Juvenile Breast Hypertrophy is a relatively rare, benign (non-cancerous) disorder of the breast in which one or both of the breasts undergo a rapid, massive increase in size during adolescence. This condition is also commonly known by the names Juvenile Gigantomastia, Juvenile Macromastia, Virginal Macromastia, and Virginal Mammary Hypertrophy. Prepubertal Hypertrophy is usually bilateral; Virginal Hypertrophy (which develops after the onset of puberty), may be either unilateral or bilateral. Due to the rarity of this condition, there historically have been no evidence-based guideline for the treatment of this condition. A recent study by Hoppe et al (Plast Reconstr Surg, Vol 127, No 6, p2224, June 2011) reviewed the various case reports in the past plastic surgery literature to help create a more cohesive set of guidelines for treatment of these patients. Here is a summary of what was found:
1) CAUSE: An exact cause has not been determined. Hypersensitivity of the breast tissue to normal levels of circulating estrogen is one hypothesis for this “dysregulated breast enlargement.” Estrogen levels have been measured in patients with Juvenile Breast Hypertrophy and have not been significantly elevated compared with unaffected patients.
2) DIAGNOSIS: Juvenile Breast Hypertrophy is a diagnosis of exclusion. Other conditions such as Virginal Fibroadenoma, Fibrocystic Disease, Phyllodes Tumor and Endocrine Conditions may need to be excluded. Ultrasound or mammography may be indicated as part of the work up. Symptoms that occur are often similar to adults who present with macromastia; namely bra strap grooving, back pain and intertriginous rashes.
3) SURGICAL TREATMENT: In some cases, surgical breast reduction alone is sufficient treatment for Juvenile Breast Hypertrophy. However, this is not always adequate, as is evidenced by the high rate of recurrence. Subcutaneous mastectomy (with subsequent tissue expansion and implant placement) has also been used with success, with a decreased chance for recurrence. Unfortunately, subcutaneous mastectomy with complete removal of breast tissue often has an inferior aesthetic result compared with breast reduction. Some surgeons feel that surgery should be delayed until the end of puberty (when breast growth is complete) if possible. All breast tissue that is removed should be submitted to a pathologist and then tested for the PTEN gene mutation and distribution of estrogen and progesterone receptors.
4) MEDICAL MANAGEMENT: Dydrogesterone (a medication similar to progesterone) and Tamoxifen (a medication that modulates estrogen receptors) have been the most popular medications used to control Juvenile Breast Hypertrophy. Tamoxifen has been used successfully pre-operatively to arrest breast growth as well as post-operatively to inhibit further breast growth. Typical doses range from 10 to 40 mg per day and may continue for 4 months. Potential side effects of Tamoxifen are real and may include: endometrial hyperplasia (with increased risk for endometrial cancer), hot flashes, increased risk for venous blood clots, and changes to bone density.
Juvenile Breast Hypertrophy is a complex condition, and usually requires a coordinated and long term management effort between the patient, the plastic surgeon and the endocrinologist.
*photos on this post are not actual patients of Dr. Brenner.