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A Long Term Review of Surgically Treated Enlarged Breasts

Authors:
  • Kwame Nkrumah University of Science and Technology (KNUST), Kumasi-Ghana

Abstract

Introduction: Breast hypertrophy (excessive enlargement of breast), a condition though rare, is well pronounced in some females. Surgery either by reduction mammaplasty or sub-cutaneous mastectomy is often employed in treatment of this condition. Aim: This study seeks to find out the long term level of satisfaction of the surgery on these persons after about 10 - 12 years after treatment. Materials and Methods: From January 1994 to December 2000, the Komfo Anokye Teaching Hospital (KATH) carried out surgeries on 43 females who presented with several degrees of breast hypertrophy. Patients were asked to answer questionnaires on their condition pre-operatively and post-operatively during the long term review process. Results: Thirty-four (79.1%) patients out of the 43 were available for the review with the patients stating there was much (100%) improvement in terms of the pain they felt in the neck, upper and lower back regions. There was no re-occurrence of the condition in any of the patients; 29 (85.3%) stated they were satisfied and that their new breast size(s) was/were excellent for them. Conclusion: The pre-operative complications experienced by these patients were resolved hence this surgical procedure was good and the quality of life of these persons had been improved.
Modern Plastic Surgery, 2013, 3, 113-119
http://dx.doi.org/10.4236/mps.2013.34023
Published Online October 2013 (http://www.scirp.org/journal/mps)
113
A Long Term Review of Surgically Treated
Enlarged Breasts
*
Pius Agbenorku
Reconstructive Plastic Surgery & Burns Unit, Department of Surgery, Komfo Anokye Teaching Hospital, School of Medical Sci-
ences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana.
Email: pimagben@yahoo.com
Received July 4
th
, 2013; revised August 3
rd
, 2013; accepted August 11
th
, 2013
Copyright © 2013 Pius Agbenorku. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Introduction: Breast hypertrophy (excessive enlargement of breast), a condition though rare, is well pronounced in
some females. Surgery either by reduction mammaplasty or sub-cutaneous mastectomy is often employed in treatment
of this condition. Aim: This study seeks to find out the long term level of satisfaction of the surgery on these persons
after about 10 - 12 years after treatment. Materials and Methods: From January 1994 to December 2000, the Komfo
Anokye Teaching Hospital (KATH) carried out surgeries on 43 females who presented with several degrees of breast
hypertrophy. Patients were asked to answer questionnaires on their condition pre-operatively and post-operatively dur-
ing the long term review process. Results: Thirty-four (79.1%) patients out of the 43 were available for the review with
the patients stating there was much (100%) improvement in terms of the pain they felt in the neck, upper and lower
back regions. There was no re-occurrence of the condition in any of the patients; 29 (85.3%) stated they were satisfied
and that their new breast size(s) was/were excellent for them. Conclusion: The pre-operative complications experienced
by these patients were resolved hence this surgical procedure was good and the quality of life of these persons had been
improved.
Keywords: Breast Hypertrophy; Reduction Mammaplasty; Sub-Cutaneous Mastectomy; Quality of Life; Satisfaction
1. Introduction
The breast is a sign of female sexual identity. The breasts
are hemispheric and located anteriorly on the pectoralis
major muscle. In the average young lady the breasts have
elliptical bases located between the second and sixth ribs
vertically; horizontally they lie between the midaxillary
line and the lateral edge of the sternum [1]. In breast-
feeding women, milk produced from the breast provides
nourishment for the babies.
Breast enlargement is a normal physiological process
that occurs in females; however it becomes a disorder
when the breast enlargement becomes pronounced caus-
ing discomfort and hardship to persons and thus affecting
their normal daily life and activities. This anomaly has
been divided into three categories namely: juvenile breast
hypertrophy or virginal/pubertal/juvenile macromastia,
gestational macromastia (macromastia occurring during
pregnancy) and macromastia in adult women with no
identifying cause.
Virginal breast hypertrophy/juvenile gigantomastia/
juvenile macromastia is the excessive enlargement of the
breast tissue or diffuse enlargement of breasts in young
women in early teen years. This excessive enlargement
of breasts usually causes both physical and psychosocial
problems [2-4] and could eventually affect their future. It
usually occurs in girls between 8 to 16 years with rapid
enlargement of breasts; hormonal studies in these indi-
viduals are normal [5-7]. Although it is a benign con-
dition and may not necessarily lead to death of the indi-
vidual, it causes the individual to develop negative self
image and hence affects the individual’s life in totality.
The growth is usually bilateral though cases of unilateral
hypertrophy have also been reported [7,8]. The aetiology
of juvenile breast hypertrophy is uncertain [5-7]. Al-
though virginal breast hypertrophy occurs sporadically,
some familial cases have also been reported [5,9].
Usually the sizes of both breasts vary in a way result-
ing in asymmetry. Due to the nature of the breast and
size, they usually find it difficult to get the right sized bra
*
Conflict of interest: The author declares that he has no conflict o
f
interest to disclose.
Cop
yright © 2013 SciRes. MPS
A Long Term Review of Surgically Treated Enlarged Breasts
114
to fit them. Also, the weight of the breasts causes intense
pain in their neck and upper region; the condition inca-
pacitates them from partaking in some activities such as
sports.
Treatment of breast hypertrophy is by surgical proce-
dure which may be reduction mammaplasty or subcuta-
neous mastectomy with simultaneous or secondary breast
implant placement depending on the condition. Improve-
ments in the quality of life of persons who have under-
gone surgery by reduction mammaplasty have also been
documented [10-12]. Accurate diagnosis is necessary be-
fore surgery; mammography is needed to exclude any
underlying tumour. However, some authors require sur-
gery be carried when the breasts have fully developed
since this may result in avoidance of multiple operations
[13,14]. Studies by Agbenorku et al. from Komfo Ano-
kye Teaching Hospital (KATH) revealed an increase in
the number of patients presenting with symptomatic ma-
cromastia in the Plastic Surgery Unit of KATH [15-17].
This study seeks to find out the long term satisfaction of
these persons after surgery.
2. Materials and Methods
2.1. Study Setting
Komfo Anokye Teaching Hospital (KATH), located in
Kumasi is the second-largest hospital in Ghana and the
only tertiary health institution in the middle belt of the
country. It is the main referral hospital for the Ashanti,
Brong-Ahafo, Northern, Upper East and Upper West
Regions.
2.2. Data Collection and Analysis
From January 1994 to December 2000 forty-three (43)
females suffering from enlarged breasts (macromastia/
breast hypertrophy) presented themselves to KATH Plas-
tic Surgery Unit where they consented to undergo sur-
gery depending on the condition each presented. Inferior
pedicle was employed in patients (20 - 39 years) who un-
derwent reduction mammaplasty whiles nipple areolar
grafts was employed in patients who underwent subcuta-
neous mastectomy with implants (19 years and younger).
For the review exercise the patients were contacted
using the addresses given and by telephone calls. The
consents of these patients were sought and they were
presented with questionnaires by the assistant research
officer. This review was undertaken from April 2011
through to March 2012.
Information obtained was displayed descriptively in
tables using SPSS version 18.0 (SPSS, Inc., Chicago, IL,
USA).
2.3. Ethical Clearance
Ethical Clearance was obtained from the Kwame Nkru-
mah University of Science and Technology School of
Medical Sciences/Komfo Anokye Teaching Hospital Com-
mittee on Human Research, Publication and Ethics, Ku-
masi.
3. Results
Reduction mammaplasty was carried out on 25 patients
while subcutaneous mastectomy with simultaneous breast
implant placement was carried out on 18 patients. Bilat-
eral hypertrophy was recorded in 39 patients while uni-
lateral cases were recorded in 4 patients. Average tissue
excised from each breast was 4000 g. Out of the 43 pa-
tients who had undergone surgery, 34 (79.1%) were
available for the review. The patients were all females
with ages ranging from 10 - 39 years at the time of sur-
gery and 20 - 49 years post-surgery (review time) (Table
1).
There was no re-occurrence of the conditions recorded
after surgery during this long term review (Figures 1-5).
The pre- and post-operative conditions were displayed
and listed in “Table 2”.
Persons who experienced complications after surgery
during the follow up were asked to grade the extent of
complication as being 1-Bad, 2-Worse or 3-Worst (Table
3).
4. Discussion
4.1. Physiological Complications
Breast hypertrophy is associated with a lot of discomfort
creating various inconveniences for individuals suffering
from the condition. Breast reduction and subcutaneous
mastectomy are some of the surgical procedures which
help to alleviate these pains and discomfort.
Breast hypertrophy poses serious effects on the mus-
coskeletal system resulting in upper/lower back pain,
shoulder pain, neck pain and shoulder grooving. From
this study, pre-operatively, 30 (88.2%) reported experi-
encing neck pain, all 34 (100.0%) patients reported ex-
Table 1. Age distribution of the patients at surgery and
post-surgery times (those who were available for the re-
view).
Pre-surgery (years) Frequency
Post-surgery Review
(years)
10 - 14
5 20 - 24
15 - 19
13 25 - 29
20 - 24
4 30 - 34
25 - 29
5 35 - 39
30 - 34
4 40 - 44
35 - 39
3 45 - 49
Copyright © 2013 SciRes. MPS
A Long Term Review of Surgically Treated Enlarged Breasts
Copyright © 2013 SciRes. MPS
115
(a) (b) (c)
Figure 1. A 16-year-old girl: (a) Pre-surgery; (b) Immediate post-surgery; (c) Long-term post-surgery results.
(a) (b) (c)
Figure 2. A 13-year-old girl: (a) Pre-surgery; (b) Immediate post-surgery; (c) Long-term post-surgery results.
(a) (b) (c)
Figure 3. A 12-year-old girl: (a) Pre-surgery; (b) Immediate post-surgery; (c) Long-term post-surgery results.
periencing shoulder pain, upper/lower back pain, shoul-
der grooving from bra straps and breast pain. Post-
operatively, the patients reported that the pains in all the
areas stated above had resolved and were no longer ex-
periencing any pain except for only one patient (2.9%)
who stated she was still experiencing some neck pain.
This pain in the neck region reported by this patient
might be caused by another disease or condition other
than the breast pathology. Sabino (2008) stated reduction
mammaplasty relieved pain in the lower back region in
patients with breast hypertrophy [18]. Relief from the
pre-operative complications by patients in the current
study is confirmed in a similar study by Davis et al.
(1995); they found out that reduction mammaplasty de-
creased breast size and significantly relieved pre-opera-
tive symptoms associated with mammary hypertrophy
[19]. Davis et al. (1995) reported further that pre-opera-
tive complaint of shoulder grooving (94%), shoulder
A Long Term Review of Surgically Treated Enlarged Breasts
116
(a) (b) (c)
Figure 4. A 14-year-old girl: (a) Pre-surgery; (b) Immediate post-surgery; (c) Long-term post-surgery results.
(a) (b) (c)
Figure 5. A 26-year-old girl: (a) Pre-surgery; (b) Immediate post-surgery; (c) Long-term post-surgery results.
Table 2. Pre- and post-operative conditions of the patients (N = 34).
Pre-operative No. of patients (percentage) Post-operative No. of patients (percentage)
Headache
23 (67.6) 3 (8.8)
Neck pain
30 (88.2) 1 (2.9)
Shoulder pain
34 (100.0) 0 (0.0)
Upper back pain
34 (100.0) 0 (0.0)
Lower back pain
34 (100.0) 0 (0.0)
Shoulder grooving
34 (100.0) 0 (0.0)
Pain/numbness in the finger(s)
28 (82.4) 0 (0.0)
Breast pains
34 (100.0) 0 (0.0)
Intertrigo
30 (88.2) 0 (0.0)
Difficulty in participating in sports
30 (88.2) 0 (0.0)
Difficulty finding clothes to fit
30 (88.2) 0 (0.0)
Teasing by people
34 (100.0) 0 (0.0)
Poor self image
34 (100.0) 0 (0.0)
Inability to breastfeed
7 (20.6) 18 (52.9)
Decreased milk production
4 (11.8) 8 (23.5)
Reduced nipple sensitivity
0 (0.0) 20 (58.8)
Nipple deformation
29 (85.3) 16 (47.1)
Copyright © 2013 SciRes. MPS
A Long Term Review of Surgically Treated Enlarged Breasts
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Tab
le 3. Extent of complications in the patients after surgery.
Bad (1) No. of
patients (percentage)
Worse (2) No. of
patients (percentage)
Worst (3) No. of
patients (percentage)
Inability to breastfeed
0 (0.0) 0 (0.0) 18 (52.9)
Decreased milk production
6 (17.7) 2 (5.9) 0 (0.0)
Reduced nipple sensitivity
15 (44.1) 3 (8.82) 2 (5.88)
Nipple deformation
7 (20.6) 4 (11.8) 5 (14.7)
Headache
2 (5.9) 1 (2.9) 0 (0.0)
Neck pain
1 (2.9) 0 (0.0) 0 (0.0)
pains (93%), back pain (81%) were significantly reduced
following surgery [19]. A similar retrospective study un-
dertaken to evaluate the long term results of reduction
mammaplasty by Brühlmann and Tschopp (1998) on 114
patients who underwent an average reduction of 1266 g
revealed 91.5% of the patients noticed a decrease in
shoulder, neck and back pain and lessening of brassiere
grooves [20].
From the current study, follow up revealed non-oc-
currence of the conditions. For 18 (52.9%) patients who
underwent sub-cutaneous mastectomy, they were in their
early teens and the result from this study showed non-
recurrence of the enlarged breast condition after about
twelve (12) years post surgery. Furnas (1982) also re-
ported that massive juvenile hypertrophy of the breast in
a 12-year old girl was successfully treated with subcuta-
neous mastectomy and secondary placement of gel-filled
silastic implants. Six years later, no evidence of further
residual breast tissue was noted [21]. However, some
studies have shown recurrence of the condition after sur-
gery by reduction mammaplasty. Samuelov and Sip-
lovich (1988) reported a case of a 12-year-old girl pre-
senting with juvenile breast hypertrophy who was treated
by bilateral reduction mammaplasty with free transplan-
tation of areolae and nipples and removal of 8200 g of
breast tissue. Eleven months later, subcutaneous mastec-
tomy with subpectoral tissue expander insertion was
performed due to recurrent breast enlargement with re-
moval of an additional 5000 g. Thus, with young girls,
subcutaneous mastectomy with simultaneous or secon-
dary breast implant placement is preferred to prevent any
recurrence [22].
In the current study pre-operatively, 23 (67.6%) re-
ported experiencing headache due to their condition;
however, post-operatively, 3 (8.8%) stated experiencing
headache with 2 (5.9%) and 1 (2.9%) stating theirs as
bad and worse respectively. This headache could also not
necessarily be connected to the surgery but rather maybe
caused by other disease conditions or even stress or anxi-
ety. Pain/numbness felt in fingers was reported by 28
(82.4%) before surgery and was totally resolved in all
these patients after surgery.
Intertrigo, a condition that occurs in moist area of the
skin is usually associated with breast hypertrophy. The
size and volume of the breast that lies against the chest
wall causes the skin under the breast to fold on each other
causing rash and ulceration beneath the breasts. Pre-
operatively, this condition was reported by 30 (88.2%);
post-operatively the condition had resolved in all the
patients.
Persons suffering from breast hypertrophy have al-
ways faced the challenge of participating in sports and
finding clothes to perfectly fit on them. In the current
study, 30 (88.2%) reported difficulty in participating in
sports and finding clothes to fit. However, after surgery,
all these persons stated they were able to exercise and
participated in any sport and also could easily find
clothes to fit them. This is confirmed by Raispis et al.
(1995) in their findings; they reported 65% of patients
who had undergone reduction mammaplasty stated they
could exercise more after surgery [23].
Pre-operatively, 7 (20.6%) in this study reported they
were unable to breast feed because of the pain they were
experiencing. Post-operatively, 18 (52.9%) reported they
were unable to breast feed; these people had all under-
gone subcutaneous mastectomy hence all breast tissue
had been removed and replaced with implants. These
persons who underwent subcutaneous mastectomy with
simultaneous breast implant placement were in their
early teens during time of surgery.
Decreased milk production pre-operatively was ex-
perienced by 4 (11.8%) patients, however, after surgery,
the number had increased to 8 (23.5%) with 6 (17.7%)
stating theirs as bad and 2 (5.9%) stating theirs as worse.
Patients who were made to grade the extent of milk pro-
duction had all undergone reduction mammaplasty and
hence their mammary gland was available for milk pro-
duction. The results obtained from this study showed that,
some patients experienced some degree of complication
relating to breastfeeding after reduction mammaplasty.
However, Aillet et al. (2002) carried out a study to assess
breastfeeding after reduction mammaplasty and con-
cluded that adolescents who underwent reduction mam-
maplasty could nurse their infants with a complication
Copyright © 2013 SciRes. MPS
A Long Term Review of Surgically Treated Enlarged Breasts
118
rate similar to that of the normal population [24]. In a
similar study to assess the long term results of reduction
mammaplasty in teenage girls, Aillet et al. (2001) con-
cluded that breastfeeding was possible after surgery [25].
Before surgery there was no report of reduced nipple
sensitivity. However, after surgery, 20 (58.8%) of the
patients stated their nipple sensitivity had reduced with
15 (44.1%) stating theirs as bad; 3 (8.82%) stated theirs
as worse and 2 (5.88%) said theirs was worst. Nipple
deformation pre-operatively was reported by 29 (85.3%)
patients, but after surgery the number had reduced to 16
(47.1%); 7 (20.6%) reported theirs as bad, 4 (11.8%) and
5 (14.7%) reported theirs as worse and worst respectively.
Changes in the nipple sensitivity and nipple deformation
may have been caused by the severing of some nerves in
this area during the time of surgery.
4.2. Psychological Complications
Psychological trauma experienced by persons suffering
from breast hypertrophy has been documented by quiet a
number of researchers. In this study, all patients, 34
(100.0%) reported being teased because of their condi-
tion, but after surgery, teasing stopped. All the patients
reported that before surgery they had a poor image of
themselves, but after surgery they had a positive self im-
age and their quality of life had improved since they
could now go about their normal duties without develop-
ing any ill-feeling such as depression and anxiety. Simi-
larly, Mello et al. (2010) stated in their study that both—
self esteem and quality of life significantly improved after
breast reduction surgery [26]. Blomqvist et al. (2000)
also stated in their finding that reduction mammaplasty
resulted in significantly improved quality of life [27].
Thoma et al. (2007) also concluded that patients who
underwent breast reduction experienced an improvement
in health related quality of life [28].
Satisfaction after breast surgery is an important tool
which helps the individual to develop a positive self im-
age. From this study, 85.3% of the patients reported a
high level of satisfaction of their breasts after surgical
intervention. Satisfaction was also recorded by Serletti et
al. (1992) in their study. They surveyed 109 patients us-
ing questionnaires and found out that, majority were
pleased with their breast shape and size [29]. Another
study was carried out by Makki and Ghanem (1998) to
find on the long term results, morbidity and patient satis-
faction after reduction mammaplasty. Their survey in-
cluded 296 patients who underwent reduction mamma-
plasty between January 1987 and December 1996 and
reported 67.6% satisfaction rate [30].
5. Conclusion
Breast surgery provides relief to persons suffering from
breast hypertrophy. From the study, it was observed that
pre-operative complications associated with this condi-
tion were very unbearable. However, after surgical in-
tervention either by reduction mammaplasty or subcu-
taneous mastectomy the lives of these persons had been
improved. Although a few post-operative complications
were recorded, the overall satisfaction was excellent. For
young adolescents, the preferred surgical procedure to
treat breast hypertrophy is by subcutaneous mastectomy
with simultaneous or secondary breast implant place-
ment.
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Chapter
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This study documents that reduction mammoplasty is a procedure with excellent long-term patient satisfaction. This has not been previously well documented. One hundred nine patients after reduction mammoplasty were surveyed by questionnaire. Results of the questionnaire indicated that the majority of patients were pleased with their breast size and breast shape. The majority had equal-sized breasts. Most were comfortable after surgery and had an easier time buying clothes. Ninety-four percent of patients would have the procedure again. Multiple techniques for reduction mammoplasty were used and there were no significant differences with the exception of a change in nipple sensation. Nipple sensation was best preserved by using the inferior pedicle technique.
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Juvenile hypertrophy of the breast is a relatively rare condition rapidly leading to gigantomastia in peripubertal females. The pathology is limited to the breast, with otherwise normal growth and development. We have reported the first familial pattern seen in this unusual condition. Ablation of the breast is always required. We favor reduction mammaplasty to avoid breast implants, despite the need for additional procedures secondary to recurrent hypertrophy. Our second patient provides support for this approach, demonstrating amelioration in breast growth despite the initial period of rapid regrowth.
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Juvenile breast hypertrophy in a 12-year-old girl was treated by bilateral reduction mammoplasty (amputation type) with free transplantation of the areolae and nipples and removal of 8,200 g of breast tissue. Eleven months later, subcutaneous mastectomy with subpectoral tissue expander insertion was performed due to recurrent enlargement of the breasts, with removal of an additional 5,000 g. Three months later, silicone prostheses replaced the tissue expander, with reconstruction of areolae and nipples. One year later, a good result was observed and the breasts have been satisfactorily reconstructed.