What are the treatment options for a patient with macromastia and chronic upper back pain between the scapulae?

Treatment of Macromastia-Related Upper Back Pain

For a patient with large breasts (macromastia) and chronic upper back pain between the shoulder blades, reduction mammoplasty (breast reduction surgery) is the definitive treatment and should be prioritized after conservative measures fail, as it provides significant and sustained pain relief with low complication rates. 1

Understanding the Clinical Problem

Macromastia causes a well-documented syndrome of chronic musculoskeletal pain that includes:

• Upper back pain between the scapulae (60-92% of patients) 2
• Neck pain, shoulder pain, and headaches 2, 1, 3
• Postural changes including increased thoracic kyphosis and cervical lordosis 1
• Painful bra strap grooving and potential neurologic symptoms 1, 3

The key clinical insight is that 97% of macromastia patients have at least three of these pain symptoms preoperatively, and spine surgeons may overestimate the contribution of vertebral degenerative changes when the primary driver is breast weight. 2, 4

Treatment Algorithm

Initial Conservative Management (Trial Period)

Before surgical referral, implement a multimodal pain management strategy:

Pharmacologic Options:

• NSAIDs as first-line therapy for effective pain relief over 2-12 weeks 5, 6
• Acetaminophen as adjunct or alternative if NSAIDs contraindicated 6
• Extended-release oral opioids may be considered for refractory back pain over 1-9 weeks, though this is typically excessive for macromastia-related pain 5, 6

Physical/Restorative Therapy:

• Physical therapy and exercise programs provide back pain relief for 2-18 months 5, 6
• Focus on postural correction and core strengthening 5

Psychological Support:

• Cognitive behavioral therapy, biofeedback, and relaxation training provide relief for 4 weeks to 2 years 5, 6
• Address the significant psychological burden that accompanies macromastia 7

Critical Caveat: The 2025 BMJ guidelines strongly recommend AGAINST interventional spine procedures (epidural injections, facet injections, radiofrequency ablation) for chronic axial spine pain, as these do not improve morbidity or quality of life. 5 This is particularly important in macromastia patients where the pain source is mechanical breast weight, not spinal pathology.

Definitive Surgical Treatment

Reduction mammoplasty is indicated when:

• Conservative treatment (weight loss if applicable, physical therapy, pain management) has failed 1
• Resection weight anticipated to be >500g per side (most insurance threshold) 1
• Patient has documented chronic symptoms affecting quality of life 1

Expected Outcomes from Breast Reduction:

• 100% of patients experience reduction in pain symptomatology 2
• 25% achieve complete elimination of all pain symptoms 2
• Postoperative pain levels become statistically equivalent to or less than control populations without macromastia 2
• Significant improvement in posture and gait 1
• Low complication rate 1
• Headache improvement in 34-100% of patients who had preoperative headaches 3

Clinical Decision Points

When to suspect macromastia as primary pain driver:

• Young to middle-aged female with chronic upper back/interscapular pain 3
• Pain pattern includes neck, shoulders, and upper back together 2, 1
• Visible bra strap grooving or postural changes 1
• Imaging shows degenerative changes that seem disproportionate to symptom severity 4

When to refer to plastic surgery:

• After 3-6 months of conservative management without adequate relief 1
• Patient meets insurance criteria (typically >500g anticipated resection per side) 1
• Pain significantly impacts quality of life and function 2

Important Pitfall: Spine surgeons may pursue unnecessary spinal interventions when macromastia is the primary pain generator. Awareness of this condition prevents overestimation of vertebral pathology contribution to axial pain. 4

What NOT to Do

• Do not pursue interventional spine procedures (injections, ablations) as these are strongly contraindicated for chronic axial spine pain and will not address the mechanical cause 5
• Do not delay surgical referral indefinitely if conservative measures fail, as reduction mammoplasty has proven efficacy and safety 2, 1
• Do not attribute all symptoms to spinal degenerative disease without considering breast weight as the primary mechanical driver 4