Turkish Journal of Plastic Surgery

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 29  |  Issue : 1  |  Page : 28--32

Galactorrhea and galactocele formation after augmentation mammoplasty and augmentation mastopexy


Safvet Ors 
 Private Aesthetic Plastic and Reconstructive Surgeon, Kayseri, Turkey

Correspondence Address:
Dr. Safvet Ors
Hunat Mah, Nuh Naci Yazgan Caddesi No: 21, 38050 Kayseri
Turkey

Abstract

Purpose: Some of the most common complications associated with augmentation mammoplasty (AUM) and augmentation mastopexy (AUMX) include infections, seroma, hematoma, capsular contracture, asymmetry, hypertrophic scars, implant rupture, and deformities. Galactocele and galactorrhea can rarely be observed after AUM and in reduction mammoplasties other than the AUMX, while galactorrhea is often observed after chest wall deformity correction surgery and thoracic surgery. Patients and Methods: In our clinic, galactorrhea was developed in five out of 540 patients who underwent AUM or AUMX, and one of these patients also had galactorrhea and galactocele in the accessory breast tissue. No patients were postmenopausal, and none of them had a history of pituitary, adrenal, thyroid, or ovarian surgery. Lactation started in average 10–15 days after surgery and lasted about 4–5 weeks. The patients were followed up for 1–10 years. In one patient who was found to be pregnant, galactorrhea ceased spontaneously 2 weeks after the termination of the pregnancy by curettage. Results: This clinical study presents the cases of five patients with galactorrhea and galactocele in the accessory breast tissue, with particular focus on treatment and possible risks, and discusses whether large nipples may cause a risk for galactorrhea. This study presents the second largest series of cases with galactorrhea in literature after the study reported by Caputy and Flowers. Level of evidence: Level V.



How to cite this article:
Ors S. Galactorrhea and galactocele formation after augmentation mammoplasty and augmentation mastopexy.Turk J Plast Surg 2021;29:28-32


How to cite this URL:
Ors S. Galactorrhea and galactocele formation after augmentation mammoplasty and augmentation mastopexy. Turk J Plast Surg [serial online] 2021 [cited 2021 Jan 21 ];29:28-32
Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/28/305904


Full Text



 Introduction



Galactorrhea is the spontaneous flow of milk from the nipples other than nursing period. Galactocele is a retention cyst containing milk or a milky substance that is usually located in the mammary glands. Augmentation mastopexy (AUMX) and augmentation mammoplasty (AUM) procedures have become more common with the widespread rise in popularity of aesthetic surgery worldwide.[1] Some of the more common complications associated with AUM and AUMX include infections, seroma, hematoma, capsular contracture, asymmetry, hypertrophic scars, implant rupture, and deformities.[2],[3],[4],[5] Galactocele and galactorrhea can rarely be observed after AUM and in reduction mammoplasties (RM) other than the AUMX,[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] while galactorrhea is often observed after chest wall deformity correction surgery and thoracic surgery.[30],[31],[32],[33],[34] A total of four cases of galactorrhea after AUM were reported up until 1994,[6],[7],[8] and after this date, a series of eight cases were published.[16] In a review published in 2015, the total 34 cases of galactorrhea associated with AUM, AUMX, and RM were reported.[19] At present, the total number of reported cases of galactorrhea is fewer than 40, and some of these cases also had galactocele.[9],[14] The use of oral contraceptives, premenopausal period, and recent breastfeeding have been reported as the cause in some cases.[6],[7],[8],[9] Prolactin levels were found to be normal in the majority of these cases, with only a minority recording elevated levels.[6],[7],[8],[9],[10]

In our clinic, galactorrhea has been observed in five patients that underwent AUM or AUMX, and of these patients, three had undergone AUM and two had undergone AUMX. This clinical study presents the cases of five patients with galactorrhea and galactocele in the accessory breast tissue, with particular focus on treatment and possible risks, and discusses whether large nipples are risk for galactorrhea. This study presents the second largest series of cases with galactorrhea in literature after the study reported by Caputy and Flowers.[15]

 Patients and Methods



Total 540 patients underwent AUM and AUMX in our clinic involving 1080 implants between 2000 and 2018. All patients were operated by the same surgeon under general anesthesia, with 430 undergoing AUM and 110 undergoing AUMX. The implant brands were Eurosilicone®, Mentor®, Natrella®, and Motiva®. Of the implants, 95% were round-shaped and 5% were anatomic implants, and they were all medium- and high-profile textured cohesive gel types. All patients with galactorrhea were inserted a Mentor® high-profile textured gel round implant. The implant was placed subpectorally in 465 patients and suprapectorally in 75 patients. The implants were inserted via the inframammary fold in patients that underwent AUM (3 cases). In AUMX (2 cases), the nipple-areolar complex was elevated by 3–7 cm using the superior pedicle technique. All patients remained in hospital for one or two nights postsurgery and were discharged without any problems. None of the preoperative medical histories was remarkable for hormonal abnormality; four patients were multiparous and one patient was nulliparous (single). The patients were aged 28, 34, 37, 41, and 44 years, with a mean age of 36.8 ± 5.56 years. Multiparous four patients that breastfed their babies for a year after their pregnancy had delivered their babies 6–15 years ago. Of the five patients in the study, four underwent subpectorally implant placement and one underwent suprapectorally implant placement.

 Results



Lactation started in average 10–15 days after surgery and lasted about 4–5 weeks. The patients were followed up for 1–10 years. Blood prolactin, steroid, and thyroid hormone levels were within normal ranges in all patients except one in the preoperative and postoperative period. The patients received no drug or food supplement. All patients were started on antibiotherapy against infections. Patient's data are summarized in [Table 1].{Table 1}

The blood beta-human chorionic gonadotropin level of a 28-year-old patient was found to be considerably elevated [Figure 1]a and [Figure 1]b. Pregnancy at 5 weeks of gestation was overlooked, as preoperative tests do not routinely include pregnancy testing. In one patient who was found to be pregnant, galactorrhea ceased spontaneously 2 weeks after the termination of the pregnancy by curettage. The same patient underwent mastopexy surgery 9 years later, and there was no recurrence of galactorrhea.{Figure 1}

Galactorrhea developed bilaterally 9 days after surgery and was accompanied by a swelling and tenderness in the axillar region in a 37-year-old patient. The axilla appeared slightly swollen in the preoperative period, and postoperative ultrasound examination findings were consistent with accessory breast tissue. Approximately 4 ml fluid was aspirated [Figure 2]. No growth was observed in the culture test, and the laboratory test results were consistent with breast milk. No recurrence occurred after aspiration and the galactorrhea ceased spontaneously in 4 weeks.{Figure 2}

The nipple was larger than it should be in patients undergoing AUMX [Figure 3]a. A bulla developed on day five in a patient with a large nipple. Partial skin loss was observed on the left side as a result of an impaired perfusion due to the presence of a bulla and overstretching. The right side healed without problem, while depigmentation developed on the left side as a result of secondary healing. The galactorrhea ceased spontaneously in four patients 5 weeks later. The nipple size reduced 6 months after surgery in the patients with large nipples [Figure 3]b.{Figure 3}

Galactorrhea occurred on the 12th and 14th days in two 34- [Figure 4]a and [Figure 4]b and 41-year-old [Figure 5]a and [Figure 5]b AUM patients. Bromocriptine was started on the 34-year-old patient and galactorrhea boşluk (space) stopped at 4 four weeks. Galactorrhea stopped spontaneously at week five in the 41-year-old patient.{Figure 4}{Figure 5}

 Discussion



Lateral thoracotomy, thoracoplasty, median sternotomy, submammarian laceration, breast reconstruction with deltopectoral flap, herpes zoster, burns of the chest wall, prolactinoma, anorexia nervosa, hypothalamic diseases, kidney disease, liver disease, polycystic ovary syndrome, hypophyseal tumors, and various herbal drugs may all cause elevated prolactin levels.[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] The use of estrogens, tricyclic antidepressants, risperidone, opioids, amphetamines, reserpine, verapamil, methyldopa, cimetidine, H2-receptor blockers, metoclopramide, phenothiazines, stimulation of the nipples or breasts, stress overload, lung cancer, and the use of certain illicit drugs can all lead to the onset of galactorrhea.[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] For this reason, the patients' medical history must be inquired in detail for to identify possible risks in the preoperative period. Although there are many causes of galactorrhea, there is no clear cause of galactorrhea in patients undergoing AUM and AUMX. One prospective study evaluating AUM and serum prolactin levels reported no significant relationship.[29] It has been reported that galactorrhea is associated with the over stimulation of prolactin receptors by other steroid hormones, rather than an increase in blood prolactin levels.[37] The tissue pressure caused by the prosthesis, surgical stress, and various psychosocial factors may influence the occurrence of galactorrhea.[8] The stimulation of thoracic nerve endings that are projected to the hypothalamus and pituitary glands via the dorsal nerve roots results in prolactin secretion. A surgical transection of, or injury to, the thoracic nerves causes an effect that mimics the sucking reflex.[8] Stimulation of the thoracic nerve endings and increased sensitivity in the prolactin receptors are the most likely causes. Galactorrhea generally starts on average within 1 month of surgery and usually ceases spontaneously without the need for bromocriptine. Although galactorrhea is a rare benign condition, it may lead to severe morbidity as a result of infection, mastitis, and galactocele in patients with breast implants. The use of oral contraceptives has been identified as a risk factor for galactorrhea,[8],[9],[10],[11],[12],[13],[14] although none of the patients in the present study were using oral contraceptives. Furthermore, the pre- and postmenopausal period is regarded as another risk factor,[8],[20] but none of the patients in the present study were premenopausal, and all were young patients with normal menstrual cycles. AUM and AUMX performed within a year of breastfeeding has been reported as a risk factor for galactorrhea;[8] however, all patients in the present study had ceased breast feeding 5–15 years previously. The authors consider patients with larger nipples to be at greater risk of developing galactorrhea, which was the case for two patients in the present study. It was noted in the study that the nipple of one patient enlarged after surgery to cover the entire areola, resulting in impairment in blood supply. The authors thus conclude that breasts with large nipples may be more easily stimulated, leading to a greater risk of galactorrhea. Galactorrhea has been reported in breast surgeries other than AUM and AUMX, with a number of cases being reported in which galactorrhea developed after reduction mammoplasty.[21],[22],[23] Accordingly, it would be wrong to blame the development of galactorrhea on implants alone.

There is no classification in literature about nipple size. Therefore, we measured the width and height of the excited nipple in 30 of the random patients and developed a simple algorithm. According to this algorithm, patients' nipples were classified as large, small, and medium. Of the five patients who developed galactorrhea, two were large. For now, we do not know if there is a direct connection between the size of the nipple and galactorrhea. The fact that 40% of the patients with galactorrhea have a large nipple suggests that large nipple may be a risk. This is a theory and can be proved by large wide patient series.

It has been reported in previous studies that galactorrhea can cause necrosis of the areola, nipple, and skin.[21],[22] The cause of the partial loss of the areola in a patient that underwent AUMX was attributed to galactorrhea. The blood supply to the nipple and skin around the areola may be compromised by the overstretching of the breast tissue as a result of edema, enlargement of the milk glands, and milk stasis, and so for this reason, the authors believe that the early initiation of galactorrhea therapy is important in this group of patients. Our two patients had a large nipple before surgery. Nipple grew even more with venous insufficiency in one patient. There were no signs of venous insufficiency during the first 4 days postoperatively. On 5th day, venous insufficiency and on 16th day galactorrhea occurred. The flaps were not closed taut enough to impair the blood circulation. There were no other risks that disrupt the areola circulation. Venous insufficiency usually occurs the next day in the areola. Linking venous insufficiency to galactorrhea may not seem right at first. However, it is known that wound healing is impaired in patients with galactorrhea. Wound healing may also be affected before starting galactorrhea.

Other than pregnancy, the use of high-profile implants, tight corsets after surgery, and stimulation of thoracic nerves by the implant are believed to be possible causes for the onset of galactorrhea. Although the Mentor brand implant was used in all five patients in the present study, the authors do not believe that the brand of the implant was a factor in galactorrhea development. Pregnancy should be ruled out first in a patient of childbearing age presenting with galactorrhea. We do not recommend breast massage after surgery, and hence breast stimulation is not considered to be a factor.

A 28-year-old patient underwent mastopexy surgery 9 years after developing galactorrhea, and no recurrence was observed, and so pregnancy was considered to be the cause of the galactorrhea. Galactorrhea and seroma are inevitable in pregnancy. The absence of pregnancy was confirmed by medical history prior to surgery, although no routine pregnancy tests were performed. Galactorrhea was detected in another patient in the 4th week of pregnancy that underwent abdominoplasty, but ceased spontaneously upon the termination of the pregnancy. As such, pregnancy should be considered a significant cause of galactorrhea and must be ruled out, and it would be wise to include pregnancy testing in routine preoperative tests on patients of childbearing age.

Although previous studies have reported galactorrhea and galactocele in normal breast tissue,[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] there has been no study to date reporting galactorrhea in accessory breast tissue.[44] This is the first reported case of a person undergoing AUM that developed galactorrhea in the normal breast and galactocele in the accessory breast tissue.

 Conclusion



Galactorrhea occurs in 1% of patients following such surgical interventions as AUMX, AUM, and reduction mammoplasty.[10],[15] Galactorrhea and galactocele are simple and treatable complications, but may cause serious problems if left untreated.[21],[22] When postoperative galactorrhea is observed, blood prolactin level should be checked, pregnancy should be ruled out, and ultrasound should be performed. If blood prolactin level is normal and there is no collection, the patient should be followed up for a month. It will usually spontaneously improve within a month. If blood prolactin level is high and surgical incision is wide, bromocriptine treatment should be started immediately and other possible causes should be investigated. If there is a fluid collection or cystic lesion on the ultrasound, it should be intervened. These patients should closely be monitored because galactorrhea may adversely affect wound healing. In patients at risk, starting galactorrhea treatment from the 1st day may prevent possible complications. A flowchart of diagnosis and treatment is given in [Figure 6].{Figure 6}

Acknowledgment

The authors have no financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Cosmetic surgery national data bank: Statistics. Aesthet Surg J 2013;34:1S-22.
2Iwuagwu FC, Frame JD. Silicone breast implants: Complications. Br J Plast Surg 1997;50:632-6.
3Shafir R, Heyman Z, Tsur H, Itzchak Y. Ultrasound scanning as an aid in the diagnosis and treatment of periprosthetic hematoma after breast surgery. Plast Reconstr Surg 1983;71:858-60.
4Brand KG. Infection of mammary prostheses: A survey and the question of prevention. Ann Plast Surg 1993;30:289-95.
5McGrath MH, Burkhardt BR. The safety and efficacy of breast implants for augmentation mammaplasty. Plast Reconstr Surg 1984;74:550-60.
6Hartley JH Jr., Schatten WE. Postoperative complication of lactation after augmentation mammaplasty. Plast Reconstr Surg 1971;47:150-3.
7Hugill JV. Lactation following breast augmentation: A third case. Plast Reconstr Surg 1991;87:806-7.
8Rothkopf DM, Rosen HM. Lactation as a complication of aesthetic breast surgery successfully treated with bromocriptine. Br J Plast Surg 1990;43:373-5.
9Guerra M, Codolini L, Cavalieri E, Redi U, Ribuffo D. Galactocele after aesthetic breast augmentation with silicone implants: An uncommon presentation. Aesthetic Plast Surg 2019;43:366-9.
10Basile FV, Basile AR. Diagnosis and management of galactorrhea after breast augmentation. Plast Reconstr Surg 2015;135:1349-56.
11Yang EJ, Lee KT, Pyon JK, Bang SI. Treatment algorithm of galactorrhea after augmentation mammoplasty. Ann Plast Surg 2012;69:247-9.
12Ayestaray B, Dudrap E, Chaibi A. Galactorrhea after aesthetic breast augmentation with silicone implants: Report of two cases and management of postoperative galactorrhea. Aesthetic Plast Surg 2011;35:408-13.
13Marino A, Patel T, Whitten E, Peiris AN. Persistent hyperprolactinemia following mammoplasty: A rare association. Tenn Med 2009;102:47-8.
14Chun YS, Taghinia A. Hyperprolactinemia and galactocele formation after augmentation mammoplasty. Ann Plast Surg 2009;62:122-3.
15Caputy GG, Flowers RS. Copious lactation following augmentation mammaplasty: An uncommon but not rare condition. Aesthetic Plast Surg 1994:18:393-7.
16Velasco VR. Hyperprolactinemia and mammary prostheses. A report of eight cases. J Reprod Med 1986;31:267-70.
17Acartürk S, Gencel E, Tuncer I. An uncommon complication of secondary augmentation mammoplasty: Bilaterally massive engorgement of breasts after pregnancy attributable to postinfection and blockage of mammary ducts. Aesthetic Plast Surg 2005;29:274-9.
18Mestak O, Mestak J, Borsky J. Hyperprolactinaemia: A cause of severe postoperative complication after reduction mammaplasty. J Plast Surg Hand Surg 2014;48:421-2.
19Bouhassira J, Haddad K, Roziers BB, Achouche J, Cartier S. Lactation after breast plastic surgery: Literature review. Ann Chir Plast Esthet 2015;60:54-60.
20Paredes EJ, Shafighi M, During V, Sterne GD. An unusual case of galactorrhea in a postmenopausal woman complicating breast reduction. J Plast Reconstr Aesthet Surg 2009;62:542-6.
21Arnon O, Mendes D, Winkler E, Tamir J, Orenstein A, Haik J. Galactorrhea complicating wound healing following reduction mammaplasty. Aesthet Surg J 2006;26:300-1.
22Bentley M, Ghali S, Asplund OA. Galactorrhoea causing severe skin breakdown and nipple necrosis following breast reduction. Br J Plast Surg 2004;57:682-4.
23Schuurman AH, Assies J, Horst CM, Bos KE. Galactorrhea after reduction mammaplasty. Plast Reconstr Surg 1993;92:951-4.
24Graíño FM, Fernández CP, Burrieza PI. Galactorrhea after reduction mammaplasty. Plast Reconstr Surg 1990;85:645-6.
25Song IC, Hunter JG. Galactorrhea after reduction mammaplasty. Plast Reconstr Surg 1989;84:857.
26Bronson DL. Galactorrhea after reduction mammaplasty. Plast Reconstr Surg 1989;83:580.
27Bruck JC. Galactorrhea: A rare complication following reduction mammaplasty. Ann Plast Surg 1987;19:384-5.
28Sandler MP, Forman MB, Lopis R, Kalk WJ. Galactorrhoea, amenorrhoea and hyperprolactinaemia after an operation on the breast: A case report. S Afr Med J 1980;57:95-6.
29El-Hassan ND, Zaworski RE, Castro A, LeMaire WJ. Serum prolactin levels following augmentation mammaplasty. Plast Reconstr Surg 1981;68:215-7.
30Aufses AH. Abnormal lactation following radical mastectomy. N Y State J Med 1955;55:1914-5.
31Berger RL, Joison J, Braverman LE. Lactation after incision on the thoracic cage. N Engl J Med 1966;274:1493-5.
32Grossman S, Buchberg AS, Breecher E, Hallinger M. Idiopathic lactation following thoracoplasty. J Clin Endocrinol Metab 1950;10:729.
33Richardson GS. Reflex lactation (thoracotomy) and reflex ovulation (intercostal block): Case report, review of the literature and discussion of mechanisms. Obstet Gynecol Surv 1970;25:1021.
34Salkin D, Davis EW. Lactation following thoracoplasty and pneumonectomy. J Thorac Surg 1949;18:580-90.
35Tewksbury A, Olander A. Management of antipsychotic-induced hyperprolactinemia. Ment Health Clin 2016;6:185-90.
36Fran AG, Wilson JD. Endocrine disorders of the breast. In: Wilson D 3, Foster DW, editors. Wiflinms Textbook of Endocrinology. Philadelphia: W.B. Saunders; 1985. p. 402.
37Frantz AG. Prolactin secretion in humans. In: Gannong WF, Martini L, editors. Frontiers in Neuroendocrinology. London: Oxford University Press; 1973. p. 402.
38Vance ML, Evans WS, Thomer M0. Bromocriptine. Ann Inter Med 1984;100:78.
39Lazopoulos A, Krimiotis D, Schizas NC, Rallis T, Gogakos AS, Chatzinikolaou F, et al. Galactorrhea, mastodynia and gynecomastia as the first manifestation of lung adenocarcinoma. A case report. Respir Med Case Rep 2019;26:146-9.
40Peitl MV, Peitl V, Grahovac T, Pavlović E. Galactorrhea – Side effect of risperidone in combination with depakine chrono in a patient with bipolar disorder. Psychiatr Danub 2010;22:125-7.
41Chowdhury A, Chakravorty S, Sinha I, Chowdhury S. Cirrhosis of the liver presenting with galactorrhea. J Clin Gastroenterol 1997;25:716-7.
42Pratap B, Sundaram V, Abraham G, Matthew M, Bhaskar S. Cessation of galactorrhea in a chronic kidney disease patient with non-tumoral hyperprolactinemia after renal transplantation. J Assoc Physicians India 2008;56:54-5.
43Karimi H, Nourizad S, Momeni M, Rahbar H, Momeni M, Farhadi K. Burns, hypertrophic scar and galactorrhea. J Inj Violence Res 2013;5:117-9.
44Patel RV, Govani D, Patel R, Bhayani B. Adolescent right axillary accessory breast with galactorrhoea. BMJ Case Rep 2014:1-2.