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.