Galactorrhea after breast augmentation: case report and literature review
Galactorreia após mamoplastia de aumento: relato de caso e revisão da literatura

INTRODUCTION

Augmentation mammoplasty using implants is a procedure performed with high frequency worldwide. In 2020 alone, 1,624,281 surgeries were performed, according to the International Society of Aesthetic Plastic Surgery (ISAPS)¹. Although very safe, it is not free from complications. Some of these complications are well known, such as hematoma, seroma, capsular contracture, infection, unsightly scarring, and poor positioning of implants, and some are uncommon, such as galactorrhea²,³.

Galactorrhea and galactocele can occur in up to 0.96% of patients undergoing breast augmentation with implants. On average, they take 15-90 days to manifest. Galactocele was defined as the accumulation of milk in the surgical pocket, and this content can be drained spontaneously through the surgical wound⁴. Galactorrhea is defined as the spontaneous excretion of milk by the papilla without sucking stimulus³.

The cause of postoperative galactorrhea and galactocele has not yet been fully elucidated. It is believed that the trigger may be due to the increase in prolactin due to surgical stimulation or nerve compression of the rib cage. Some theories point out that the mechanical compression of the implants on the gland or even the effect of other medications taken by the patient may be responsible for such intercurrence⁵.

Treatment is based on prolactin inhibitors such as bromocriptine⁴,⁶,⁷ and may be associated with percutaneous or open surgical drainage of the galactocele⁷. Because it is a rare intercurrence that the surgeon may face one day, we present a case experienced in our service, as well as the treatment scheme used and the postoperative follow-up with 10 months of surgery.

OBJECTIVE

To present a case of galactocele in a patient who underwent breast augmentation with implants, to report on the management of the case, applied treatment, and results.

CASE REPORT

We report the case of a 35-year-old female patient, complaining of hypoplastic breasts and desire for breast augmentation (Figures 1A and 1B), admitted to Hospital Irmãos Penteado, Dr. Ricardo Barouldi, in Campinas, S P. She had two previous pregnancies and had stopped breastfeeding one year after the surgery. The patient tended to form a keloid scar without other important antecedents. In October 09, 2020 a breast augmentation surgery was performed using 300ml textured implants in the subglandular plane and via an access route in the inframammary fold. The postoperative period was uneventful, and the patient evolved adequately.

Figure 1A - Preoperative patient (front view). Figure 1B. Preoperative patient (lateral view).

Figure 1A - Preoperative patient (front view). Figure 1B. Preoperative patient (lateral view).

Thirty days after the surgical procedure, a milky secretion (Figure 2) drains spontaneously through the surgical wound without pain, fever, or other symptoms, in addition to bilateral galactorrhea. Cabergoline 0.5mg every 12 hours was used, associated with cefadroxil 500mg every 12 hours for 48 hours. This regimen of cabergoline pulses was repeated 45 days after the surgical procedure. With this approach, the patient presented a progressive decrease in secretion drained by the surgical wound, completely ceasing 60 days after the surgery.

Figure 2 - Spontaneous drainage from the surgical wound of milky secretion.

Figure 2 - Spontaneous drainage from the surgical wound of milky secretion.

The patient evolved with a hypertrophic scar in the region of the inframammary fold, which was treated with four sessions of intra-cicatricial infiltration of triamcinolone acetate. Six months after the operation (Figures 3A and 3B), the breasts are symmetrical, without signs of contracture or additional alterations; the patient is satisfied with the result and without new episodes of galactorrhea or galactocele.

Figure 3A - Six-month postoperative period (frontal view). Figure 3B. Six-month postoperative period (lateral view).

Figure 3A - Six-month postoperative period (frontal view). Figure 3B. Six-month postoperative period (lateral view).

DISCUSSION

Galactorrhea is a rare complication that occurs in breast augmentation surgeries. It was first described in 1971 as the spontaneous release of milk not associated with breastfeeding⁶,⁷. Initially, it can be confused with infection or breast abscess due to edema, pain, and the appearance of secretion⁸. Among the causes of galactorrhea, we can highlight nipple stimulation, pregnancy, use of medications that increase prolactin production, iatrogenic hyperprolactinemia above 27ng/ml, thyroid alterations, renal alterations, and prolactinomas⁹.

Among the causes of postoperative galactorrhea after breast augmentation, it has been suggested that there is an increase in prolactin in response to lactotrophic cells in the anterior pituitary, which leads to milk production; prolactin can increase up to 5 times due to the surgical stimulus⁹. Another theory indicates that the surgery’s irritation of the costal nerves leads to a suppression of the hypothalamic axis, with a decrease in the release of dopamine⁴. However, the systematic review published by Sharma & Basu4 found that not all patients had high levels of prolactin in the postoperative period.

We can point out some risk factors associated with galactorrhea, such as the last pregnancy close to the surgery period, greater number of pregnancies, previous lactation, and use of contraceptive medication.

Regarding the implant insertion plane, those allocated in a subglandular position and periareolar incision are more related to galactorrhea⁴. According to Chun & Taghinia¹⁰, this is due to the obstruction of some galactophoric ducts in the breast. The onset of symptoms is reported in an average of 15 days and may manifest after 90 days after surgery³,⁶.

Some tests can be routinely used, such as measurement of serum levels of prolactin, Beta-HCG, complete blood count, C-reactive protein, thyroid tests, and IV Sudan test to determine milk⁶,⁷,¹¹. Regarding imaging tests, ultrasonography, secretion cultures, and pituitary magnetic resonance in case of hyperprolactinemia above 100ng/ml4 may be necessary for diagnostic confirmation.

After confirmation of the condition, we must proceed with drug treatment. Authors propose different approaches, including using bromocriptine at a dose of 2.5mg twice daily as the first line and cabergoline 0.5mg 1-2 tablets per week and as the second line2,⁴,¹¹. Antibiotic treatment may also be included due to the risk of infection associated with the implant⁴,¹¹, dopamine inhibitors, leukotriene inhibitors, to avoid the chance of capsular contracture6, and explant with pocket washing⁴,⁶,¹¹.

In the literature review, we found that most published studies are case reports similar to this one: two case series and one systematic review.

We believe that expanding the number of studies on this topic will be important to unify behaviors and minimize this intercurrence.

CONCLUSION

Galactorrhea and galactocele are rare complications of breast augmentation. With an adequate diagnosis and early treatment, we managed to treat it without changing the outcome of our surgeries. More investigations are needed regarding this rare intercurrence to unify conducts and minimize complications.