BREAST

Management of Gestational Gigantomastia

Matthew R. Swelstad, M.D.
Brad B. Swelstad, M.D.
Venkat K. Rao, M.D.,
M.B.A.
Karol A. Gutowski, M.D.
Madison, Wis.
Background: Gigantomastia of pregnancy is a rare, severely debilitating con-
dition characterized by massive enlargement of breasts and resulting in tissue
necrosis, ulceration, infection, and, occasionally, hemorrhage. Typically, reso-
lution of breast hypertrophy to near prepregnancy size occurs in the postpartum
period. Treatment is controversial.
Methods: The authors present a patient with gestational gigantomastia for
whom nonoperative management failed and who subsequently required bilat-
eral mastectomies. In addition, the authors performed a comprehensive review
of reported cases and generated a treatment algorithm.
Results: The patient tolerated the mastectomies well and went on to deliver
a healthy child. Postpartum delayed breast reconstruction with tissue ex-
pansion and implant placement yielded good results. The literature review
demonstrates that medical management has successfully avoided surgery
during gestation in 39 percent of cases since 1968. However, 35 percent of
patients eventually underwent breast reduction (12 percent) or mastectomy
(88 percent) during pregnancy. Spontaneous or elective termination of the
pregnancy accounted for 30 percent of outcomes. Patients who underwent
breast reduction and then became pregnant had a 100 percent (four of four
patients) chance of recurrence. Two women had mastectomy and subsequent
pregnancies. One woman developed multiple small areas of recurrence that
were surgically excised. The other woman had two additional pregnancies
with no recurrence of symptoms.
Conclusions: Medical therapies to manage gestational gigantomastia are
inconsistent in outcome. Since some patients respond, these therapies are
worth trying. However, if the patient and/or fetus are experiencing signif-
icant morbidity, then surgical intervention is warranted. Breast reduction or
mastectomy with delayed reconstruction is the preferred procedure. If the
mother is considering future pregnancies, mastectomy offers the lowest risk
of recurrence. (Plast. Reconstr. Surg. 118: 840, 2006.)

P
almuth1,2 is credited with reporting the first
case of gestational gigantomastia in 1648.
He stated, “Both breasts enlarged in every
pregnancy and the axillary glands swelled to the
size of a child’s head.” Lewison et al.3 stated,
“True gigantomastia develops rapidly during
pregnancy, undergoes regression after delivery,
and recurs with subsequent pregnancies.” Al-
though it remains a diagnosis of exclusion, most
physicians recognize the condition.
Traditionally, cases were managed nonopera-
tively by focusing on wound care and fetal/
maternal support. Antibiotics and hormone-
related therapies have expanded nonoperative
therapeutic modalities. Elective termination of
From the Division of Plastic and Reconstructive Surgery, De-
partment of Surgery, University of Wisconsin Medical School.
Received for publication March 21, 2005; accepted June 23, 2005.
Copyright ©2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000232364.40958.47
pregnancy has even been recommended by
some authors.4 –7 Conversely, surgery and anes-
thesia have evolved, allowing surgical interven-
tion to become a more viable option.
METHODS
This article presents a case of gestational gi-
gantomastia together with a comprehensive re-
view of the literature. Our review included all cases
of gestational gigantomastia reported in English
since 1968. We chose this date because Moss2 per-
formed an excellent review of all reported cases (a
total of 55 cases) before 1968. Since Moss’s report,
23 additional cases have been published. Gesta-
tional gigantomastia is extremely rare, and most
reports are of single cases, not a series of cases.
This makes reviewing the literature difficult, be-
cause standardized data points are not available.
In addition, the time frame over which cases have
been collected is very long (1648 to the present).

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Volume 118, Number 4 • Gestational Gigantomastia
During this period, substantial changes have oc-
curred in medicine that modified the treatment of
this condition. Because of high surgical risk, early
patients were not provided with surgery as a ther-
apeutic option. This is in contrast to surgical ther-
apy today, where there are significantly fewer an-
esthetic and surgical risks. Early cases offer a better
understanding of the gestational and postpartum
course of the condition when surgery is not uti-
lized. More recent cases offer insight into surgical
treatment outcomes. We believe reviewing all
cases together offers the best information on the
natural history and etiology of gestational gigan-
tomastia. This information forms the basis of our
proposed treatment algorithm.
CASE REPORT
A 34-year-old G1P0 woman was admitted to the hos-
pital at 22 weeks of gestation for management of mam-
mary hyperplasia. The patient noted rapid enlarge-
ment of her breasts between 6 and 8 weeks’ gestation.
She had previously been admitted to another hospital
for dehydration, urinary tract infection, and progres-
sively enlarging breast ulcerations. Bromocriptine had
been initiated but stopped due to nausea. At the time
of transfer, her breasts had massive ulcerations, a peau
d’orange appearance, and diffuse cellulitis (Fig. 1).
The patient was bedridden because of her breast
weight, taking multiple antibiotics for persistent cellu-
litis, and suffering from painful ulcerations. She
needed total parenteral nutrition because of her poor
nutritional status. Intrauterine growth retardation was
noted at 28 weeks’ gestation. Therefore, with the sup-
port of her perinatologist, she underwent bilateral mas-
tectomies. During the operation, the fetus was moni-
tored closely by the perinatologist. The breast tissue was
very vascular, and she received 9 units of packed red
Fig. 1. A 34-year-old woman at 22 weeks’ gestation presents
with massive breast hypertrophy and ulceration.
blood cells during the operation. The resected right
breast weighed 8410 g and the left breast weighed
8600 g. Histologic analysis showed marked lobular hy-
pertrophy with ductal proliferation and abundant peri-
ductal fibrosis. These findings are consistent with mac-
romastia secondary to pregnancy.8 Postoperatively, she
had mild cellulitis of the left breast that was treated with
nafcillin. On postoperative day 9, she was discharged
home. At term, she delivered a normal baby. Postpar-
tum breast reconstruction with tissue expanders was
performed (Fig. 2), followed by the placement of saline
breast implants. She has decided to postpone recon-
struction of her nipples.
BREAST PHYSIOLOGY AND
HISTOLOGY
The breast is composed of three principal tis-
sue types: fat, stroma, and glandular tissue. These
tissue types are organized within the breast around
alveoli and lobules. The lobular stroma undergoes
cyclic hypertrophy during the menstrual cycle,
with intralobular fluid accumulation. During
pregnancy, glandular tissue hyperplasia allows a
greater capacity for milk production. These
changes are mediated through complex hor-
monal interactions.9
Three predominant hormones regulate breast
physiology. These hormones are prolactin, estro-
gen, and progesterone. The effects of these and
other hormones are numerous and vary through-
out the menstrual and gestational cycle (Fig. 3).10
Fig. 2. Postpartum breast reconstruction with tissue expanders
and saline implants. Nipple reconstruction has been deferred.
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 Plastic and Reconstructive Surgery • September 15, 2006

Fig. 3. Hormonal regulation of the breast. ACTH, adrenocorticotropic hormone; CRH, corticotropin-releasing hormone; FSH, follicle-
stimulating hormone; GH, growth hormone; GHRH, growth hormone–releasing hormone; GnRH, gonadotropin-releasing hormone;
hCG, human chorionic gonadotropin; hPL, human placental lactogen; IGF, insulin-like growth factor; LH, luteinizing hormone; SRIF,
somatotropin release–inhibiting factor (somatostatin); TRH, thyrotropin-releasing hormone; TSH, thyroid-stimulating hormone.

Microscopic examination of breast tissue from
patients with gestational gigantomastia most often
shows glandular hyperplasia, overgrowth of con-
nective tissue, and tissue fibrosis. These findings
are consistent with normal breast tissue changes
during pregnancy. Adenosis, an increased num-
ber of acinar units per lobule, and fibroadenomas,
hormonally responsive intralobular stromal tu-
mors, are also frequently identified.
NATURAL HISTORY
Gestational gigantomastia complicates be-
tween 1:28,000 and 1:118,000 deliveries.3,11 We re-
port the only case at our hospital from 1990 to
2003, during which 40,669 deliveries were per-
formed.
Risk factors for gestational gigantomastia are
not fully appreciated. However, gestational gigan-
tomastia most commonly occurs in multiparous
women (although primiparous women may be af-
fected). Caucasian women are more likely to be
affected than African-American women (9:4).12
Fetal gender and maternal age do not appear to
cause significant risk; paternal risk factors have yet
to be identified.
Patients with gigantomastia may develop
breast ulceration, hemorrhage, cellulitis, pain, de-
creased mobility, and situational depression. After
gestational gigantomastia occurs, 93 percent of
subsequent pregnancies (13 of 14) are affected.
Only one woman has been diagnosed with gesta-
tional gigantomastia and not had recurrence of
symptoms with subsequent pregnancies. She was
20 years old and developed gestational giganto-
mastia in her first pregnancy. Her second preg-
nancy occurred without incident.13
In addition to physical and emotional stress,
gestational gigantomastia may cause maternal and
fetal death. Spontaneous termination of preg-
nancy occurred in seven (10 percent) of 69
women. In pregnancies carried to at least 8
months, two infants died in the peripartum
period.14,15 Two women died while pregnant. One
of these women died after her breasts turned black
in the fourth month of her pregnancy.16 No re-
ported cases of maternal death have been re-
ported since 1920.16
Gestational gigantomastia is recognized 63
percent (32 of 51 cases) of the time during the first
trimester, 30 percent (15 of 50) of the time during

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the second trimester, and 8 percent (four of 50)
of the time during the third trimester. Interest-
ingly, some of the women affected noted some
breast enlargement as early as 1 to 8 years before
pregnancy4,16 –20 and as late as 7 months’
gestation.21 The difference in observed onset may
be related to reporting bias but may also reflect
heterogeneous etiologies.
The range of postpartum breast involution var-
ies, but most women maintain a larger breast size
than baseline. It is difficult to quantify the degree
and time course of postpartum involution, be-
cause of inconsistent reporting in the literature
and increasing surgical intervention both during
and shortly after delivery.
ETIOLOGY
The etiology and pathogenesis of gestational
gigantomastia remain largely unknown. Numer-
ous theories exist, but none is universally appli-
cable. Lewison et al.3 presented a patient with
depressed urinary steroid metabolites and im-
paired liver function and concluded that altered
steroid metabolism with impaired liver function
played a role in the patient’s condition. In the
same study on a different patient, histological ex-
amination of the breast suggested elevated estro-
gen levels as a cause, but hormonal assays showed
only a decrease in progesterone levels. Treatment
with stilbestrol, a potent progestin, stopped fur-
ther hypertrophy. From these cases, Lewison et al.3
theorized that hormone receptor hypersensitivity
may contribute to gestational gigantomastia. In a
separate study by Lafreniere et al.,12 normal levels
of prolactin, progesterone, and estrogen recep-
tors were found in biopsied breast tissue from
patients with gestational gigantomastia. However,
at the same time they found elevated levels of
prolactin with normal progesterone and estrogen
levels. To decrease the serum prolactin levels,
Lafreniere et al.12 administered bromocriptine, a
dopamine agonist, which inhibits prolactin secre-
tion from the anterior pituitary. Further growth
was suppressed, but they did not observe any re-
duction in breast size. The authors subsequently
believed that hormone abnormalities contribute
significantly to the etiology of gestational gigan-
tomastia. Hormone profiles are intermittently re-
ported by various authors, but no conclusive
trends have been observed (Tables 1 and
2).5–7,11,12,15,17–31
The notion that malignancy can cause gesta-
tional gigantomastia was proposed by Windom
and McDuffie.29 They reported a case of massive
breast enlargement during pregnancy found post-
partum to be massive lymphomatous infiltration
from a non-Hodgkin’s lymphoma.
Gargan and Goldwyn25 hypothesized that a
stimulatory autoimmune-mediated complex, sim-
ilar to that seen in Grave’s disease, is responsible
for gestational gigantomastia; however, they ac-
knowledged no direct evidence.
With several different yet viable theories pre-
sented in the literature addressing the etiology of
gestational gigantomastia, it becomes difficult to
incorporate all the data into one universally ap-
plicable concept. This is why we believe that ges-
tational gigantomastia results from multiple dif-
ferent disease processes. For example, in some
cases, hormone abnormalities, tissue receptor sen-

Table 1. Summary of All Gestational Gigantomastia Cases Reported in the Literature

Summary of Cases Before 1968* 1968 to Present All Cases
No. of cases 55 23 78
First trimester onset 18/28 (64%) 14/23 (61%) 32/51 (63%)
Elective terminations 2/46 (4%) 4/23 (17%) 6/69 (8.7%)
Spontaneous terminations 4/46 (8.5%) 3/23 (13%) 7/69 (10%)
Maternal deaths 2/46 (4%) 0/23 (0%) 2/69 (3%)
Recurrence without surgery and subsequent
pregnancy 11/12 (91.5%) 2/2 (100%) 13/14 (93%)
Recurrence after breast reduction and subsequent
pregnancy 0/0 (0%) 4/4 (100%) 4/4 (100%)
Recurrence after mastectomy and subsequent
pregnancy 1/1 (100%) 1/2 (50%) 2/3 (66.5%)
Successful management without surgery during
pregnancy † 9/23 (39%) 9/23 (39%)†
Successful management with surgery during
pregnancy † 8/23 (35%) 8/23 (35%)†
Management with mastectomy during pregnancy 9 7 16/17 (94%)
Management with breast reduction during pregnancy 0 1 1/17 (6%)
*Cases reported in Moss, W. M. Gigantomastia with pregnancy: A case report with review of the literature. Arch. Surg. 96: 27, 1968.
†Incomplete data.

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 Plastic and Reconstructive Surgery • September 15, 2006

Table 2. Summary of Gestational Gigantomastia Cases Reported in the Literature since 1968
Hormone and
Age Reproductive Laboratory
Authors Year (yr) History Onset Profile Comment
Kapur and 1968 37 G2P1 6 months Spontaneous termination; mastectomy 2.5 years
Chawla22 postpartum, 6000/6000 g
Ship and 1971 22 G2P1 1 week Reduction mammaplasty 2 years before for
Shulman19 macromastia; mastectomy at 3 months, 27,500/
27,500 g
Leis et al.23 1974 23 G4P2A1G5P2A2 3 months High prolactin, First pregnancy normal, second and third
Kullander15 1976 low urinary gestational gigantomastia ending in
estrogen, LFTs spontaneous termination; two cesarean
normal deliveries (one child died 1.5 days postpartum
with low weight); reduction mammaplasty 10
months post-partum (from last pregnancy) for
incomplete regression, 1100/1600 g
Miller and 1979 22 G1P0 Huge at 12 weeks Elective termination; mastectomy with implant
Beeker5 reconstruction 6 months postpartum;
subsequent pregnancy with enlargement of
small masses excised postpartum
16 G1P0 Huge at 8 weeks Elective termination; mastectomy with implant
reconstruction
Hedberg et al.21 1979 26 G1P0 Presented at 7 Hormones
months normal
Wølner-Hanssen 1981 30 G1P0 Presented at 30 High prolactin, Reduction mammaplasty 4 months postpartum,
et al.24 weeks LFTs normal 2700/2060 g
Lafreniere et 1984 18 G2P0A1 10 weeks High prolactin Previous elective termination for social reasons;
al.12 mastectomy at 24 weeks, 4050/3460 g
Gargan and 1987 32 G5P2 21 weeks Hormones Some enlargement 4 months prepartum;
Goldwyn25 normal reduction mammaplasty at 21 weeks’ gestation,
6895/6700 g
Stavrides et al.17 1987 28 G3P1A1 1 year prepartum, Hormones Incomplete postpartum regression, therefore
presentedat 19 normal mastectomy with implant reconstruction, 1800/
weeks 1750 g
Jackson et al.26 1989 24 G3P2 14 weeks Hormones Only case of pseudohyperparathyroidism in
normal, gestational gigantomastia; mastectomy at 24
hypercalcemia weeks with resolution of hypercalcemia
Beischer et al.11 1989 27 G2P1 Immediate Reduction mammaplasty 6 months postpartum
28 G4/P3 Immediate Reduction mammaplasty postpartum, 3700/4700
g
Tchabo and 1989 28 G2P0A2 First trimester High LH, GH, Elective termination at 10 weeks; reduction
Stay6 ␤-hCG, and mammaplasty and tubal ligation 6 months
prolactin postpartum, 2000/1800 g
Propper et al.27 1991 24 G2P1 Last trimester Previous pregnancy normal; occurred during
lupus exacerbation; clinical diagnosis of
vasculitis
Wolf et al.28 1995 30 G3P1A1 8 weeks Hormones Spontaneous termination in second pregnancy at
normal, LFTs 20 weeks, no gestational gigantomastia;
normal gestational gigantomastia in third pregnancy;
reduction mammaplasty 8 weeks postpartum,
4300/5100 g
Cheung and 1997 34 G4P3A1 First trimester Elective termination at 12 weeks; incomplete
Alagaratnam7 regression
Windom and 1999 26 G2P1 (twins) 24 weeks High LDH, uric Concerns of pre-eclampsia led to preterm
McDuffie29 acid induction; left labial nodule removed during
episiotomy repair with pathology of high-grade
lymphoma; patient died 9 months postpartum
Colon and 1999 34 G1P0 8 years Hormones Mastectomy during pregnancy, 5287/3567 g;
Salloum18 prepartum, normal, LFTs tissue expander/implant reconstruction
huge at 8 weeks normal postpartum; two subsequent pregnancies
without complication
Agarwal et al.30 2002 24 G2P1 13 weeks Hormones Managed nonsurgically
normal, LFTs
normal
Ahcan et al.20 2003 27 G1P0 10 weeks Previous reduction mammaplasty 4 years earlier
for macromastia, 5110/5120 g
Vidaeff et al.31 2003 N/A G1P0 32 weeks Previous reduction mammaplasty 2 years earlier
for macromastia; mirror syndrome, emergency
cesarean delivery, newborn died within 24
hours; maternal ARDS, sepsis, and renal failure
postpartum; emergent bilateral simple
mastectomies resulted in clinical improvement,
6920/4510 g
Swelstad et al. 2006 34 G1P0 6 weeks Mastectomy at 28 weeks, 8410/8600 g; tissue
expander/implant reconstruction postpartum
LFT, liver function test; LDH, lactate dehydrogenase; LH, luteinizing hormone; GH, growth hormone; hCG, human chorionic gonadotropin;
ARDS, acute respiratory distress syndrome.

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Volume 118, Number 4 • Gestational Gigantomastia
sitivity, malignancy, and/or autoimmune mecha-
nisms may be responsible. Since several factors
and disease processes cause gestational giganto-
mastia, this explains why many proposed etiolo-
gies cannot be applied universally and why non-
surgical interventions yield highly variable results.
MEDICAL MANAGEMENT
Since gigantomastia may represent a common
phenotypic outcome from multiple different dis-
ease processes, patients should be evaluated ag-
gressively for identifiable, treatable, and even ma-
lignant etiologies. This workup should measure
the white blood cell count, hematocrit level, plate-
let level, and electrolyte levels and include liver
function tests, hormone profiles (estrogen, pro-
gesterone, and prolactin), and tissue biopsy or
rheumatological evaluation (Fig. 4).
Fig. 4. Management algorithm for gestational gigantomastia.
In one case, this broad evaluation identified
pseudohyperparathyroidism that resolved after
mastectomy.26 In another case, the gestational gi-
gantomastia was believed to be associated with an
exacerbation of systemic lupus erythematosus.27
Windom and McDuffie29 presented a case of ges-
tational gigantomastia complicated with a new di-
agnosis of lymphoma. Unfortunately, even with
identification of laboratory abnormalities, most
medical therapies have had suboptimal results.
Bromocriptine is the most widely used medical
regimen, resulting in mild regression or arrest in
breast hypertrophy. Effects are variable and usually
temporary, and do not restore breast volume to
normal.7,11,12,17,21,23,28 However, Agarwal et al.30 re-
ported a case in which bromocriptine was success-
fully used to avoid surgical intervention in a patient
with a normal hormone profile. Kullander15 re-
ported mammary growth arrest with 2 Br-alpha er-
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 Plastic and Reconstructive Surgery • September 15, 2006

gocryptine, another prolactin secretion inhibitor, in
a patient with nonpathological levels of circulating
prolactin. Treatment with various androgens, estro-
gens, and progestins have also been attempted, with
inconsistent results.2–5,17,19,30,32,33 Lewison et al.3 did
note arrest of breast growth with norethindrone, a
progestational agent, in one patient, but they also
noted inability to suppress growth with stilbestrol, a
testosterone analogue, in another patient. Wolf et
al.28 found no significant improvement with tamox-
ifen or dexamethasone but slight improvement with
bromocriptine in a patient with a normal hormone
profile. Nonhormonal medications have also been
attempted. Hydrochlorothiazide has successfully
been used to temporarily reduce breast swelling.2
Furosemide was used with no benefit.30 Hydrocor-
tisone did not show any effect,34 but prednisone may
have yielded a small benefit12,27 (Table 3). Before
initiating any of these drug therapies one must in-
form the patient of the known and unknown risks of
these medications to both maternal and fetal out-
come.
SURGICAL MANAGEMENT
Since 1968, the literature demonstrates that 39
percent of gestational gigantomastia cases have
been successfully managed nonsurgically during
pregnancy. When medical management fails to
provide an adequate quality of life for the mother
and good health for the mother and fetus, surgical
intervention should be considered.6,30,35 However,
the mother needs to understand the risks associ-
ated with surgery, including the potential use of
blood products. In addition, she needs to be aware
that surgical and anesthetic risks pertain not only
to her but to her fetus.
Bilateral mastectomy with delayed reconstruc-
tion and breast reduction are the most common
surgical procedures performed for women with
gestational gigantomastia. The decision to per-
form one versus the other depends on multiple
factors. Breast reduction reduces the volume of
breast tissue but does not eliminate the risk of
recurrence with subsequent pregnancies. Patients
who underwent breast reduction either before
pregnancy, during pregnancy, or after delivery
and again became pregnant had a 100 percent
(four of four) chance of recurrence. In addition,
breast reduction does not eliminate the risk of
further hypertrophy during the existing preg-
nancy. As long as breast tissue remains, it is likely
it will become hypertrophic with subsequent preg-
nancies. Bilateral mastectomy with delayed recon-
struction has a lower risk of recurrence with sub-
sequent pregnancies. Two women who had
mastectomies went on to have additional preg-
nancies. In 1957, Williams reported that one of
these women who underwent bilateral simple mas-
tectomy for gestational gigantomastia developed
multiple small areas of recurrence during a sub-
sequent pregnancy.6 The areas were excised with-
out complication. The recurrence was likely the
result of retained breast tissue at the time of mas-
tectomy. Importantly, she was not affected to the
same degree as with her previous pregnancy. The
other woman had two additional pregnancies with
no recurrence of symptoms.18 She had undergone
complete bilateral mastectomy. The difference in
outcome between these two women represents the

Table 3. Literature Review of Medical Therapies and Associated Outcomes

Medical Therapy Author(s) Outcome on Breast Size
23 21
Bromocriptine Leis et al., Hedberg et al., Mild regression or arrest in hypertrophy;
Lafreniere et al.,12 Stavrides et variable effects; usually temporary; did not
al.,17 Beischer et al.,11 Wolf et restore normal breast volume
al.,28 Cheung and Alagaratnam7
Agarwal et al.30 Avoided surgical intervention
Wolf et al.28 Slight improvement
2 Br-alpha ergocryptine Kullander15 Arrest of mammary growth
Androgens, estrogens, progestins Moss,2 Lewison et al.,3 Blaydes and Inconsistent results
Kinnebrew,32 Williams,33 Greeley
et al.,4 Miller and Beeker,5
Stravrides et al.,17 Ship and
Shulman,19 Agarwal et al.30
Tamoxifen Wolf et al.28 No significant improvement
Dexamethasone Wolf et al.28 No significant improvement
Hydrochlorothiazide Moss2 Temporarily reduced breast swelling
Furosemide Agarwal et al.30 No benefit
Hydrocortisone Nolan34 No effect
Prednisone Lafreniere et al.,12 Propper et al.27 Small benefit

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importance of removing the entire breast if the
lowest recurrence rate is desired.
Intraoperative and perioperative manage-
ment issues must also be considered when decid-
ing between breast reduction and bilateral mas-
tectomy. Specifically, bilateral mastectomy with
delayed reconstruction requires multiple postpar-
tum reconstructive procedures and imparts the
psychological trauma of losing one’s breasts on
the patient.
However, performing bilateral mastectomy in
patients with gestational gigantomastia is faster
and can be performed with less blood loss than
breast reduction. Reducing the duration of the
operation exposes the mother and fetus to less of
the potentially teratogenic anesthetic agents. Al-
though blood loss in routine breast reductions can
be limited to a minimum, in patients with gesta-
tional gigantomastia, blood loss is substantially
greater because of the severely engorged and fri-
able vessels. Our patient required 9 units of blood.
Bleeding can be so severe that the first mastecto-
mies in gestational gigantomastia were staged
(each side performed during separate operations)
to minimize the physiologic effects of surgery on
mother and fetus. Finally, selection of a surgical
procedure needs to consider postoperative wound
healing. In patients with gestational gigantomas-
tia, large areas of ulceration and breast necrosis
may complicate flap design and led to poor post-
operative healing. There are no data in the liter-
ature commenting on differences in postoperative
wound care in patients with gestational giganto-
mastia who have undergone breast reduction ver-
sus mastectomy. It is up to the surgeon to plan the
procedure in a way to minimize problems with
wound healing.
Therefore, if a woman is planning on future
pregnancies and wishes to reduce the risk of re-
currence as much as possible, then bilateral mas-
tectomy with delayed reconstruction is her best
option. If a woman is not planning on future preg-
nancies, is clinically stable, and understands the
possibility of increased operative blood loss and
continued hypertrophy during the existing preg-
nancy, then breast reduction is a viable option.
Patients who are poor surgical candidates despite
appropriate medical management (secondary to
sepsis, cardiac failure, pulmonary failure, bleeding
disorders, and so on) are better candidates for
mastectomy (Fig. 4).
Wolf et al.28 do not believe mastectomy or
breast reduction should be used in the manage-
ment of gestational gigantomastia. Instead, if the
woman’s life is at risk, they recommend termina-
tion of the pregnancy or induction of preterm
labor. In the case presented by Wolf et al., preterm
labor was induced at 32 weeks’ gestation. The
child did well and the mother’s condition im-
proved. Elective termination has been reported in
8.7 percent of cases. We believe mastectomy and
breast reduction save the mother the enormous
psychological cost of losing the fetus and from
remaining hospitalized throughout the remain-
der of the pregnancy. No reported cases in the
literature describe fetal or maternal loss secondary
to mastectomy or breast reduction during preg-
nancy.
SUMMARY
Gestational gigantomastia appears to be a
common phenotypic outcome from one or more
aberrant growth-related pathways resulting in mas-
sive breast enlargement. The diagnosis is one of
exclusion. Medical management is usually ineffec-
tive but remains first-line therapy in the hopes of
avoiding surgery during pregnancy. If the quality
of a woman’s life suffers significantly or endangers
fetal viability, then surgical management should
be utilized. Bilateral mastectomy with delayed re-
construction offers the lowest risk for recurrence
if the woman becomes pregnant again. It can also
be performed faster with less blood loss. Breast
reduction avoids the morbidity associated with
mastectomy but has a greater risk of recurrence
with subsequent pregnancies, requires a longer
operative time, and may expose the mother and
fetus to more donor blood products.
Venkat K. Rao, M.D., M.B.A.
Division of Plastic and Reconstructive Surgery
University of Wisconsin Medical School
600 Highland Avenue
Madison, Wis. 53792
rao@surgery.wisc.edu
DISCLOSURE
The authors have no financial interests to disclose.
REFERENCES
1. Palmuth, P. Observationes medicarum centuriae. Braunschweig
Cent ii: OBS, 1648, Vol. 89.
2. Moss, W. M. Gigantomastia with pregnancy: A case report
with review of the literature. Arch. Surg. 96: 27, 1968.
3. Lewison, E. F., Jones, G. S., Trimble, F. H., and Da Costa
Lima, L. Gigantomastia complicating pregnancy. Surg. Gy-
necol. Obstet. 110: 215, 1960.
4. Greeley, P. W., Robertson, L. E., and Curtin, J. W. Mastoplasty
for massive bilateral benign breast hypertrophy associated
with pregnancy. Ann. Surg. 162: 1081, 1965.
5. Miller, C. J., and Beeker, D. W. Management of first trimester
breast enlargement with necrosis. Plast. Reconstr. Surg. 63:
383, 1979.
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 Plastic and Reconstructive Surgery • September 15, 2006
6. Tchabo, J. G., and Stay, E. J. Gravidic macromastia: Case
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