COVER STORY 15 Breastfeeding After Cosmetic Surgery From Myth to Truth Author: Gina Weissman DMD, RN, IBCLC, Israel

Reduction Surgery Vertical technique – note Photos: © Gina Weissman no horizontal incision

et’s start with the bottom line: in What is hiding behind the scar? The ly in the lower quadrant, may damage the L principle, all breast surgery is like- factors that affect postoperative milk fourth intercostal nerve that plays a crucial ly to affect a woman’s ability to breast- production. role in breastfeeding and the milk ejection feed. surgery has more The extent of the effects of breast surgery reflex affecting the amount of milk that the of an impact than augmentation but on breast feeding depend on a few differ- baby will receive. Stretching the nerve, not lifts, augmentation and other surgeries ent factors such as, preoperative mammary just cutting it, can also impair function. may also affect a woman’s milk supply gland function; types of incisions; degree (Neifert 1992) and ability to breastfeed. The question of removal or destruction of the glandu- we should be asking however is not: if lar tissue; the extent of the nerve damage; Breast augmentation a woman is able to breastfeed after sur- time elapsed between surgery and breast- There are many reasons for breast aug- gery or not, but rather: to what extent feeding; if there were breastfeeding expe- mentation surgery, usually related to a woman will be able to breastfeed. Al- riences or attempts between the surgery the woman’s self-image and may include most every woman who has undergone and the current breastfeeding; and most things such as asymmetry which may breast surgery can produce something. importantly the way breastfeeding is con- mean surgery on a single side. When (Harris et al., 1992) ducted and the mother‘s attitude toward breast milk production is assessed, the While full and exclusive breastfeeding are breastfeeding - as with every mother. condition of the before surgery is not always possible after surgery, as in any a crucial component to be considered even situation where the mother’s milk supply Types of incisions before examining the effect of surgery. Al- is insufficient to meet the baby’s needs, The location, nature, and length of the inci- though a small breast does not necessarily the mother can often partially breastfeed sions in the surgery may affect breast feed- predict difficulty in breastfeeding, there and supplement with formula. Thus, both ing/milk production due to the damage to are certain breast structures that may in- mother and baby benefit from the breast- the glandular tissue and areolar nerves. An dicate difficulty in producing milk. feeding experience. incision near or above the , especial- Lack of breast tissue (­hypoplasia), › 16 COVER STORY

Photo 1: Augmentation with the PeriAreolar technique. Silicone leak-causing capsular contracture

› cone-shaped breasts, breasts very far Silicon and its implications on breast- attributed to the localized pressure of the apart; Lack of development or asymme- feeding implants which reduces the blood supply try. Women who choose augmentation In recent years, concerns have been raised that tumors need to thrive or perhaps the in these cases usually receive informa- about the transference of silicon to the body’s immune system’s response to im- tion that they lack breast tissue or that milk. The silicone used in modern implants plants reduces the risk of developing cancer enlargement may harm breastfeeding. In is a high viscosity silicone gel, this signifi- in the region. (Breast Implant Surveillance addition, they are sometimes mistaken- cantly reduces the risk of leakage from the Reports to the U.S. Food and Drug Admin- ly told that they can breastfeed normally implant. istration: Maternal-Child Health Problems from the breast that did not undergo sur- In 2001, the AAP Drug Committee S. Lori Brown, Joan Ferlo Todd, Judith gery. (Didie and Sarwer 2003) determined: „The levels of silicone in the U. Cope & Hari Cheryl Sachs) There are various implant insertion blood and milk of breastfeeding women methods designed to reduce scars and with silicone implants are similar to those Breast reduction surgery create a natural appearance. The fold of in milk of women without implants (Sem- There are many physical and psychological the breast is the most common position, ple et al., 1998). In addition, the levels of reasons that lead women with large breasts and today the implant is most often in- silicon in cow’s milk has been found to be (breast hypertrophy) to undergo breast re- serted under the muscle which allows the 10 times higher than that of the milk of duction surgery. They suffer greatly from surgeon to release the muscle without women with implants and even higher in their condition and in the end just want to damaging the mammary glands, preserv- formula.“ be like everyone else and are not necessar- ing the nerves and blood vessels of the In another study, „Silicon is found in a ily concerned with breast function and the -areola complex. This is good news simplified form in the environment and it ability breastfeed in the future. The effect for mothers who want to breastfeed. (see is difficult to prevent ingestion.“ The study of surgery on breastfeeding depends on photo 1) concluded: „There is no reason why women the amount of tissue removed, the location with silicone breast implants should not of the removal and the extent of damage Revision breastfeed.“ (Berlin 1994) to the remaining tissue. There are many It is important to note that despite pre- Silicon is considered to be inert, and it methods to perform breast reduction sur- cise incision and location of the implant, is unlikely to be absorbed into the baby‘s gery and the one chosen is dependent on breast augmentation surgery revised on digestive system (Hale, 2008). From 1994- the woman‘s breast structure, surgeon‘s average every 7 years (Spears et al., 2003). 2006, the Food and Drug Administration preferences, experience and the purpose of This is often due to breast prolapse, a de- (FDA) banned the use of silicone because the surgery. Even standard methods vary sire to resize, hematomas, infections and of suspected increased risk of breast can- between surgeons, and all of them can im- other complications. (photo 1) This may cer. It later retracted the ban when it be- pair milk production. cause nerve damage, affect the milk pro- came clear that not only does silicone not The surgeries that most moderate- duction system, and reduce the chances of increase the risk of breast cancer, but may, ly affect milk production are the opera- breastfeeding. (Strom 1997, Michalopou- to some extent reduce the risk of breast tions where the nipple-areola complex is los, 2007) cancer. It is hypothesized that this can be not completely cut, but only shifted and

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Photo 2a: Reduction surgery – verticular technique 4 weeks pp; Photo 2b: Reduction Surgery Vertical technique – note no horizontal second birth, fully breastfeeding incision

the lower part of the breast attached to 0%, depending on the type of surgery per- not reach full milk supply, but with the sec- the nipple-areola complex remains intact formed. The large range reflects the lack of ond she will have more milk and perhaps (Sandsmark, M., et al 1992). (photo on page uniformity in the criteria for evaluating enough to exclusively supply the baby’s 15, photos 2a and 2b) This connection is breastfeeding. It is also important to con- needs. called a pedicle and contains ducts, nerves sider that additional health background Reinervation is the process in which and blood supply that are still attached to factors also influence success in breast- nerve cells may be regenerated and recon- their relative systems. The pedicle can be feeding. Women who undergo reductions, nected. in different areas of the breast and the scar are often also overweight, this is a risk The fourth intercostal nerve is the main position will be according to the placement factor for successful breastfeeding. They messenger to the brain from the breast, it’s of the pedicle. The use of the lower pedicle, may also suffer from hormonal effects lateral section innervates the nipple-areola which means that the blood vessels and that contribute to and may affect complex and is located at around 4 o’clock nerves are in the area below the nipple-are- breastfeeding as well, such as polycys- on the left breast and 8 o’clock on the right ola complex, best preserves the ability to tic ovaries, diabetes, or hypothyroidism. breast. Its stimulation results in the release produce milk. With such a background, some difficulty of oxytocin triggering the milk ejection Other methods include: the free im- as a result of the surgery itself can even reflex and for the production of plant method in which the nipple-areola further challenge breastfeeding. milk. Regeneration of this neural-system complex is completely severed from the is an important key to milk production. breast and then re-connected; the vertical The body’s amazing repair process The degree of renewal does not depend on incision method, most common in Israel post surgery: the previous breastfeeding experience, but and the United States in recent years as Recanalization is an important physio- mainly on the location of the cut and de- it requires a shorter surgery. This is more logical phenomenon in women who have gree of damage to the nerve. aesthetic but more harmful to milk pro- undergone breast surgery. In this process, Severed nerves will regrow at a rate duction because the tissue is removed breast tissue is re-grown, cut-off milk duct of about 1 mm per month and may take from the lower part of the breast and usu- reconnects and new duct develop. The pro- 6 months to a year to regrow (Shaw et al., ally involves cutting the fourth intercostal cess is greatly enhanced as a direct result of 1997). When women show sensitivity to nerve; a Bellini cut is a cut made around breastfeeding, which encourages the milk heat and touch, it indicates a functioning the areola and then liposuction is per- production system to create new ducts. In nerve and will communicate the appro- formed, this technique is usually used for addition, branches of new ducts and fis- priate sensations to the pituitary gland minimal reductions or in addition to other sures are generated in small amounts in to produce prolactin and oxytocin. The methods. response to released with each ability of the breast to function depends Many researchers have tried to deter- . The more the mother has on the condition of the glands and the mine the effect of breast reduction sur- breastfed in the past, and the more cycles ducts, but the more time has passed after gery on breastfeeding, and have reached she has undergone since the surgery, the the surgery, the more it is likely for the different conclusions about the success more recanalization may occur. So, with nerves crucial for breastfeeding have of safe breastfeeding, between 70% and her first baby after the surgery she may resumed function. › 18 COVER STORY

Photo 3: Reduction surgery – Vertical technique engorgement 4 days pp, first birth.

› Breastfeeding challenges that Engorgement directly correlated with the duration of the mothers may face after breast surgery Women who have undergone breast sur- lactation period in previous births. gery tend to experience more engorge- Nipple pain: ment. If the breast produces milk and it Lack of fullness among mothers who Technique is a very important part of a is not used the cells begin the process of undergo augmentation due lack of pleasant and effective breastfeeding expe- apoptosis (degeneration) this occurs in the rience for all women. All the more so for cells connected to the severed ducts. It is Postpartum mothers should to feel a women after breast surgery. It is there- important to pump to express the milk change in their breasts that will manifest as fore crucial to emphasize the importance from those cells whose ducts have not been a sense of fullness. If the mother does not of technique of a good to the breast cut so as not to lose this critical active tis- experience fullness in the lactogenesis 2 from the first breast feeding in order to sue mass. The faster the engorgement is re- phase, they need to be assessed by a doctor avoid nipple pain. lieved, the less it is likely to affect the func- as she may have low prolactin levels, result- Women who have undergone breast tional cells and impair milk production. It ing in insufficient prolactin to affect milk surgery may sometimes experience condi- is important to evaluate the efficiency of production. She also may not have enough tions which are rare in women who have breastfeeding and consider pumping after active mammary glands. The good news is not had surgery, such as vasospasm, which each feeding, especially in the early days. that there is usually something that can be causes the nipple to blanch after breast- Sometimes mothers experience a different done to improve this. feeding and can be accompanied by pain. degree of engorgement in each breast and Preventing any rubbing of the nipple with some will experience engorgement only in Lack of milk ejection reflex (MER): the tongue as a result of improper latch to certain areas of the breast. Absence of or partial sensation in the nipple the breast during breastfeeding may reduce After augmentation surgery, the im- may indicate nerve damage that may inter- this phenomenon. plant sometimes presses the gland, mak- fere with milk extraction and may adversely Some babies may have difficulty latch- ing it difficult to remove the lymphatic affect milk supply. Frequent breastfeeding ing and extracting milk because the nip- fluid, thus increasing engorgement. If the and extra milk extraction by manual expres- ple-areola complex may be incomplete due mother‘s breasts were relatively small be- sion and pumping with a good pump in the to surgical changes. A deep, asymmetric fore the enlargement surgery, and in ad- first few weeks will ensure that the breasts latch will increase the possibility of milk dition she experienced engorgement, she produce as many prolactin receptors as pos- flow, it is also recommended to experiment could lose quite a lot of her mammary sible, and the milk supply will reach its max- with different positions. In addition, there gland function. imum potential. (photos 4 and 5) are various techniques to help make the The engorgement experienced by most nipple more prominent when latching the women who have undergone breast reduc- Helping postoperative mothers baby to the breast, such as Dianne Wests’s tion surgery may increase from birth to to maximise their breastfeeding “Nipple Nudge” which can make it easier birth. (photo 3) This is a result of addition- potential for them. al regrowth and recanalization occurring If a mother who has undergone breast sur- with each . Engorgement can be gery seeks help before she gives birth her

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Photo 4: Engorgement after augmentation The incision location Photo 5 Manual expression helped milk removal in the lack of MER prevented MER. due to large incision.

chances of achieving a successful breast- cess to maximise a mother’s breastfeeding to refer to sources of information and feeding experience are higher. There are ability and avoiding possible complications support for breastfeeding after breast sur- many proactive steps that she can take and such as engorgement and nipple pain. gery such as: factors that will contribute to her success › Clinics in Human Lactation: Breastfeed- such as, document breast changes in preg- Treat engorgement as quickly as pos- ing after Breast and Nipple surgeries nancy in order to predict breastfeeding sible by Diana West, IBCLC, and Dr. Elliot ability; considering birth approaches that Engorgement signals to the body that the Hirsch, MD minimize interventions; AME: Antenatal milk it has produced is not required and › The BFAR book: Defining your Own Suc- Manual Expression. this triggers the process of shutting down cess: Breastfeeding After Breast Reduc- the system and mammary glands that pro- tion Surgery by Diana West, IBCLC What to do once the baby is born: duced it, apoptosis. In the case of a mother › www.bfar.org › Early and frequent extraction of milk with many branches of mammary glands from the breast the shutting down of a few of them may Unless the duct in nipple-areola complex not affect her breastfeeding experience are completely severed by the free implant in any significant way. In a postoperative method, it is reasonable to assume that a mother who is likely to have fewer func- mother who has undergone breast surgery tioning branches of mammary glands it is can provide at least a little colostrum for critical to avoid engorgement as the loss of her baby in the first few days. As with all even a few could greatly reduce her ability new mothers the first hour and then the to produce milk. first 24 hours can have a huge effect on the amount of milk produced. The Parker Monitor Study shows that mothers who breastfeed It is very important to monitor the baby’s or express milk in the first hour and then stool and urine output and weight. It is breastfeed or express at frequent intervals possible that in the first few days the baby in the first 24 hours have significantly will gain weight well and will not need sup- more milk 2-3 days later when lactogen- plementation, but later weight gain may be esis 2 occurs. reversed and it will be necessary to reevalu- ate the need for formula supplements. Ensure Effective Technique An effective latch is an important part of Support any comfortable and successful breast- Studies have shown the importance of a Gina Weissman, feeding experience - for the postoperative supportive medical staff with knowledge DMD, RN, IBCLC IBCLC since 1999; Doctor mother even more so. Ensuring an effec- of successful breastfeeding after breast of medical Dentistry (DMD), tive latch is an important part of the pro- surgery. In addition, it is recommended Registered Nurse 20 COVER STORY

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