receptors' expressions in juvenile gigantomastia

Background Juvenile breast hypertrophy is characterised by massive enlargement of the breast in the peri-pubertal period. We aimed to analyse body size measurements (body mass index [BMI], waist-to-hip circumference ratio [WHR]), digit ratio (ratio of II and IV digits' length [2D:4D]) and oestrogen receptor (ER) alpha (ERα) and progesterone receptors (PRs) in the breast gland in women with juvenile gigantomastia. Methods The study involved 30 women (mean age 25.7 years) (mean age of onset - 14.8 years). ERα and PR expressions were detected immunohistochemically in breast gland samples. For comparison, 100 controls (50 women and 50 men) were included. Results BMI and WHR in women with gigantomastia were higher than in control women and the former had a higher WHR than expected for their BMI. 2D:4D in the examined women did not differ from that in control women. However, left 2D:4D was negatively related to the age of gigantomastia onset. There were no correlations between ER and PR expressions and the analysed body and digit ratios. Conclusions The lack of a relationship between 2D:4D and juvenile breast hypertrophy may suggest that foetal exposure to sex hormones may not be crucial in its aetiology. However, the link between high left 2D:4D and early development of gigantomastia suggests that prenatal sex hormones have a role in its development timing. High WHR, and particularly high WHR relative to BMI, may indicate that these women had at some stage of development higher circulating androgens, which may have been converted to oestrogens in breasts due to local aromatase activity. Verification of this hypothesis could allow consideration of the role of aromatase inhibitors in juvenile breast hypertrophy.

Batwing mammoplasty: a safe oncoplastic technique for breast conservation in breast cancer patients with gigantomastia

BACKGROUND

Surgical management of breast cancer with gigantomastia can be challenging when planning breast conservation, as major breast reduction is required. Complex oncoplastic procedures can carry an additional surgical risk in this situation. We suggest batwing mammoplasty as a simple and safe oncoplastic procedure for those patients.

MATERIALS AND METHODS

Fourteen patients with gigantomastia diagnosed with breast cancer were included in this prospective cohort study. All underwent batwing mammoplasty and contralateral symmetrisation procedure between May 2016 and June 2018. Patient satisfaction assessed by the Breast-Q questionnaire.

RESULTS

All patients had a body mass index above 30kg/m2 with a mean of 36.7kg/m2 (range 31.6-44.9kg/m2). The mean distance from midclavicular point to nipple was 42cm (range 38-50cm). The mean operative time was 83 minutes for procedures done by a single surgeon. Mean specimen weight was 1.2kg (ranging from 1.035-1.63kg). Postoperative complications occurred in 14.2% of patients. Nipple-areola complex viability was not compromised nor sensation impaired. The mean Breast-Q score for patient satisfaction with breasts was 68.6 (range 61-74). The mean score for physiological wellbeing was 77.3 (range 64-84) and the mean score for physical wellbeing was 35 (range 31-40).

CONCLUSION

Batwing mammoplasty is a safe and simple oncoplastic procedure in patients who have breast cancer with gigantomastia. It has short operative time and low complications rate. In our cohort of patients, there was no delay in the delivery of adjuvant treatment. The cosmetic outcome was favourable with a high patient satisfaction.

Clinical Presentations of Breast Disorders in Pregnancy and Lactation

The breast tissue undergoes significant physiological change during pregnancy and lactation. These changes can give rise to some unique disorders during pregnancy , puerperium and lactation or exaggerate pre-existing conditions. Clinical examination becomes less reliable due to textural change and density of breast tissue as a result of hormonal changes. The main symptoms during pregnancy and lactation are breast pain, mastitis, lactational abscess, breast lump, and blood- stained nipple discharge.Lactational mastitis/ abscess must be treated without delay. Open incision and drainage of lactational abscess is rarely required, any lactational abscess should be treated with appropriate antibiotics and ultrasound guided aspiration of the pus.Any breast lump during pregnancy and lactation should be investigated with triple assessment. Pregnancy associated breast cancer (PABC ) must be ruled out. The choice of investigations and treatment needs careful consideration. While ultrasound is the investigation of choice, mammography can be performed with abdominal shielding if malignancy is suspected. Core biopsy is necessary for evaluation of any breast pathology but it comes with risk of infection, bleeding, hematoma and even milk fistula.The treating clinical specialist must be aware of certain unusual unique clinical conditions in pregnancy and lactation including accessory axillary breast tissue, gigantomastia and Raynaud's phenomenon.

Idiopathic gigantomastia: newer mechanistic insights implicating the paracrine milieu

PURPOSE

Gigantomastia refers to pathological breast enlargement usually occurring in the peripubertal or peripartum period. Idiopathic gigantomastia, however, is a rare entity with hypotheses citing local expression of hormones and growth factors in causing this disease, none of which have been systemically analysed. The purpose of this study was to delve deeper into the mechanistic pathways causing this condition.

METHODS

Herein, we describe three patients of idiopathic gigantomastia, all of whom had had normal puberty and uneventful pregnancies. Further, one of the patients had postmenopausal gigantomastia which is extremely rare, with only four cases described in the literature. Serum markers of autoimmunity, incriminated hormones and growth factors analysed, were normal in all the cases. Breast tissue specimens were subjected to histopathological examination and immunohistochemistry for ER, PR and Her-2-Neu. Quantitative immunofluorescence for aromatase, IGF2, EGFR, TGF-β, PDGFR-α, β, IGF1 and PTHrP was also performed.

RESULTS

Of these, the tissue expression of aromatase, IGF2, EGFR, TGF-β, PDGFR-α and β were found to be upregulated, whereas IGF1 and PTHrP were comparable to normal breast.

CONCLUSION

This observation that paracrine overexpression of these factors is responsible for the pathogenesis of apparently idiopathic gigantomastia may have therapeutic ramifications in the future for patients with this debilitating condition.

The Place of Reductive Surgery in the Management of Gestational Ulcerative Gigantomastia: A Case Report at Sourô Sanou Teaching Hospital

Introduction

Gestational gigantomastia is a rare benign disease of unknown cause. We report a case of bilateral gigantomastia in pregnancy in order to locate the place of reductive surgery in its care which is quite controversial.

Case

A 25-year-old woman gravida 2 para 1 was referred for an exaggerated bilateral breast enlargement at 32-week gestation. The examination showed bilateral giant breasts with collateral venous circulation and trophic changes marked by the necrosis of the distal third of the mammary skin involving the nipple-areolar complex. She underwent a biopsy of the ulcerative breast tissue, and the histology report did not show a malignant cell. After active foetal lung maturation and induced delivery, a breast reductive surgery with nipple plasty was performed 21 days postpartum. The postoperative course was marked by a period of lymphangitis. The cosmetic and psychological result was satisfactory at 6 months and at 18 months.

Conclusion

Gestational gigantomastia is a benign disease that can simulate carcinomatous mastitis. The breast reductive plasty keeps its place in our context.