Gigantomastia is defined as an increase in breast tissue, not caused by an accident, tumor, hemorrhage, inflammation, or pregnancy. which interferes with physical activity. Gigantomastia is associated with a constellation of physical symptoms, including neck, back, and shoulder pain, grooving from the brassiere straps, and intertrigo. Further, gigantomastia is associated with psychosocial symptoms, such as mood disorder [1]. The surgical literature has many articles describing its techniques and aesthetic results of reduction mammaplasty. Reduction mammaplasty, regardless of the surgical method, can improve pain and discomfort, cosmetic appeal, and social, physical, and psychologically well-being. While the postoperative outcomes from reduction mammaplasty can vary for each patient, an objective and quantitative analysis of symptomatic relief due to reduction mammaplasty is limited.

Thermography uses an infrared camera to capture the temperature change of the skin, which can be observed as an increase or decrease in the bloodstream, inflammation, and the dysfunction of nerves. The first use of diagnostic infrared thermography was performed in 1957 by Lawson, who discovered that the skin temperature over the tumor of the breast was higher than that of the normal tissue [2]. However, the use of this technology for medical applications has not been clearly demonstrated due to poor performance and high cost of infrared cameras. Over the past 10 years, there has been a resurgence of interest in the medical application of infrared thermography, due to improvements in infrared camera technology and in new algorithms. Improvements in infrared sensors, image processing, and analysis techniques have allowed a more accurate analysis of thermal information for the physiologic reaction of pain, and infrared thermography has been used in the diagnosis of musculoskeletal pain [3-7]. Infrared thermography has several advantages. It is simple to use, non-invasive, and employs objective biological indicators of pain-related responses in the musculoskeletal system [6]. The purpose of our study was to evaluate the efficacy of reduction mammaplasty, as measured by the symptom relief using an objective indicators.

Between January and May 2009, patients who visited our clinic for gigantomastia were evaluated, retrospectively, for breast, neck, shoulder, back pain, hand numbness, and headaches. Fifteen subjects were enrolled in this study, and they all underwent reduction mammaplasty, and presented neck and shoulder pains. The spine balance and curvature was measured by a spinal X-ray. Due to adaptation, patients were exposed to 23°C measuring space for 15 minutes, which was blocked from ambient light and heat. The surface body temperature was measured at the cervical and thoracic areas, by infrared thermography (Iris-5000; Medicore, Seongnam, Korea). Nine patients had post-surgical follow-up examinations and the infrared thermography readings were taken from the same locations 3 to 4 months after surgery. These readings were then compared with the baseline operative data. Pre-, and postoperative changes in body surface temperature sere assessed with paired t-test, and p<0.05 was considered statistically significant. Height, body weight, age, body mass index (BMI), and the weight of the removed breast were analyzed with multiple regression tests for the effect of the change in the body surface temperature. SPSS version 17.0 (SPSS Inc., Chicago, USA) was used for all statistical analyses.

The mean age of the group was 40.6±10.3 years, and the mean BMI was 24.6± 2.1 kg/m². In all cases, there was pain in the shoulder region. Further, cervical, and back pain were also reported, except in two cases (Table 1). The average weight of the breast tissue removed by surgery was 616± 241.8 g from the right, 603± 259.6 g from the left. The preoperative whole spine X-ray findings revealed all cases did not fit the balance and the curvature. Age, height, weight, BMI and weight of the removed breast tissue did not significantly correlate with the body surface temperature and the change in body surface temperature (p> 0.050). On pre, and postoperative infrared thermography, the average cervical surface temperature had a meaningful change, which was 1.9°C on the right (p=0.042), and 1.5°C on the left side (p=0.020). However, average thoracic surface temperature did not change significantly (1.0°C, right, p=0.210; 1.2°C, left, p=0.188) (Table 2) (Figure 1). However, in most patients, cervical and thoracic surface temperatures, after surgery, were lower than before, but in some cases, they were higher (Table 3). Therefore, we performed statistical analyses focused on the changes in both directions, and observed statistically significant changes in both lesions (p<0.050) (Table 4).

Human posture in the erect position is maintained by ligamentous and muscular support. The center of gravity of the human body in profile passes from the external auditory meatus through the odontoid process, which is slightly posterior to the center of the knee, and to a point slightly anterior to that of the lateral malleolus [8]. Excessively large breasts can affect posture and the normal axis of gravity through the body, by increasing the cervical lordosis. The resulting postural change is not only fatiguing but also promotes pain by increasing the muscle tension in the extensor muscles of the neck. Excessively large breasts also lead to thoracic kyphosis and downward rotation of the scapula with tension traction on the attachment of the levator scapulae muscle, which leads to myofascititis at the attachment site [9]. In addition, heavy breasts lead to gradual weakening of the trapezius muscles that are responsible for stabilizing the surrounding structures. These changes in anatomical posture, due to several symptoms caused by heavy breasts, consequently cause an imbalance in the body, and thus, pain [8,10].

In addition to the cosmetic effect of reduction mammaplasty, there are reports of increased functional activity and pain relief after surgery [11,12]. These studies contribute to our understanding of the symptoms associated with heavy breasts and to our knowledge of the physical changes after surgery. However, most studies were retrospective study, and did not use diagnostic methods, which allow for the objective interpretation of results [13-15]. Sequential infrared thermographic imaging can be helpful in determining and tracking the treatment effectiveness because it can be recorded on both sides of an asymmetric area or the surrounding temperature is high, compared to lesions in part [16,17].

Thermographic measurement of skin temperature can be affected by the external environment, measurement time, and measuring interval. These affects may be mitigated by maintaining a constant temperature, by preventing the exchange of ambient light and heat at the point of imaging and keeping equilibrium with the skin and the surrounding measuring site. For example, results can differ between readings in the morning and afternoon on the same day, but most of these differences are less than 0.5°C, which does not have any reported clinical significance [5,18]. We performed the exam in an enclosed space, with external light blocked, from 1:00 PM to 4:00 PM, to hold imaging conditions as constant as possible for each patient.

The pathogenesis of symptoms, due to heavy breast include structural changes of the spine and spinal muscles that leads to inflammation and local change in metabolism. As a result, the skin temperature of these lesions would expected to be higher than normal, which was observed on thermographic imaging. In contrast, before the surgery, the skin temperature of a specific area can be lower than the temperature after the surgery. Ammer et al. [19] explained this phenomenon as pain creating a higher temperature caused by inflammation. However, it can create lower skin temperature, which is caused by stimulating the sympathetic nervous system. It leads to vasoconstriction and deteriorating blood circulation to the surface of the skin. Thus, pain may increase or decrease the surface temperature of the skin, and this is believed to be responsible for the dispute regarding the analysis of thermography results.

In this study, the average pre-, and postoperative infrared thermography readings of the cervical surface, with reference to the Ammer et al. study [19], showed a meaningful change, which was 1.9°C on the right (p=0.042), and 1.5°C on the left side (p=0.020). However, the average thoracic surface temperature did not show a statistically significant change. As shown in Table 3, in some cases, the skin temperature was rising after the surgery, which serves to compensate for the temperature difference in the statistical analysis. Therefore, as done by Ammer et al. study [19], we performed a statistical analysis on the change in the temperature, rather than an increase or decrease in temperature, and the result was a statistically significant change in the body surface temperature (Table 4).

On the thermographic exam, the body surface temperature of obese patients was lower than the temperature of patients with normal body weight because adipose tissue has low thermal conductivity [20]. The average BMI of the enrolled patients was 24.6 kg/m². Five of the 15 patients were classified as mild obese (BMI >25 kg/m²). The severity of obesity can affect the imaging results because the central axis of the body is altered and joints are deformed, which mimic the symptoms of heavy breasts. For this reason, Freire et al. [21] also excluded the patient with BMI of 30 or higher in the study of functional activity and the degree of pain reduction after a reduction mammaplasty. In our study, one patient who was severely obese (BMI >30 kg/m²) was excluded from the analysis of the infrared thermographic exam, because the errors caused by obesity could not be disambiguated from the symptoms of heavy breasts.

After breast reduction, long-term adaptation will be necessary to change the skeletal structure by the resolution of overload. Mizgala and MacKenzie [22] also reported pain reduction in patients, but 16% of patients still remained in mild or moderate pain. The persistent pain after surgery was caused by the change of skeletal structure, which did not improve in a short postoperative time, and the constant tension of the muscles, due to the support of an already transformed skeletal structure.

The limitations of this study are that the number of subjects was small and the correlations of postsurgical thermography results with clinical symptoms and changes in posture were not analyzed. Accordingly, if the correlations of thermography results with clinical symptoms and changes in posture are analyzed in studies with more patients in the future, we believe that thermography will be useful to quantitatively and objectively evaluate the effect of mammaplasty.