Common Breast Disorders in Teenagers: Macromastia, Asymmetry, Gynecomastia – PediaCast 529
- Drs Richard Kirschner, Ibrahim Khansa and Canice Crerand visit the studio as we consider common breast disorders in teenagers. Macromastia and asymmetry impact young women, while gynecomastia affects teenage boys. We explore physical symptoms, emotional distress and surgical interventions. We hope you can join us!
- Breast Disorders in Teenagers
- Breast Asymmetry
- Plastic and Reconstructive Surgery at Nationwide Children’s Hospital
- Request an Appointment at Nationwide Children’s
- Common Breast Disorders in Adolescents (700 Children’s Blog)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It's Episode 529 for January 12, 2023. We're calling this one "Common Breast Disorders in Teenagers: Macromastia, Asymmetry, Gynecomastia". I want to welcome all of you to the program and a very happy new year to all of you.
We are kicking off the year with a topic that, to my knowledge, we have never talked about on PediaCast before. And that sort of illustrates the problem with these disorders because we've been doing pediatric podcasts since 2006 and this was not on our radar, and it probably has not been on the radar for your family.
So it's not something that is talked about very often, which actually then leads to a lack of awareness of the physical and emotional impact that these disorders can have on teenagers, which, as we will see, can be quite significant. Two of these disorders affect young women, macromastia, that just means an excessive growth of breast tissue. And asymmetry is unequal development of the breasts, so they're different sizes. And then the final disorder we're going to cover is gynecomastia, and this involves persistent breast development in teenage boys.
Now, traditional thinking has held that there was not anything you could do for these conditions, at least during the teenage years. You'd have to wait until adulthood to address them.
And while it is true that you want ideally for breast development to be complete before embarking on surgical interventions, you do not necessarily have to wait until these young patients are 18 or 21 to intervene surgically. And in fact, the evidence suggests that these procedures are safe during the teenage years and result in long-lasting improvement in quality of life and emotional and physical wellbeing.
Lots more to say about each of these disorders. And we have three terrific guests joining us in the studio as we consider them. Dr. Richard Kirschner and Dr. Ibrahim Khansa are plastic and reconstructive surgeons at Nationwide Children's Hospital. And Dr. Canice Crerand is a pediatric psychologist and psychological researcher at Nationwide Children's.
They will be here soon, but first, let's cover our usual quick reminders. Don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music and most other podcast apps for iOS and Android.
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So let's take a quick break. We'll get our expert guests settled into the studio and then we will be back to talk about common breast disorders in teenagers. It's coming up, right after this.
Dr. Mike Patrick: Dr. Richard Kirschner is Chief of Plastic and Reconstructive Surgery at Nationwide Children's Hospital. He's also a professor of Pediatrics and Plastic and Reconstructive Surgery at the Ohio State University College of Medicine.
Dr. Ibrahim Khansa is a plastic surgeon at Nationwide Children's and an assistant professor of Plastic and Reconstructive Surgery at Ohio State.
Dr. Canice Crerand is also with us today. She is a pediatric psychologist at Nationwide Children's and an assistant professor of Pediatrics at Ohio State.
All three have a passion for helping teenagers with disorders of breast development and they're here to talk about three of these conditions, macromastia and asymmetry in young women and gynecomastia in teenage boys.
Before we take an in-depth look at these conditions, let's give a warm PediaCast welcome to our guests, Dr. Richard Kirschner, Dr. Ibrahim Khansa, and Dr. Canice Crerand. Thank you all so much for joining us today.
Dr. Richard Kirschner: Absolutely, our pleasure.
Dr. Canice Crerand: Thank you.
Dr. Ibrahim Khansa: Thank you for having us, Dr. Mike.
Dr. Mike Patrick: Yeah, I really appreciate all three of you. I mean, to get two plastic surgeons and a psychologist who have really busy schedules altogether in the studio at once is fabulous.
I want to start with you, Dr. Khansa. The first topic that we're going to discuss is macromastia. Explain exactly what does that term mean.
Dr. Ibrahim Khansa: Sure. Macromastia. Macro is large and mastia is breast. So it just refers to disproportionate enlargement of the breast in women. It can be a combination of enlargement of the breast gland and the fatty tissue around it. It's often a combination of both.
Dr. Mike Patrick: Is there a specific size where you would start to call it macromastia? Or does it have more to do with if there are symptoms that the larger breasts are causing?
Dr. Ibrahim Khansa: Great question. There are various definitions out there in the literature. We don't really use those. It's just if the breasts are too large for that particular patient to the point where they are causing symptoms, then we would call that macromastia.
Dr. Mike Patrick: And we'll talk more about what those symptoms are here in a couple of minutes. How common is this disorder among teenagers?
Dr. Ibrahim Khansa: Yeah, it's quite common because there's not a clear-cut definition. It's really hard to get very clear numbers. What we do know is that there are over 90,000 breast reductions that occur in the United States every year. So it is not an uncommon condition.
Dr. Mike Patrick: And you do a fair number in the teenage population, as well.
Dr. Ibrahim Khansa: Yeah. Here at Nationwide Children's, we do a large number of breast reductions on teenagers who are having symptoms and having difficulty with their large breast size.
Dr. Mike Patrick: I think this is a good topic for general pediatricians, as well. And we do have a lot of them that listen to this podcast too, because I think that there is probably a lack of awareness that you can do something about this. And it may be something too, that if an individual teenage patient is having symptoms that are caused… Well, first, they may not even know that those symptoms are caused by breast enlargement.
But they may not think that breast reduction surgery is even a possibility. So I think that just increasing awareness among primary care doctors is going to be an important thing too, right?
Dr. Ibrahim Khansa: Absolutely, yes. So we see a lot of patients who present in a delayed fashion because they weren't aware that breast reduction is an option. Or they thought that they had to wait until a certain age. So hopefully, we can help dispel some of the misconceptions today.
Dr. Mike Patrick: And then what are some of those physical symptoms that someone could experience when they have macromastia?
Dr. Ibrahim Khansa: For sure, yeah. I would say there's significant physical symptoms as well as emotional and mental health symptoms.
Starting with the physical symptoms of macromastia, really, the most common ones are pain, pain in the neck, the back, the shoulders. Sometimes, they even have headaches. A lot of the patients will seek massages, treatment by chiropractors, physical therapy.
They'll use heat packs. Oftentimes, they will have tried various medications like nonsteroidal anti-inflammatory drugs and Tylenol.
It is often hard for them to find clothes that fit. Oftentimes the bra, the brassiere is carrying a heavy weight. It leaves grooves in their shoulders.
And then, in certain circumstances, the patients may have rashes under their breasts or between their breasts.
Most of the patients report that they're having difficulty performing activities that they want to do, such as sports or even activities of daily living.
And I would say a major component of this would be the emotional aspect of macromastia too, that Dr. Crerand can tell us more about.
Dr. Mike Patrick: Yeah. And we do want to bring you in. What does that look like in terms of mental health considerations, when we're talking about kids with macromastia?
Dr. Canice Crerand: Sure. I think the first point I'd like to make is that this is not just a cosmetic issue. The psychosocial burdens associated with macromastia can be quite profound. We know that adolescents can have impacts on their thoughts, their feelings and their behaviors.
In terms of their thoughts, oftentimes they experience a lot of negative cognitions about their physical appearance. So they may have a lot of body image dissatisfaction and struggles to find parts about their appearance that they like. That can take a toll on their overall self-esteem.
We also know that from an emotional standpoint, when individuals are experiencing more negative thoughts about themselves, that can often give rise to distress. That distress might look like worry or anxiety about what other people think about their appearance, whether they're going to be teased or bullied about their breast size.
Unfortunately, a lot of young women will experience harassment. Or people may make unfavorable judgments about their sexuality or about their interests in romantic relationship because of their breast size.
So those kinds of worries and fears can really take a toll on their mental health, as Ibe mentioned, there can be concerns just with activities of daily living. A lot of girls will report that it's difficult to find stylish clothes. So they really have a sense of feeling different from their peers, that they can't do the things that they want to do. And that can really affect them emotionally and socially.
Dr. Mike Patrick: Yeah, absolutely. And we know that teenagers often compare themselves to each other. So even like smaller breasts, larger breasts, both of those are going to kind of bring attention to them that may not be wanted.
Dr. Canice Crerand: Exactly. And I think one of the big challenges is that these concerns often develop during adolescence, which is a time which is fraught with lots of changes to begin with, even if you don't have macromastia.
So you're going through puberty. You are beginning to explore your identity. There's increased interest in fitting in with your peers, in forming romantic relationships. So those are all some of the contexts that's happening around this. So the fact that it has a significant psychosocial burden isn't surprising.
Dr. Mike Patrick: Yeah, absolutely. Even little things that we may not think about, like trading clothes with friends. Your friend's clothes don't fit you, but they fit others in your friend group. Or finding a dress for prom can be a big issue.
Dr. Canice Crerand: Exactly, yeah.
Dr. Mike Patrick: And then as I was researching this, I saw that this can be associated with disordered eating.
Dr. Canice Crerand: Yes. So in some instances, young women will attempt to reduce their breast size by engaging in diet and sometimes exercise to try to lose weight. Thinking that if they can lose weight, that will decrease the shape or the size of their breasts. And unfortunately, as many of us know, you can't just target weight loss. And oftentimes, while they may lose some, it's not going to correct the exaggerated size of their breasts.
And in some instances, their distress is so great where their body image dissatisfaction is so great around their breasts, that they may take their eating concerns to a more pathologic level. So really restricting their calories, potentially engaging in purging behaviors. So it really can have a detrimental impact on their overall health.
Dr. Mike Patrick: Yeah. How can parents kind of be on the lookout for subtle signs that this may be happening if you believe your child is experiencing macromastia? The physical symptoms may be easy to spot, but the mental health stuff may be more difficult for parents to figure out what's going on.
Dr. Canice Crerand: Yeah, so that's a great question. And I think sometimes, you'll begin to see avoidance. So maybe young girls will take themselves out of social opportunities or decide that they no longer want to play a sport. They don't want to go to the dance, they don't want to go to the party.
Maybe they're really restricting their social interaction. So that could be a red flag, that maybe there are some concerns going on about their appearance or their breast size.
Dr. Mike Patrick: And really just having open conversations with your kids when you do have those concerns and starting those conversations, even though they may be uncomfortable for parents sometimes, but it's important to do that really at an early age.
Dr. Canice Crerand: Absolutely. And even just approaching it from, "You know, I'm noticing that you don't want to go to the dances or that you're spending more time at home. I'm wondering if we could talk about what's going on."
Dr. Mike Patrick: Yeah. That's a fabulous way to introduce that that topic. So let's say we have a child, they have macromastia, they maybe have some physical symptoms with it. We think that there is some emotional issues involved as well. What's the first step that a family can take for figuring this out? Who do you talk to you first?
Dr. Canice Crerand: That's a great question. And I may punt that over to one of my surgeon colleagues here. But I think the pediatrician may be a good place to start, just to find out referrals and options. And maybe even to bring it up in how this is affecting the child's overall health, not just their physical health, but their mental health as well.
Dr. Mike Patrick: Yeah, I think primary care doctor is a great place to start. And hopefully, they have awareness. If they don't, parents can point them toward this podcast and they can take a listen and educate themselves, too.
But Dr. Khansa, what does that look like when a family very first comes in for a consultation for this issue?
Dr. Ibrahim Khansa: When they first come in, they start by meeting our nurse practitioner, Andrea Brun, who asks them a bunch of questions, examines them, kind of asks about what their desires are. And then, if they seem like good candidates for surgery, that's when they go on to meet with a surgeon. And that's when we talk about the surgical intervention in detail.
I would say that a good percentage of our patients come in already with a mental health professional taking care of them. If they don't and if they do have mental health difficulties, we do have two clinical psychologists on the team who are always able to see the patients on short notice. So that is a very important component of the care of adolescent patients with breast problems that we really pay attention to. So it's not just the surgery.
Dr. Mike Patrick: You had mentioned before that some people think that you can't do this during the teenage years. Do you have to wait for breast development to be complete though?
Dr. Ibrahim Khansa: Ideally, we want to wait until the breast development or the breast growth has been complete and stable for at least 12 months. Now, a good guideline as to when that might occur is about three to four years after menarche or the first period. That tends to be when the breast size stabilizes.
There are rare circumstances where the breasts are growing very rapidly and causing significant symptoms and a lot of pain. We may intervene early, knowing that there might be some breast regrowth. But I would say for the very vast majority of patients, we try to wait until the growth has been done for 12 months.
Dr. Mike Patrick: And then what is this procedure in terms of mechanics look like? Is there scarring? You're just taking out fat or is there other tissue? Just kind of walk us through the procedure.
Dr. Ibrahim Khansa: The procedure is called the breast reduction, and it includes both a reduction and a lift through an incision, which I'll describe in a second. We remove a combination of breast tissue, fat and skin. The scar for the vast majority of patients will look like an anchor.
So there is a circle around the areola, which is the dark area around the nipple. Then there's a vertical scar that goes up and down under that areola. And then there's a scar in the fold under the breast. So we call that pattern an anchor and it's the combination of these three scars.
The scars tend to heal pretty well over time. It also tends to be kind of the permanent mark that somebody has had a breast reduction. It is something that we pay attention to, but overall, they tend to be pretty good over time.
Dr. Mike Patrick: When you say a breast lift, what exactly does that mean?
Dr. Ibrahim Khansa: So a lift is one where the distance from the sternal notch to the nipple is long and we make it shorter. Basically, we're just lifting the breast higher up on the chest.
Dr. Mike Patrick: So that, actually, you're moving the nipple, too?
Dr. Ibrahim Khansa: Yes.
Dr. Mike Patrick: Does that come then with risk for future breastfeeding?
Dr. Ibrahim Khansa: That's a great question. The question of whether you can breastfeed or whether a female patient can breastfeed after breast reduction has not been studied very well, because not every woman even attempts to breastfeed in the future. Now, if we look at the literature, the thinking is that the majority of these patients will be able to breastfeed if they desire. They may need to supplement breast milk with formula, but really the answer is difficult because the studies are not great.
Dr. Mike Patrick: Yeah. And this is all I'm sure when you're having your consultation with the family, you're kind of walking them through the risks and the benefits and shared decision making with families.
Dr. Ibrahim Khansa: Yeah, for sure. Yeah. I mean, the surgical results are excellent. I would say the two things that patients should be prepared for are scars, which are lifelong. We do discuss the breastfeeding and the fact that they should be able to breastfeed, but there's a possibility that they may not be able to.
And then, altered nipple sensation is another thing that they should be prepared for. The sensation to the nipple may be decreased long term or even absent. But most of the time, it's intact.
Dr. Mike Patrick: The surgery itself, is this a same day surgery? Will they have to spend the night in the hospital?
Dr. Ibrahim Khansa: The surgery takes about three to four hours. I would say the majority of our patients here at Nationwide stay the night. There are circumstances where we may send them home the same day, but I would say the majority stay the night.
Pain control is something we pay attention to. Pain is not usually a huge issue after this operation. We find that a lot of the patients might have nausea and vomiting after surgery. So that's one reason why we keep them overnight.
Dr. Mike Patrick: And then what about insurance coverage for this? So a three- or four-hour operation and overnight stay in the hospital, that bill is going to add up pretty quickly.
Dr. Ibrahim Khansa: Yeah, for sure.
Dr. Mike Patrick: So is it something that insurance companies are paying for? Do you have to fight with them to get them to cover it?
Dr. Ibrahim Khansa: Sometimes.
Dr. Ibrahim Khansa: So breast reduction, the goal is to get it covered by insurance. Our goal, at least. So that will depend upon the individual insurance plan that every patient has. And obviously, there's the deductible and other issues that come into play.
What the insurance companies want to see is they want to make sure that the surgery is being done to address functional problems that address activities of daily living. So the issues I mentioned earlier, pain that's resistant to treatment, rashes that are resistant to treatments. If the patient has those, we will usually submit the surgery to insurance ahead of time to make sure it is authorized before we do it.
And I would say probably three-quarters of the time we can get it approved, maybe a little higher. If we don't, then we will appeal with the insurance. Sometimes, we do a peer-to-peer. So we'll fight on the behalf of the patient to try to get it approved.
Dr. Mike Patrick: Peer-to-peer means you're talking to the medical director of the insurance company and convincing them of the wellbeing of the child is really at stake here.
Dr. Ibrahim Khansa: Yeah, and why we think this is a medical procedure and not a cosmetic procedure.
Dr. Mike Patrick: Absolutely. What about Medicaid and the Medicaid HMO companies? Is it the same with them as the private insurance companies, or are they less likely to cover it?
Dr. Ibrahim Khansa: I would say that probably with Medicaid and CareSource and government plans, it has recently been a little easier to get things approved than private insurance plans.
Dr. Mike Patrick: Because that's an area where there could be a disparity in health, based on socio-economic status. And we want all kids to have comfortable lives and to be physically and emotionally fit. And so, that's good to hear. That's probably the awareness piece of it is permeating into the government programs.
Dr. Ibrahim Khansa: Absolutely, yeah. The willingness of the government programs to approve these surgeries really makes us happy that those children are getting equal access to care.
Dr. Mike Patrick: And then what about long-term outcomes? Is there the possibility that the breasts… Throughout life as we gain weight, the breast do become larger and as you lose weight, they do, to some degree, become smaller. Is that ever an issue where you might have to have another surgery?
Dr. Ibrahim Khansa: Yeah, you may. So our job is to make sure the breasts are not growing or that they've been stable for 12 months at the time of the reduction. Now, there are life changes that may occur that can affect the size and the shape of the breast later on. So weight gain, your breasts can grow with weight gain.
Another thing that may happen is pregnancy and breastfeeding. So that will cause the breast to grow and then shrink. And with multiple pregnancies where the breast is growing and shrinking, you may get what we call a sag or ptosis. And so that's when the breast kind of fall down on the chest wall, and you may need a lift after that.
Dr. Mike Patrick: Got you. And then what about the emotional long-term outcomes for kids? Does this really make a difference for folks in your experience?
Dr. Canice Crerand: Yeah, it does. And the research is really starting to bear that out as well. So pre-operatively, we know that adolescents will struggle with self-esteem. They may have eating disorder-like symptoms, as we discussed before.
They have impairments in their quality of life. They have physical symptoms, as we've talked about here today. And largely, those issues resolve. And there are some studies that suggest that youth actually are now reporting scores of self-esteem and quality of life that are comparable to their peers.
So we really see a nice rebound in terms of how they're feeling about themselves and feeling more comfortable in their skin.
Dr. Mike Patrick: Yeah, that that's fantastic, really, really great. And I love that there's data to show that this is true. And then, I'm sure it helps when you're talking to insurance companies to be able to share that data.
Dr. Canice Crerand: It does, but I think, by and large, the psychosocial impacts are often ignored. So I think part of what's great about talking with you here today is that we can kind of get the word out that the evidence base is growing and that this really is not just a cosmetic issue. It does have mental health impacts. And I think we need to think about the whole child, not just their physical health and think about the mental and emotional impact of these conditions.
Dr. Mike Patrick: Yeah, absolutely. All right, I want to bring Dr. Kirschner into the conversation. And we're going to talk about breast asymmetry next. So why don't we just start with an explanation of what exactly that is? Because everybody has a little asymmetry, right?
Dr. Richard Kirschner: True. So I think to understand breast asymmetries, it's important to start at the very beginning. So one thing to understand is that the tissue that's later going to develop into the breasts appears very early on during embryonic development. And at the time of birth, there are small breast buds that are present on the chest wall.
That's important to understand because anything that can interfere with the normal development of those breast buds, anything that occurs early on during infancy and childhood, in fact, can later interfere with the normal development of the breasts.
So normal breast development in teens usually begins between the age of 8 and 13, what we call thelarche, and precedes normally over the course of about two to four years. So, when we talk about breast asymmetries, we as surgeons like to sort of divide them up into three main categories because it's really a mixed bag of disorders.
The first category is what we call developmental asymmetries. And this is simply seen when one breast is hypoplastic or underdeveloped or one breast is hyperplastic or overdeveloped. And this is really one of the most common causes of breast asymmetry that we see in teens and really represents a somewhat more exaggerated version of what you referred to as really kind of just the normal physiologic development of the breast, where we normally see some degree of asymmetry.
The second category is what we refer to as congenital asymmetries, and these really fall into two main buckets. The first of these is a disorder known as Poland Syndrome. Poland syndromes are pretty rare congenital disorder that we see in about 1 in 30,000 children.
And it's a disorder that affects the chest, the breast, and sometimes the upper extremity. We'll often see hand differences associate with Poland syndrome. And generally in Poland syndrome, a large segment of the pectoralis muscle, so that main muscle on the chest wall, is missing. And this can be associated with disorders of the overlying breast, which can be seen to be small or misshapen or misplaced.
As breast asymmetry develops during puberty, during development in these young women, they may often seek cosmetic correction of the breast. In fully-developed women, there may be a smaller breast on the affected side or often absence of the breast altogether. And the nipple areola complex is often displaced. It's often seen to be higher.
The other type of congenital breast asymmetry we see is what we refer to as tuberous breasts. Tuberous breast is one that not only has a deficiency in volume and is smaller. But there's also a deficiency in the overlying skin envelope which can be constricted, particularly at the base of the breast.
So sort of a small constricted breast with an abnormal, more tubular shape. And very often, in tubular breast deformity, we'll see herniation or protrusion of the normal breast tissue through the nipple areola complex, which is often enlarged.
And then finally there are what we call acquired asymmetries. And this is the reason why I had mentioned just the normal development of the breast bud because anything that is an insult to that breast bud during childhood can lead to a later asymmetry. So things, for example, radiation to the chest wall for any disorder in childhood can interfere with later breast growth. Fortunately, that's something that's very, very rare.
Trauma to the breast blood can occur even during infancy with placement, for example, of a chest tube for a child that's hospitalized in the neonatal intensive care unit, or during the surgical removal of benign or malignant tumors later during childhood. So it's important for surgeons that are doing surgical procedures in and around the chest that they're very cognizant of the fact there is a small breast bud that normally can't be seen but can be disrupted with surgery that's misguided.
And then, finally, burn scars may also restrict growth of the breast by leading to a constriction of the of the skin envelope. And that can lead to a smaller breast on that side.
And then the last is asymmetries can result from abnormal enlargement of one breast. And there's a couple of reasons why we may see that. One is juvenile hypertrophy, which is sort of a condition where during the course of normal development, we see sort of a very rapid extreme development of one or both breasts, what we call juvenile hypertrophy. Normally, that affects both breasts, but occasionally, it can affect just one.
And then, rare causes of enlargement of one breast include tumors, benign tumors, one that's known as a giant fibroadenoma or tumors known as phyllodes tumors, which can be either benign or malignant. And obviously, you can see how for breast asymmetries, precise diagnosis is very, very important because obviously we're going to treat hyperplasia overgrowth of breast very differently than we would a tumor that causes breast enlargement.
Dr. Mike Patrick: Absolutely. You kept mentioning that each of these individual things that you're talking about are rare. But when you add them all together, how does that compare with macromastia? Are they still less common that you see asymmetry problems? Or as a group, is it still quite a high number?
Dr. Richard Kirschner: It's not rare, but not uncommon, right? Since it's a mixed bag, it's hard to get a handle on exactly what the incidences of breast asymmetry as a whole. Certainly, we see breast asymmetry less commonly than we see macromastia, as Dr. Khansa described.
But the important thing to remember, too, is, as you described, a certain degree of asymmetry is normal. So during normal breast development, it's not unusual to see one breast developing at a different rate than the other. And then eventually, over time, we see that one breast will, the symmetry will improve with time.
Dr. Mike Patrick: And so, this is also something that you typically wait until the breast development is finished?
Dr. Richard Kirschner: Yeah. So with the exception of things like breast tumors, when we see developmental breast asymmetries, it's really best to delay any decision about surgical intervention until development is complete, in order to avoid a progressive asymmetry after surgery.
Dr. Mike Patrick: And then in terms of symptoms with this, obviously, this is a cosmetic issue. Are there physical issues as well or is there pain associated with breast asymmetry?
Dr. Richard Kirschner: There may or may not be. So for example, with breast hypoplasia, underdevelopment with a small breast, we generally don't see symptoms. And so, it's really more of a cosmetic issue.
But for one-sided breast hyperplasia or breast enlargement due to juvenile hypertrophy or to a tumor, we can very often see the same type of symptoms that we see from macromastia, as described by Dr. Khansa.
Dr. Mike Patrick: And then, I would imagine that the mental health issues with breast asymmetry, especially if there's a large difference, can be quite high, right?
Dr. Canice Crerand: Sure. So it certainly impacts their day-to-day functioning. Clothing selection, again, can be a real stressor for adolescents. Buying a bra, when you have a very discrepant size on of each breast, can be difficult.
They may avoid activities where the discrepancy may be more noticeable. So, for example, going to the beach, wearing a bathing suit, physical activities or athletic activities.
From a mental health standpoint, we know that we can see decreases in self-esteem, increases in body image dissatisfaction, sometimes anxiety or even depression, especially if they're really isolating themselves from their social group because of their concerns.
Dr. Mike Patrick: And in addition to, and this is probably true for macromastia as well, in addition to the surgery itself, really seeing someone, talking to someone, having a counselor or therapist is going to be very important, right?
Dr. Canice Crerand: Absolutely. And one point I'd like to make too, is that when we see mental health concerns coming along with some of these breast conditions, that may not be the only cause. Mental health is complex.
So certainly having a physical difference, that may make you more vulnerable to being stigmatized by others. Or just even having more body image concerns can increase your risks for those problems. But we know that kids may also have other concerns going on as well. So having that mental health support can be important. And having someone who can sort of differentiate what may be related to the breast condition, what may be related to other issues going on in the youth's life can be helpful, too.
Dr. Mike Patrick: And then, in terms of the surgical interventions themselves, if you're reducing the size of one breast to correct asymmetry, I suspect that that's pretty similar to what Dr. Khansa was talking about. Is there breast augmentation type techniques as well, if you need to make a smaller breasts larger?
Dr. Richard Kirschner: There are. So, as we talked about it, there are so many different types of breast asymmetries. And so, the way we approach them surgically is very much individualized.
But certainly for, for example, juvenile hypertrophy that affects one breast, we have one-sided breast enlargement. We use standard breast reduction techniques to reduce the size of that breast. And as we said, typically, we'll wait until breast development is complete before intervening, the exception being management of tumors, for example.
But another exception to this, for example, would be Poland syndrome. So very often, we'll see pre-teen girls come to our office noticing a discrepancy in breast development associated with Poland syndrome. And in that case, we actually have the ability to place a tissue expander, which essentially is an adjustable saline-filled implant. We can place that tissue expander early on during breast development beneath the smaller breast and then gradually expand that expander throughout development to keep pace with the volume of the other breast.
Dr. Richard Kirschner: So we present that option for young women and whom that matters during those developmental years. We present that option of being able to keep up with the volume discrepancy. And then later, once breast development is complete, we can remove that tissue expander and replace it with a permanent breast implant.
For developmental breast asymmetries, sort of one-sided breast hypoplasia or underdevelopment, we use standard augmentation mammoplasty breast augmentation techniques with placement of breast implants.
Dr. Mike Patrick: Because this is more cosmetic and more mental health issues involved and less on the physical symptoms side, is it more difficult to get these things covered by insurance? Or do you typically not have issues with that?
Dr. Richard Kirschner: We typically do have issues with that. And again, I think the crux of the matter is a procedure will be covered if the insurance company deems it to be medically necessary. So we'll very often see, for example, in congenital syndromes like Poland syndrome, getting insurance coverage is often much easier. For developmental breast asymmetries, where we just see one breast is smaller than the other, in the absence of a congenital difference like Poland syndrome, that's often much more difficult.
Dr. Mike Patrick: Yeah, because these the insurance companies are business and we're talking quality of life issues. And so, sometimes, they don't necessarily look at quality of life. But I suspect that if this thing leads to anxiety and depression, by the time you've gone through multiple counseling and medications, maybe you've been hospitalized. Maybe you've had suicidal ideation. And there's a monetary cost to all of that too, correct?
Dr. Canice Crerand: Very, very true. And I think one that maybe they're not appreciating.
Dr. Mike Patrick: Yeah. You just have to get them to listen to this podcast.
Dr. Richard Kirschner: That's typically one of the most frustrating things that we deal with in trying to get these procedures approved, because it's clear what the functional difficulty is here in young women that have breast asymmetries and the emotional impact of that. And yet, that's typically taken off the table when insurance companies make a determination as to whether or not a procedure is covered.
And for a lot of the treatment for breast asymmetries, for most private insurance companies, the consumers will find that it's a contract exclusion. So every insurance company's a little bit different in how they make the determination, but very often, it'll actually be excluded from the contract.
So we encourage all parents, as they're seeking consultation for treatment for breast asymmetries, to look at their policies, and if they have any questions, to call their insurance companies to see what is and is not covered.
Dr. Mike Patrick: And then, if the insurance company, if you're still having issues with them, there are state agencies that kind of oversee the whole health insurance industry that you could potentially complain to as a parent.
Dr. Richard Kirschner: Yeah. And actually, one of the things we found most effective is, as Dr. Khansa mentioned, we'll often appeal to the insurance company themselves and we'll do what's called a peer-to-peer. What's often even more effective is for the parents to advocate on their own behalf by appealing to the insurance company before even bringing that up to a state agency.
Dr. Mike Patrick: Absolutely. And then in terms of long-term outcomes for breast asymmetry, once there's been an intervention, is that typically the end of the line? And again, I know it's a mixed bag because there's so many different breast asymmetries. But in some situations, could there need to be multiple interventions?
Dr. Richard Kirschner: Absolutely. So, for breast reduction techniques or for reducing the size of a larger breast, those tend to be longstanding results that are quite good.
When we talk about, well, breast implants, there are a couple of things we need to consider. Uncommonly, we can see scar tissue form around a breast implant that can actually distort the shape of the breast and very often cause breast pain on that side. That's what we call a capsular contracture. So that's something that could need further surgical management in the future.
The other thing that I always ask the teenagers that I treat with breast implants to remember is that, breast implants are a device. Like any device in their home, someday it's going to fail. And so for breast implants, typically, on the order of 15 years on average, we can expect the outer shell or the outer case of that implant to tear, requiring replacement.
So for a young woman at the age of 18, undergoing breast augmentation on one side for an asymmetry, they can expect to have that implant replaced more than once over their lifetime.
Dr. Mike Patrick: Is that dangerous? I think of, I'm thinking back like many years ago, sometimes this would be in the news that there were poor outcomes from the failure of breast implants. But you mentioned saline, that seems pretty safe.
Dr. Richard Kirschner: Yeah. So the majority of reconstruction that we do in young women, we utilize saline-filled breast implants. And so, when the breast implants shell, which is made of a solid form of silicone fails and the implant ruptures, it releases physiologic normal saline into the body, which is completely harmless.
Tricky question when we talk about silicone-filled implants. And so the old silicone gel implants were made out of a sort of non-cohesive gel. So when the shell ruptured, that gel could leak out into the surrounding tissues.
Breast implant companies now are manufacturing what we call cohesive gel implants, sort of have the consistency of a gummy bear. So when the shell fails, the silicone tends to remain in that location.
Nevertheless, there is an entity known as breast implant associated illness, a series of symptoms such as headaches and joint pain and overall malaise. That has been somewhat linked to the presence of silicone implants. There isn't good scientific data, but there's anecdotal evidence that some women who have developed these symptoms improve after the implants have been removed.
And so for that reason, it's recommended that silicone implants be monitored. Now, since the gel is cohesive, you can't really tell the way you can when a saline implant fails that it has failed. So it actually requires monitoring with MRI's every several years and that's a process that can become costly.
And when implant failure is noticed on an MRI, when the shell is torn, we recommend that the implant be replaced.
Dr. Mike Patrick: And these are all things that you talk about to families as they're kind of embarking on this journey.
Dr. Richard Kirschner: Absolutely.
Dr. Mike Patrick: All right. Let's turn our attention from young women to teenage boys with a breast disorder called gynecomastia. And we're going to head back over to Dr. Khansa. Tell us a little bit more about what this condition is.
Dr. Ibrahim Khansa: Sure, yeah. So, so far, we've talked about macromastia, which is breast enlargement in the female. We talked about the breast asymmetry in the female. So gynecomastia is breast enlargement or development in a male.
And there are three time periods in a male person's life where gynecomastia is expected, benign, what we call physiologic. So when a newborn male is born, for the first few months, they may have what looks like breasts. And that's because the estrogen from the mother passed through the placenta and is in their body. Eventually that goes away after about six months.
The second time period is during adolescence or after puberty. There's changes in hormones that may cause breast development. And actually, the majority of teenage boys.
And the third time period where gynecomastia is expected and not worrisome is in an older male, so a male over 50. There are changes in hormones after 50 years old that may cause breast development.
Now, outside those three time periods is what we would be concerned, what we called pathologic gynecomastia. So, for example, a boy who has not started puberty or a middle-aged man getting new onset breast development, that is something that should be investigated.
Now, when we talk about pathologic gynecomastia, meaning gynecomastia that may be occurring due to reasons other than just normal hormonal changes, there's a whole myriad of possible causes. So liver disease can cause an imbalance in hormones, kidney disease.
Certain tumors can secrete certain hormones and cause an imbalance. Thyroid disease is another common cause.
The use of anabolic steroids is a common cause of gynecomastia because it lowers the circulating testosterone levels. There are certain medications that may be prescribed. You may have seen some ads on TV.
There's certain antipsychotics, old antipsychotics. There's a common drug called spironolactone. And marijuana use has been linked to the development of gynecomastia.
And finally, there's a couple genetic conditions. Actually, there's probably more. But the two most common ones we see are Prader-Willi syndrome and Klinefelter syndrome. Those are associated with gynecomastia.
Dr. Mike Patrick: Now, because there's more possibility of medical causes of this compared to the disorders in women that we've been discussing, it would seem that getting an endocrinologist involved may be helpful to kind of investigate if there are hormone issues involved in a particular patient.
Dr. Ibrahim Khansa: Absolutely, yes. So as part of our adolescent press program, we have an endocrinologist, Dr. Leena Mamilly, who we work with very closely. And she sees any patients who there are concerns for any hormonal imbalances or any type of pathologic gynecomastia.
Dr. Mike Patrick: Now, you had mentioned the times when you could expect to see gynecomastia. And so, it's going to be, especially if you consider those times, very common, correct? Like more than 50% of boys are going to experiences this at some point.
Dr. Ibrahim Khansa: More than two-thirds. So the published number is about 69% of adolescent boys will have experienced some degree of gynecomastia by the time they turn 14 or 15. Vast majority of the time that will go away within one to two years.
And so what remains is the patients that we see, who they have persistent gynecomastia after one to two years, that's about 8% of teenagers. And those are the ones who might be seeking surgical correction.
Dr. Mike Patrick: And then, as with the other disorders, next up, we would talk about symptoms that may be associated with this. Are there physical symptoms that boys could experience with gynecomastia?
Dr. Ibrahim Khansa: They may. Now, the major concern that these boys have, obviously, is the mental health aspect and the embarrassment. Sometimes, they will complain of tenderness, pain. Sometimes, even drainage from the nipples. But really the lion's share here falls on the mental health aspect of abnormal breast development.
Dr. Mike Patrick: And then, Canice, what do you typically see in patients that see you, these boys, what sort of mental health issues do you see with them?
Dr. Canice Crerand: Sure. So we see risks for mood and anxiety disorders, low self-esteem, body image dissatisfaction. Many of them will engage in a lot of camouflaging behaviors. So they may bind their chest to try to make it appear less noticeable.
I've encountered young men who have used duct tape, compression garments, a variety of strategies. So sometimes, they can veer on the extreme end, to try to normalize the appearance of their chest.
I think probably one of the issues that they struggle with most is that developing breasts for an individual who identifies as male is, it's discordant with their gender. And so, they may think, am I less of a boy or a man because I'm developing breasts? Will other people have questions about my sexuality or my sexual orientation?
So sometimes, those issues can get confused and concerns can arise in those areas. So I think there's just a lot of concern for stigmatization, being singled out. Boys may not want to play in shorts and skins on sports teams. They may be avoiding a lot of activities that maybe otherwise would have brought them a lot of satisfaction in their lives.
Dr. Mike Patrick: And I would suspect that just like breast asymmetry, this may be an issue with insurance companies agreeing to do a surgical procedure for this.
Dr. Canice Crerand: Yes, indeed. So I don't think they take into consideration the psychosocial impact.
Dr. Mike Patrick: Which they should, as we have said before, yes.
Dr. Canice Crerand: That'll be my theme today.
Dr. Mike Patrick: And then in terms of surgical intervention, what does that look like? Is it probably very similar to macromastia or no? Is it quite different? I don't even know.
Dr. Richard Kirschner: Yeah, it's actually quite different. So one thing again to remember is that some degree of gynecomastia during puberty is normal. And in mild cases, this can be expected to resolve over time.
So a lot of times the best treatment is just some patience. And so, for mild degrees of gynecomastia, we'll typically counsel our patients to just be patient and wait a couple of years to see if this resolves on its own.
For gynecomastia that does not resolve within a couple of years, we have two considerations when it comes to surgery. One is the excess skin, and one is the excess breast tissue. So with respect to the excess breast tissue, one thing is important to remember is that gynecomastia in teenage boys is very different than gynecomastia in older men. So in older men, the breast enlargement is typically fatty. And so, liposuction techniques can be fairly effective in that group.
But for most young men that we see, the breast enlargement is due to actual development of the glandular breast tissue, which is very, very firm. It's not fatty, it's very solid. And so, liposuction is not sufficient or able to remove that. So that actually requires resection of the breast tissue.
Now, we'll sometimes add liposuction to surgical removal of the breast tissue just to achieve a better contour. But for most cases of gynecomastia in young men, it requires making an incision and removing the excess breast tissue.
So for mild to moderate degrees of gynecomastia we can expect the skin excess to resolve on its own just due to the normal elastic stretch of the skin. If we remove that extra tissue under the skin, the skin itself will eventually flatten out.
So for mild to moderate degrees of gynecomastia, we perform the surgery through a simple curved incision that runs along the bottom half of the nipple, sort of from 03:00 to 09:00. And then through that incision we can remove the extra breast tissue. And that just leaves that one little scar under the nipple.
For larger degrees of gynecomastia where see large, ptotic or droopy breasts, where the nipple is actually now moved down lower on the breast and on the chest wall, in those cases, we actually have to remove the excess skin in order to achieve the kind of contour that we and our patients are looking for. And so that will require an incision that goes all the way around the nipple 360 degrees, so we can move the nipple to a more normal position higher on the chest wall.
And then, in addition, another incision, another scar that's under the breast, sort of a long-curved incision that we use because we removed that extra skin.
Dr. Mike Patrick: Yeah. So in that case, it is a little bit more like macromastia in women in that, there's a lift in addition to the reduction.
Dr. Richard Kirschner: Yeah, the pattern of the scars is very different but the principle is the same.
Dr. Mike Patrick: Got you, yeah. And then in terms of long-term outcomes, I suspect that if there is an endocrine reason for this, if that doesn't get fixed, you could have still enlargement happen after the procedure. So it's going to be really important to identify who has an endocrine issue and get that treated as well. But other than that, do you see much in the way of need for further interventions?
Dr. Richard Kirschner: Usually not. The scars are usually very acceptable and a very good trade-off for better contour in these young men. And so, generally, we don't see much of a need for repeat surgery. And most of the patients that undergo the surgery are very happy with the results.
Dr. Mike Patrick: Yeah, that's great. And then in terms of boys and their long-term mental health outcomes, is there as much data in that group as compared to women?
Dr. Canice Crerand: Yeah, there's actually been a series of studies that have come out of Boston Children's Hospital in the past couple of years, where they've prospectively followed a cohort of young women with breast asymmetry with macromastia, as well as some boys with gynecomastia. And I think the findings are really quite striking across both, all three groups actually, where there are improvements in self-esteem, in quality of life, sometimes in eating pathology, improvements in eating attitudes and behaviors.
So we're really seeing kind of a consensus across those groups that there are positive outcomes associated with surgical correction for these conditions.
Dr. Mike Patrick: That's terrific. One of the things I love about Nationwide Children's Hospital is we have a lot of multidisciplinary teams that help kids with particular disorders. And these breast disorders is included.
We've already talked, here, we have plastic surgery, psychology here in the studio. We've talked about endocrinologists. Are there others who are part of your multidisciplinary team treating breast disorders in young women and teenage boys?
Dr. Ibrahim Khansa: Yeah, there's many others. So I would say our Adolescent Breast Program at Nationwide Children's was the brainchild of Dr. Kirschner. And it was a way to bring together all the specialties that take care of adolescents with breast concern.
So when the patients first come in, they see our nurse practitioner, Andrea Brun, who's wonderful. And then they see one of the four surgeons. So it's Dr. Richard Kirschner, Dr. Gregory Pearson, Dr. Kim Bjorklund or me. And then, in gynecomastia patients where there are concerns for hormone imbalance, they may see an endocrinologist, that's Dr. Leena Mamilly.
If there are any mental health concerns before or after surgery, they may see one of the two clinical psychologists who work with us, Dr. Jess Hoehn and Dr. Chloe Freeman. And then, we have Dr. Crerand here, more on the research side.
And then, we have a wonderful nurse coordinator who helps the patients navigate the whole system, sees them in the hospital, in addition to us seeing them in the hospital, and calls the patients after they go home. That's Kelsey Davis.
And then, we have Alyssa Fogolin, who's our research coordinator, who helps us kind of measure the quality of life of our patients before and after surgery.
Dr. Mike Patrick: That is great. And then, how do patients and families get in touch with your clinic?
Dr. Ibrahim Khansa: Sure, it's very easy. So, three ways, they can call Plastic Surgery at 614-722-6299. Second way is you can request an appointment online. You go to nationwidechildrens.org and you click Request an Appointment. Or the third one is you ask your pediatrician or primary care physician to place a referral to Plastic Surgery at Nationwide Children's.
Dr. Mike Patrick: Great, very easy. And we will put links in the show notes over at pediacast.org for folks. We'll have a link to the Request an Appointment page, and of course, also to Plastic and Reconstructive Surgery at Nationwide Children's Hospital. You'll find those again in the show notes.
All right, so once again, thank you so much, to Dr. Richard Kirschner, Dr. Ibrahim Khansa and Dr. Canice Crerand. Thank you all so much for stopping by today.
Dr. Richard Kirschner: Dr. Mike, thank you for having us. It was our pleasure.
Dr. Canice Crerand: Thank you so much.
Dr. Ibrahim Khansa: Thank you, great to see you.
Dr. Mike Patrick: We are back with just enough time to say thanks, once again, to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, Dr. Richard Kirschner and Dr. Ibrahim Khansa, both with Plastic Surgery at Nationwide Children's, and Dr. Canice Crerand. She is a psychologist here at Nationwide Children's Hospital.
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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
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