CASE PRESENTATION
A 14-year-old female student from eastern Nepal visited our center with massive and gradually progressive enlargement of bilateral breasts for a year, along with chest discomfort, and pressure sores in the inframammary folds and shoulders due to bra-straps. Her large breast size had incapacitated her from attending school and social activities. Her menstrual cycle was regular over the past year. She was not under any medications. Past medical and family history was not significant.
On examination, her bilateral breasts were pendulous and enlarged disproportionately to other body parts, with widened areola, and multiple areas of pressure necrosis over the skin (Figure 1). Breasts were non-tender and firm on palpation, without any discrete masses. Axillary lymph nodes were not enlarged. She had normal body mass index (BMI) of 23.15 kg/m2 (weight=60 kg and height=161 cm). Complete blood counts, C-reactive protein, thyroid function test, follicle-stimulating hormone, luteinizing hormone, estradiol, progesterone, and prolactin were within normal limits.
Bilateral reduction mammoplasty with free nipple-areola graft was performed. Markings for neo-nipple areolar complex (neo-NAC) on both breasts were done at 23 cm from the suprasternal notch on breast meridian, with neo-NAC to inframammary fold (IMF) length of 8.5 cm (Figure 2). Full-thickness NAC was excised bilaterally. Skin and parenchymal resection of medial and lateral wedges of tissues and whole breast tissue inferior to the neo-NAC were excised till the fascia, which revealed encapsulated solid breast tissue. Specimens consisting of skin and breast tissue weighing five kilograms (kgs) and four kgs were respectively excised from the right and left breasts (Figure 3). Medial and lateral flaps were brought together and hitched at IMF. The skin over the intended neo-NAC was de-epithelized. Then, the full-thickness NAC was grafted over it and was secured with the tie over the bolster dressing. Neo-IMF and vertical limb of inverted T were sutured and the excised tissue was sent for histopathology. Histopathology revealed extensive fibrosis with collagen deposition in the mammary ducts lined by inner ductal epithelial cells and outer myoepithelial cells (Figure 4). There was focal cellular stroma without atypia. This was suggestive of pubertal macromastia without evidence of malignancy.
By the seventh day (Figure 5), her chest discomfort, neck, and back pain had subsided. During five months of follow up, she was doing fine and was satisfied with the outcome of the surgery. She improved her social interactions as well.