Aesthetic Plastic Surgery

, Volume 29, Issue 3, pp 205–209

Familial Severe Gigantomastia and Reduction with the Free Nipple Graft Vertical Mammoplasty Technique: Report of Two Cases

Authors

    • Aykut Misirlioglu
  • Tayfun Akoz
    • Aykut Misirlioglu
Case Report

DOI: 10.1007/s00266-004-0134-1

Cite this article as:
Misirlioglu, A. & Akoz, T. Aesth Plast Surg (2005) 29: 205. doi:10.1007/s00266-004-0134-1

Abstract

Background.

Gigantomastia, characterized by massive breast enlargement during adolescence or pregnancy, is thought to be caused by an abnormal and excessive end organ response to a normal hormonal milieu. The amputation technique with the free nipple–areola graft is the mainstay for severe macromastia, but it has been criticized because it results in a flattened, nonaesthetic breast with poor projection. This report presents two sisters with unusual, excessive breast enlargement.

Methods.

The measured distance from the sternal notch to the nipple was 50 cm for the first case and 55 cm for the second case. The free nipple graft transplantation based on the vertical mammoplasty technique was used, and an average of 4,200 g of breast tissue per breast was removed. To increase breast projection, superior dermoglandular flaps were used

Results.

The follow-up period was 24 months. The patients had long-lasting, pronounced breast mound projection, and the level of satisfaction for both cases was very high.

Conclusion

The ideal geometric structure of the breast is rather conical, and the authors believe that reshaping the breast tissue in a vertical plane using the vertical mammoplasty technique may be more effective in the long term and may provide better projection.

Keywords

Free NippleGigantomastiaReduction mammoplastyVertical mammoplasty

Developmental anomalies of the breast are frequently observed in women. The term of “gigantomastia” is used to describe breast enlargement to an extreme size. The etiology of gigantomastia appears to be multifactorial, often accompanied by a familial component. The main causes of this type of breast hypertrophy may be hormone disorders, hyperthyroidism, hormonal activity, and hypersensitivity of breast estrogen and progesterone receptors [7]. It should be emphasized that women with gigantomastia often are limited in their physical activities. Complaints may include severe neck strain, headache, aching shoulders, low back pain, deep brassiere strap furrows, and thoracic spine discomfort [9]. Postural problems are also reported [7,9].

Women with gigantomastia breasts have severely distorted anatomic structures and multiple techniques for reduction of the giant breast are widely used. The amputation technique with the free nipple–areola graft, the mainstay for severe macromastia since 1922 [17], has been criticized because it results in a flattened, nonaesthetic breast with poor projection [4,16]. The standard techniques originally described for free nipple graft mammoplasty have since undergone certain modifications [2,3,5,6,1115].

In this article, we present two siblings (sisters) with unusual gigantomastia. We successfully used a method of breast reduction combined with vertical mammoplasty and free nipple graft transplantation to obtain good results.

Materials and Methods

Two sisters ages 48 years (case 1) and 39 (case 2) with large breasts were evaluated at our clinic. They reported severe low back pain, deep brassiere strap furrows, and postural problems. Both women were multiparous, and the enlargement of their breasts had started in adolescence. Mammograms displayed nonspecific changes of the parenchyma tissue, and the hormonal profile as normal in both cases. The measured distance from the sternal notch to the nipple was 50 cm in case 1 and 55 cm in case 2 (Fig. 1). They informed us that their mother (age, 72 years) and their three daughters (ages 18, 20, and 24 years respectively) also had very large breasts, but we failed to obtain permission from them for further clinical examination.
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Fig. 1

The measured distance from the sternal notch to the nipple was 50 cm for case 1 (A) and 55 cm for case 2 (B).

Operative Procedure

The surgical technique that we used was based on a vertical mammoplasty technique described by Lejour [8]. Preoperative markings were made with the patients in the standing position according to the vertical technique (Fig. 2A). The new nipple location was at the inframammary crease, and the distances from the sternal notch to the position of the new nipples were marked (22 cm for case 1 and 23.5 cm for case 2). The nipple–areola complex was marked with a diameter of approximately 4 cm and removed as full-thickness grafts, with preservation of smooth muscle elements. Glandular resection was performed (4,300 g of tissue per breast in case 1 and 4,100 g of tissue per breast in case 2), with minimal undermining along the skin markings, leaving lateral and medial pillars of the breast tissue intact (Fig. 2B).
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Fig. 2

The breast markings are made according to the vertical mammoplasty technique, and the superior based vertical flaps are outlined (A). After the nipple-areola complex is removed as a full-thickness skin graft, the areas of the superior vertical flaps are deepithelialized. Glandular resection is performed, and the superior flap is backfolded to provide projection (B).

A superior deepithelialized dermoglandular flap was created and backfolded superiorly to provide projection of the breast (Figure-2., right). The lateral and medial pillars then were sutured together. Key interrupted sutures began at the most superior of the pillars while a vertical suture line of approximately 7 cm was maintained (Fig. 3A). The inferior excess skin and glandular tissue of the lateral and medial pillars were excised along the inframammary crease, and all the incisions were closed with interrupted dermal and continuous subcuticular sutures (Fig. 3). A thick, split-thickness, nipple–areola graft was sutured at its new nipple–areola position, and a tie-over bolster dressing of Vaseline-soaked gauze was applied for 5 days.
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Fig. 3

Suture of the medial and lateral glanduler pillars to create the breast cone. After approximately 7 cm of vertical length suture line is maintained, the horizontal resection is made at the new inframammary crease.

Results

The patients were followed for a period of 24 months. In case 1, a minor revision was performed because of a “dog ear” at the inframammary line 8 months after surgery. The conical breast shape was maintained. No “bottoming out” was seen. The patients had long-lasting pronounced breast mound projection, and the level of satisfaction for both patients was very high (Fig. 4 and 5).
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Fig. 4

Postoperative view of case 1 at 24 months after surgery.

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Fig. 5

Postoperative view of case 2 at 24 months after surgery.

Mammographic analysis was obtained 12 months postoperatively, and nonspecific postreduction changes included thickening of the skin at the suture lines, increased density, and benign intraparenchyma calcifications [1,1214].

Discussion

Gigantomastia, characterized by breast enlargement during adolescence or pregnancy, is thought to be caused by an abnormal and excessive ends-organ response at normal hormonal levels [10].

In this condition, the breasts grow rapidly to enormous size without spontaneous regression [7]. The sizes of the breasts presented in the current study were amazingly large, but radiologic and hormonal study results were normal. Breast enlargement began during the adolescence stage in each case and increased during pregnancy. It is interesting to note the presence of similar macromastia in all the female members of the family. Perhaps congenital excessive end-organ response also is present in this family.

The large breasts in this study may have been suitable for amputation free nipple breast reduction techniques because of the increased sternal notch–nipple distance. The standard free-nipple amputation technique [17] frequently is criticized for producing a breast and nipple with poor projection, and several modifications have been described [2,3]. In this study, the free nipple method based on a vertical reduction technique was used in the both cases.

The vertical mammoplasty technique described by Lejour [8] has miscellaneous advantages such as elimination of the transverse incision and provision of a long-lasting attractive breast shape without flattening. As with the cases presented in this study, it is nearly impossible to avoid transverse incisions in such enlarged breasts. Our objective using the principles of the technique described in the current study was to reshape and reposition the breast tissue by using a vertical technique, and to obtain a better projection and breast type. Using this technique, we first excised the glandular tissue in a vertical plane, then projected and reshaped the breasts convenient to the inframammary line while strictly preserving the required vertical length (7 cm) of the breasts and excising the inferior tissues in the horizontal plane.

With our method, a superior dermoglandular flap was used to provide adequate upper fullness. The length of the flap can be modified and then the upper pole fullness or the projection of the breast can be adjusted as required. The technique is simple, rapid, and secure, and can be performed in an advantageous “cut-as-you-go” manner.

Discussion

The ideal geometric structure of the breast is rather conical, and we believe that reshaping of the breast tissue in a vertical plane may be more effective in the long term and may provide better projection. Cases in which the described technique was used have given permanent and more pleasant results over the long term, but there is an urgent need for larger scale studies to obtain a definite judgment.

Copyright information

© Springer Science+Business Media, Inc. 2005