Breast Hypertrophy

Breast hypertrophy is excessive growth of breast tissue causing physical symptoms. Macromastia is breast weight above about 1,000 to 1,500 g per breast, or resection weight above 500 g per breast in adult reduction. It is a functional and often psychosocial problem, not only a cosmetic one.

Types and causes

• Pubertal (juvenile or virginal) hypertrophy: rapid massive growth at puberty, linked to end organ sensitivity to normal oestrogen. Can exceed 1,000 g per breast.
• Gestational hypertrophy: massive growth in pregnancy, rare, with high recurrence in later pregnancies.
• Obesity related and hormonal: weight gain, oestrogen and progesterone therapy, hyperprolactinaemia.
• Drug induced: penicillamine, bucillamine, cyclosporine, cimetidine, spironolactone, some antipsychotics.
• Idiopathic adult macromastia: most common in adults, familial tendency.
• Asymmetric hypertrophy: consider tumour (phyllodes, giant fibroadenoma), cyst or developmental asymmetry.
• Pathophysiology: increase in glandular tissue, fat and stroma, with ptosis from ligamentous stretch (Cooper ligaments). Weight causes strain on cervical and thoracic spine.
• Classification of ptosis (Regnault): grade I (nipple at fold level), II (below fold, above lower breast contour), III (below fold and at lower contour), pseudoptosis.
• Epidemiology: reduction mammoplasty is a common procedure, with highest rates in women aged 30 to 50 years, and rising in adolescents with severe symptoms.
• Gynaecomastia in males is a separate entity.

Symptoms

• Chronic neck, shoulder and upper back pain, headaches, thoracic kyphosis, and shoulder grooving from bra straps (bra strap grooves with brachial plexus compression and ulnar paraesthesia).
• Intertrigo, recurrent rash and skin maceration in the inframammary fold, with infection.
• Difficulty exercising, poor posture, breathing restriction in severe cases, and sleep disturbance.
• Psychosocial: body image distress, teasing, depression, social avoidance, difficulty finding clothes.

Examination

• Measure breast size (sternal notch to nipple distance, nipple to inframammary fold, base width), degree of ptosis, symmetry, skin quality, and shoulder grooves. Assess BMI and posture.
• Full clinical breast examination, axillae and lymph nodes. Look for masses (phyllodes, fibroadenoma), skin tethering, and nipple discharge.
• Rapid unilateral enlargement requires exclusion of malignancy.
• Differential diagnosis: breast carcinoma, phyllodes tumour, giant fibroadenoma, lipoma, breast abscess, gigantomastia from pregnancy, pseudohypertrophy from adipose tissue, and lymphoma.
• Red flags: asymmetric or rapidly enlarging breast in an adolescent, palpable mass, skin changes, bloody discharge, and family history of breast cancer.

• Mostly clinical. Aim to define symptom burden, exclude pathology and determine suitability for surgery.
• Detailed history: onset, hormonal factors, drugs, pregnancy history, weight, family history of breast cancer, smoking, previous breast surgery and breastfeeding intentions.
• Measurements and photographs for planning and insurance. Estimating expected resection weight using the Schnur sliding scale (for BSA) supports medical necessity.
• Breast imaging: ultrasound for under 30 years or dense breasts, and mammography from age 40 (or from 30 to 35 with family history), preoperatively, as occult cancer is found in 0.5 to 1% of reduction specimens.
• Core biopsy of any mass. Histopathology of all resected tissue.
• Laboratory tests when indicated: TSH, prolactin, oestradiol and pregnancy test for rapid or pubertal enlargement, HbA1c, and haemoglobin.
• Genetic counselling and testing when family history suggests BRCA or other risk.
• Spinal assessment (radiographs) in severe back pain, and cardiopulmonary evaluation in obesity.

Conservative measures (trial before surgery in most adults)

• Supportive well-fitted bras with wide padded straps, physiotherapy, posture exercises and core strengthening, weight loss if BMI is raised (reduces breast volume), analgesia (paracetamol 1 g, ibuprofen 400 mg), topical treatments for intertrigo (clotrimazole 1% cream twice daily, zinc oxide barrier, absorbent cotton liners), and silicone padding for strap grooves.
• Stop implicated drugs. Treat hyperprolactinaemia with cabergoline 0.25 to 0.5 mg twice weekly.
• Medical therapy for juvenile hypertrophy and gestational hypertrophy has limited success: tamoxifen 10 to 20 mg daily, medroxyprogesterone, danazol 200 mg daily, bromocriptine 2.5 mg daily, or cabergoline, used before or instead of surgery. Dopamine agonists suit gestational hypertrophy. Surgery in pregnancy is avoided except for life-threatening necrosis or infection.

Reduction mammoplasty (definitive)

• Indicated for persistent symptoms despite 3 to 6 months of conservative treatment, usually with an expected resection of 300 to 500 g per breast or more.
• Techniques:
  • Inferior pedicle (Wise pattern), the standard, reliable nipple perfusion.
  • Superior or medial pedicle, vertical scar (Lejour, Lassus) for moderate reduction.
  • Free nipple graft for very large breasts (over 1,500 g) or very long sternal notch to nipple distance (over 40 cm), accepting loss of sensation and lactation.
  • Liposuction-assisted reduction for fatty breasts with minimal ptosis.
• Preoperative: stop smoking at least 4 weeks (smoking raises nipple and skin necrosis risk), stop oestrogen-containing contraceptives and consider venous thromboembolism prophylaxis (Caprini score), optimise BMI (ideally below 35), stop aspirin and NSAIDs 7 to 10 days if possible, and mammography.
• Perioperative: cefazolin 2 g IV (3 g if over 120 kg) before incision, enoxaparin 40 mg SC in higher-risk patients, intermittent pneumatic compression, local infiltration with bupivacaine 0.25% with adrenaline, and multimodal analgesia (paracetamol, NSAIDs, regional blocks).
• Postoperative: surgical bra for 4 to 6 weeks, drains if used (remove at 24 to 48 hours), and avoid strenuous activity for 4 to 6 weeks.
• Complications: haematoma (1 to 3%), infection (1 to 5%), wound dehiscence at the T junction (up to 10 to 20%), nipple or flap necrosis (1 to 2%, higher in smokers and large resections), fat necrosis (palpable lump, mimics cancer), altered nipple sensation (loss in 5 to 15%), asymmetry, hypertrophic scar, and reduced lactation (variable, often preserved with pedicled techniques). Revision rate 5 to 10%.
• Outcomes: marked relief of back, neck and shoulder pain in over 90%, improved quality of life, and sustained satisfaction. Breast cancer risk is not increased, and reduction in volume may modestly lower risk.

Adolescents

• Delay surgery until breast growth has stabilised (at least 6 months with no growth, ideally age 15 and over, 1 to 2 years post menarche) unless symptoms are severe. Recurrence may occur with continued growth, with possible need for reoperation.

Special situations

• Gestational hypertrophy: bromocriptine or cabergoline, supportive care, and reduction postpartum.
• Phyllodes tumour or giant fibroadenoma: wide local excision with 1 cm margins for phyllodes.
• Psychological support, particularly in adolescents.

Follow-up

• Review at 1 to 2 weeks, 6 weeks, 3 months and 12 months. Routine breast screening continues per age and risk. Tell the patient to report new lumps.