Breastfeeding After Cosmetic Breast Surgery Presented by Diana West, BA, IBCLC

BREASTFEEDING AFTER COSMETIC BREAST SURGERY Augmentation Mammoplasty (Breast Implants)

Presented by Reduction Diana West, BA, IBCLC Augmentation [email protected]

Breast Augmentation History Breast Augmentation History  1885: First augmentation (injection of  1950s-1960s: 50,000 patient’s own fat) – poor results women received silicone injections  1889: Paraffin (wax) – disastrous results  Developed  1900-1945: Many substances tried – awful results granulomas and  1945: Flap-based technique rotated patient’s hardening requiring mastectomy chest wall tissue into breast to increase volume – nope

Breast Augmentation History Breast Implants

 1961:  1992: Silicone implants removed from US market  Dr. Frank Gerow squeezed plastic transfusion bag filled with blood due to safety concerns  Thought it felt like a woman's breast  2006: Health Canada and FDA declared silicone  Developed the first silicone gel implants made by Allergan and Mentor companies to breast implant with Dr. Thomas be safe Cronin for Dow Corning  2012: Sientra approved by FDA to manufacture of  1964: silicone implants  Laboratoires Arion developed first saline breast implant

Breast Implants Incidence of Breast Augmentation Surgery  2001-2010:  2013: 290,224 women in the US MOST Poly Implant Prothèse popular (PIP) silicone implants cosmetic surgery  Used industrial grade in 2013 silicone, not medical grade  High rupture, inflammation, malignancies, hardening, death rates  Dec 2011: France first country to recall PIP implants, file fraud suit  Dec 2013: PIP owner/founder Jean-Claude Mas jailed and fined in France  Many other criminal and civil suits pending

“We all have things that we want to change Pervasive advertising about ourselves and for many women, this relates to the size, shape or position of their breasts. Considering how prominent the breasts are to a woman’s overall appearance, it is not surprising to learn that many women would like to increase the size of their breasts.” – Sydney Breast Enlargement & Cosmetic Surgery

Teen More Teens Having Augmentations Augmentations  Teens increasingly 9000 requesting breast 8000 8204 implants as birthday, 7000 holiday, and 6000 graduation gifts 5000

4000

 American Society of 3000 Plastic Surgeons 2000 (ASPS) FDA, and Health 1000 1396 Canada strongly recommend 0 against breast implants under 18 1997 2012

Breast Augmentations by Age Teen Augmentations  53% to correct breast abnormalities  22% Tubular breast  17% Severe breast asymmetry  9% Congenital micromastia (severe underdevelopment)  5% Poland's syndrome (congenital absent breast)

Why Breast Physical Reasons for Breast Augmentation Surgery? Augmentation Surgery Physical discomfort Reduction in breast volume after Psychological discomfort Weight loss Weight loss surgery Pregnancy Normal aging

Physical Reasons for Breast Psychological Reasons for Augmentation Surgery Augmentation Surgery

Desire to “fit in” and be “normal” Desire to feel womanly and Balance difference in breast size attractive May not be told about hypoplasia and Doubts about femininity possible diminished lactation capability Low self-esteem

Psychological Reasons for Psychological Augmentation Surgery Reasons

 Study by Didie and Sarwer (2003) “Most women who seek  Reasons women have breast breast augmentation are augmentation surgery not trying to outdo other women in breast size;  More motivated by their feelings rather they want than partners or socio-cultural to catch up.” representations of beauty  Higher incidence of: Surgery of the Breast: Principles and Art . Divorce (Spear, ed) . Unhappy marriages . Emotional discomfort . Diminished feelings of femininity . Depression

Lactation Implications of Nerve Impairment Augmentation Surgery  Plastic surgeons often tell mothers that augmentation will not affect breastfeeding “since nothing is being removed from the breast”

 This overlooks many factors of augmentation surgery that can affect lactation

Nerve Impairment

Regeneration of damaged nerves  Body’s normal repair process  Responds to passage of time  Regrow at rate of 1 mm/month

Why Does Nerve Duct Impairment Response Matter?  Milk ejection reflex Recanalization depends on nerve response = Growth of ductal tissue  Good News: Milk .Severed ducts reconnecting? ejection can be triggered without .New ductal pathways? direct nerve response  Breast compression . If implant above the muscle, should be done with hand on top

Duct Impairment Duct Impairment  Responds to hormonal  Lactation outcome and physical stimuli also depends on . Tissue grows and matures with each inherent number of menstruation and pregnancy glands and ducts . Direct response to lactation (Daly, Kent, Owens, Hartmann, 1999)  Recent discovery: • Number and length of lactations after surgery Number of ductal openings on nipple vary (Ramsey, 2005) • Better outcomes for subsequent lactations  Can vary from 4-15  Average of 9

Two Main Augmentation Technique Categories Augmentation by Injection Injection Implantation

Lipoaugmentation Lipoaugmentation  Patient’s Own Body Fat Injected into Breasts  Patient’s Own Body Fat Injected into Breasts  Harvested from liposuction One technique uses Brava®  Can fill in defects / abnormalities or soften existing external breast tissue implant appearance expander  No clinical evidence safer or better than saline / silicone . increases breast  Enlargement depends on amount of spare fat vascularity / volume . prevents fat reabsorption

Lipoaugmentation Hyaluronic Acid (HA) Injection  RISKS  Soft gel-like substance injected into breasts  LIMITED to ~1 cup size increase  Hyaluronic acid occurs naturally in the body  Procedure may have to be repeated  Marketed under name “Macrolane”  Unpredictable or low survival rates of transferred cells  Known by doctors as a "Boob Jab”  Cell reabsorption  Out-patient “lunchtime” procedure  Cyst development  Local anesthesia  Tissue scarring  Placed under breast tissue  Calcification  Procedure less than 1-2 hours  Difficulty detecting breast cancer by mammogram  Almost no recovery time . Differentiating between malignant and fat transfer calcifications Allen RJ, Heitland AS. Autogenous augmentation mammaplasty with microsurgical tissue transfer. Plast Reconstr Surg. 2003 Jul;112(1):91-100.

Hyaluronic Acid (HA) Injection  Requires yearly touch-ups  Used primarily in Europe (not UK)  Prior to 2012 British Association of Aesthetic Plastic Augmentation Surgeons, (BAAPS) saw one in four complications by Implantation  In 2012, Swedish manufacturer Q-Med withdrew Macrolane from UK market due to “cancer screening concerns”  Not yet approved by FDA or Health Canada  EFFECT ON MILK AND BREASTFEEDING UNKNOWN

Types of Implants Types of Implants

Saline Silicone FDA approved for age 22  FDA approved for age 18 Small incision  Pre-filled so need Saline filling can be larger incision increased or decreased  Usually inframammary incision  Can’t use axillary incision

Implant Outcome Variables Implant Location

 Two primary factors affect the Subglandular amount of milk the mother will be UNDER the able to make gland ABOVE the 1. Implant location muscle Subpectoral 2. Incision placement UNDER the muscle

Implant Location Implant Location  Subglandular (ABOVE the muscle)  Subpectoral  PRO (BELOW the muscle) . Least complicated  PRO . Chest muscles cannot . capsular contracture move implant when flexed . visible implant rippling  CON  CON . risk capsular contracture . implant vulnerability . Recovery time longer . risk implant "rippling” . More painful . pressure on glandular tissue . more likely to negatively affect milk production

Implant Location Incision Placement For aesthetics, surgeons place incisions in less visible areas Four most common incision sites:  Inframammary  Tunneling to implant location from  Transaxillary remote incision can cause duct  Transumbilical and nerve damage  Periareolar

Same Scars Patterns Selected Breast Augmentation Techniques and their “Surgery of the Breast: Principles and Art,” Spear, ed., 1998. Probable Effects

Augmentation with lift on Lactation (mastopexy) can look the same as reduction

“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.

Periareolar Greatest risk to lactation is periareolar incision (Hurst, 1996)  Very common  Likelihood of severed ducts  Incision around areola to hide  Likelihood of severed nerves scaring . Incisions in the lower, outer quadrant will result in  Can be placed reduced innervation to the nipple and areola subglandular or . Dramatically reduces milk ejection response subpectoral  LIKELY to damage ducts, glands, and nerves “Surgery of the Breast: Principles and Art,” Spear, ed., 1998.

Inframammary Transaxillary  Commonly called “crease” technique  Incision in upper, outer  Scars not visible region of the breast, near arm juncture (“pit”)  Most common augmentation procedure  Can be placed subglandular, subpectoral,  Scar generally invisible or submuscular  Can be subglandular  Avoids the gland and ductal tissue or submuscular  Preserves nipple/areolar innervation  If revision necessary, periareolar incision likely  If revision necessary, periareolar incision likely

TransUmbilical Breast Breast Augmentation (TUBA)  Not common Augmentation  Implant inserted through navel Surgical Photos  Moved under skin into breast  No incisions on breast  Recovery time less Warning: The following  Difficult to position accurately slides display breast augmentation surgery in  Can be subglandular or submuscular graphic detail  If revision necessary, periareolar incision likely

Liposuction

Augmentation Mammoplasty Periareolar Technique

“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.

Augmentation Mammoplasty Augmentation Inframammary Technique Mammoplasty

Inframammary Technique

“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.

Augmentation Surgical Mammoplasty Variables  Surgeon’s skill Inframammary  Time since surgery  Ducts and nerves Technique reconnect and regenerate  Five years usually minimum for optimal outcome  Inherent lactation capability  Breastfeeding management  Attitude/perspective

Breast Augmentation Complications  Commonly requires additional surgeries Change:

 Average duration to revision is seven years Implant type Location Size

Muscle Flex Distortion Traction Rippling

 Chest muscle  Occurs when implant pulls on scar scarring into tissue, which pulls on skin implant

Capsule Contracture Necrosis  Dead tissue  Scar tissue forms around  Grows around implant implant  Shrinks over time  Can leave  Constricts implant large,  Happens frequently permanent scars  Seroma  Collection  REMEDY: Surgery to release implant from scar tissue of fluid around  May require several surgical treatments implant

Synmastia Leaking  Submuscular implants  ~10 percent  Muscle attached to sternum cut by surgeon  Starts six or more months post-op  Pressure of post-operative swelling forces implant to move toward center  Difficult to repair

Rupture Rupture

Saline  deflates and the salt water Risk higher: absorbed by body Cup size increased more than 2 sizes Silicone gel  decreased breast size, TUBA technique hard knots, uneven appearance, pain or UNDERfilling of implant tenderness, tingling, swelling, numbness, . Can fold during movement burning, sensation changes, inflammation Excessive compression during mammogram of scar tissue around implant, increased Trauma, injury, or intense physical manipulation scar tissue

Massive Rupture Pregnancy  Pain as enlarging glands compress against implants  Worse with capsular contractures

What Women Worry About What Women Worry About  Implants can affect milk quality or  Breastfeeding causes breasts to composition???  Silicone can leak into the milk??? sag, so surgery will be ruined???  Silicone not higher in milk of women with implants (Semple, 1998)  Breast enlargement stretches  Silicon 10 times higher in cow's milk and Cooper’s ligaments even higher in infant formulas (Semple, 1998)  Silicone drops used for colic  Caused by pregnancy and weight gain,  Silicone inert and not absorbed in digestive tract (Hale, 2004) not breastfeeding  Exception: Massive implant rupture  Without proper support, happens anyway

The Bottom Line on Breastfeeding after Breast Implants Augmentation Surgery Breast implant surgery CAN damage lactation nerves and ducts Particularly: Questions? . Periareolar incisions . Subglandular implant placement Thoughts? . Complications . Follow-up surgeries through areola Comments?

Incidence of Breast Reduction Surgery  2013: 41,164 in US

Down 2% from 2012

Reduction Mammoplasty (Breast Reduction)

Why Breast Reduction Surgery? Physical Discomfort  PAIN Physical discomfort  Back, neck, shoulder grooves  Neuromuscular dysfunction Psychological discomfort  Headaches, nerve damage  Posture, breathing difficulties  Breast problems  Premature, exaggerated sagging  Significantly unequal breast size  Interference with exercise, activities  Clothes fitting poorly  Inability to exercise comfortably, lie on stomach  Unusual Enlargement  Not returning to pre-pregnant size  Weight gain  Hormone imbalances

Physical Discomfort Psychological Discomfort  1999 survey by the University of Pennsylvania  1999 (very) informal survey by me School of Medicine  50 women who had reduction  100+ women who had reduction mammaplasty surgery responded by email  Most common reasons for surgery . Lower back pain (92%)  80% had reduction because of sexual . Shoulder grooves from bra straps (84%) harassment, usually . After surgery during teen years  83% improvement in shoulder groove pain  78% decrease in lower back pain  Unwanted, humiliating, frightening sexual advances  Not just peers

Sexual Harassment  Social/cultural/family  In our society, pressure large breasts = promiscuity  Desire to “fit in” and be “normal”

 Poor self-image

 Perceive physical abnormality

 Feel “freakish”

 Not taken seriously or respected for abilities

Liposuction Selected Reduction Mammoplasty  AKA Surgical Techniques  Scarless and their Probable  Binelli Effects on Lactation  Several small incisions made to access fat tissue  Possible to avoid area near areola

Liposuction Pedicle Techniques  Areola and nipple remain  Limitation: skin can attached to mound of breast only shrink two cup tissue containing sizes  Blood vessels  Ducts  Usually used with  Nerves other procedures

Incision Patterns Inferior Pedicle Technique

 Most common technique  Minimal nerve, duct, and blood supply damage  Most tissue removed from perimeter  Avoids most lactation tissue

Inferior Pedicle Technique Superior Pedicle Technique

 Lactation capability  Wedges of tissue substantially protected removed below areola (Brzozowski, 2000)  Area most likely to  Higher milk production contain lactation than Superior Pedicle tissue technique (Sandsmark , 1992)  Incision below (superior  Higher milk production to) pedicle may sever Free Nipple Graft 4th intercostal nerve technique (Marshall, 1994)

Central Pedicle Technique Free Nipple Graft  AKA the “circumareolar technique”  Least visible scarring  Complete removal of areola and nipple  Only incision around areola  Wedges of tissue removed . Areola remains attached from lower breast . Tissue removed through incision  Many ducts and glands  Blood and nerve supply removed or severed to areola largely preserved  Extensive damage to  4th intercostal nerve likely remaining tissue to be damaged  Some degree of  Amount of tissue removal reinnervation and determined by desired shape recanalization possible (Ahmed and Kolhe, 2000)

Breast Reduction Surgical Photos Implications of Reduction Mammoplasty for Lactation

Surgical Variables Affecting Lactation Surgical Variables Affecting Lactation

MOST IMPORTANT: Type of surgery  Techniques that minimize scarring usually Severe nerve damage probable destroy more nerves, blood supply, and lactation tissues —Interferes with milk ejection  Mothers can find technique used on surgical —Decreased release of oxytocin consent form Some milk ducts almost always severed —Reduced milk transfer

Other Variables Affecting Breastfeeding after Milk Production Capability Reduction Research Studies  Almost all women who had reduction mammoplasty  LIKE AUGMENTATION: can lactate, although they may not have a full milk  Surgeon’s skill supply (Harris, 1992)  Healing process  35% exclusive breastfeeding  Time since surgery  65% early cessation or . Allows ducts and nerves to reconnect and regenerate no breastfeeding . Normal sensation normal milk ejection  Inherent lactation capability  Breastfeeding management  Attitude/perspective

Breastfeeding after What Mothers May Hear Reduction Research Studies from their Surgeons  Reduction mammoplasty likely to reduce milk  “Women with large breasts can’t breastfeed anyway” supply (Souto et al, 2003)  Outcomes range from  “You’ll have a 50/50 chance of being able to 0-70%, depending upon breastfeed” type of surgery performed  They usually mean a 50/50 chance of FULL lactation, not a (Widdice [meta-analysis], 1993) 50/50 chance of ANY lactation  Mothers see they have some milk . May think they have a full milk supply . May not monitor for insufficient intake

What Mothers May Hear Possible Complications of from their Doctors Breast Reduction Surgery  Don’t breastfeed or you’ll get mastitis from  Blanching seems unrelieved engorgement! common after  HIGHLY UNLIKELY periareolar surgery  No milk outlets means no external bacterial access  Try squeezing blood back into nipple  Engorgement usually resolves by end of first week without intervention  Nifedipine (Barrett , 2013) . Lack of milk removal leads to involution/atrophy of the glands . 30 mg (slow release) 1x day for 2 weeks . Follow normal engorgement protocols . About 10% of women  CAN be prolonged engorgement from milk stasis in must repeat course severed ducts 1-3 time . Areas evident after normal LGII fullness subsides . Also available in topical

Possible Complications of Possible Complications of Breast Reduction Surgery Breast Reduction Surgery  Output between breasts may be markedly different  Most have significantly more milk on one side than the other Latching can be more difficult Pedicle often less full Harder for baby to grasp Try pressing index finger up into breast (“nipple nudge”)

The Bottom Line on Breastfeeding Managing Breastfeeding After Breast Reduction After Breast Surgery  Any surgery to reduce the breast can affect lactation  Maximize milk removal to calibrate high capability

 Reduction surgeries with the least scarring often have  The more milk that is removed in the first 2-3 weeks, the worst lactation outcomes the higher milk production capability will be for this baby  You can’t tell what kind of surgery she had by her scars . Calibration process restarts for each baby  Reduction techniques with the best lactation outcomes preserve  Extra pumping even if only just during this time  Nerve function  Glandular tissue below the areola  YOUR encouragement matters!

Managing Breastfeeding Follow standard lactation protocols After Any Cosmetic Breast Surgery Assess milk production . Diaper output, weight gain, and 24 hr test weights (weights taken before and after feedings) Supplement appropriately . Do not supplement prophylactically . Unnecessary supplementation may decrease milk production

Increase milk production Consider What You Say if necessary Mothers who have had breast surgery Increase milk removal are very vulnerable to HCP advice Galactagogues (substances that increase milk production) Discouragement of breastfeeding results in significantly lower breastfeeding rates . Prescription medications usually most effective (Deutinger et al, 1990) —Domperidone optimal if available Encouragement of breastfeeding results . Many herbs can moderately increase milk in significantly improved lactation production outcomes —Goat’s rue seems to work especially well for many (Brzozowski, 2000) post-surgical moms

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