During one month a pediatrician had two patients with potential surgical breast issues.
The first was a 19-year-old female who came to clinic for her health maintenance visit. She overall was doing well but was complaining that she had upper back, shoulder and neck pain. She also complained that her breasts were so large it was difficult to find properly fitting undergarments and that “they just get in the way” of her activities. She also noted that she attracted unwanted attention because of their large size relative to her overall body size. She was noted to be 5’2″, non-obese (BMI of 24.6) and said her breasts were a size E cup. She was noted to have grooves in her shoulder where her bra shoulder straps were. She was referred to a breast surgeon and after consultation and considering the options, she decided to have bilateral breast reduction. She was very happy with the cosmetic result, but more importantly no longer had back, neck and shoulder problems and the unwanted attention had ceased.
The second patient was a 17-year-old female who came in because of a 1 day history of left-sided breast pain, mild redness and a small mass. She was mid-menstrual cycle and had mild tenderness and redness around the areola and nipple that extended medially about 1 cm. The 2-4 mm rice grain-like mass was around 4 o’clock and close to the chest wall and this was mildly tender. She had a couple of similar lesions in the right breast at 2 and 7 o’clock toward the periphery of the breast. She had inverted nipples and the overall texture of the breast felt fibrous. She was treated for mastitis versus cellulitis in the setting of what appeared to be fibrocystic breast changes. On phone followup the next day, she was improving with the oral antibiotics. At followup 1 week later the nipple redness/swelling had resolved but the masses remained the same. She did serial self-exams and noted that these changed with her menstrual cycle and this was confirmed when she was examined one week after her period and they had decreased in size. She and her parents asked for a referral to a breast surgeon as they were concerned about the inverted nipples and the possibility of this occurring again and the potential problems with breastfeeding in the future. The family was pleased with the consultation and the information it provided.
Common reasons for seeing a breast surgeon would include management of benign or malignant masses with or without breast reconstruction, breast augmentation, and other reasons can be infection or trauma that need surgical treatment.
The breast is formed starting around the 6th week of gestation by breast buds along the mammary line. Breasts then develop from the downgrowth of epithelia into the mesenchymal tissue, which continues to grow. Around 8-9 months a pit forms as entry into the lactiferous ducts. “Nipple inversion is caused either by failure of the lactiferous ducts to develop and grow during maturation of the breast tissue or by fibrosis around the lactiferous ducts due to inflammation (e.g. mastitis, cancer, previous breast surgery). Congenital inverted nipples are caused by failure of the mesenchymal tissue to develop or the lactiferous ducts to lengthen.
In general, full maturation of the breast should be ensured before an elective breast procedure. Depending on the age, family history and other factors, mammography may also be appropriate before surgery.
Macromastia symptoms can occur at any age including the adolescent and young adult population. Common problems are upper back, neck, and shoulder pain. Properly fitted clothing, both under- and outer-garments, can be more difficult to find and more expensive than standard sized clothing. The skin can easily be irritated and once irritated hard to treat because of moisture, heat, maceration, poor air circulation and friction from the soft tissues or clothing. Candida skin problems are common. Additionally, patients may have psychological distress because of their own body image or because it attracts unwanted attention. Reduction mammaplasty is an option for many women (and the occasional man as they can also suffer from this problem) who want to improve the shape, size and symmetry of the breasts. There are several surgical techniques but overall patients are usually very happy with the results. Complications can include usual surgical problems such as infection, blood loss, hematoma or seroma, ischemia to tissues or grafts, and delayed wound healing. Longer term complications can include suboptimal scar formation and scar related problems such as keloids or pain, asymmetry, loss of shape, nipple malposition, abnormal sensation, breast pain, lymphedema and inability to breastfeed. Some of these problems are an expected outcome depending on the type of surgery planned.
Inverted nipples are very common (~10%) and usually do not require any treatment. However problems with body image or difficulty in breastfeeding can cause problems. For some women, the nipple can be easily everted with pressure (i.e. manual or with a nipple shield) and may maintain the projection. For other women, it may be severely retracted and cannot be everted. Nipple inversion is commonly bilateral. At least one study found a correlation between body mass index and inverted nipples (i.e. thin individuals had a more inverted nipples). Surgical technique vary and complications can include recurrence of inversion, epidermalysis, scaring and cellulitis. Loss of sensation and difficulty in breastfeeding or movement of milk through the ducts may occur, but obviously the surgeries attempt to minimize the disruption to the ducts. Cellulitis can occur with these surgeries or for other reasons as bacteria are present in the ducts. The author was unable to determine the rate of mastitis/cellulitis for patients with inverted and projected nipples.
Questions for Further Discussion
1. What are the current recommendations for screening for genetic markers and/or mammography for young women at risk for breast cancer?
2. How efficacious is breast self-examination for detecting cancer?
3. What are common causes of benign breast disease?
- Disease: Macromastia | Inverted Nipples | Plastic and Cosmetic Surgery
- Symptom/Presentation: Breast Problems
- Specialty: Surgery
- Age: Teenager
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Hall-Findlay EJ, Shestak KC. Breast Reduction. Plast Reconstr Surg. 2015;136(4):531e-544e. doi:10.1097/PRS.0000000000001622
Gould DJ, Nadeau MH, Macias LH, Stevens WG. Inverted nipple repair revisited: a 7-year experience. Aesthet Surg J. 2015;35(2):156-164. doi:10.1093/asj/sju113
Greco R, Noone B. Evidence-Based Medicine: Reduction Mammaplasty. Plast Reconstr Surg. 2017;139(1):230e-239e. doi:10.1097/PRS.0000000000002856
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa