- Email: [email protected]
Re: Gigantomastia - a classification and review of the literature
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 262e283
CORRESPONDENCE AND COMMUNICATIONS
Re: ‘Complete spontaneous regression in Merkel cell carcinoma’ Merkel cell carcinoma (MCC) is a very aggressive primary cutaneous neoplasm most often occurring on the head and neck of the elderly. Complete spontaneous regression (CSR) of MCC was first described in 1986. In relation with the significant review published in your journal (Vesely et al.1), we would like to comment the following: 1. We published in 2005 one interesting case and a review of spontaneous regression of Merkel cell carcinoma.2 However, this case has not been included in Vesely ´s review. We reported a 79-year-old woman with MCC on the right cheek underwent spontaneous regression of the malignancy, documented by photographic followup, computed tomography and histological studies. Six years after an exhaustive follow-up, no recurrence was observed. 2. Then, we based our review in the excellent publication of Conelly et.al.3 in 2000 about this pathology. We reviewed eleven cases published in the English literature and divided them in two groups: primary complete spontaneous regression and complete spontaneous regression of recurrences or metastasis. Only 6 cases of complete MCC regression following incisional biopsy have been reported (primary CSR), along with 5 further cases in which regression occurred after local or regional recurrence of the neoplasm (secondary CSR). Sais et al.4 published the only case of spontaneous regression of MCC not located in the region of the head and neck (right thigh). However, treatment in this case consisted of an ‘excision biopsy’ documenting focal invasion of the deep excision margin that was not accompanied by subsequent recurrence after 40 months of follow-up. In our opinion, the inclusion of this case within the group of MCCs with primary CSR is controversial. This case could have been included in table 2 (‘cases of partial spontaneous regression in Merkel cell carcinoma’) of the discussed work.1
References 1. Vesely MJ, Murray DJ, Neligan PC, et al. Complete spontaneous regression in Merkel cell carcinoma. J Plast Reconstr Aesthet Surg 2008;61:165e71.
2. Junquera L, Torre A, Vicente JC, et al. Complete spontaneous regression of Merkel cell carcinoma. Ann Otol Rhinol Laryngol 2005;114:376e80. 3. Connelly TJ, Cribier B, Brown T, et al. Complete spontaneous regression of Merkel cell carcinoma: a review of the 10 reported cases. Dermatol Surg 2000;26:853e6. 4. Sais G, Admella C, Soler T. Spontaneous regression in primary cutaneous neuroendocrine (Merkel cell) carcinoma: a rare immune phenomenon? J Europ Acad Dermatol and Venereol 2002;16:82e3.
Luis Junquera Aintza Torre Lorena Gallego Central University Hospital, Department of Oral and Maxillofacial Surgery, Celestino Villamil s/n, 33009, Oviedo, Spain E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.08.011
Re: Gigantomastia - a classification and review of the literature Sir, We read with great interest Dancey’s1 and colleagues article on gigantomastia. We compliment the authors for their extensive literature analysis. We agree on the difficulty to find a proper definition to gigantomastia, the definitive diagnosis being made during surgery after having the removed breast tissue weighed. However, we find it relevant to point out the following points: e The Body Mass Index is a major element when talking about gigantomastia and was insufficiently highlighted. BMI should be recorded every time a patient is referred for breast reduction. It has a major clinical implication. Obese patients should be recommended to loose weight and stabilize drastically before undergoing breast DOI of original article: 10.1016/j.bjps.2007.10.041.
Correspondence and communications
e
e
e
e
reduction. We believe that the cosmetic outcome and the rate of recurrence of gigantomastia are directly related to further weight balance. We agree with the 44% of the teams who have responded to the author’s inquiry, that we should talk about gigantomastia when the weight of breast removed during a breast reduction procedure is superior to 1000gr. When it comes to mastectomy we retain a weight of 1500 g as a cut off. Gigantomastia is often associated with severe breast ptosis. The importance of ptosis, that we evaluate with the sternal notch to nipple areola complex (NAC) distance, is determining in the choice of breast reduction technique. The vitality of the NAC depends on its vascular supply.2,3 The choice of the NAC bearing pedicle is a major issue when retaining a surgical technique. Our choice is the superior pedicle in the majority of cases4 because of its reliability and long term predicable results. We believe that free nipple graft technique can very often be avoided.4,5 The classification is nothing more than the list of etiology: idiopathic, obesity, juvenile, pregnancyinduced and drug-induced, that we also cited in our study.4 It is important to know the etiologies and pathophysiology to make a precise diagnosis and retain the true surgical indication vs medical treatment. But unfortunately this classification has no direct impact on the surgical strategy adopted by the plastic surgeon towards the correction of ptosis, the amount of breast to be removed and the technique to be used. We finally regret that no reference was made to our article nor have we been contacted for the inquiry. Our article reported a serie of 26 patients with extensive information on the etiology, BMI, the weight of breast resected, and the modified superior pedicle breast reduction technique.4
Conflict of interest None.
Funding None.
References 1. Dancey A, Khan M, Dawson J, et al. Gigantomastiaea classification and review of the literature. J Plast Reconstr Aesthet Surg 2008;61:493e502 [Epub 2007 Nov 28]. 2. O’Dey D, Prescher A, Pallua N. Vascular reliability of nippleareola complex-bearing pedicles: an anatomical microdissection study. Plast Reconstr Surg 2007 Apr 1;119:1167e77. 3. Wu ¨ringer E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998 May;101:1486e93. 4. Mojallal A, Comparin JP, Voulliaume D, et al. Reduction mammaplasty using superior pedicle in macromastia. Ann Chir Plast Esthet 2005 Apr;50:118e26. 5. Papalia I, d’Alcontres FS, Colonna MR, et al. The superior pedicle mammaplasty for the treatment of pedunculous breast. Ann Ital Chir 2007 NoveDec;78:503e6.
263 A. Mojallal M. Moutran E. Martin F. Braye Edouar Herriot Hosptal, Plastic Surgery Department, 5 Place d’Arsonval, 69003 Lyon, France E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.07.014
Letter to the Editor Sir, We would like to thank Mojallal et al for their interest in our article and the points that they raise. We also feel that BMI measurement is important in these patients and we highlight this in our paper. In fact, the basis of the subdivision in idiopathic (type 1) gigantomastia into type 1a (BMI > 30) and type 1b (BMI < 30) is BMI. Those patients with a BMI of 30 or above have excessive breast growth which is partly dictated by their excess weight. This tends to be of insidious onset and will reduce to a greater or lesser degree with a programme of weight loss. Under the current NHS cosmetic guidelines, we are unable to offer these patients surgical treatment until their weight has been optimised. In our unit this equates to a BMI of less than 30. The literature search found a total of 15 patients presenting with idiopathic gigantomastia. None of these patients had their BMI documented and this highlights a shortfall in the current literature. We agree that gigantomastia causes proportionate ptosis of the breast which must be addressed in the surgical treatment of these patients. Whilst we are also proponents of the superior or superio- medial pedicle technique, we disagree with the authors in dismissing inferior pedicle or free nipple grafts. It is commonly taught that an inferior pedicle technique is only appropriate if the distance from the nipple to inframammary fold is less than 15 cm (on the basis of a 2:1 ratio). In reality, provided the pedicle is not completely removed from the chest wall, there will be numerous perforators entering into the pedicle along its length. In addition, it does not necessarily follow that ptosis will increase the nipple to inframammary fold distance. It may well disproportionately increase the ptotic nipple to proposed nipple distance. This would give a long superior pedicle length which could possibly compromise nipple perfusion. Under these circumstances an inferior pedicle technique would have advantages. In our institution inferior pedicle reductions were performed on several gigantomastia patients with good effect. There have been numerous reports in the literature using inferior pedicle techniques and showing no increase in complication rate with resection weights of over 1000 g.1,2,3 Free nipple grafts can give
CORRESPONDENCE AND COMMUNICATIONS
Re: ‘Complete spontaneous regression in Merkel cell carcinoma’ Merkel cell carcinoma (MCC) is a very aggressive primary cutaneous neoplasm most often occurring on the head and neck of the elderly. Complete spontaneous regression (CSR) of MCC was first described in 1986. In relation with the significant review published in your journal (Vesely et al.1), we would like to comment the following: 1. We published in 2005 one interesting case and a review of spontaneous regression of Merkel cell carcinoma.2 However, this case has not been included in Vesely ´s review. We reported a 79-year-old woman with MCC on the right cheek underwent spontaneous regression of the malignancy, documented by photographic followup, computed tomography and histological studies. Six years after an exhaustive follow-up, no recurrence was observed. 2. Then, we based our review in the excellent publication of Conelly et.al.3 in 2000 about this pathology. We reviewed eleven cases published in the English literature and divided them in two groups: primary complete spontaneous regression and complete spontaneous regression of recurrences or metastasis. Only 6 cases of complete MCC regression following incisional biopsy have been reported (primary CSR), along with 5 further cases in which regression occurred after local or regional recurrence of the neoplasm (secondary CSR). Sais et al.4 published the only case of spontaneous regression of MCC not located in the region of the head and neck (right thigh). However, treatment in this case consisted of an ‘excision biopsy’ documenting focal invasion of the deep excision margin that was not accompanied by subsequent recurrence after 40 months of follow-up. In our opinion, the inclusion of this case within the group of MCCs with primary CSR is controversial. This case could have been included in table 2 (‘cases of partial spontaneous regression in Merkel cell carcinoma’) of the discussed work.1
References 1. Vesely MJ, Murray DJ, Neligan PC, et al. Complete spontaneous regression in Merkel cell carcinoma. J Plast Reconstr Aesthet Surg 2008;61:165e71.
2. Junquera L, Torre A, Vicente JC, et al. Complete spontaneous regression of Merkel cell carcinoma. Ann Otol Rhinol Laryngol 2005;114:376e80. 3. Connelly TJ, Cribier B, Brown T, et al. Complete spontaneous regression of Merkel cell carcinoma: a review of the 10 reported cases. Dermatol Surg 2000;26:853e6. 4. Sais G, Admella C, Soler T. Spontaneous regression in primary cutaneous neuroendocrine (Merkel cell) carcinoma: a rare immune phenomenon? J Europ Acad Dermatol and Venereol 2002;16:82e3.
Luis Junquera Aintza Torre Lorena Gallego Central University Hospital, Department of Oral and Maxillofacial Surgery, Celestino Villamil s/n, 33009, Oviedo, Spain E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.08.011
Re: Gigantomastia - a classification and review of the literature Sir, We read with great interest Dancey’s1 and colleagues article on gigantomastia. We compliment the authors for their extensive literature analysis. We agree on the difficulty to find a proper definition to gigantomastia, the definitive diagnosis being made during surgery after having the removed breast tissue weighed. However, we find it relevant to point out the following points: e The Body Mass Index is a major element when talking about gigantomastia and was insufficiently highlighted. BMI should be recorded every time a patient is referred for breast reduction. It has a major clinical implication. Obese patients should be recommended to loose weight and stabilize drastically before undergoing breast DOI of original article: 10.1016/j.bjps.2007.10.041.
Correspondence and communications
e
e
e
e
reduction. We believe that the cosmetic outcome and the rate of recurrence of gigantomastia are directly related to further weight balance. We agree with the 44% of the teams who have responded to the author’s inquiry, that we should talk about gigantomastia when the weight of breast removed during a breast reduction procedure is superior to 1000gr. When it comes to mastectomy we retain a weight of 1500 g as a cut off. Gigantomastia is often associated with severe breast ptosis. The importance of ptosis, that we evaluate with the sternal notch to nipple areola complex (NAC) distance, is determining in the choice of breast reduction technique. The vitality of the NAC depends on its vascular supply.2,3 The choice of the NAC bearing pedicle is a major issue when retaining a surgical technique. Our choice is the superior pedicle in the majority of cases4 because of its reliability and long term predicable results. We believe that free nipple graft technique can very often be avoided.4,5 The classification is nothing more than the list of etiology: idiopathic, obesity, juvenile, pregnancyinduced and drug-induced, that we also cited in our study.4 It is important to know the etiologies and pathophysiology to make a precise diagnosis and retain the true surgical indication vs medical treatment. But unfortunately this classification has no direct impact on the surgical strategy adopted by the plastic surgeon towards the correction of ptosis, the amount of breast to be removed and the technique to be used. We finally regret that no reference was made to our article nor have we been contacted for the inquiry. Our article reported a serie of 26 patients with extensive information on the etiology, BMI, the weight of breast resected, and the modified superior pedicle breast reduction technique.4
Conflict of interest None.
Funding None.
References 1. Dancey A, Khan M, Dawson J, et al. Gigantomastiaea classification and review of the literature. J Plast Reconstr Aesthet Surg 2008;61:493e502 [Epub 2007 Nov 28]. 2. O’Dey D, Prescher A, Pallua N. Vascular reliability of nippleareola complex-bearing pedicles: an anatomical microdissection study. Plast Reconstr Surg 2007 Apr 1;119:1167e77. 3. Wu ¨ringer E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998 May;101:1486e93. 4. Mojallal A, Comparin JP, Voulliaume D, et al. Reduction mammaplasty using superior pedicle in macromastia. Ann Chir Plast Esthet 2005 Apr;50:118e26. 5. Papalia I, d’Alcontres FS, Colonna MR, et al. The superior pedicle mammaplasty for the treatment of pedunculous breast. Ann Ital Chir 2007 NoveDec;78:503e6.
263 A. Mojallal M. Moutran E. Martin F. Braye Edouar Herriot Hosptal, Plastic Surgery Department, 5 Place d’Arsonval, 69003 Lyon, France E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.07.014
Letter to the Editor Sir, We would like to thank Mojallal et al for their interest in our article and the points that they raise. We also feel that BMI measurement is important in these patients and we highlight this in our paper. In fact, the basis of the subdivision in idiopathic (type 1) gigantomastia into type 1a (BMI > 30) and type 1b (BMI < 30) is BMI. Those patients with a BMI of 30 or above have excessive breast growth which is partly dictated by their excess weight. This tends to be of insidious onset and will reduce to a greater or lesser degree with a programme of weight loss. Under the current NHS cosmetic guidelines, we are unable to offer these patients surgical treatment until their weight has been optimised. In our unit this equates to a BMI of less than 30. The literature search found a total of 15 patients presenting with idiopathic gigantomastia. None of these patients had their BMI documented and this highlights a shortfall in the current literature. We agree that gigantomastia causes proportionate ptosis of the breast which must be addressed in the surgical treatment of these patients. Whilst we are also proponents of the superior or superio- medial pedicle technique, we disagree with the authors in dismissing inferior pedicle or free nipple grafts. It is commonly taught that an inferior pedicle technique is only appropriate if the distance from the nipple to inframammary fold is less than 15 cm (on the basis of a 2:1 ratio). In reality, provided the pedicle is not completely removed from the chest wall, there will be numerous perforators entering into the pedicle along its length. In addition, it does not necessarily follow that ptosis will increase the nipple to inframammary fold distance. It may well disproportionately increase the ptotic nipple to proposed nipple distance. This would give a long superior pedicle length which could possibly compromise nipple perfusion. Under these circumstances an inferior pedicle technique would have advantages. In our institution inferior pedicle reductions were performed on several gigantomastia patients with good effect. There have been numerous reports in the literature using inferior pedicle techniques and showing no increase in complication rate with resection weights of over 1000 g.1,2,3 Free nipple grafts can give