Mondor’s Disease after Aesthetic Breast Surgery: A Case Series and Literature Review

INTRODUCTION

Superficial vein thrombosis and thrombophlebitis were initially described by Mondor[1] in 1939 in the subcutaneous veins of the anterolateral thoracoabdominal wall. Mondor’s disease commonly affects the vessels of the lateral thoracic, thoracoepigastric, and superior epigastric veins. The involvement of upper arms, abdomen, groin, or penis is less common.[2]

The concept of Mondor’s disease has been further developed and now also includes subcutaneous thrombosis of the dorsal vein of the penis and retractile scarring of the fascia after breast surgery without concomitant superficial vein thrombosis.[3]

The pathogenesis is not completely understood. The initial event may be a trauma, surgery, medical drug therapy, or hypercoagulability. The possible role of cancer has been debated as cancer can cause thrombotic events.[4]

The sudden onset may scare patients. They may feel a strain or a painful induration under the skin, but the disease can also be asymptomatic. One can see and palpate a cord-like induration of affected veins. Doppler ultrasound examination allows confirmation of the disease in the form of a superficially located, longitudinal, anechoic lesion such as rosary beads without blood flow.[5]

In case of biopsy, immunohistochemical staining for CD31 and D240 is considered as reliable to distinguish small veins from lymphatic vessels. Differential diagnoses include (sclerosing) lymphangitis, lymphangiosis carcinomatosa, mastodynia, and penile fracture, depending on the affected sites.[6]

Usually, Mondor’s disease is a benign, self-limiting condition with spontaneous resolution. Nonsteroidal anti-inflammatory drugs, anticoagulation therapy, and even surgery have been used for its treatment as necessary.[37] Successful triamcinolone injections have been reported recently.[8]

CASE REPORTS

We report a retrospective analysis of 652 female patients who underwent aesthetic breast surgery within the last 10 years. Mondor’s disease was confirmed by the Doppler ultrasound. Three cases aged 52, 34, and 38 years (0.46%) could be identified, who developed Mondor’s disease after breast surgery. None of these patients had hypercoagulability, trauma (except surgery), or breast cancer.

Case report 1

A 52-year-old woman with breast ptosis and hypertrophy underwent bilateral breast reduction. The procedure was performed under general anesthesia. The postoperative period was entirely uneventful until 9 weeks later, when she presented with longitudinal fibrous strings in the lateral thoracic vessels (under the left breast) and also in the abdominal wall. No pain or other symptoms were reported. The clinical diagnosis was superficial thrombophlebitis (Mondor’s disease) following breast surgery. The fibrous cord disappeared spontaneously 3 weeks later [Figure 1A and B].

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Figure 1

(A) Longitudinal fibrous strings after breast reduction. (B) The same patient with Mondor’s disease of the abdominal wall

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Case report 2

A 34-year-old woman presented with Mondor’s thrombophlebitis 2 years after augmentation mammoplasty. She did not report any problem after the surgery and remained asymptomatic for 2 years. She reported that after an exhaustive physical activity, a painful fibrous and hard cord tumor in the left side of the thoracoabdominal wall was observed. The physical examination showed a normal breast, without contracture and a good quality periareolar scar. Ultrasonography, magnetic resonance imaging, and mammography were normal. The diagnosis was Mondor’s disease. We prescribed warm compresses and nonsteroidal anti-inflammatory drugs. The symptoms disappeared in 2 weeks [Figure 2A and B].

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Figure 2

(A) Mondor’s thrombophlebitis 2 years after augmentation mammoplasty. (B) The same patient 2 weeks after clinical treatment

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Case report 3

A 38-year-old woman was admitted to obtain a bilateral retroglandular silicone breast implant via inframammary fold. The postoperative period was uneventful until the 3rd week. The patient observed a fibrous cord below the right breast without any other symptoms. The clinical diagnosis was thrombophlebitis of the subcutaneous vein as a symptom of Mondor’s disease. The cord-like lesions disappeared 2 weeks later without any treatment [Figure 3].

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Figure 3

Mondor’s disease presenting as a fibrous cord below the right breast 3 weeks after silicone breast implant

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DISCUSSION

Mondor’s disease is a benign, self-limited vascular disease. Approximately 75% of the patients are women. The incidence of Mondor’s disease among the female patients with breast disorders is between 0.5% and 0.8%.[9]

Trauma to the breast can cause Mondor’s disease. In the literature, ultrasound-guided core biopsy, mammotome biopsy, mastopexy with breast augmentation, breast reduction surgery, and tight bra, but also due to gigantomastia.[101112131415161718] It is important to exclude breast cancer in such cases.[91920]

In our case series of 652 women, breast surgery was the trigger for postoperative Mondor’s disease in 0.46% of patients. The largest series has been reported from France with eight patients. The authors suggested that Mondor’s disease is caused in this setting by fascial changes.[21] An Italian group reported three cases after implant-based breast reconstruction in nonobese, nonsmoking patients without hypercoagulability of thrombotic risks.[12] Another three cases have been reported after subfascial breast augmentation.[13] We observed a delay of several weeks between surgery and the onset of symptoms. Sometimes the delay between surgery and Mondor’s disease can be as long as 13 years.[22] On the other hand, there is neither a close relationship between Mondor’s disease and silicone breast implants nor between Mondor’s disease and capsule contracture.[23]

In two of our three patients, no treatment was warranted. The third patient was treated by nonsteroidal drugs and warm compresses. The lesions disappeared within 2–3 weeks without leaving any footprints. However, secondary ulcerations may rarely occur as a complication.[24]

CONCLUSION

Mondor’s disease is a rare but possible complication after aesthetic breast surgery. Although disconcerting for the patient, the disease is benign and self-limiting. Treatment is not always necessary, and in most of such cases, nonsteroidal anti-inflammatory drugs are the first choice.