Gestational Gigantomastia in Multiparity: Successful Management with Bilateral Reduction and Free Nipple Grafts

Introduction

Gestational gigantomastia (GG), also referred to as gravid macromastia, is a rare condition characterized by excessive and rapid breast growth during pregnancy [1]. It is associated with significant breast enlargement, often leading to edema and venous congestion [1]. Globally, it is estimated that approximately 1 in every 28 000 to 100 000 pregnancies are affected by GG [2].

A consensus on a definitive definition of gigantomastia remains unreached. Despite the lack of standardized measurement criteria across studies, gigantomastia is generally characterized by breast tissue that exceeds 3% of the total body weight, marked breast hypertrophy exceeding 1.5 kg per breast, or the presence of breasts that need to be surgically reduced by 1 to 2 kg [3].

The etiology remains unclear, but hormonal changes, particularly of prolactin, are thought to play a role [4]. Risk factors and associated conditions are not well established [5]. Genetic factors may play a role, with specific polymorphisms in aromatase (CYP19A1) genes potentially increasing the risk [6].

Diagnosis is primarily clinical, supported by imaging, such as ultrasound or magnetic resonance imaging, and hormonal assays, particularly elevated prolactin and progesterone levels. It is essential to exclude malignant conditions, such as phyllodes tumors or lymphomas, especially in atypical or unilateral presentations [7–9]. Management strategies are highly individualized and depend on the severity of symptoms and the gestational stage. Conservative measures can include supportive garments, analgesia, and hormonal therapy, such as bromocriptine; however, safety considerations often limit medical therapy during pregnancy. In cases with severe symptoms, complications, or failure of conservative treatment, surgical intervention, either reduction mammaplasty or mastectomy, is considered, typically postpartum, unless complications mandate earlier action [5,10,11].

GG poses a significant burden, from physical discomfort to profound psychosocial effects [10]. Excessive breast enlargement, which is characteristic of GG, can lead to a markedly diminished quality of life, marked by a constellation of debilitating symptoms [10]. Intense pain, constant and throbbing, can significantly interfere with daily activities, sleep, and overall well-being [10].

Several individual case reports have illustrated the broad clinical spectrum of GG. For example, Ecanow et al described a case complicated by breast infarctive necrosis in a patient with concurrent SARS-CoV-2 infection, highlighting the potential for ischemic complications if left unmanaged [12]. Ibrahim et al reported a fatal outcome in a patient who declined surgical treatment and developed severe sepsis, emphasizing the critical importance of timely intervention [13]. Conversely, Okere et al detailed a successful outcome using a multidisciplinary surgical approach tailored to the patient’s preferences, demonstrating the importance of individualized care [14]. These reports underscore the severity, timing, and outcome variability of GG, further validating the need to document new presentations. Given the condition’s rarity, standardized care guidelines are limited, making each new case valuable to clinical understanding.

This report presents a rare case of GG in a 36-year-old multiparous woman who developed massive bilateral breast enlargement during her fourth pregnancy, accompanied by severe back pain. The case details the clinical presentation, radiological findings, laboratory results, and successful surgical management through bilateral breast reduction.

Case Report

A 36-year-old woman, gravida 4 para 3+1, presented to our breast and endocrine surgery clinic 6 months postpartum, on August 29, 2024, with a primary concern of bilateral breast enlargement and palpable lumps. Her breast enlargement had gradually worsened during her recent pregnancy. It had started during the second trimester, with significant enlargement noted over the previous 10 months. After delivery, a degree of improvement was observed, but her breast size was not back to baseline. Associated symptoms included severe lower back pain, trapezius muscle spasms, shoulder and upper limb numbness, and significant discomfort throughout the past months. Remarkably, this breast enlargement was absent in all of her previous pregnancies. Menarche occurred at age 13 years. She had no breastfeeding history. Her past medical history revealed she had hypothyroidism that was well managed on levothyroxine. Her past surgical history included an open appendectomy performed 16 years prior and a right fibroadenoma excision 1 year prior. Her social and family histories were otherwise unremarkable, with no prior history of breast or thyroid malignancies. A thorough review of body systems revealed no other significant medical concerns.

Physical examination revealed a significant degree of bilateral breast hypertrophy (Figure 1). The patient’s height was 168 cm, and weight was 99.1 kg, resulting in a body mass index of 35.11. Inspection of her breast revealed no evidence of overlying skin or nipple-areolar complex involvement, such as peau d’orange sign, nipple asymmetry, retraction, or hemorrhage. Furthermore, no erythema or induration was observed. Palpation of the breasts did not reveal any palpable fibroadenomas. Breast measurements were taken, and the distance from the sternal notch to the nipple was measured on the right breast at 50 cm and on the left breast at 52 cm. Further detailed measurements are presented in Table 1.

Laboratory investigations revealed an elevated serum prolactin level (432 μIU/mL; reference range: 86–324 μIU/mL) and elevated serum progesterone (7.9 nmol/L; reference range: 0.7–4.3 nmol/L), consistent with the patient’s recent pregnancy. Other laboratory parameters were within established reference ranges, including complete blood count, comprehensive metabolic panel, lipid profile, thyroid function tests, liver function tests, alkaline phosphatase, and coagulation profile.

Breast ultrasound demonstrated a heterogeneous, dense fibroglandular background echotexture in both breasts. Multiple bilateral, variably sized, circumscribed, oval, parallel vascular hypoechoic masses were identified. The largest mass in the right breast measured 6.9×3.3 cm, located at the 10 o’clock position near the nipple, while the largest mass in the left breast measured 5.2×1.1 cm at the 12 o’clock position (Figures 2, 3). Numerous bilateral masses exceeded 3 cm in diameter, hindering comprehensive biopsy. Additionally, multiple bilateral small, simple cysts and bilateral severe physiological duct dilatation, consistent with postpartum status, were observed. Axillary ultrasound revealed a few benign-appearing bilateral axillary lymph nodes.

A multidisciplinary team, including a breast and endocrine surgeon, plastic and reconstructive surgeon, anesthesiologist, and pain medicine specialist, collaboratively managed the patient’s case. Bilateral breast reduction with a free nipple graft was elected as the definitive treatment and was conducted in mid-November, 1 month after her presentation to our clinic. The surgical procedure involved bilateral nipple incisions (42-mm cookie cutter), nipple de-epithelialization, and free nipple graft harvesting. Hemostasis was maintained throughout the surgery, which lasted approximately 3 h (Figure 4). A total of 5.150 kg of right breast tissue was excised, measuring 38.0×32.0×8.0 cm. Similarly, 5.530 kg of left breast tissue was excised, measuring 36.0×30.0×9.0 cm. The patient experienced an uneventful postoperative recovery, with no significant complications following the surgical intervention. She was discharged home in stable condition and followed up at regular intervals.

Histopathological examination of the resected breast tissue revealed extensive areas of fibrocystic changes, characterized by the presence of multiple fibrous and cystic structures occupying significant portions of the breast parenchyma. Microscopically, the tissue demonstrated varying degrees of fibrosis, ductal ectasia, and cyst formation. There was no evidence of atypical ductal hyperplasia, atypical lobular hyperplasia, or malignancy. The pathologist’s final diagnosis was benign breast tissue with fibrocystic changes.

Postoperatively, the patient was monitored at 1- and 2-month intervals following bilateral reduction mammaplasty with a nipple-sparing technique. Throughout the follow-up period, no complications were observed, indicating an uneventful recovery (Figure 5).

Discussion

GG is a rare condition that occurs during pregnancy and can persist in the postpartum period. The purpose of this case report is to provide valuable insight into this infrequent clinical entity, especially regarding the diagnosis and management of GG. To the best of our knowledge, based on an extensive literature review, between 1962 and early 2025, less than 80 cases were reported.

This case demonstrates that GG can occur even in later pregnancies without a prior history, challenging the common assumption that it typically presents in early gestations. Furthermore, it emphasizes the potential for GG to cause significant musculoskeletal and psychosocial morbidity, which can persist into the postpartum period. The case illustrates that a multidisciplinary approach and timely surgical intervention, specifically bilateral breast reduction with free nipple grafts, can lead to excellent functional and cosmetic outcomes.

A thorough review of the literature by Alhindi et al encompassed 66 case reports that comprehensively addressed the clinical presentation, management strategies, and outcomes associated with GG [11]. Key findings from this analysis revealed that the mean age of patients at presentation was 28.79 years. Regarding the onset, 47% of patients experienced GG during the first trimester of pregnancy. Rapid bilateral breast enlargement emerged as the predominant presenting symptom, observed in 80.59% of cases. In contrast, our patient was 36 years old and developed GG for the first time in her fourth pregnancy during the second trimester, after 3 prior uneventful gestations. This divergence underscores that GG can occur even in later pregnancies and at a higher maternity age than typically reported. Despite the atypical timing of this case, the patient’s clinical features, such as dramatic bilateral breast hypertrophy accompanied by severe back, shoulder, and chest discomfort, mirror the classic symptomatology described in other cases. Regarding medical management, bromocriptine was the most frequently prescribed pharmacotherapeutic intervention in 54.28% (19/35) of cases. Surgical intervention, primarily bilateral breast reduction, was undertaken in 50% (24/48) of cases. Moreover, most patients (74.07%, 40/54) experienced uneventful recoveries following treatment [11].

The occurrence of gigantomastia is not necessarily exclusively related to the first pregnancy; however, a history of gigantomastia significantly increases the likelihood of recurrence in subsequent pregnancies [15]. In the present case, the patient first experienced GG during her fourth pregnancy. Gigantomastia is primarily attributed to benign etiologies, with malignancy constituting a rare underlying cause. Therefore, a thorough evaluation to rule out malignancy is essential. While the precise etiology of gigantomastia has not been fully established, several case reports have implicated malignancy as an underlying factor in its development. In their respective case reports, Sakai et al [7], Hynes et al [8], and Foreste et al [9] described instances of unilateral gigantomastia arising from underlying malignancies. A common characteristic observed across these cases was the unilateral presentation of breast enlargement. This underscores the importance of thoroughly evaluating malignancy in unusual presentations; in our case, imaging and pathology confirmed no evidence of cancer.

The substantial weight of enlarged breasts can exert significant strain on the back, neck, and shoulders, leading to chronic pain and postural abnormalities. In the literature, the excised tissues per breast had a mean weight of 6159.57 g (range between 1100 and 17 000 g) in the right breast and a mean weight of 5911.6 g (range between 1125 and 17 000 g) in the left breast, which is in accordance with our case, in which a total of 10.68 kg of breast tissue was removed (5.15 kg from the right and 5.53 kg from the left) [11].

The significant physical and functional limitations GG imposes can profoundly affect a woman’s mental and emotional well-being. The stretched and fragile skin can be prone to ulceration, infection, and even necrosis, due to a compromised blood supply. Nevertheless, our patient did not develop any skin ulceration, ischemia, or systemic complications, despite the extreme degree of breast hypertrophy. Ecanow et al reported the first case of GG complicated by breast infarctive necrosis, in the setting of SARS-CoV-2 infection [12]. Ibrahim et al described a tragic outcome for a patient with GG complicated by severe sepsis [13]. Despite the identification of Proteus species and subsequent blood culture positivity for Staphylococcus aureus, the patient and her family declined the recommended surgical intervention of bilateral simple mastectomy. Following a preterm stillbirth at 22 weeks gestation, the patient’s condition rapidly deteriorated, and she developed severe sepsis. Ultimately, despite intensive medical treatment, the patient died of sepsis. The early definitive management in our case likely prevented such sequelae, and the patient experienced an uneventful recovery, with complete resolution of her musculoskeletal symptoms. Her outcome was in line with that of literature reports, which indicates that most patients have an uncomplicated recovery after appropriate therapy [11].

Given the multifaceted and debilitating nature of GG, surgery is the mainstay of management and is considered the most effective management strategy, while taking into account the disease severity, timing relative to pregnancy, and the patient’s preferences [14]. By reducing the size and weight of the breasts, surgery can alleviate pain, improve mobility, prevent complications, and enhance body image. In the published case reports, reduction mammoplasty and total mastectomy were the most commonly reported management strategies. While reduction mammoplasty offers the potential for preserving breastfeeding capabilities, it carries a higher risk of recurrence, due to the possibility of residual breast tissue undergoing hyperplasia during subsequent pregnancies [2]. Total mastectomy, in contrast, minimizes the risk of recurrence. In our patient’s case, the presentation was late in the course, as she presented months following onset, with massive breast hypertrophy, and she strongly desired a prompt, definitive solution. As a result, we did not attempt medical management. By the time of her evaluation, she had delivered, therefore diminishing hormonal drive for further growth and the severity of her enlargement was such that conservative measures were unlikely to provide meaningful relief. We proceeded directly to surgical intervention, with the understanding and agreement of the patient after thorough counseling. Mastectomy was offered to the patient; however, she refused, given that the patient had completed her family and her wished to retain her breasts. Ultimately, she underwent bilateral breast reduction with free nipple grafts. This approach was chosen because the extreme breast size and ptosis precluded safely preserving the nipple-areolar complex on a vascular pedicle at the new, elevated position. By converting the nipple-areolar complex to a full-thickness graft on each side, we could reattach the nipples appropriately after removing the excess tissue. The patient was very receptive to this plan, as it would achieve a significant reduction in size while still maintaining the appearance of natural breasts.

While this technique allows nipple preservation, it carries inherent risks [16]. Free nipple grafts can potentially result in diminished or absent nipple sensation, affecting sexual pleasure and the ability to breastfeed. Additionally, the grafted nipple may not achieve optimal projection, leading to an aesthetically less-than-ideal outcome. Furthermore, uneven pigmentation of the nipple-areolar complex can occur, affecting the cosmetic appearance. Finally, free nipple grafts can compromise the integrity of the lactiferous ducts, potentially impairing lactation. Therefore, these potential complications should be thoroughly discussed with patients prior to their undergoing breast reduction with free nipple grafts, to ensure informed decision-making regarding surgical options. The presented case achieved a successful outcome: over 10 kg of tissue were removed, the breasts were dramatically reduced in size with an aesthetically pleasing contour, and the grafted nipple-areolar complexes healed well.

This case highlights that, even in severe presentations of GG, a carefully planned reduction mammoplasty can provide definitive treatment with excellent functional and cosmetic outcomes, avoiding the need for more ablative surgery. The effective multidisciplinary management and uneventful recovery observed in this case reinforce the importance of individualized, patient-centered care in achieving optimal results for this rare and challenging condition.

The current knowledge base regarding GG is constrained by a paucity of research and a significant reliance on case reports and small case series. While these studies provide valuable insights, their limited sample sizes can hinder the generalizability of their findings. To address this, future research should prioritize conducting larger-scale studies, including prospective cohort studies, to better understand the epidemiology, pathophysiology, recurrence rates, and long-term outcomes associated with GG.

Conclusions

This case highlights the potential for GG to develop during later pregnancies, even without a prior history. The patient presented with severe musculoskeletal symptoms and underwent successful bilateral breast reduction with free nipple grafts, resulting in full recovery and symptom resolution. This case underscores GG’s significant physical and psychosocial burden and the importance of early recognition, exclusion of malignancy, and individualized, multidisciplinary management. When appropriately timed and planned, surgical intervention can offer effective symptom relief and favorable cosmetic outcomes. Thorough preoperative counseling and shared decision-making between the surgeon and patient is crucial to ensure patients are fully informed about the potential risks and limitations associated with each surgical intervention, allowing them to make informed decisions regarding their surgical options. Given the rarity and variability in management approaches, further studies are warranted to evaluate long-term outcomes and to consider the development of standardized treatment protocols or clinical guidelines for GG.