Postaugmentation Galactocele Without Periareolar Incision and 8 Years After Pregnancy.

Abstract

Sir: Galactocele is a rare breast augmentation complication. Addressing the risk factors involved, Harper et al1 found from previous galactocele reports that 100% of the implants were placed through periareolar incisions and 75% of patients either were on oral contraceptives at the time of their surgery or were lactating after pregnancy, with a remote history of augmentation mammaplasty. A recent retrospective study involving 832 patients and 3 (0.36%) cases of galactocele2 found that the use of a periareolar incision significantly increased the incidence of galactorrhea, but no mention toward increased risk of galactocele. We present a case of postaugmentation galactocele formation without periareolar incision and 8 years after her unique pregnancy. Our patient was a 26-year-old, gravida 1, para 0, abortus 1, without any significant medical or surgical history. She stopped oral contraceptives 30 days before and after surgery. An ultrasound scan showed 1 small (1.1 cm3) benign simple cyst in each breast. She underwent bilateral subglandular augmentation mammaplasty with 285 mL high-profile Silimed (Rio de Janeiro, Brazil) silicone gel implant and vertical, infra-areolar skin excess resection. She developed a painful enlargement of her left breast on postoperative day 17, without signs of inflammation or fever (Fig. ​(Fig.1).1). A postoperative ultrasound scan showed liquid collection around the implant but not suggestive of hematoma. A guided needle aspiration removed 89 mL of creamy fluid; the culture was negative for bacterial growth but biochemistry analyses concluded that it was breast milk. The patient was referred to a mastologist who started dopamine receptor agonist (bromocriptine), despite normal prolactin, for 2 weeks with no recurrence. Due to breast and implant pocket enlargement, the patient underwent revision surgery 6 months later to correct the left ptosis (Fig. ​(Fig.2)2) by skin resection, and the implant was moved to a dual plane pocket. The implant on the other side was also moved to the dual plane pocket due to breast symmetry. Fig. 1. Marked enlargement of the left breast at day 17 postoperatively. Fig. 2. Residual asymmetry due to left breast and implant pocket enlargement after galactocele’s treatment at 6 weeks postoperatively. Galactocele’s pathogenesis is still unknown, but obstruction of breast ducts associated with high levels of prolactin may play a significant role.3 Hyperprolactinemia may be due to intercostal nerve stimulation during surgery, leading to autonomic control over central neurogenic paths diminishing dopamine output into hypophysis’ portal circulation, increasing prolactin levels and milk secretion.4 Because our patient had none of the risk factors previously reported5 (periareolar incision, contraceptives intake, recent pregnancy or lactation, or hyperprolactinemia symptoms), we rely our etiopathogenesis hypothesis on duct obstruction because simple cysts were found preoperatively inside breast parenchyma. The treatment involved ultrasound-guided needle aspiration associated with dopamine agonist (bromocriptine) to halt hyperprolactinemia and milk production, which was successful with no recurrence. Other causes of hyperprolactinemia should be ruled out. Although it is rare, surgeons should be aware of this complication in augmentation mammaplasty. Considering the potential increased risk for galactocele, patients with previous thoracic or breast surgery, breast cysts, or spontaneous breast discharge should be assessed preoperatively for prolactin status to correct eventual disorders.