Hypertrophy of breast

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Gigantomastia
Classification and external resources
In 1670, the physician Durston drew this illustration of first recorded case of non-gravid gigantomastia; the woman died of the condition.
The first recorded case of gigantomastia, diagnosed in a 23- or 24-year-old woman, circa 1670.
ICD-10 N62
ICD-9 611.1
DiseasesDB 1628

Hypertrophy of the breast (macromastia and gigantomastia) is a rare medical condition of the breast connective tissues. The indication is a breast weight that exceeds approximately 3% of the total body weight.[1] There are varying definitions of what is considered to be excessive breast tissue, that is the expected breast tissue plus extraordinary breast tissue, ranging from as little as 0.6 kilograms (1.3 lb) up to 2.5 kilograms (5.5 lb) with most physicians defining macromastia as excessive tissue of over 1.5 kilograms (3.3 lb). Some resources distinguish between macromastia, where excessive tissue is less than 2.5 kg, and gigantomastia, where excessive tissue is more than 2.5 kg.[2] The enlargement can cause muscular discomfort and over-stretching of the skin envelope, which can lead in some cases to ulceration.[3] Hypertrophy of the breast tissues might be caused by increased histologic sensitivity to the female hormones prolactin, estrogen, and progesterone; or an abnormally elevated hormone(s) level in the blood, or both.[4] Breast hypertrophy is a benign progressive enlargement, which can occur in both breasts (bilateral) or only in one breast (unilateral). It was first scientifically described in 1648.[5]

General condition[edit]

Hypertrophy of the breast can affect the breasts equally, but usually affects one breast more than the other, thereby causing asymmetry, when one breast is larger than the other. The condition can also individually affect the nipples and areola instead of or in addition to the entire breast. The effect can produce a minor size variation to an extremely large breast asymmetry. Breast hypertrophy is classified in one of five ways: as either pubertal (virginal hypertrophy), gestational (gravid macromastia), in adult women without any obvious cause, associated with penicillamine therapy, and associated with extreme obesity.[3] The underlying cause of the rapidly growing breast connective tissue, resulting in gigantic proportions, is thought to be a heightened sensitivity to female hormones prolactin, estrogen and progesterone.

Virginal breast hypertrophy[edit]

When gigantomastia occurs in young women during puberty, the medical condition is known as juvenile macromastia or juvenile gigantomastia and sometimes as Virginal breast hypertrophy. Along with the excessive breast size, other symptoms include red, itchy lesions and pain in the breasts. A diagnosis is made when an adolescent's breasts grow rapidly and achieve great weight usually soon after her first menstrual period. Some doctors suggest that breast development occurs before onset of menstruation.[6]

Some women with virginal breast hypertrophy experience breast growth at a constant rate for several years, but the breasts rapidly develop, exceeding normal growth. Some adolescent females experience minimal or negligible breast growth until their breasts suddenly grow very rapidly in a short period of time. This causes great physical discomfort.[citation needed] Women suffering VBH often experience an excessive growth of their nipples. In severe cases of VBH, hypertrophy of the clitoris occurs.[citation needed]

At the onset of puberty, some females who have experienced little or no breast development can grow three or more cup sizes within a few days.[7]

Gestational hypertrophy[edit]

This same effect can also occur at the onset of pregnancy or between the 16th to 20th week of gestation. When the swelling in the connective tissue occurs after birth, it can negatively impact long term milk supply.[7] The swelling increases with each subsequent pregnancy.

The extremely rapid growth of the breasts can result in intense heat. The woman's breasts can generate extraordinary discomfort, turning feverish, red, itchy, and even causing the skin to peel. The swelling can suppress the milk supply, pinching off the milk ducts, and leading to mastitis.[7]

Medical treatment[edit]

Medical treatment has not proven consistently effective. Medical regimens have included tamoxifen,[8] progesterone, bromocriptine, and testosterone. Gestational macromastia has been treated with breast reduction drugs alone without surgery.[9] Surgical therapy includes reduction mammaplasty and mastectomy.[10] However, breast reduction is not clinically indicated unless at least 4 pounds (1.8 kg) of tissue per breast needs to be removed.[11] In the majority of cases of macromastia, surgery is medically unnecessary, depending on body height. Topical treatment includes regimens of ice to cool the breasts.[7]

When hypertrophy occurs in adolescence, noninvasive treatments, including pharmaceutical treatment, hormone therapy, and steroid use are not usually recommended due to known and unknown side effects. Once a girl's breast growth rate has stabilized, breast reduction may be an appropriate choice. In some instances after aggressive or surgical treatment, the breast may continue to grow or re-grow, a complete mastectomy may be recommended as a last resort.

Pregnancy is recognized as the second most common reason for hypertrophy. When secondary to pregnancy, it may resolve itself without treatment after the pregnancy ends.[12]

Medical insurance coverage[edit]

Insurance companies in USA typically require the physician to provide evidence that a woman's large breasts cause headaches or back and neck pain before they will pay for reduction mammoplasty. Insurance companies also mandate a woman who is overweight, which is often the case with gigantomastia, to first lose a certain amount of weight. They also commonly require the patient to try alternative treatments like physical therapy for a year or more.[13] A plastic surgeon in Seattle, Dr. Phil Haeck, told a reporter that most of his breast reduction patients pay their own way. "I’ve had people finance it; I’ve had people get second mortgages, take out home equity loans."[13]

Reported instances[edit]

Gigantomastia[edit]

A painting by Lam Qua of Lu-shi, age 42, on April 17, 1848, prior to breast reduction surgery.

Gigantomastia occurs in 1 out of every 28,000 to 100,000 pregnancies.[14] It can also affect men, although very rarely. One early case study dates to 1670. The patient died four months after the onset of enlargement. One breast removed after the woman's death weighed 64 pounds (29 kg).[15]

On April 17, 1848, a 42-year-old woman named Lu-shi was treated for hypertrophy in a Chinese hospital. She was treated by a missionary physician. On December 24, 1849, the left breast, measuring 2 feet 2.5 inches (0.673 m) in circumference, and weighing 6 pounds (2.7 kg), was removed in a procedure lasting three and a half minutes. The right breast was removed one month later. It measured 2 feet (0.61 m) in circumference and weighed 5.5 pounds (2.5 kg).[16]

One of the most severe cases of macromastia reported in the world medical literature was from Ilorin in Nigeria. In 2007, Dr Ganiyu Adebisi Rahman and his colleagues reported the case of a 26-year-old woman who presented with massive swelling of her breasts and bilateral axillary swellings, both of six years duration. Dr Rahman led a team of surgeons in Ilorin to perform a total bilateral excision of the hypertrophied axillary breasts and bilateral breast amputation with composite nipple-areola complex graft of the normal position of the breasts. The total weight of the breast tissues removed was 44.8 kilograms[17]

In the October 2002 Journal of Reproductive Medicine, Dr. N. Agarwal with three other doctors from the All India Institute of Medical Sciences in New Delhi reported on a 24-year-old woman who was pregnant with her second child. During her 19th week of pregnancy, she experienced a "massive bilateral breast enlargement." She was treated for six months after her child was born before her breasts were reduced to their normal size.[14]

In 2005, a woman reported that her breasts grew at puberty from nothing to a C cup in one month. When she became pregnant for the first time, her breasts increased two cup sizes in a few days. Immediately after her first birth, her breasts grew three cup sizes. After her second child was born, her breasts increased six cup sizes. After her third childbirth, they grew 10 cup sizes, and after her fourth child was born, they grew nine cup sizes. In this instance, the swelling abated about 10 days after childbirth, but her bra cup size remained E to a G for the next year. About one year postpartum, her breasts rapidly atrophied to AA cup size.[7]

Another extreme case was observed in 2008 in Maria Vittoria Hospital in Turin, Italy, where the amount removed from both breasts was 38 kilograms (84 lb). The growth occurred during puberty making it a case of juvenile gigantomastia, but the patient did not seek treatment until the age of 29.[18] Another extreme case was observed on August 28, 2003, when a 24-year-old woman was admitted to the Clinical Center Skopje in Macedonia with gigantomastia of pregnancy and the amount later removed from both breasts was 33 kilograms (73 lb) total.[19][20] A second case in Macedonia was reported when the breasts of a 30-year-old woman from a remote mountain village in eastern Macedonia suddenly grew to more than 30 kilograms (66 lb) total.[20]

As the disorder becomes more widely known, media reports have increased. French Canadian Isabelle Lanthier appeared on Montel Williams' talk show where she told how her chest grew from 34 inches (86 cm) to 52.5 inches (133 cm) in five months during her pregnancy. At their largest, one breast weighed 15 pounds (6.8 kg) and the other 12 pounds (5.4 kg). Her husband custom made a special bra to support her breasts. In 2007, a Chilean TV station covered the story of 32-year-old Jasna Galleguillos from Antofagasta, who experienced ongoing back pain, making everyday tasks very difficult to perform. She underwent breast reduction surgery to relieve her pain. Surgeons removed 4.250 kilograms (9.37 lb) from one breast and 3.330 kilograms (7.34 lb) from the other breast.[21]

On October 29, 2009, the Philippine television network GMA News and Public Affairs, producers of Wish Ko Lang (Just My Wish) hosted by Vicky Morales, profiled the story of Pilma Cabrijas, a 30-year-old woman afflicted by gigantomastia. The woman was told by a folk healer that her condition may have been caused by a curse. The measured bust circumference without appropriate bra support was 63 inches (160 cm). The weight of her breasts was not reported in detail, but seemed to weigh "as much as two children". She had breast reduction surgery performed, but her breasts regrew. The producers of Wish Ko Lang paid for additional surgery.[22]

Nude model Norma Stitz is exploiting this condition and is officially named as being the person with the largest natural breasts by the Guinness Book of Records with breasts weighing 35 pounds (16 kg) each.[23]

Virginal breast hypertrophy[edit]

In 1993, the Japanese journal Surgery Today reported on the case of a 12-year-old girl. Only 152 centimetres (60 in) tall and weighing 43 kilograms (95 lb), her breasts began to develop at age 11 before the onset of menstruation. Over the next eight months, both breasts grew abnormally large, and physicians treating her found that her physiological development was normal except for her breasts. The weight produced by their symmetrical and massive enlargement resulted in marked curvature of the spine. Lab tests of her blood for hormones and biochemical substances showed normal values, though tests revealed that it might have been cause by hypersensitivity to estrogen. She underwent a bilateral reduction mammoplasty. Surgeons removed 2 kilograms (4.4 lb) of tissue from her right breast and 1.9 kilograms (4.2 lb) from her left breast. She was administered tamoxifen afterward to suppress breast regrowth.[24]

A more severe case of virginal breast hypertrophy of an 11-year old girl was reported in 2008. The breasts had begun to grow rapidly at puberty and had reached the point of causing physical impairment and respiratory compromise after one year. The skin was intact without any ulcerations. Blood chemistry and endocrine investigation was normal. A bilateral reduction mammaplasty with free nipple grafts was performed. 6 kg of the right breast and 6.5 kg of the left breast removed, resulting in a removal of 12.5 kg of tissue in all (24% of the total body weight).[25]

Social considerations[edit]

Extremely large breasts, also known as macromastia[26] or gigantomastia, are a source of considerable attention. Some women try to hide or mask their breasts with special clothing, including minimizing brassieres. Women with this condition may be subject to psychological problems due to unwanted attention and/or harassment. Depression is common among sufferers.

In the case of a 12-year-old Japanese girl reported in 1993, her "massively enlarged" breasts caused her "intense psychological problems, incapacitating her in school activities and social relations."[24] Actress Soleil Moon Frye, who starred as a child in the sitcom Punky Brewster, reported in an interview with People magazine that boys taunted her, calling her "Hey, Punky Boobster!" It affected her professional and social life negatively. "People started to think of me as a bimbo," she said in the interview. "I couldn't sit up straight without people looking at me like I was a prostitute," Frye said.[27]

Finding large bra sizes and styles that fit is challenging. Also, larger bras are more costly, challenging to find, and unflattering to the wearer. Ill-fitting bras with narrow straps can cause chronic irritation, redness, and indentations in the shoulders. Skin rashes under the breasts are common, particularly during warm weather. Heavy breasts may cause headaches, neck pain, upper and lower back pain, and numbness or tingling in the fingers.

Many definitions of macromastia and gigantomastia are based on the term of "excessive breast tissue", and are therefore somewhat arbitrary, as excessive tissue can often be regarded only from an aesthetic viewpoint and not from a medical one. Breasts of human females developed only under the aesthetic selection, as can be deducted by comparison to the breasts of other related primates. The size of the breasts is not related to their functionality, and therefore almost all human breast tissue is excessive from a functional viewpoint. In other words, the line between "just big breasts" and a medical condition is an individual one, as long as there are no ulcerations or other disease-related observations present. This is also the reason many health insurance companies refuse to pay for reduction surgeries when there are only psychological but no strong physical impairments. The current definitions are dependent on society and surgeons' perception of normal and beautiful breast size and may be subject to change in the future.

References[edit]

  1. ^ Dafydd, H.; Roehl, K.R.; Phillips, L.G.; Dancey, A.; Peart, F.; Shokrollahi, K. (2011). "Redefining gigantomastia". Journal of Plastic, Reconstructive & Aesthetic Surgery 64 (2): 160–3. doi:10.1016/j.bjps.2010.04.043. PMID 20965141. 
  2. ^ To Wo Chiu (2011). Stone's Plastic Surgery Facts and Figures (3rd ed.). Cambridge University Press. p. 188. 
  3. ^ a b Note: the criterium of >600g is used with the term "macromastia" in this source: Sharma, K; Nigam, S; Khurana, N; Chaturvedi, KU (2004). "Unilateral gestational macromastia--a rare disorder". The Malaysian journal of pathology 26 (2): 125–8. PMID 16329566. 
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  5. ^ Palmuth, T (1648). "Observations medicuarum centinae tres posthumae". Cent II (Obs 89). Braunschweig. 
  6. ^ "Puberty Stages of Development". Ask the Expert FAQs. OBGYN.net. Retrieved 2006-11-21. 
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  18. ^ Borsetti, G.; Merlino, G.; Bergamin, F.; Cerato, C.; Boltri, M.; Borsetti, M. (2009). "A 38 kg skin-reducing bilateral mastectomy: A unique case". Journal of Plastic, Reconstructive & Aesthetic Surgery 62: 133. doi:10.1016/j.bjps.2008.03.067. 
  19. ^ Antevski, Borce; Jovkovski, Oliver; Filipovski, Vanja; Banev, Saso (2010). "Extreme gigantomastia in pregnancy: Case report—my experience with two cases in last 5 years". Archives of Gynecology and Obstetrics 284 (3): 575–8. doi:10.1007/s00404-010-1714-8. PMID 20978777. 
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