re: gigantomastia - a classification and review of the literature

CORRESPONDENCE AND COMMUNICATIONS

Re: ‘Complete spontaneousregression in Merkel cell carcinoma’

Merkel cell carcinoma (MCC) is a very aggressive primarycutaneous neoplasm most often occurring on the head andneck of the elderly. Complete spontaneous regression (CSR)of MCC was first described in 1986. In relation with thesignificant 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 reviewof spontaneous regression of Merkel cell carcinoma.2

However, this case has not been included in Veselysreview. We reported a 79-year-old woman with MCC onthe right cheek underwent spontaneous regression ofthe malignancy, documented by photographic follow-up, computed tomography and histological studies. Sixyears after an exhaustive follow-up, no recurrence wasobserved.

2. Then, we based our review in the excellent publicationof Conelly et.al.3 in 2000 about this pathology. Wereviewed eleven cases published in the English litera-ture and divided them in two groups: primary completespontaneous regression and complete spontaneousregression of recurrences or metastasis. Only 6 cases ofcomplete MCC regression following incisional biopsyhave been reported (primary CSR), along with 5 furthercases in which regression occurred after local orregional recurrence of the neoplasm (secondary CSR).Sais et al.4 published the only case of spontaneousregression of MCC not located in the region of the headand neck (right thigh). However, treatment in this caseconsisted of an ‘excision biopsy’ documenting focalinvasion of the deep excision margin that was notaccompanied by subsequent recurrence after 40months of follow-up. In our opinion, the inclusion ofthis case within the group of MCCs with primary CSR iscontroversial. This case could have been included intable 2 (‘cases of partial spontaneous regression inMerkel cell carcinoma’) of the discussed work.1

References

1. Vesely MJ, Murray DJ, Neligan PC, et al. Complete spontaneousregression in Merkel cell carcinoma. J Plast Reconstr AesthetSurg 2008;61:165e71.

2. Junquera L, Torre A, Vicente JC, et al. Complete spontaneousregression of Merkel cell carcinoma. Ann Otol Rhinol Laryngol2005;114:376e80.

3. Connelly TJ, Cribier B, Brown T, et al. Complete spontaneousregression of Merkel cell carcinoma: a review of the 10 reportedcases. Dermatol Surg 2000;26:853e6.

4. Sais G, Admella C, Soler T. Spontaneous regression in primarycutaneous neuroendocrine (Merkel cell) carcinoma: a rareimmune phenomenon? J Europ Acad Dermatol and Venereol2002;16:82e3.

Luis JunqueraAintza Torre

Lorena GallegoCentral University Hospital, Department of Oral andMaxillofacial Surgery, Celestino Villamil s/n, 33009,

Oviedo, SpainE-mail address: Junquera@uniovi.es

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.08.011

Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 262e283

Re: Gigantomastia - a classificationand review of the literature

Sir,

We read with great interest Dancey’s1 and colleaguesarticle on gigantomastia. We compliment the authors fortheir extensive literature analysis. We agree on the diffi-culty to find a proper definition to gigantomastia, thedefinitive diagnosis being made during surgery after havingthe removed breast tissue weighed.

However, we find it relevant to point out the followingpoints:

e The Body Mass Index is a major element when talkingabout gigantomastia and was insufficiently highlighted.BMI should be recorded every time a patient is referredfor breast reduction. It has a major clinical implication.Obese patients should be recommended to loose weightand stabilize drastically before undergoing breast

DOI of original article: 10.1016/j.bjps.2007.10.041.

Letter to the Editor

Sir,

We would like to thank Mojallal et al for their interest in ourarticle and the points that they raise. We also feel that BMImeasurement is important in these patients and we high-light this in our paper. In fact, the basis of the subdivision inidiopathic (type 1) gigantomastia into type 1a (BMI> 30)and type 1b (BMI< 30) is BMI. Those patients with a BMI of30 or above have excessive breast growth which is partlydictated by their excess weight. This tends to be of insid-ious onset and will reduce to a greater or lesser degree witha programme of weight loss. Under the current NHScosmetic guidelines, we are unable to offer these patientssurgical treatment until their weight has been optimised. Inour unit this equates to a BMI of less than 30. The literaturesearch found a total of 15 patients presenting with idio-pathic gigantomastia. None of these patients had their BMIdocumented and this highlights a shortfall in the currentliterature.

We agree that gigantomastia causes proportionateptosis of the breast which must be addressed in thesurgical treatment of these patients. Whilst we are alsoproponents of the superior or superio- medial pedicletechnique, we disagree with the authors in dismissinginferior pedicle or free nipple grafts. It is commonlytaught that an inferior pedicle technique is only appro-priate if the distance from the nipple to inframammaryfold is less than 15 cm (on the basis of a 2:1 ratio). Inreality, provided the pedicle is not completely removedfrom the chest wall, there will be numerous perforatorsentering into the pedicle along its length. In addition, itdoes not necessarily follow that ptosis will increase thenipple to inframammary fold distance. It may welldisproportionately increase the ptotic nipple to proposednipple distance. This would give a long superior pediclelength which could possibly compromise nipple perfusion.Under these circumstances an inferior pedicle techniquewould have advantages. In our institution inferior pediclereductions were performed on several gigantomastiapatients with good effect. There have been numerousreports in the literature using inferior pedicle techniquesand showing no increase in complication rate with resec-tion weights of over 1000 g.1,2,3 Free nipple grafts can give

Correspondence and communications 263

reduction. We believe that the cosmetic outcome andthe rate of recurrence of gigantomastia are directlyrelated to further weight balance.

e We agree with the 44% of the teams who have respon-ded to the author’s inquiry, that we should talk aboutgigantomastia when the weight of breast removedduring a breast reduction procedure is superior to1000gr. When it comes to mastectomy we retaina weight of 1500 g as a cut off.

e Gigantomastia is often associated with severe breastptosis. The importance of ptosis, that we evaluate withthe sternal notch to nipple areola complex (NAC)distance, is determining in the choice of breast reduc-tion technique. The vitality of the NAC depends on itsvascular supply.2,3 The choice of the NAC bearingpedicle is a major issue when retaining a surgicaltechnique. Our choice is the superior pedicle in themajority of cases4 because of its reliability and longterm predicable results. We believe that free nipplegraft technique can very often be avoided.4,5

e The classification is nothing more than the list ofetiology: idiopathic, obesity, juvenile, pregnancy-induced and drug-induced, that we also cited in ourstudy.4 It is important to know the etiologies andpathophysiology to make a precise diagnosis and retainthe true surgical indication vs medical treatment. Butunfortunately this classification has no direct impact onthe surgical strategy adopted by the plastic surgeontowards the correction of ptosis, the amount of breastto be removed and the technique to be used.

e We finally regret that no reference was made to ourarticle nor have we been contacted for the inquiry. Ourarticle reported a serie of 26 patients with extensiveinformation on the etiology, BMI, the weight of breastresected, and the modified superior pedicle breastreduction technique.4

Conflict of interest

None.

Funding

None.

References

1. Dancey A, Khan M, Dawson J, et al. Gigantomastiaea classifica-tion and review of the literature. J Plast Reconstr Aesthet Surg2008;61:493e502 [Epub 2007 Nov 28].

2. O’Dey D, Prescher A, Pallua N. Vascular reliability of nipple-areola complex-bearing pedicles: an anatomical microdissectionstudy. Plast Reconstr Surg 2007 Apr 1;119:1167e77.

3. Wuringer E, Mader N, Posch E, et al. Nerve and vessel supplyingligamentous suspension of the mammary gland. Plast ReconstrSurg 1998 May;101:1486e93.

4. Mojallal A, Comparin JP, Voulliaume D, et al. Reduction mam-maplasty using superior pedicle in macromastia. Ann Chir PlastEsthet 2005 Apr;50:118e26.

5. Papalia I, d’Alcontres FS, Colonna MR, et al. The superiorpedicle mammaplasty for the treatment of pedunculous breast.Ann Ital Chir 2007 NoveDec;78:503e6.

A. MojallalM. Moutran

E. MartinF. Braye

Edouar Herriot Hosptal, Plastic Surgery Department,5 Place d’Arsonval, 69003 Lyon, FranceE-mail address: dr.mojallal@gmail.com

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.07.014