Ten years ago, when I was pregnant with my first son, I did not even bother to learn about breastfeeding because I was certain I could not do it. I had had breast reduction surgery five years before I became pregnant, and my surgeon had been very clear that it would not be possible to breastfeed after the surgery. All the breastfeeding books I read were very discouraging and implied that surgery was one of the few circumstances that made breastfeeding impossible.
As in many aspects of mothering, I was soon to learn that the intellect does not always coincide with what the mother's heart and body know. At the moment my son Alex was born, something incredible came over me. I insisted that he be brought to me so that I could put him to my breast. It had been a long, high-tech labor, but I was deep in right brained "primal mode." Nursing him seemed the most basic and natural next step after the delivery. I asked my husband to bring him to me so I could nurse him. With a bit of surprise, he quickly brought Alex to me from the warming isolette. I lowered the corner of my hospital gown and latched him on as if I had been doing it for years. He latched eagerly and well. I felt a sense of deep satisfaction unlike anything I had ever known before. The next day, I was nursing him as my in laws visited us in the hospital. I wondered aloud if breastfeeding was really working. My father-in-law confidently said, "You're doing it, Mom!" I think it was at that moment that I realized how intricately bound breastfeeding and mothering really are.
I became fiercely determined to make breastfeeding work for my baby and me. Although I learned that I did not have enough milk for Alex, I also learned that I could supplement him with formula at the breast--and I rejoiced in any amount of my own milk that he received. Alex had many severe allergies, and I know my milk made a tremendous difference in reducing his exposure to allergenic substances.
I have now successfully breastfed three sons with increasing amounts of milk. I am still nursing the youngest, who is now three and climbing on and off my lap to "eesh" as I write this article. My desire to breastfeed my sons was such an important part of my development as a mother that it now seems natural to me to extend my passion about breastfeeding to helping other mothers who have had breast surgery, and teaching lactation professionals about the topic so that they can better help their post-surgical clients.
LACTATION FUNCTIONALITY AFTER BREAST SURGERY
In the ten years since I began exploring the possibility of breastfeeding after my breast surgery, it has become apparent that almost all mothers who have had breast surgery (barring mastectomy or radiation) are able to produce some amount of milk. The question has become not if such a mother can lactate, but rather how much milk she will be able to make. (1)
Women tend to remember very vividly the statements their surgeons make about their future breastfeeding capabilities. Many mothers who have had breast surgery are told, as I was, that breastfeeding is not possible, or that they have "a 50/50 chance." Unfortunately, many cosmetic surgeons have an incomplete understanding of the process of lactation. Their projections of lactation capability are often based on the assumption that any lactation is full lactation; that is, if a woman has any milk at all, she has a full milk supply. They do not realize that it is possible to have a partial (incomplete) milk supply. They are not usually referring to the amount of milk a mother might be able to make, but are rather estimating a 50 percent chance that she will be able to lactate at all. So a mother may think that if she has any milk, she will be able to exclusively breastfeed, or that if she has no milk, she will not be able to breastfeed at all. It is important for mothers to understand that the process of lactation, especially after breast surgery, is more complex than these basic assumptions indicate.
While any surgery to the breast can reduce lactation functionality, there are many factors that directly affect the ultimate outcome. When anticipating lactation capabilities, tremendous emphasis is often placed on the state of the ducts. It is important to understand, though, that the condition of the nerves that affect lactation is equally important. An incision in the lower, outer portion of the areola is likely to sever the fourth intercostal (between the ribs) nerve, which is critical to lactation because of its role in triggering the release of oxytocin, which in turn triggers the milk ejection reflex (MER). (2) For this reason, surgeries in which there is less scarring because the incisions are "hidden" on the areola are usually more injurious to lactation than those in which there is extensive scarring. How well the lactation glands functioned before surgery, the postoperative course, the length of time between the surgery and lactation, other lactation experiences between the surgery and current baby, breastfeeding management, and the mother's attitude toward breastfeeding can also be important influences on her breastfeeding success.
DUCT AND NERVE REGENERATION
Recanalization is an exciting phenomenon for women who have had breast surgery. It is the process wherein breast tissue is regrown, reconnecting previously severed ducts or connecting new ductal pathways. The most extensive instances of recanalization seem to have occurred in direct response to lactation demand. Any duration of lactation, therefore, prompts the mammary system to reestablish new ducts. The extent to which recanalization will occur seems to be directly correlated with the duration and degree of lactation. A mother whose previous lactation efforts resulted in an incomplete supply may find that future attempts result in a much greater yield. In some mothers, recanalization has resulted in a complete milk supply for subsequent children. Lactation tissue is also formed in response to hormones that occur during menstruation. Therefore, the longer the mother has lactated and the more menstrual cycles she has experienced, the greater the extent of recanalization.
Reinnervation is the process in which damaged nerves regenerate. In particular, when the nerves in the nipple-areolar complex regenerate, mothers produce a much greater supply of milk. The process of reinnervation is not influenced by the process of lactation or previous lactation events, but rather occurs at a predictable rate of one millimeter per month. When a woman's nipples regain normal response to touch and temperature, this indicates that the nerve infrastructure is functioning well and can conduct the appropriate sensations to the pituitary gland for production of the hormones prolactin and oxytocin, which are critical for lactation. Of course, the ability of the mammary system to fulfill the demand is dependent on the state of the glands and ducts. Nonetheless, the more time that has passed since the surgery, the greater the chances that the nerves critical to lactation will have regenerated.
BREAST REDUCTION SURGERY
Breast reduction surgery was the fourth most common cosmetic surgery in 2003. In that year 113,140 breast reduction surgeries were performed in the US--a 207 percent increase since 1997. The increase may be influenced by the fact that many US health insurance companies now underwrite the expense of the surgery if certain physical criteria are met. (3) These criteria may include a certain minimum amount of breast tissue that will be removed and striking indicators of excessive breast weight, such as shoulder grooves from bra straps. Many women with large breasts also have back or shoulder pain, headaches, damage to their spinal nerves, and difficulties in posture and breathing. Large breasts can also interfere with aerobic exercise and physical activities.
Yet the psychological reasons women have breast reduction surgery are often more compelling than their physical discomforts, though women may be reluctant to candidly discuss these reasons. Most women who have had such surgery develop early, when social influences are felt most keenly. In a society that equates large breasts with promiscuity, a young woman with larger breasts than other girls will attract attention that may make her very uncomfortable. Sexual harassment is quite common in schools and can be humiliating and frightening. Even mothers who understand the value of breastfeeding may urge their daughters to have the surgery in order to protect them from harassment.
Because their physical appearance differs so greatly from that of their peers, young women with large breasts often have a poor self-image and perceive themselves as having a severe physical abnormality. They also frequently find that they are not respected for their intellectual abilities. With breast reduction surgery, their bodies can fit into the range of normal body size, and they can significantly redeem their self-esteem. This is probably why the American Society of Plastic Surgeons cites this surgery as having the highest degree of patient satisfaction. (4)
Women who have undergone breast reduction surgery have scars that differ widely according to the surgical technique used. Examples include a scar around the areola, a scar in a vertical line from the areola to the fold of the breast at the chest wall, a half-inch horizontal scar at the base of the breast, a horizontal scar of about two inches somewhere above the inframammary fold (the fold under each breast), or a long horizontal scar along the fold of the breast at the chest wall. Some scars are hidden on the areola, some resemble an inverted T, and others resemble an anchor.
Of the many breast-reducing surgical techniques, nearly all are likely to reduce lactation capability. (5,6) The surgeries that have resulted in the greatest retention of lactation capability are those in which the areolae and nipples are not completely severed, even if they are moved, (7) and the lower portion of the nipple-areolar complex remains intact. (8) An example is the inferior pedicle technique, in which the areola and nipple are moved while attached to a mound of tissue, called a pedicle, that contains the still-connected lactiferous ducts and nerves. Damage to the lactation system in such surgery is a result of cuts deeper in the breast tissue, where glands are removed and ducts and nerves are severed.
Even when the nipples have been severed completely, as in the free nipple graft technique, some women have regained nipple sensitivity and some lactation capability. (9) Of course, many women believe their areolae and nipples were severed because they have scars around the outside of the areolae. They know that the areolae and nipples were moved and therefore assume that they must have been severed in the process. However, this is unlikely to be the case in the US, where, since 1990, most women who have had breast reduction surgery have had the inferior pedicle technique.
Many mothers who have bad breast reduction surgery lament the tact that, during pregnancy, their breasts are once again as large as--or larger than--they were before the surgery. It is important to remember that such women had the surgery because they have a tendency to grow large breasts. Women who choose to undergo breast reduction surgery in adolescence may have juvenile gigantomastia, a benign disorder of the breast in which one or both breasts increase greatly in size during adolescence. A study in 200l examined juvenile gigantomastia and noted a high incidence of repeat breast reduction, as the breast tissue continued to grow in significant proportions even after the first surgery. (10) Here is an important consideration that may console mothers who experienced juvenile gigantomastia: If they had not had the surgery, the increased breast growth over time, especially when accelerated by pregnancy and lactation, would have occurred in addition to their original breast size rather than their reduced size; in other words, their breasts would have been even larger and more uncomfortable than they are currently.
Breast augmentation surgery is an increasingly common cosmetic procedure in North America. In 2003 in the US alone, 254,140 women had breast augmentation surgery, a 20 percent increase since 2000. (11) As with breast reduction surgery, the psychological reasons women have this surgery may be more compelling than the physical: They simply wish to feel more normal and attractive. A 2003 study examining the factors that motivate women to seek cosmetic breast augmentation surgery found that women were more motivated by their own feelings about their breasts than by influences from external sources, such as romantic partners or sociocultural representations of beauty. (12) This finding refutes the common stereotype of the narcissistic woman with breast implants. In fact, it has been observed that women who seek breast augmentation often have significant doubts about their femininity that stem from adolescence. According to Rebecca Cogwell Anderson in Surgery of the Breast: Principles and Art, edited by Scott L. Spear, "Most women are not seeking to outdo other women in breast size; rather they want to catch up." (13)
The original state of the breasts prior to augmentation is very important in predicting a mother's lactation capability. Although small breast size alone is not a marker for lactation insufficiency, certain breast types are known to be markers for insufficient glandular tissue. (14) These types include tubular-shaped breasts, widely spaced breasts, undeveloped breasts, and asymmetrical breasts. In Surgery of the Breast, Spear notes: "Although management of the tuberous breast and other complex anomalies may at first appear like a variant of cosmetic breast surgery and augmentation mammoplasty, in fact, many of these cases require techniques more akin to breast reconstruction." (15) When so little glandular tissue exists, lactation capability is significantly reduced.
Most women report that they are not advised that they may have inherently insufficient glandular tissue or that breast augmentation can reduce their lactation capability. (16) As with all breast surgeries, severing ducts or nerves will result in a lower milk supply. The location, orientation, and extent of the incision determine how much the milk supply will be reduced. (17) Surgeons often attempt to minimize scarring in breast augmentation surgery to improve the aesthetic appearance of the breast by placing incisions in less visible areas, such as on the areola or in the inframammary fold. As with breast reduction surgery, an incision on or around the perimeter of the areola, particularly in the lower, outer quadrant, will result in reduced nerve response in the nipple-areolar complex, significantly reducing milk supply. (18)
The location of the breast augmentation incision has a direct bearing on lactation capability. An incision around the areola or across a portion of it will reduce nerve response more than an incision under the breast or in the armpit. Placement of the implant can also affect lactation functionality. An implant positioned under the glandular tissue is more likely to put pressure on the glandular tissue and thereby reduce milk supply than an implant positioned under the chest muscle.
Four main surgical techniques are used in breast augmentation: the inframammary, the transaxillary, the transumbilical, and the periareolar. The procedure most frequently used is the inframammary technique, in which the implant is inserted in the fold where the breast meets the chest wall and so does not leave visible scars. Inframammary surgery makes less of an impact on the milk supply because neither the glandular tissue nor innervation is affected. However, if the implant is placed on top of the pectoral muscle, it can exert pressure on the lactiferous ducts and glands, which will reduce lactation.
To minimize visible scarring, a transaxillary incision is made in the extreme upper, outer region of the breast, near the juncture (pit) of the arm and the torso. The incision is generally invisible even when the arm is raised. Implants are usually placed below the pectoral muscles. The impact on lactation is usually minimal because the glandular tissue and nerves are largely undisturbed. As with the other incision techniques, placement of the implant above the pectoral muscle will result in greater impairment to lactation than placement below.
A transumbilical breast augmentation (TUBA) is performed by inserting the implant through an incision in the navel and moving it into place in the breast. In this technique, no incisions are made on the breast or into the breast tissue, although the breast tissue is disrupted and sometimes damaged as the implant is brought into position. Insertion through the umbilicus makes it difficult to position the implant accurately and requires the use of a camera scope, it also permits placement only above the pectoral muscle. Like transaxillary surgery, the transumbilical procedure preserves glandular function and nerve response; the impact on lactation is usually minimal. As with the other incision techniques, placement of the implant above the pectoral muscle will result in greater impairment of lactation than placement below.
The periareolar technique requires an incision around the areola in order to hide scarring. Placement of the implant in this procedure results in significant duct, glandular, and nerve damage, carrying significant risk to lactation. Ducts and glands are likely to be severed because the incision penetrates deeply through the breast tissue. If the implant is placed above the pectoral muscle, it may further impede lactation function by exerting pressure on the glandular tissue.
In previous decades, the public became concerned that silicon from silicone implants might transfer to human milk. But a 1998 study stated that "lactating women with silicone implants are similar to control women with respect to levels of silicon in their breast milk and blood. Silicon levels are 10 times higher in cow's milk and even higher in infant formulas." (19) A 1994 study noted that "silicone is widely present in the environment and avoiding ingestion is difficult. Silicone drops have been used for years in both the US and Europe for colic." It was concluded that there should be no absolute contraindication to breastfeeding by women with silicone breast implants. (20) It is also reassuring to note that silicone is considered to be inert and unlikely to be absorbed by the baby's digestive tract. (21)
THOSE AMAZING BREASTS!
So yes--it is possible to breastfeed after breast reduction and augmentation surgeries. It is likely that the milk supply will be reduced somewhat, especially for the first baby after the surgery, but the supply can be increased by many psychological, mechanical, and chemical methods or devices, such as pumps and galactogogues (herbs that increase lactation; see "Herbs and Healthy Lactation" in Mothering, issue no. 78). Even when the milk supply cannot be increased to the point of full lactation, many mothers find that they can still have very satisfying breastfeeding relationships by supplementing (with formula or donated milk) in ways that maximize the milk supply and the time the baby spends at the breast.
I believe it is important for mothers not to base the value of breastfeeding on the amount of milk they can produce. As Mothering readers know so well, there is much more to breastfeeding than mere milk. It is a relationship that provides the elements for developing our babies' and our own best selves. Every drop of milk that a baby receives is precious, and every moment that a baby spends at the breast is invaluable. A lack of milk need not diminish that experience.