Surgical management of gestational gigantomastia: a case report and novel staged approach

Introduction

Gestational gigantomastia is a rare condition characterized by rapid and excessive breast tissue growth during pregnancy. Quantitatively, gigantomastia is often described as requiring resection of more than 1,500 grams of tissue per breast, although no consensus definition exists (1,2). While its etiology is multifactorial, hormonal mechanisms are thought to play a central role. It affects an estimated 1 in 28,000 to 1 in 100,000 pregnancies and can cause severe physical and functional morbidity, including infection, sepsis, skin breakdown, and impaired mobility (3,4). Pathophysiologically, the condition is associated with heightened local sensitivity to hormonal and inflammatory signaling, leading to profound breast enlargement and secondary tissue compromise (4,5).

Current evidence suggests that disease progression is driven by enhanced local estrogen sensitivity and production within breast tissue, mediated by upregulation of estrogen receptor alpha and aromatase activity, with additional contributions from paracrine growth factor signaling (5,6). Gestational gigantomastia has also been reported in association with autoimmune conditions, including systemic lupus erythematosus (SLE), myasthenia gravis, and other immune-mediated diseases, with histopathologic findings such as lymphocytic infiltrates, suggesting a potential immune-mediated component in a subset of patients (7,8).

While medical management with hormone-modulating therapy may slow breast growth, definitive treatment typically requires surgical removal of most or all breast tissue. Bromocriptine is the most used medical therapy in gestational gigantomastia, but many patients ultimately require surgical intervention (3,9). To date, there has been no consensus regarding optimal timing, staging, or reconstructive approach. While reduction mammoplasty may be appropriate in selected patients, its use is limited in cases complicated by severe tissue edema, skin compromise, or systemic illness, and recurrence rates are high with subsequent pregnancies (3,10,11). As a result, mastectomy is often favored as definitive treatment in patients anticipating future pregnancies (3). Reconstructive strategies following mastectomy have traditionally relied on delayed, multi-stage approaches using tissue expanders and implants (12,13). In these patients, autologous reconstruction is less frequently described and, when performed, has involved staged approaches that incorporate tissue expansion.

The purpose of this report is to describe the management of severe gestational gigantomastia using bilateral skin-sparing mastectomy followed by delayed deep inferior epigastric perforator (DIEP) flap reconstruction without tissue expansion, highlighting a reconstructive strategy that reduces surgical staging while achieving durable outcomes. We present this article in accordance with the CARE reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-57/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

We present a 35-year-old female gravida 7 para 3 with a history of asthma and SLE who presented with bilateral breast tenderness, breast erythema, and rapidly increasing breast size at 13 weeks gestation. Her medical history was notable for prior, intermittent treatment with hydroxychloroquine (400 mg daily) for SLE, with systemic corticosteroids used during disease flares. At the time of her initial rheumatology presentation several months prior to hospitalization, she was not taking hydroxychloroquine. Her asthma was managed with inhaled budesonide-formoterol and albuterol as needed.

She reported a previous, less severe episode of gestational gigantomastia 5 years earlier, which required medical management but resolved postpartum. At that time, skin biopsy showed reactive interstitial granulomatous and neutrophilic dermatitis. She required hospitalization for intravenous antibiotics and was followed closely by rheumatology. She was ultimately managed with prednisone and hydroxychloroquine until symptoms improved. In contrast, the patient’s current pregnancy was marked by rapidly progressive systemic symptoms. Medical management was initiated in coordination with rheumatology and obstetrics. Prior to hospitalization, immunosuppressive therapy was initiated and progressively escalated, including hydroxychloroquine 400 mg daily, systemic corticosteroids (prednisone up to 40 mg daily and later methylprednisolone up to 64 mg daily), azathioprine titrated to 200 mg daily, and tumor necrosis factor-alpha inhibitor therapy (etanercept and certolizumab pegol, with transition between agents for clinical and treatment considerations). Despite this escalation, her breast enlargement progressed rapidly.

In March 2021, at 21 weeks gestation, she presented to the emergency department with fever, tachycardia, difficulty breathing, and inability to ambulate due to the size and weight of her breasts (Figure 1), and was admitted with sepsis secondary to breast cellulitis. She was treated with broad-spectrum intravenous antibiotics with clinical improvement. Following hospital admission, bromocriptine mesylate was initiated at a dose of 2.5 mg twice daily for a 2-week trial, without meaningful clinical response. Immunosuppressive therapy was managed in close coordination with rheumatology and carefully adjusted in the setting of acute infection.

Figure 1 Pre-operative views of the patient at presentation (left) and the day of bilateral mastectomy (right). Massive bilateral breast enlargement and erythema were evident on presentation. The images were published with the patient’s consent.

On examination, both breasts were markedly enlarged and erythematous, with diffuse tenderness to palpation and scattered bullae draining clear fluid. Ultrasound revealed skin thickening, extensive subcutaneous edema, and bilateral multiloculated subareolar fluid collections. Given the severity of her symptoms and desire for future pregnancies, the patient elected to terminate the pregnancy after multidisciplinary discussions and proceed with bilateral mastectomy.

Once medically stabilized, the patient underwent bilateral skin-sparing mastectomy in May 2021, 1 month following pregnancy termination. Prior to surgery, a type and screen was sent, with crossmatched blood available. Surgical ties, LigaSure (Medtronic, Dublin, Ireland), and adequate assistance for retraction were confirmed before the case start. Given marked tissue engorgement and anticipated bleeding risk, vascular surgery was consulted intraoperatively as a precautionary measure to assist with exposure and hemostatic control. The breast tissue and subdermal venous plexus were markedly engorged, without a single dominant bleeding vessel, and hemostasis was achieved in a stepwise manner. Electrocautery was used for superficial dissection and smaller vessels, LigaSure for larger intradermal perforators and areas of dense vascularity, and suture ligation or surgical clips for persistent bleeding. Blood loss was minimal, and there were no intraoperative complications. The nipple-areola complexes (NACs) were not preserved given compromised tissue viability, including significant edema, tissue friability, and concern for impaired perfusion, as her sternal notch-to-NAC distance was greater than 35 cm, with plans for delayed reconstruction. Approximately 9 kg of tissue was removed from each breast, reflecting the severity of disease and the technical complexity of operative management (Figure 2). The mastectomy skin flaps were preserved, selectively trimmed and re-draped to permit primary closure without compromising the surface area needed for subsequent autologous reconstruction. Redundant inferior and lateral skin was then excised. Closure was performed in layers with interrupted deep dermal sutures followed by a running subcuticular layer to ensure appropriate wound apposition without undue tension (Figure 3). Final pathology showed benign breast tissue with lactational change and dilated dermal lymphatics in the overlying skin, without evidence of atypia or malignancy. These findings were consistent with the histologic features of gestational gigantomastia, characterized by stromal expansion and increased vascularity (7).

Figure 2 Intraoperative view demonstrating operative setup and breast size prior to bilateral skin-sparing mastectomy (left). Gross mastectomy specimen following bilateral mastectomy (right). The images were published with the patient’s consent.

Figure 3 Post-operative photographs 1 (left) and 4 (right) months after bilateral mastectomy. The images were published with the patient’s consent.

After resolution of the preoperative infection and adequate healing of the mastectomy flaps, she underwent bilateral DIEP flap reconstruction approximately 5 months after mastectomy (Figure 4). Nipple reconstruction using a C-V flap was performed approximately 5 months later, followed by NAC tattooing approximately 1 year after nipple reconstruction (Figure 5). Her postoperative course was uncomplicated. Postoperative outcomes were assessed based on patient-reported symptom relief and functional improvement. She reported significant relief from the burden of gigantomastia, including difficulty ambulating, dyspnea, and painful skin breakdown. At 4 years following mastectomy, the patient remains highly satisfied with the cosmetic and functional results of reconstruction (Figure 6). The overall diagnostic, therapeutic, and reconstructive course is summarized in Figure 7.

Figure 4 Pre-operative view of patient prior to DIEP flap reconstruction (left). Post-operative view of patient 2 (middle) and 6 (right) months after DIEP flap reconstruction. The images were published with the patient’s consent. DIEP, deep inferior epigastric perforator.

Figure 5 Pre-operative view of patient prior to NAC reconstruction (left). Post-operative view of patient 2 (middle) and 4 (right) months after NAC reconstruction. The images were published with the patient’s consent. NAC, nipple-areola complex.

Figure 6 Post-operative view of patient 2 years after NAC tattooing. This image was published with the patient’s consent. NAC, nipple-areola complex.

Figure 7 Graphical timeline summarizing key diagnostic, medical, surgical and reconstructive milestones in the management of gestational gigantomastia. CV, DIEP, deep inferior epigastric perforator; IV; TEs.

Discussion

Gigantomastia is a rare disorder of excessive breast tissue growth. Although no consensus definition exists, it is commonly described as requiring resection of more than 1,500 grams of tissue per breast (1). Most cases are idiopathic, but it has also been reported in association with pregnancy (gestational gigantomastia), puberty (juvenile gigantomastia), autoimmune conditions such as SLE, myasthenia gravis, rheumatoid arthritis, and, less frequently, medication exposure (2,10,14). Our patient’s history of SLE is consistent with these reported associations. In patients with autoimmune disease, gestational gigantomastia may reflect immune-mediated inflammation superimposed on hormonally driven breast enlargement, providing a rationale for immunosuppressive therapy in select cases (7,8). Medical management with hormone-modulating agents or immunosuppressive therapy in the setting of autoimmune disease may be attempted, but durable control is uncommon (3). In a systematic review of 66 published cases, bromocriptine was the most frequently used agent, yet more than half of patients ultimately required surgery, most often bilateral reduction or mastectomy (9). Recurrence occurred in roughly one-quarter of patients, almost always with subsequent pregnancies (9).

A history of gestational gigantomastia is an important predictor of recurrence in subsequent pregnancies. In a review of 76 reported episodes, Fofung et al. identified prior gestational gigantomastia as the strongest single predictor of recurrence (15). This observation has direct implications for prepregnancy counseling, as patients with a prior episode should be counseled regarding the high likelihood of recurrence and the limited durability of tissue-preserving approaches. In this context, mastectomy is regarded as the procedure of choice for women anticipating future pregnancies, as it is the most reliable means of preventing recurrence (9). In addition to definitive disease control, bilateral mastectomy eliminates residual breast tissue and may secondarily reduce future breast cancer risk, although this is not the primary indication for surgery (16).

When breast reduction is considered as a surgical option, technique selection is critical and depends on tissue quality and overall clinical context. Wise-pattern reduction mammaplasty involves a circumareolar incision with a vertical limb extending to the inframammary fold and a transverse inframammary incision, resulting in an inverted-T scar pattern that allows for large-volume skin excision and parenchymal resection. However, this technique relies on adequate tissue perfusion and healing across extensive skin flaps and incisions, which may be compromised in patients with marked tissue edema, pre-existing skin breakdown, or systemic illness. In these settings, wise-pattern reductions carry an increased risk of wound dehiscence, infection, and tissue necrosis and are therefore not appropriate (17).

The timing of reconstruction remains debated. Immediate reconstruction may be considered in stable patients, but in cases of active inflammation or infection, delayed reconstruction is generally preferred due to higher risk of wound breakdown, infection, and implant loss (10,12,18). One case of immediate implant-based reconstruction required implant removal for infection and later conversion to autologous reconstruction (19). Autologous options, particularly DIEP flaps, are increasingly favored for their aesthetic and long-term outcomes, but are typically delayed until after delivery to allow use of the abdomen as a donor site.

Autologous reconstruction in patients with gestational gigantomastia has been described, but use of DIEP flaps remains rare (9,18-20). In one published case, staged reconstruction began with tissue expander placement 12 months after mastectomy, followed by DIEP flap reconstruction once an adequate pocket had been created (20). More recently, bilateral skin-sparing mastectomy with immediate reconstruction using the Goldilocks technique, which utilizes de-epithelialized mastectomy skin flaps to create an autologous breast mound, and free nipple grafting has been reported as an additional option in select, clinically stable patients (21). Collectively, these cases highlight an expanding reconstructive spectrum in the management of this rare and challenging condition.

In the present case, delayed DIEP flap reconstruction was performed within 6 months of mastectomy, once infection and inflammation had resolved, without the use of tissue expanders. This approach reduced the total number of operations while achieving durable restoration of breast form. The absence of tissue expansion required careful preoperative planning to accommodate the large skin requirements typical of these cases, emphasizing the value of a multidisciplinary approach and individualized timing.

Reconstruction after gestational gigantomastia presents distinct challenges related to infection, soft-tissue loss, and timing relative to pregnancy. Autologous options, particularly DIEP flaps, remain infrequently described in this setting, and data on long-term outcomes is limited. This case demonstrates that delayed DIEP flap reconstruction can achieve durable long-term results without staged expansion, even after a history of severe infection. The primary limitation of this report is the single-patient design, and additional cases will be important to further define patient selection, timing, and long-term outcomes. Nonetheless, this case contributes meaningful data supporting delayed autologous reconstruction as a definitive approach once infection and inflammation have resolved.

Conclusions

Gestational gigantomastia is a rare condition with significant morbidity that often requires definitive surgical management. Bilateral mastectomy followed by delayed DIEP flap reconstruction without tissue expanders is a safe and effective reconstructive strategy that limits the need for multiple staged operations while restoring long-term form and function. This approach is broadly applicable but is particularly relevant for patients anticipating future pregnancies, in which the risk of recurrence after reduction is highest.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-57/rc

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-57/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-57/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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