Anatomically, the woman has cone-shaped breasts, located in the thorax, in the anterior region, passing through the right and left midclavicular line. It has between 3 to 5 glands that flow into the papillae, with the function of producing milk for breastfeeding  . According to the biotype of each woman, the breasts are bigger or smaller, being modified by the variation of weight and number of children. Based on bra numbers, they can be small, medium, large and giant  . In the cases reported in this paper, the size is beyond the classic classification found in articles and books. In the first publication of the proposed technique of mammary reduction, when it exceeds 2 kg of excised part there is the need for grafting of the areola-papillary complex due to the proportion of the flap exceeds 2:1, when the possibility of necrosis increases considerably  . These breasts cause in their carriers difficulties of social relation and possibility of unemployment, making it a public health case. According to the article 10 of the law 9.656/98, any disease listed in the list of international diseases of the WHO must be treated, and the inflammatory disorders of breast is inserted in ICD 10 N-61, thus, it is not an aesthetic condition in Brazil. The patients were not chosen. They are public service patients. In Brazil, we have 5% of obese women with gigantomastia. The lower-class population is treated in public service. We are not yet ready to treat obese people better.
2. Material and Method
We selected examples of women with gigantomastia: Washerwomen, seamstresses, cloth-ironers, gardeners and cooks. We will report in the study cases with needs for repairing surgeries and that are unable to undergo bariatric surgery due to the risk of pulmonary tamponade due to the weight of the breasts near the neck, in addition to frequent thromboses   .
2.1. Case 1―Washerwoman (Figure 1)
N.P.C., woman, 45, 5 pregnancies, 4 births, 1 miscarriage, married, works as a washerwoman, lives in Aparecida de Goiânia/Goiás, Brazil. She sought the basic health unit X complaining of pruritus in the breasts and back pain. She had grade III obesity, but reports that her breasts began to grow and be disproportionate to her height from adolescence, worsening over the years, especially during breastfeeding. The patient stressed that her body is harmed and suffers from her work activities. At work, due to the size of their breasts, N.P.C. cannot make the necessary movement for the washing process and for the rinsing of the clothes, and sometimes ends up injuring her own breasts by tapping with the brush. Besides the difficulty of movement, their breasts end up coming in contact with the humidity and the chemical substances used for washing, which is the main hypothesis that caused her clinical picture.
2.2. Case 2―Seamstress (Figure 2)
M.S.S, 48, female, white, married, three children, works as a seamstress, was born in Ceres/Goiás, Brazil, lives in Aparecida de Goiânia/Goiás, Brazil. She sought the health service complaining of an exaggerated increase in breast size with severe spinal pain, presenting postural impairment caused by spinal deviation, shoulder depression caused by the bra strap, redness and pruritus caused by contact with sweat in folds, with limitations of her usual activities resulting from these symptoms. She reported that her breasts began to grow after the first gestation and that have been increasing over the years, disproportionate to the rest of the body. The volume of her breasts prevents her from correctly performing her work, since she cannot approach the sewing machine table and
Figure 1. Washerwoman.
Figure 2. Seamstress.
when she does it, she risks sewing her own breast that enters the machine without her noticing. She mentioned that the cloth becomes trapped between the table and the breast, thus disrupting the fabric movement by the sewing machine, and that she also cannot perform manual sewing/embroidery, since the breasts hinder the arms from closing enough to perform the movements necessary. Besides the physical aspect, the patient presented depressive symptoms due to the exaggerated increase of the breasts, reporting that she feels ashamed to leave the house. She also presented psychic disorders mainly related to sexuality, feeling of inferiority, and difficulty of social interaction.
2.3. Case 3―Cloth-Ironer (Figure 3)
M.H.G., female, black, 47, cloth-ironing, married, four children, was born in Araguaína/TO, Brazil, lives in São Luís dos Montes Belos/Goiás, Brazil. The
Figure 3. Cloth-ironer.
patient sought the health service complaining of back pain that made her unable to perform daily activities, including her work (ironing clothes―from this work she provides for the four children and the husband, currently unemployed). One week ago, she was dismissed from work for not being able to do the same she used to do, in addition to the weekly absences. She reported having extremely large breasts, which has also made it difficult to perform their duties, since one of them is burned for having leaned against the iron at high temperature.
2.4. Case 4―Gardener (Figure 4)
W.C.R., brown, 38, female, gardener, married, two children, was born in Niquelândia/GO, live in Niquelândia/GO, 117 kilos. The patient sought the health service complaining of breast augmentation in the last 2 years, which makes hinders her from exercising her daily activities at home and in the work. She said that the breast augmentation generated severe back pain, difficulty handling garden equipment because of the weight and risks because of the difficulty in handling them. She is unable to remain crouched for short period or to climb small slopes due to the weight of the breasts that generates pains and fatigue and refers to “not stopping at the same job due to the employer's lack of patience” because of her delay in performing the tasks. She claims to have depressed mood for being ashamed of the breasts and for the way people look at her, in addition to the daily humiliation she suffers from the delay in performing gardening tasks.
M.N.O, 53, divorced, Catholic, nulliparous, works as a cook and lives in the city of Aparecida de Goiânia, Goiás, Brazil. She sought care from the public health services, complaining of recurrent burns on her breasts during her work, caused by the excessive size of her breasts, which also makes her bump into the pots, always being burned. This situation limits the exercising of her tasks due to the disproportionate size of her breast, and she also reported that her bra exceeds the number 54. This situation culminated with her unemployment. Thus, she
Figure 4. Gardener.
Figure 5. Preoperative (cook).
Figure 6. Postoperative with Resende Technique―1 year.
has requested for the possibility of a surgical intervention. M.N.O mentioned being hypertensive and diabetic. She also mentioned that her menopause manifested early in her life, at age of 39. M.N.O presented BMI = 47.18 kg/m (weight: 109 kg, height: 1.52 m) and BP: 130 × 90 mm Hg.
Sociodemographic Characteristics of patients:
Clinical Characteristics of patients:
Many concerns arise when we come across patients who have never been able to purchase and wear a normal bra. Their bras are made at home or by contracted seamstresses. All the women reported in the present work surpassed 105 kg of body weight, the height varied from 1.50 m and 1.62 m, and the breasts from 2 kg to 6 kg from each side. All of them would like to have bariatric surgery, but due to excessive “zeal” it was not indicated because of the risk of death. In these cases, we ask them lose weight, in their own free will, at least 5 kg, before the preoperative request   . We noticed that there was low blood glucose and low blood pressure. Only after this weight loss did we perform mammary reduction and, after a year, the patients were referred to the bariatric team. All patients stayed for one year at the Obesity Workshop to learn about the dangers and benefits of weight loss, breast reduction and the possibilities of a more healthy body and future repairing plastics   . After all these procedures, we observe an adequate psychological preparation. They felt more comfortable and happy with the smaller breasts, operated by using the Resende technique    , which we call bodily relief (Figure 6).