Adolescent medicine presents a unique challenge. Many pediatricians find themselves extrapolating treatment of childhood issues or modifying adult treatment to address adolescent issues. But the reality is adolescents are not big kids or little adults. They are a unique group that require special considerations and analysis for appropriate treatment.
Macromastia, enlarged breast, is a condition that affects many teenagers. It impacts their self-esteem, limits physical ability, and causes musculoskeletal and dermatologic issues, and yet most pediatricians cannot recall a specific lesson that covered the evaluation and treatment of this condition. Juvenile, or virginal, gigantomastia is a rare condition that consists of a period of rapid breast tissue growth followed by sustained growth in the peripubertal years. Growth can be symmetrical or asymmetrical. Either condition can lead to disfigurement, social anxiety, unwanted attention, and withdrawal. Therefore, acknowledging the condition and intervening are essential.
With obesity on the rise, the issue of macromastia continues to grow. Although macromastia and obesity can occur independently, obesity certainly augments the condition, and more and more physicians are confronted with complaints of neck, back, and shoulder pain. Left untreated, macromastia can cause physical limitation leading to further morbidity. The exact etiology is unknown, but it is presumed to be associated with a hypersensitivity of the mammary estrogen receptors and exposure to exogenous estrogen through food, drugs, or the environment.
Although a patient who has significant discomfort may benefit from physical therapy and strengthening exercises to improve posture, the definitive treatment for macromastia and juvenile gigantomastia is surgical breast reduction, even in adolescence. Medical management with injections of tamoxifen will halt the continued growth, but it will not reduce the size, and therefore will not correct the associated side effects. Weight loss may reduce the general appearance, but it will do little to reduce the actual size of the breast tissue itself.
Because breast development arrests before adulthood, delaying surgical intervention to adulthood is not necessary. In a retrospective study, recurrence took place with juvenile gigantomastia only if intervention was done in early adolescence and did not take place at all with macromastia ( Mayo Clin Proc. 2001;76:503-10 ).
Indications for surgical intervention are chronic shoulder, neck, and back pain; shoulder grooving; skin irritation and skin breakdown underneath the breast; and social stress. It is important that the growth of the breast has ceased for at least a year, and a psychological assessment of the impact of the condition is performed.
Misconceptions associated with breast reduction include that it is for cosmetic purposes only; that macromastia can be reduced by weight loss, and therefore a surgical intervention is not necessary; that lactation is not possible after the procedure; and that insurance will not cover this procedure. As explained previously, there is an identifiable negative impact of macromastia on the musculoskeletal system as well as huge self-esteem and social issues.
Decades ago, breast reduction was seen as a cosmetic surgery. Surprisingly, many insurance companies will now cover the procedure if the morbidity is well documented.
Inability to breastfeed was the initial concern with early surgical intervention. Several studies have evaluated this, and all have come to the same conclusion: Although milk production may be reduced, postsurgical patients can breastfeed without difficulty. Given that lactation is not inhibited and continued stress on the musculoskeletal system causes further harm, early intervention is imperative.
Breast reduction surgery is safe. There is a risk of bleeding, infection, fat necrosis, and loss of sensation, but there is no higher incidence of these adverse effects in adolescents than there is in adults ( J Pediatr Adolesc Gynecol. 2013;26:228-33 ).
Macromastia clearly impacts the emotional, social, and physical well-being of an adolescent, and it likely will not be addressed by the young patient because of embarrassment. Therefore, it is up to the pediatrician to inquire about body image with all routine health exams, and to keep up to date with the latest recommendations to ensure the best outcomes.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at firstname.lastname@example.org .