INTRODUCTION
Breast ptosis is characterized by the disproportion between the skin of the breast
and its contents. This change has mastopexy as a surgical procedure aiming to correct
the breast problem1. Its association with flaccidity and hypomania is common, which makes its surgical
approach difficult2,3,4. In 1969, Goulian and Conway suggested placing breast implants next to the mastopexy,
aiming at a better aesthetic effect in these cases2. However, the combined procedure adds complications related to the presence of the
prosthesis to complications related to the mammoplasty itself5.
For a better aesthetic result, the choice of the nipple-areolar pedicle, implant location,
type of glandular resection, type of incision and implant format should be taken into
account5,6.
The most frequent complications of this surgical approach are ptosis recurrence, hypertrophic
scars, keloids, flattening of the mammary cone, loss of sensation, inadequate positioning
or distortion of the areola, nipple flattening, infections, hematomas, seromas and
suture dehiscence7. However, some unusual outcomes can also occur, such as galactocele or galactorrhea8. Little is known about the pathophysiology of these atypical results, but it is believed
to be due to the manipulation of breast tissue during the surgical procedure8,9.
There are few reports in the literature about galactorrhea or galactocele after mastopexy
with the placement of breast implants, which is a rare complication of this procedure8,9.
OBJECTIVE
In this sense, the present study aims to report and discuss a case of post-mastopexy
galactorrhea with a prosthesis.
CASE REPORT
The present study was approved by the Ethics Committee and has CAAE number: 40146720.7.0000.5549.
Female patient, 53 years old, G2P2A0 and two periods of previous breastfeeding, lasting
2 years each. She is undergoing hormone replacement treatment using dienogest and
estradiol valerate—no other comorbidities. On physical examination, breasts with no
scars and/or nodulations, ptosis classified as Regnault grade II.
On August 24, 2019, in the city of Patos de Minas (MG), he underwent bilateral mastopexy
associated with the inclusion of 260ml, textured, round, high-projection prostheses
of the Motiva brand, with an inverted “T” scar and positioned in the subfascial plane.
In the same procedure, blepharoplasty was also performed. The surgical time was 4h30,
and the patient was discharged within 24 hours.
In the immediate postoperative period, the patient reported pain and unilateral swelling
in the left breast. Cefadroxil monohydrate 500mg and celecoxib 200mg 12/12 hours for
six days, 1g dipyrone, 1g effervescent vitamin C and dextran and hypromellose eye
drops were prescribed due to blepharoplasty. In addition to the medication, manual
lymphatic drainage was also started to reduce the edema.
Nine days after the surgery, due to the maintenance of symptoms, an ultrasound of
the breasts was requested, performed on 09/05/2019. The report confirmed a discrete
peri-implant fluid collection (seroma) in the left breast. Control ultrasounds were
performed 7 and 14 days after the first one, confirming the presence of a discreet,
anechoic, homogeneous fluid collection around the implant, better identified in the
left breast’s superolateral quadrant of the left breast.
On the 30th postoperative day, the patient developed galactorrhea. Cabergoline 0.5mg
was prescribed, one tablet, single -dose, without improvement in one week. The treatment
was repeated once more in a single dose. However, she continued to report mastalgia
and edema on the left.
Follicle- stimulating hormone (FSH), ultrasensitive TSH, macroprolactin and prolactin
tests were requested. The results were, respectively, 34.66mUI/ mL, 3.25microUI/mL,
37.06ng/ml with a recovery percentage of 75% and 37.1ng/ml. Thus, alterations in the
results of macroprolactin and prolactin are observed, which led to the confirmation
of galactorrhea due to hyperprolactinemia.
After 15 days of using the second dose of 0.5mg cabergoline, galactorrhea was interrupted,
evolving to an asymptomatic condition, with an improvement of pain and edema.
Control ultrasound corroborated the findings, showing only silicone breast implants
without signs of peri-implant fluid collection and BIRADS-2. The patient evolved without
any other symptoms.
DISCUSSION
Like any other surgical approach, augmentation mammaplasties are subject to complications9. However, mastopexies have a higher degree of difficulty due to the characteristics
of the patient’s skin, greater sagging and little elasticity1,10. Among the different complications in the postoperative period of breast correction,
galactorrhoea has few literary reports9.
In the clinical case presented, there is milky secretion after the surgical procedure
and symptoms of pain, discomfort and unilateral breast enlargement, defining asymmetry.
Different studies indicate that surgical techniques that manipulate the lactiferous
ducts may be related to the phenomenon of galactorrhea11. To reduce the disturbance of these ducts, some surgeons opt for an inframammary
incision when there is no need to perform a mastopexy9.
Galactocele is not always associated with hyper-prolactinemia. When serum prolactin
concentrations are normal, galactorrhea is considered physiological and transient
due to excessive stimulation of breast tissue. Patients undergoing augmentation mammoplasty
have nipple stimulation by abrupt distension and compression due to the breast implant,
becoming contributing factors for the secretion of prolactin12.
When we understand the physiology of lactation, we understand how sulpiride and other
dopamine inhibitors that interact in this hormonal cycle can stimulate milk production
and be involved in the formation of the galactocele. On the other hand, dopamine agonists,
such as bromocriptine and cabergoline, act by inhibiting prolactin and, consequently,
lactation, essential in the treatment of galactocele13.
The occurrence of lactation is a rare complication of breast plastic surgery. The
pathophysiology of this complication may be associated with inadequate secretion of
prolactin in the surgical context. Factors favoring this complication would be the
number of pregnancies, a recent and extensive breastfeeding history, and the intake
of certain medications, such as an estroprogestational pill. The main symptom of this
complication is the occurrence of unilateral or bilateral galactorrhea, on average
6 to 12 days after surgery. The main differential diagnosis is a postoperative infection.
Depending on the case, treatment may vary from simple surveillance to the association
of dopamine agonists, antibiotic therapy and surgical revision. Dopamine agonists
are the first choice, as long-term follow-up of patients has proven their effectiveness
in reversing gonadal changes linked to hyperprolactinemia and reducing pituitary adenomas14,15.
Cabergoline - medication used in the case reported - is a dopamine agonist derived
from Ergot (a common contaminating fungus of rye and other cereals, or by the excessive
or misguided use of ergoline-derived drugs) with long action after oral administration,
used in the treatment of hyperprolactinemia, in addition to idiopathic disorders,
pituitary adenomas, amenorrhea, oligomenorrhea, anovulation and galactorrhea14.
The recommended starting dose of cabergoline is 0.5mg per week, given in one or two
doses per week. The weekly dose should be increased gradually, preferably by adding
0.5mg weekly at monthly intervals, until an optimal therapeutic response is achieved.
The therapeutic dose is normally 1mg per week but can range from 0.25mg to 2mg per
week. Cabergoline doses of up to 4.5mg per week have been used in hyperprolactinemic
patients14. In the case reported, cabergoline was used at a dose of 0.5mg, in two doses one
week apart, totaling 1mg.
This therapeutic regimen was effective in inhibiting lactation after bilateral mastopexy
associated with the inclusion of prostheses in the present case.
CONCLUSÃO
Post-mastopexy galactocele with prosthesis is a rare complication and may or may not
be associated with hyperprolactinemia, but little is known about the actual pathophysiology
of the development of this condition.
When galactorrhea begins in the postoperative period of breast surgery, it is mandatory
to carry out hormone measurements to identify the increase in prolactin. Lactation
inhibitors are used as a treatment, with good results and established protocols. It
was unnecessary to perform invasive procedures to control and resolve the case, only
using oral medication.
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1. Centro Universitário Atenas, Paracatu, MG, Brazil.
2. Hospital Federal de Bonsucesso, Rio de Janeiro, RJ, Brazil.
Corresponding author: Ludimilla Santos Araújo Rua Raul Botelho, 251, Alto do Córrego, Paracatu, MG, Brazil Zip Code: 38606-032
E-mail: ludinhasantos@hotmail.com
Article received: May 21, 2021.
Article accepted: July 14, 2021.
Conflicts of interest: none.
Institution: Centro Universitário Atenas, Paracatu, MG, Brazil.
