Breast Concerns

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Chapter 545 Breast Concerns

Girls with breast disorders commonly present with questions about the development and appearance of their breasts, breast pain, nipple discharge, and concerns about the presence of a mass. Although children and adolescents are unlikely to have malignant or life-threatening breast problems, this population of patients should be referred to practitioners who have experience and familiarity with the immature and developing breast to avoid overtreatment with unnecessary diagnostic or surgical procedures.

Breast Development

Development of the breast begins around wk 5 of gestation, when the ectoderm on the anterior body wall thickens into a ridge known as the milk line. This ridge of tissue extends from the area of the developing axilla to the area of the developing inguinal canal. The ridge above and below the area of the pectoralis muscle recedes in utero, leaving the mammary primordium, which is the origin of the lactiferous ducts. The initial lactiferous ducts form between wk 10 and 20 and become interspersed through the developing mesenchyme, which becomes the fibrous and fatty portions of the breast. The breast bud, under the stimulation of maternal estrogen, becomes palpable at wk 34 of gestation. This breast bud regresses within the 1st mo of life, because the estrogen stimulation is no longer present. The areola appears at 5 mo of gestation, and the nipple is seen shortly after birth. It is initially depressed and later becomes elevated.

Thelarche, or the onset of pubertal breast development, is hormonally mediated and normally occurs between the ages of 8 and 13 yr, with an average age of 10.3 years. The initiation of thelarche and progression in females is affected by race, with normal thelarche occurring earlier in African-American girls than in Caucasian or Asian girls.

Once thelarche is initiated, normal development of the breast occurs over 2-4 yr and is classified by the sexual maturity rating (SMR) system into 5 stages. Maturation can sometimes occur asymmetrically owing to fluctuation of the hormonal environments and various end organ sensitivities. Lack of development by age 13 yr is considered delayed and warrants endocrinology evaluation. Menarche usually occurs approximately 2 yr after initiation of breast development.

Abnormal Development

Precocious Puberty

Premature thelarche is usually an isolated condition but it may be the first symptom of precocious puberty. Precocious puberty occurs in 14-18% of girls with premature thelarche (Chapter 556). Serial examinations, with particular emphasis on growth velocity, secondary sex characters such as pubic hair, pigmentation of the labia or areola, or vaginal bleeding are imperative to identify precocious puberty. Unless there are associated signs of precocious puberty, the parents should be reassured and the child should be followed.

Polymastia and Polythelia

Supernumerary breast tissue (polymastia) and accessory nipples (polythelia) occur in approximately 1-2% of the population (Fig. 545-2). The abnormally placed tissue can be seen anywhere along the milk line but is usually noted on the chest, upper abdomen, or just inferior to the normally positioned breast. An association has been made between polythelia and anomalies of the urinary and cardiovascular system. Surgical excision of the accessory breasts or nipple is not usually needed. Resection of accessory tissue may be warranted if the patient has pain or for cosmetic reasons.

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Figure 545-2 Accessory nipple located inferior to the left breast.

(From Sadove AM, van Aalst JA: Congenital and acquired pediatric breast anomalies: a review of 20 years’ experience, Plast Reconstr Surg 115:1039–1050, 2005.)