A 26-year-old woman with macromastia

presented by

David Elpern M.D., Williamstown, MA, USA

on November 29, 2004

Dermatologist, The Skin Clinic, Williamstown, MA, USA

Abstract We are presenting a 26-year-old woman with breast hypertrophy (macromastia). The points addressed are the morbidity of this disorder and the value of reduction mammoplasty with regards to physical and psychosocial well-being. It is speculated that insurance carriers underestimate the disability these women experience.
26-year-old woman
several years

This 26 yo woman was initially seen in November 2002 for superficial ulcerations of breasts. A college student, she comes from modest means and works two jobs to support herself. There is a past history of depression and Crohn's Disease. Her medications include Effexor (venlafaxine HCl), Asachol (mesalamine) and budesonide. Her bowel disease and mood disorder are stable. Over the past two years, the breast ulcerations have healed with simple topical therapy (zinc oxide and silver sulfadiazine cream).
In her own words, her main problem is "The physical discomfort that I am having is throughout my whole back my neck and shoulders. Since I am such a large-breasted person, I have trouble standing up straight because this causes pain."

Physical Examination

In November of 2002 she had three small (~1cm diameter) superficial relatively clean appearing ulcers on the left breast. These healed uneventfully within a few weeks. She has had a occasional ulcer since all of which resolved with topical therapy as describe above. She has large breasts, her bra size is 52.



Laboratory Data



Biopsy of ulcer showed central ulceration lined by granulation tissue and acute inflammatory debris. No foreign material on polarization.


Breast Hypertrophy with ulcerations

Reasons Presented
This young woman has attempted to get a breast reduction covered by her insurance company but has been denied on two occasions. Once they said she had pyoderma gangrenosum because of her history of Crohn's Disease. She is being presented to get a concensus that may help me to plead her case to her insurance carrier.

R.M. is being presented for discussion of the role a physician can play in recommending surgery for a young woman who is at a disadvantage because of massively enlarged breasts. She is working, had to support herself and obtain an education but has been denied reconstructive surgery by her insurance carrier. I do not feel there is enough evidence to call her ulcers pyoderma gangrenosum. They healed uneventfully with simple therapy and were never deep or chronic.
I suspect the ulcers may have been traumatic possibly factitial but the process is not ongoing.


1: Taylor AJ, Tate D, Brandberg Y, Blomqvist L. Cost-effectiveness of reduction mammaplasty. Int J Technol Assess Health Care. 2004 Summer;20(3):269-73. University of Hull, Hull, UK. (view abstract)

2. Collins ED, Kerrigan CL, Kim M, Lowery JC, Striplin DT, Cunningham B, Wilkins EG. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. 2002 Apr 15;109(5):1556-66.
Department of Surgery, Section of Plastic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA. (view abstract)

Comments from Faculty and Members

E. Dale Collins, MD Associate Professor of Surgery and Director, Comprehensive Breast Program One Medical Center Drive, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA on Nov 29, 2004

This woman looks like someone who would benefit significantly from breast reduction. I suspect that if you ask, she will report having breast-related pain all or most of time in her neck, upper back and shoulder area. This is directly linked to the weight of her breasts. Insurer's often underestimate the degree of pain these women live with on a daliy basis. I hope she will be able to obtain coverage for the surgical procedure.

Phung Huynh, MD, Department of Dermatology, NY Medical College, New York, NY, USA on Nov 29, 2004

You can fight the insurance company on this. I know that patients have had their insurance companies pay for breast reduction in the past because it was causing medical problems. She may need to see orthopaedics to fight for the breast reduction surgery.

Caroline Koblenzer M.D., Professor of Dermatology and Psychiatry, University of Pennsylvania, Philadelphia, PA, USA on November 29, 2004

This is indeed a tragic case. It is, in my opinion, a medical necessity for this young woman to undergo breast reduction surgery. Indeed I have had, in my practice, woman for whom breast-reduction surgery was covered by insurance, whose breasts were not as significantly enlarged as in this case.

Not only is surgery a medical necessity, but there is no question that it would also be cost-effective.

Such macromastia as we see in this case, causes chronic strain on the back and shoulder muscles, and ultimately damage to the spine.

The quality of life for these patients is significantly diminished. Not only is there chronic pain, but activities are severely limited---for example, this patient could not engage in sports, dancing, or many forms of physical exercise, because not only are the breasts are in the way,but the weight of their movement up and down increases the already severe strain on the back. Similarly, many of the commonly practised sexual activities would be strictly limited by the intrusion of the massive volume of the breasts.

Apart from the devastating psychological impact of all these factors, the inevitable increase in weight that follows on the imposed lack of exercise will ensue, and all the well-know co-morbidities that go along with that.

Clothing is strictly limited in both size and style for these patients, while the distortion of body image, the sense of being "different" from others, and the inevitable lowering of self-esteem has a very negative psychological impact, and undoubtedly contributes to this patient's depression.

Anatoli Freiman MD, Montreal, Canada on Nov 29, 2004

As the patient's main complaint is the back pain, which I imagine can be quite severe, perhaps the orthopedic morbidity of such degree of macromastia would be an important medical indication for surgery, and should be considered by the insurance company.

Monroe Richman MD, Koloa, USA on Nov 29, 2004

Sad commentary that in this ? age of enlightment the insurance carrier does not approve of surgery.

Benjamin Barankin MD, Department of Dermatology, University of Alberta, Edmonton, Canada on Nov 29, 2004

There is no doubt that she would greatly benefit from a reduction mammoplasty for her psyche, musculoskeletal/back, and ulcerations which occur not uncommonly in those with pendulous breasts; because of gravity and poor circulation & lymphatic drainage, she is likely to have repeated ulcerative episodes on her breasts irrespective of her Crohn's.

Stephen Glinick M.D., Providence, RI, USA on Nov 29, 2004

It is absolutely ridiculous that the insurance company in this case refuses to pay for a reduction mammoplasty. If I ever saw a better candidate I can't recall it. She should fight ever step of the way.

Jole Bamford MD, USA, on Nov 29, 2004

Patient may want to share experiences with insurance carriers and/or patients with similar problems. Google "blogumentary", an open source documentary film about how anyone (pt, citizen, dr, insurance agent) can possibly have an effect by networking on line with others. One well known, main example was related to how Dan Rather was exposed for presenting false documents on TV - people doubted, then talked and figured out the font used in the paper was not available when the paper was said to be written >>> the rest is history.

Gregory Herbich MD, Honolulu, HI, USA on Nov 30, 2004

These cases are usually covered by health insurance provided the patients have back pain, bra straps cutting the skin and intertrigo.
The surgical procedure would probably entail amputation and a free nipple graft due to the enormous size. Complications includ fat necrosis, skin breakdown, loss of sensation, graft slough but otherwise the patients are generally pleased with the outcome.

Doug Johnson MD, Dept of Medicine, University of Hawaii School of Medicine, Honolulu, HI, USA on Dec 1, 2004

This patient would obviously benefit from the procedure and the approval is usually done by the plastic sturgeon. The carrier probably has a policy that is available with criteria necessary to complete the procedure. My previous nurse had the procedure done and it was covered by her insurance. Find a reconstructive surgeon who has experience in the area and let them carry the ball. Your photos and a letter of appeal would be strong evidence for doing the procedure.

Judith J Petry MD, FACS, Westminster, VT, USA on Dec 1, 2004

There is a large body of scientific documentation in the peer-reviewed medical literature demonstrating the efficacy of reduction mammaplasty for women suffering from macromastia. Statistically significant improvement in back, neck and shoulder pain, shoulder grooving, posture, pulmonary function, body image, emotional well-being and quality of life are proven outcomes and have been shown to persist for at least 3 years post-op in one long-term study. (1-4) Any disease entity that caused a symptom complex similar to that caused by macromastia would never be denied insurance coverage for treatment unless there were an irrational argument used to do so. That is the usual cause of denial of coverage for macromastia; the irrational argument that the surgery is cosmetic in nature. As defined by the American Society of Plastic Surgery, “Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem….. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.”
There can be no question that the woman pictured in your “Current Case” suffers from a developmental deformity that is causing physical and emotional symptoms that seriously interfere with normal function and quality of her life. Her experience of daily life is hampered by a situation that could be reproduced by carrying a heavily weighted knapsack hung from the shoulders and strapped to the chest, day after day, year after year. The results are predictable: poor posture, shoulder grooving, neck pain, shoulder pain, back pain, decreased pulmonary function, poor body image, decreased social function, and depression. All worsening with time.
If the surgery to correct such a problem were particularly dangerous or fraught with high morbidity, the decision to deny insurance coverage might be easier to understand. The surgery is not any more dangerous than other reconstructive surgery. It rarely requires transfusion, does not require invasion of a body cavity and most patients are discharged from hospital after 24 hours. The patients are consistently delighted with the results in spite of significant permanent scars.
I am convinced that the most frequent cause for insurance denial in cases of true macromastia is a complete lack of knowledge and absence of compassion.

1. Blomqvist L, Brandberg Y. Three-year follow-up on clinical symptoms and health-related quality of life after reduction mammaplasty. Plast Reconstr Surg. 2004 Jul;114(1):49-54.
2. Sood R, et al. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Plast Reconstr Surg. 2003 Feb;111(2):688-94.
3. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Ann Plast Surg. 2000 Dec;45(6):575-80.
4. Glatt BS, Sarwer DB, O'Hara DE, Hamori C, Bucky LP, LaRossa D.
A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg. 1999 Jan;103(1):76-82.
5. http://www.plasticsurgery.org/FAQ-What-is-the-difference-between-cosmetic-and-reconstructive-surgery.cfm

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