Gigantomastia due to retromammary lipoma: An aesthetic management

Abstract

INTRODUCTION:

A “giant” lipoma is defined as a tumor having dimensions greater than 10 cm. Giant lipomas are rare and giant breast lipomas are exceptionally uncommon. Only six cases have been described in world literature till date. Herein we describe a case of giant breast lipoma and discuss its surgical management.

CASE REPORT:

A 43-year-old lady presented with left sided unilateral gigantomastia. Clinical examination, radiology and histopathology diagnosed lipoma. Excision of the tumor was planned, together with correction of the breast deformity by reduction mammoplasty using McKissok technique. A tumor measuring 19 cm × 16 cm × 10 cm and weighing 1647 grams was removed. The nipple areola complex was set by infolding of the vertical pedicles and the lateral and medial flaps were approximated to create the final breast contour. The patient is doing well on follow up.

DISCUSSION:

Giant lipomas are rare and of them, giant breast lipomas are extremely uncommon. They can grow to immense proportions and cause significant aesthetic and functional problems. The treatment is excision. But reconstruction of the breast is almost always necessary to achieve a symmetric breast in terms of volume, shape, projection and nipple areola complex symmetry compared to the normal opposite breast. Few authors have used various mammoplasty techniques for reconstruction of the breast after giant lipoma excision. Our case has the following unique features: (i) It is the third largest breast lipoma described in the literature till date, weighing 1647 grams; (ii) The Mckissock technique has been used for parenchymal reshaping which has not been previously described for giant breast lipoma.

CONCLUSION:

This case demonstrates that reduction mammoplasty after giant lipoma removal is highly rewarding, resulting in a smaller-sized breast that is aesthetically more pleasing, has better symmetry with the contralateral breast, and provides relief from functional mass deficit.

Introduction

A lipoma is a benign, soft, encapsulated tumor of adipose tissue, usually composed of mature fat cells. It is the most common benign soft tissue tumor. It can occur anywhere in the body and typically presents as a painless, small, slow growing subcutaneous mass. Sanchez et al. defined a “giant” lipoma as a tumor having dimensions greater than 10 cm [1]. Giant lipomas are rare and giant breast lipomas are exceptionally uncommon. Only six cases have been described in world literature till date [2,4–7]. Herein we describe a case of giant breast lipoma and discuss its surgical management.

Case report

A 43-year-old lady presented with left sided unilateral gigantomastia (Fig. 1). She complained of a mass in her left breast for 15 years which gradually increased in size to the present dimensions. She now sought medical consultation because it had become heavy and caused pronounced breast asymmetry.

On examination a soft, mobile mass of about 16 cm × 14 cm was palpated in her left breast. There was no palpable lymph node in the axillae or neck. Mammography showed a tumor measuring 17 cm in the largest axis, with presence of calcifications. High resolution ultrasound revealed a tumor of the left breast, which measured 15 cm × 17 cm, consistent with a lipoma. A Tru-cut biopsy taken from the core of the breast tumor revealed mature fatty cells.

Excision of the tumor was planned, together with correction of the breast deformity by reduction mammoplasty using McKissok technique.

Preoperative markings were made in the Wise pattern for McKissok vertical pedicle technique (Fig. 2). The pedicle was deepithelized. Medial segment of the breast was excised. The lipoma became visible after excision of medial segment. The vertical bipedicle was developed with very thin compressed breast tissue (Fig. 3). The lipoma mass was enucleated. It measured 19 cm × 16 cm × 10 cm and weighed 1647 grams (Fig. 4). The nipple areola complex was set by infolding of the vertical pedicles and the lateral and medial flaps were approximated to create the final breast contour. There was no post-operative complication and the aesthetic outcome was satisfactory. Histopathology confirmed the diagnosis of lipoma (Fig. 5). The patient is doing well at three years of follow up without any evidence of tumor recurrence (Fig. 6a, b).

Discussion

Giant lipomas are rare, and their usual locations are the neck, back, hips, buttocks, and extremities. Of them, giant breast lipomas are extremely uncommon. Only 6 case reports have been found in the literature till date [2–7].

Regarding the definition of giant lipoma there are two opinions. Sanchez et al. defined a “giant” lipoma as a tumor having dimensions greater than 10 cm [1], whereas according to Hawary et al. a “giant breast lipoma” should be at least 5 cm in one dimension and weigh more than 500 g [8].

Giant breast lipomas can grow to immense proportions and the problems associated are manifold. They cause asymmetry of breast and significant aesthetic concern for the patient. Functional problems arise, including lymphedema and nerve compression. These lesions also cause significant diagnostic dilemma [1].

The differential diagnosis of giant breast lipoma includes giant virginal hypertrophy, giant fibroadenoma, phylloides tumor, mammary hamartomas and carcinoma [9]. Lipomas are very difficult to diagnose clinically and clinical judgement alone is incorrect in 26% cases [10]. However imaging is not diagnostic either. On ultrasonography or mammography, a giant lipoma is difficult to differentiate from liposarcoma. Histopathology is required for tissue diagnosis, amongst which FNAC is again usually non-diagnostic. Tru-cut biopsy is required for definitive pathological diagnosis [6].

The treatment of a giant breast lipoma like any other lipoma is excision. But reconstruction of the breast is almost always necessary to achieve a symmetric breast in terms of volume, shape, projection and nipple areola complex symmetry compared to the normal opposite breast. This is required for the following reasons:

(i) to compensate for the large dead space after tumor excision; (ii) for correcting the mesenchymal atrophy that has been created from compression by the giant expanding tumor; and (iii) to manage the greatly expanded skin envelope.

Few authors have used various mammoplasty techniques for reconstruction of the breast after giant lipoma excision. Aboudib et al. used the superior lateral flap for reconstruction after removal of a lipoma measuring 15.9 cm × 9.5 cm × 9.5 cm and weighing 400 g [11]. Ribeiro et al. managed a lipoma measuring 35.9 cm × 23.9 cm × 20 cm and weighing 5700 g by using parenchymal cross flaps [4]. Bonomi et al. resorted to three dermoglandular flaps for reshaping the breast after removal of a lipoma weighing 283 g and measuring 17.5 cm × 14.3 cm × 6.2 cm cm [7]. Whereas Grossman et al. utilized the superior-medial pedicle wise-pattern oncoplastic breast reconstruction for a lipoma 17 cm × 17 cm in dimensions and 1 kg in weight [6]. The inferior pedicle Wise pattern technique was used by Rodriguez et al. for a 1220 gm breast lipoma [2].

In the present case the lipoma was huge, weighing more than 1.5 kg which is the third largest breast lipoma described in literature. After excision, it resulted in a large dead space and paper thin compressed breast parenchyma. The Mckissock bipedicled Wise pattern technique was preferred over a single pedicle for a number of reasons. First it provided better nipple areola viability though the double pedicle. As the breast tissue was extremely compressed, the dual blood supply deemed to be safer. Secondly, the additional tissue required to fill up the dead space was provided by simply by infolding of the pedicles. No extra volume replacement was required to create a match with the opposite side. Thirdly the technique also gave excellent exposure for tumor resection. Finally, this technique was favoured by the authors for unilateral reduction mammoplasty because they have found that by using the measurements described in Mckissock technique, better outcome in the form of equality, projection and nipple areola position can be achieved. The authors performed this technique in preference to the inferior pedicle wise pattern technique because of its dual advantage of a better blood supply as well as utilizing the dermoglandular pedicles themselves to fill up the resected space. There being a paucity of native breast parenchymal tissue after lipoma excision, the vertical bipedicle was ideally suited to create the breast mound.

The patient had small breast on right side, so this reconstruction gave her a good cosmetic appearance in terms of breast shape and contour. Further improvement in shape can be obtained by lipofilling or implants. Lipofilling will give the patient the advantage of utilizing her autologous tissue of breast augmentation. But the patient being a thin lady, the amount of fat obtained will be restricted. The patient was offered the choice of bilateral breast implants which she refused due to cost constraints.

Our case has the following unique features: (i) It is the third largest breast lipoma described in the literature till date, weighing 1647 grams; (ii) The Mckissock technique has been used for parenchymal reshaping which has not been previously described for giant breast lipoma.

Conclusion

This case demonstrates that reduction mammoplasty after giant lipoma removal is highly rewarding, resulting in a smaller-sized breast that is aesthetically more pleasing, has better symmetry with the contralateral breast, and provides relief from functional mass deficit.