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Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 1
BREASTFEEDING
AFTER COSMETIC
BREAST SURGERY
Presented byDiana West, BA, IBCLC
ReductionAugmentation
Augmentation Mammoplasty
(Breast Implants)
Breast Augmentation History
1885: First augmentation (injection of patient’s own fat) – poor results
1889: Paraffin (wax) – disastrous results
1900-1945: Many substances tried – awful results
1945: Flap-based technique rotated patient’s chest wall tissue into breast to increase volume
– nope
Breast Augmentation History 1950s-1960s: 50,000
women received silicone injections Developed
granulomas and hardening requiring mastectomy
Breast Augmentation History
1961: Dr. Frank Gerow squeezed plastic
transfusion bag filled with blood
Thought it felt like a woman's breast
Developed the first silicone gel breast implant with Dr. Thomas Cronin for Dow Corning
1964: Laboratoires Arion developed first
saline breast implant
Breast Implants 1992: Silicone implants
removed from US market due to safety concerns
2006: Health Canada and FDA declared silicone implants made by Allergan and Mentor companies to be safe
2012: Sientra approved by FDA to manufacture of silicone implants
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 2
Breast Implants 2001-2010:
Poly Implant Prothèse(PIP) silicone implants Used industrial grade
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
Incidence of Breast Augmentation Surgery 2013: 290,224 women in the US MOST
popular cosmetic surgery in 2013
“We all have things that we want to change 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
Pervasive advertising
Teens increasinglyrequesting breast implants as birthday, holiday, and graduation gifts
American Society of Plastic Surgeons (ASPS) FDA, and Health Canada strongly recommend against breast implants under 18
Teen Augmentations
More Teens Having Augmentations
1396
8204
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1997 2012
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 3
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 Augmentation Surgery?
Physical discomfort
Psychological discomfort
Physical Reasons for Breast Augmentation Surgery
Reduction in breast volume afterWeight lossWeight loss surgeryPregnancyNormal aging
Physical Reasons for Breast Augmentation Surgery
Balance difference in breast sizeMay not be told about hypoplasia and
possible diminished lactation capability
Psychological Reasons for Augmentation Surgery
Desire to “fit in” and be “normal”
Desire to feel womanly and attractive
Doubts about femininityLow self-esteem
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 4
Psychological Reasons for Augmentation Surgery Study by Didie and Sarwer (2003)
Reasons women have breastaugmentation surgery
More motivated by their feelingsthan partners or socio-cultural representations of beauty
Higher incidence of: Divorce Unhappy marriages Emotional discomfort Diminished feelings of femininity Depression
Psychological Reasons“Most women who seek breast augmentation are not trying to outdo other women in breast size; rather they wantto catch up.”
Surgery of the Breast: Principles and Art (Spear, ed)
Lactation Implications of Augmentation Surgery Plastic surgeons often tell mothers that
augmentation will not affect breastfeeding“since nothing is being removed from the breast”
This overlooksmany factorsof augmentationsurgery that canaffect lactation
Nerve Impairment
Nerve Impairment
Regeneration of damaged nerves Body’s normal repair process
Responds to passage of time
Regrow at rate of 1 mm/month
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 5
Why Does Nerve Response Matter? Milk ejection reflex
depends on nerve response
Good News: Milk ejection can be triggered without direct nerve responseBreast compression If implant above the
muscle, should be done with hand on top
Duct Impairment
Recanalization= Growth of ductal tissue
Severed ducts reconnecting?
New ductal pathways?
Duct ImpairmentResponds to hormonal
and physical stimuli
Tissue grows and matures with eachmenstruation and pregnancy
Direct response to lactation (Daly, Kent, Owens, Hartmann, 1999)
• Number and length of lactations after surgery
• Better outcomes for subsequent lactations
Duct Impairment Lactation outcome
also depends on inherent number of glands and ducts
Recent discovery:Number of ductal openings on nipple vary (Ramsey, 2005)
Can vary from 4-15 Average of 9
Two Main Augmentation Technique Categories
Injection
Implantation
Augmentation by Injection
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 6
Lipoaugmentation Patient’s Own Body Fat Injected into Breasts Harvested from liposuction
Can fill in defects / abnormalities or soften existing implant appearance
No clinical evidence safer or better than saline / silicone
Enlargement depends on amount of spare fat
Lipoaugmentation Patient’s Own Body Fat Injected into Breasts
One technique uses Brava®
external breast tissue expander increases breast
vascularity / volume
prevents fat reabsorption
Lipoaugmentation RISKS LIMITED to ~1 cup size increase
Procedure may have to be repeated
Unpredictable or low survival rates of transferred cells
Cell reabsorption
Cyst development
Tissue scarring
Calcification
Difficulty detecting breast cancer by mammogram 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 Soft gel-like substance injected into breasts
Hyaluronic acid occurs naturally in the body
Marketed under name “Macrolane”
Known by doctors as a "Boob Jab”
Out-patient “lunchtime” procedure Local anesthesia
Placed under breast tissue
Procedure less than 1-2 hours
Almost no recovery time
Hyaluronic Acid (HA) Injection Requires yearly touch-ups
Used primarily in Europe (not UK)
Prior to 2012 British Association of Aesthetic Plastic Surgeons, (BAAPS) saw one in four complications
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
Augmentation by Implantation
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 7
Types of Implants
SalineFDA approved for age 22
Small incision
Saline filling can be increased or decreased
Types of Implants
Silicone FDA approved for age 18
Pre-filled so need larger incision
Usually inframammaryincision
Can’t use axillary incision
Implant Outcome Variables
Two primary factors affect the amount of milk the mother will be able to make
1. Implant location
2. Incision placement
Implant Location
SubglandularUNDER the
gland
ABOVE the muscle
SubpectoralUNDER the
muscle
Implant Location Subglandular
(ABOVE the muscle) PRO Least complicated Chest muscles cannot
move implant when flexed
CON risk capsular contracture implant vulnerability risk implant "rippling” pressure on glandular tissue more likely to negatively
affect milk production
Implant Location
Subpectoral(BELOW the muscle) PRO capsular contracture
visible implant rippling
CON Recovery time longer
More painful
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 8
Implant Location
Tunneling to implant location from remote incision can cause duct and nerve damage
For aesthetics, surgeons place incisions in less visible areas
Four most common incision sites: Inframammary
Transaxillary
Transumbilical
Periareolar
Incision Placement
Augmentation with lift (mastopexy) can lookthe same as reduction
“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.
“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.
Same Scars Patterns Selected Breast
Augmentation Techniques
and their Probable Effects
on Lactation
Periareolar Very common Incision around
areola to hidescaring
Can be placed subglandular or subpectoral
LIKELY to damage ducts,glands, and nerves
“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.
Greatest risk to lactation is periareolarincision (Hurst, 1996) Likelihood of severed ducts
Likelihood of severed nerves Incisions in the lower, outer quadrant will result in
reduced innervation to the nipple and areola
Dramatically reduces milk ejection response
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 9
Inframammary Commonly called “crease” technique
Scars not visible
Most common augmentation procedure
Can be placed subglandular, subpectoral, or submuscular
Avoids the gland and ductal tissue
Preserves nipple/areolar innervation
If revision necessary, periareolar incision likely
Transaxillary Incision in upper, outer
region of the breast, neararm juncture (“pit”)
Scar generally invisible
Can be subglandularor submuscular
If revision necessary, periareolar incision likely
TransUmbilical Breast Augmentation (TUBA) Not common
Implant inserted through navel
Moved under skin into breast
No incisions on breast
Recovery time less
Difficult to position accurately
Can be subglandularor submuscular
If revision necessary, periareolar incision likely
Breast Augmentation
Surgical Photos
Warning: The following slides display breast
augmentation surgery in graphic detail
Liposuction
AugmentationMammoplasty
Periareolar Technique
“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 10
Augmentation MammoplastyInframammary Technique
“Surgery of the Breast: Principles and Art,” Spear, ed., 1998.
Augmentation Mammoplasty
Inframammary Technique
Augmentation Mammoplasty
Inframammary Technique
Surgical Variables Surgeon’s skill
Time since surgery Ducts and nerves
reconnect and regenerate
Five years usuallyminimum for optimal outcome
Inherent lactation capability
Breastfeeding management Attitude/perspective
Breast Augmentation Complications Commonly requires additional surgeries
Average duration to revision is seven years
Change:
Implant type
Location
Size
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 11
Chest musclescarring into implant
Muscle Flex Distortion Traction Rippling
Occurs when implant pulls on scar tissue, which pulls on skin
Capsule Contracture
Scar tissue Grows around implant Shrinks over time Constricts implant Happens frequently
REMEDY: Surgery to release implant from scar tissue May require several surgical treatments
Necrosis Dead tissue
forms aroundimplant
Can leave large, permanent scars
Seroma Collection
of fluid around implant
Synmastia Submuscular implants Muscle attached to
sternum cut by surgeon Pressure of
post-operative swelling forces implant to move toward center
Difficult to repair
Leaking
~10 percent
Starts six or more months post-op
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
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Rupture
Saline deflates and the salt water absorbed by body
Silicone gel decreased breast size, hard knots, uneven appearance, pain or tenderness, tingling, swelling, numbness, burning, sensation changes, inflammation of scar tissue around implant, increased scar tissue
Rupture
Risk higher:Cup size increased more than 2 sizesTUBA techniqueUNDERfilling of implant Can fold during movement
Excessive compression during mammogramTrauma, injury, or intense physical
manipulation
Massive Rupture Pregnancy
Pain as enlarging glands compress against implants
Worse with capsular contractures
What Women Worry About
Breastfeeding causes breasts to sag, so surgery will be ruined???Breast enlargement stretches
Cooper’s ligaments
Caused by pregnancy and weight gain,not breastfeeding
Without proper support, happens anyway
What Women Worry About Implants can affect milk quality or
composition??? Silicone can leak into the milk???
Silicone not higher in milk of women with implants (Semple, 1998)
Silicon 10 times higher in cow's milk and even higher in infant formulas (Semple, 1998)
Silicone drops used for colic Silicone inert and not absorbed in digestive tract
(Hale, 2004) Exception: Massive implant rupture
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 13
The Bottom Line on Breast Implants
Breast implant surgery CAN damagelactation nerves and ductsParticularly: Periareolar incisions Subglandular implant placement Complications Follow-up surgeries through areola
Questions?Thoughts?
Comments?
Breastfeeding after Augmentation Surgery
Reduction Mammoplasty(Breast Reduction)
Incidence of Breast Reduction Surgery
2013: 41,164 in US
Down 2% from 2012
Why Breast Reduction Surgery?
Physical discomfort
Psychological discomfort
PhysicalDiscomfort PAIN
Back, neck, shoulder grooves Neuromuscular dysfunction
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
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 14
Physical Discomfort
1999 survey by the University of Pennsylvania School of Medicine 100+ women who had reduction mammaplastyMost common reasons for surgery Lower back pain (92%) Shoulder grooves from bra straps (84%) After surgery 83% improvement in shoulder groove pain 78% decrease in lower back pain
Psychological Discomfort 1999 (very) informal survey by me 50 women who had reduction
surgery responded by email
80% had reduction because of sexualharassment, usually during teen years
Unwanted, humiliating, frightening sexual advances
Not just peers
Sexual Harassment
In our society,
large breasts = promiscuity
Social/cultural/family pressure Desire to “fit in” and be “normal”
Poor self-image Perceive physical abnormality
Feel “freakish”
Not taken seriously or respected for abilities
Selected Reduction Mammoplasty
Surgical Techniques and their ProbableEffects on Lactation
Liposuction
AKA ScarlessBinelli
Several small incisions made to access fat tissue Possible to avoid
area near areola
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 15
Liposuction
Limitation: skin can only shrink two cup sizes
Usually used with other procedures
Pedicle Techniques Areola and nipple remain
attached to mound of breast tissue containing Blood vessels
Ducts
Nerves
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
Lactation capability substantially protected (Brzozowski, 2000)
Higher milk production than Superior Pedicle technique (Sandsmark , 1992)
Higher milk production Free Nipple Graft technique (Marshall, 1994)
Superior Pedicle Technique
Wedges of tissue removed below areola Area most likely to
contain lactationtissue
Incision below (superior to) pedicle may sever 4th intercostal nerve
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 16
Central Pedicle Technique AKA the “circumareolar technique” Least visible scarring Only incision around areola Areola remains attached Tissue removed through incision
Blood and nerve supply to areola largely preserved 4th intercostal nerve likely
to be damaged
Amount of tissue removal determined by desired shape
Free Nipple Graft
Complete removal of areola and nipple Wedges of tissue removed
from lower breastMany ducts and glands
removed or severed Extensive damage to
remaining tissue Some degree of
reinnervation and recanalization possible(Ahmed and Kolhe, 2000)
Breast Reduction Surgical Photos
Implications of Reduction Mammoplastyfor Lactation
Surgical Variables Affecting Lactation
MOST IMPORTANT: Type of surgerySevere nerve damage probable
—Interferes with milk ejection
—Decreased release of oxytocin
Some milk ducts almost always severed—Reduced milk transfer
Surgical Variables Affecting Lactation
Techniques that minimize scarring usually destroy more nerves, blood supply, and lactation tissuesMothers can find technique used on surgical
consent form
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 17
Other Variables AffectingMilk Production Capability LIKE AUGMENTATION: Surgeon’s skill
Healing process
Time since surgery Allows ducts and nerves to reconnect and regenerate
Normal sensation normal milk ejection
Inherent lactation capability
Breastfeeding management
Attitude/perspective
Breastfeeding after Reduction Research Studies Almost all women who had reduction mammoplasty
can lactate, although they may not have a full milk supply (Harris, 1992)
35% exclusive breastfeeding 65% early cessation or
no breastfeeding
Breastfeeding after Reduction Research Studies Reduction mammoplasty likely to reduce milk
supply (Souto et al, 2003)
Outcomes range from 0-70%, depending upon type of surgery performed (Widdice [meta-analysis], 1993)
What Mothers May Hear from their Surgeons “Women with large breasts can’t breastfeed anyway”
“You’ll have a 50/50 chance of being able to breastfeed” They usually mean a 50/50 chance of FULL lactation, not a
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 from their Doctors Don’t breastfeed or you’ll get mastitis from
unrelieved engorgement! HIGHLY UNLIKELY No milk outlets means no external bacterial access Engorgement usually resolves by end of first week
without intervention Lack of milk removal leads to involution/atrophy of the glands Follow normal engorgement protocols
CAN be prolonged engorgement from milk stasis in severed ducts Areas evident after normal LGII fullness subsides
Possible Complications of Breast Reduction Surgery Blanching seems
common after periareolar surgery Try squeezing blood
back into nipple Nifedipine (Barrett , 2013)
30 mg (slow release) 1x day for 2 weeks
About 10% of women must repeat course 1-3 time
Also available in topical
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 18
Possible Complications of Breast Reduction Surgery
Latching can be more difficultPedicle often less full
Harder for baby to grasp
Try pressing index finger up into breast(“nipple nudge”)
Possible Complications of Breast Reduction Surgery Output between breasts may be markedly different Most have significantly more milk on one side than the other
The Bottom Line on Breastfeeding After Breast Reduction
Any surgery to reduce the breast can affect lactation
Reduction surgeries with the least scarring often have the worst lactation outcomes
You can’t tell what kind of surgery she had by her scars
Reduction techniques with the best lactation outcomes preserve Nerve function
Glandular tissue below the areola
YOUR encouragement matters!
Managing Breastfeeding After Breast Surgery
Maximize milk removal to calibrate high capability
The more milk that is removed in the first 2-3 weeks,the higher milk production capability will be for this baby
Calibration process restarts for each baby
Extra pumping even if only just during this time
Managing Breastfeeding After Any Cosmetic
Breast Surgery
Follow standard lactation protocolsAssess 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
Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
Copyright © 2014 by Diana West, IBCLC 19
Increase milk production if necessaryIncrease milk removalGalactagogues (substances that increase milk
production) Prescription medications usually most effective
—Domperidone optimal if available
Many herbs can moderately increase milk production—Goat’s rue seems to work especially well for many
post-surgical moms
Consider What You SayMothers who have had breast surgery
are very vulnerable to HCP adviceDiscouragement of breastfeeding results
in significantly lower breastfeeding rates(Deutinger et al, 1990)
Encouragement of breastfeeding results in significantly improved lactation outcomes (Brzozowski, 2000)
THE END
Questions?Thoughts?
Comments?
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Breastfeeding After Cosmetic Breast SurgeryPresented by Diana West, BA, IBCLC
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