Breastfeeding after Breast Reduction Surgery
Gaithersburg MD USA
From: LEAVEN, Vol. 38 No. 4, August-September 2002 p. 75-79.
Since its publication in the summer of 2001, DEFINING YOUR OWN SUCCESS: BREASTFEEDING AFTER BREAST REDUCTION SURGERY by Diana West is becoming known among health professionals, lactation consultants, and Leaders as the definitive book on this topic. For a variety of reasons, breast reduction surgery is an experience that many women face or consider in today's culture. West brings her readers to an in-depth look at the various intersections of breastfeeding and reduction surgery and carefully lays out the options available to women so that they may direct their experiences with the confidence that breastfeeding is possible. This book is an incomparable resource for anyone dealing with mothers who are or wish to breastfeed and have had or are considering breast reduction surgery. La Leche League International is pleased to present a substantial excerpt from chapter four of West's book, DEFINING YOUR OWN SUCCESS: BREASTFEEDING AFTER BREAST REDUCTION SURGERY.
Breastfeeding after breast reduction surgery (BFAR) would be so much simpler if it were possible to clearly spell out each woman’s abilities by saying that if she had "type A" surgery, and does "B," she will have "C" result. The truth is that there are so many variables that few experiences are the same. In fact, the range of BFAR experiences is extremely diverse and dependent upon myriad factors, including the type of surgery a woman had, and her state of mind, attitude, environment, support structure, and what she was able to do to prepare.
The Range of BFAR Experiences
BFAR experiences are comprised of combinations of variables of two factors: lactation capability and feeding method. A mother’s lactation capability will fall somewhere on a continuum of possible experiences: there will either be a full milk supply, a partial milk supply, or no milk supply at all. Feeding method options will encompass feeding at the breast, feeding at the breast with an at-breast supplementer, and feeding with artificial feeding devices. The method by which a mother chooses to feed her baby will depend upon milk supply, the feeding method most appealing to her in terms of comfort and convenience, and her baby’s preferences.
Determining Lactation Potential
When consulting with a plastic surgeon prior to breast reduction surgery, women are usually advised that the surgery will affect their lactation capability to some degree. Depending on the surgery, doctors commonly describe the potential capability by stating that there is either no possibility that she will be able to lactate, a "50/50" chance, or that it will not affect her lactation capability at all. What the surgeons perceive as the answer to the question of lactation capability, however, and what women really need to know can be quite different. A surgeon’s projections of lactation capability is often based on the assumption that any lactation is full lactation. It is not often qualified by how much of a milk supply the mother will have. In fact, the "50/50" chance so often quoted refers to having a 50 percent chance that she can lactate at all. The critical information to a future mother, however, is not whether she will be able to lactate at all, but rather how much she will be able to lactate.
It may be that the reason plastic surgeons tend to predict post-surgical lactation capabilities in terms of "all" or "nothing" is because the process of lactation is not well understood by many physicians, especially those outside of the obstetrical/gynecological and pediatric specialties. In fact, the mammary system is comprised of many co-operative, redundant networks of glands and ducts. It is possible that some portion of the original number of gland/duct networks will remain intact after the surgery. It is even possible that some of the gland/duct networks that are damaged by the surgery will reconnect, which is known as "recanalization."
The body is remarkably resilient; almost all women who have breast reduction surgery will be able to lactate to some degree. But if a significant portion of the lactation system was impaired by the surgery, then the milk supply will not be enough to meet a baby’s entire nutritional requirement.
Unfortunately, few studies have been conducted to investigate the effects of breast reduction surgery on lactation. Nonetheless, it is helpful to examine the latest research on lactation after breast reduction surgery as a fairly objective way to understand the probability of doing so.
One often referenced study by Harris et al. collected information by sending a standardized questionnaire to women who had had inferior-based pedicle breast reduction surgery. Seventy-three patients were contacted. Of the 68 who responded, 20 patients had become pregnant after reduction mammoplasty. All 20 women lactated. Seven of these women (35 percent) went on to breastfeed successfully. Thirteen (65 percent) decided not to breastfeed or discontinued breastfeeding for personal reasons. This study does not actually provide a great deal of information beyond indicating that the women studied were able to lactate.
A study published in early 2000 specifically investigated the impact of the inferior pedicle reduction technique upon lactation. Brzozowski et al. sent a standardized questionnaire to 334 women who had had this type of surgery between 1984 and 1994, ranging in age from 15 to 35 years at the time of surgery. In the questionnaire, they defined successful breastfeeding as the ability to feed at the breast for at least two weeks.
Seventy-eight patients had children after their breast reduction surgery. Fifteen of the 78 patients (19.2 percent) breastfed exclusively, 8 (10.3 percent) breastfed with formula supplementation, 14 (17.9 percent) had an unsuccessful breastfeeding attempt, and 41 (52.6 percent) did not attempt breastfeeding. Of the 41 patients not attempting to breastfeed, 9 patients did so as a direct consequence of discouragement by a health care professional. Of the 78 women who had children postoperatively, a total of 27 were discouraged from breastfeeding by medical professionals with only 8 of the 27 (29.6 percent) subsequently attempting to breastfeed, despite this recommendation. In comparison, 26 patients were encouraged to breastfeed; nineteen (73.1 percent) of them did subsequently attempt breastfeeding. Postpartum breast engorgement and lactation were experienced by 31 of the 41 patients not attempting to breastfeed. Of these 31 patients, 19 believed that they would have been able to breastfeed due to the extent of breast engorgement and lactation experienced.
This study concluded that:
Given the use of an inferior flap mammaplasty technique and patient encouragement, the possibility for breastfeeding after reduction mammaplasty exists. This prevalence falls near the breastfeeding rate found in the population not having undergone breast surgery, according to an article in the Canadian Journal of Public Health.
Another study also published in early 2000 by Ahmed and Kolhe compared the nipple and areolar sensation after breast reductions that used the free nipple and inferior pedicle surgical techniques. They found some degree of recovery of nipple and areolar sensation in all patients, with areolar sensation being similar in the two groups, but nipple sensation being superior in the inferior pedicle group. This was particularly interesting because it had always been widely believed that the free nipple technique resulted in a complete loss of nipple and areola sensation. This would have a severe impact upon lactation since milk production depends a great deal on responding to nerve stimulation during breastfeeding. This study gives new hope to those who had the free-nipple surgical technique, especially those for whom considerable time has elapsed.
Finally, a study by Sandsmark et al. in 1999 compared the effects of the superior and inferior pedicle techniques. The 292 patients studied had received surgery between 1984 and 1990. Two hundred and thirty-three received the superior pedicle technique, 36 received the inferior pedicle technique, and 23 had other types of reduction surgery. Not surprisingly, the authors found that the inferior pedicle technique yielded better results in terms of increased sensitivity, particularly of the nipple-areola complex, and better lactation.
The information in texts, both clinical reference books and more popular consumer-oriented books, differs greatly in the opinions presented on the possibility of breastfeeding after breast reduction surgery. Drs. Riordan and Auerbach present the most accurate information in their book, Breastfeeding and Human Lactation, in which they state that "Full breastfeeding may be possible with the pedicle technique, but it is rarely possible with the free-nipple technique, because blood supply of the nipple-areola is completely severed." This conclusion is quite accurate; the free-nipple technique yields a significantly diminished probability of lactation.
Certainly, the research available on breastfeeding after breast reduction surgery needs to be expanded. In Surgery of the Breast, Principles and Art, edited by Scott Spear, it is stated that:
Lactation after breast reduction remains an unresolved question. Normal lactation after reduction certainly occurs frequently but may be impaired in some patients. The precise percentage or number of patients with impairment of lactation after breast reduction remains to be documented in future studies.
With the increased prevalence of women who want to breastfeed following breast reduction surgery, it is likely that more research into this field will occur, resulting in even better developments in reduction mammoplasty surgical techniques to preserve the lactation function.
Baseline Lactation Capability
As the research and anecdotal evidence demonstrates, the question is not whether a woman will have milk, because she almost certainly will. The true question is how much milk she will have. In order to project what the likely lactation potential will be for a mother, several critical factors that define the state of a woman’s present mammary system must first be considered. These factors do not determine the lactation capability, however. They are merely an indication of a mother’s baseline lactation capability.
Type of Surgery
The starting place to determine the baseline lactation capability is to know what type of breast reduction surgery a mother experienced. This information is important because some surgical techniques preserve more lactation tissue than others.
Although the type of reduction surgery experienced will have a significant impact on future lactation capability, the aspect of the breast reduction surgery that is most likely to affect lactation is the surgical treatment of the areola and nipple, which can vary even among similar surgical techniques according to the individual woman’s anatomy and the surgeon’s skill. The surgeries that have resulted in the greatest lactation capability are those in which the areolas and nipples were not completely severed, even though they may have been moved. Many women believe their areolas and nipples were severed because they have a scar around the outside of the areola. They may also know that the areola and nipple were moved, and therefore assume they must have been severed to do so. With surgical techniques performed since 1990, this is unlikely to be the case. Most current breast reduction surgical techniques involve moving the areola and nipple attached to a wedge of tissue, called a pedicle, which contains the lactiferous sinuses. The pedicle remains attached to the ducts that connect to the lactiferous sinuses, as well as the primary nerves. If damage to the lactation system occurs in these types of surgeries, it is more likely to be a result of cuts deeper in the breast tissue, where glands were removed along with fatty tissue and ducts were severed.
The types of surgeries that
utilize the inferior pedicle technique have consistently yielded the
greatest lactation results. However, in his book, Everything You
Wanted to Know about Cosmetic Surgery But Couldn’t Afford to Ask,
Dr. Alan Gaynor states:
There are slightly different methods of doing the same technique. The inverted T is most widely used. Several techniques use this approach because it is possible to maintain the integrity and function of the breast. The internal treatment of the gland can vary a lot according to the surgeon.
There are, of course, breast reduction surgical techniques that do completely sever the areola and nipple from the breast. These techniques were commonly performed in the 1970s and 1980s before the more advanced pedicle techniques were developed. They are also occasionally performed on women who, according to the judgment of the surgeon, have such large breasts that the pedicle technique would not provide satisfactory results.
When the areola and nipple have been completely severed, lactation will be far less likely. However, although it is not common with non-pedicle surgery, some possibility of lactation remains because of the miraculous process of recanalization. On occasion, women who have had their areolas and nipples completely removed have been known to be able to easily express colostrum during pregnancy. While this was certainly a good sign and proved that some ducts had recanalized, they later found that they were able to produce very little milk. This is usually because the severed nerves prevent the lactation system from producing milk in response to nerve stimulation at the nipple and areola. Colostrum is produced easily because it is hormonally driven and not dependent upon nipple/areolar stimulation. Only very rarely have women with completely severed areolas and nipples produced a significant milk supply, and usually this is a result of the use of substantial amounts of galactagogues. Of course, the amount of the milk supply does not at all preclude any woman from having a deeply satisfying breastfeeding relationship because she can supplement at the breast with a specially designed at-breast supplementer.
Length of Time between Surgery and Subsequent Pregnancy
The next important consideration that influences milk supply is the length of time between surgery and subsequent pregnancy. The anecdotal experience has been that, despite the type of surgery, a woman seems to have a better milk supply when her surgery occurred five or more years before her pregnancy. This could be the result of three separate physiological processes, each of which contributes to repairing and developing the mammary system.
The first two of these processes, recanalization and reinnervation (regrowth of ductule and neural pathways, respectively), are pertinent to mention in this context because both healing processes are more probable when the interval between the surgery and the pregnancy is greater. Both processes are also directly responsible for increases in the milk supply. Although recanalization seems to result more from the demands of actual lactation, it is still probable that some recanalization, like reinnervation, would occur as a normal healing process of the body.
The third beneficial process is the normal, progressive linear development of the mammary system, wherein hormonal influences result in further mammary system development with each menstrual cycle experienced until the event of the first pregnancy, when the mammary system normally becomes fully mature. A longer length of time between the surgery and the pregnancy enables this process to redevelop mammary tissue.
Breast Changes during Pregnancy
Ask the mother whether she has experienced any enlargement, including a feeling of heaviness, of her breasts during pregnancy. Also, has she had any soreness or tenderness? Changes such as these during pregnancy will not indicate how much of the mammary system is functioning or if ducts are connected to the nipples, but they do indicate that the breast tissue is responding appropriately to hormonal influences and that at least some of the mother’s mammary system is intact. If the mothers has been pregnant before her surgery, these changes will be less pronounced during this pregnancy than during previous pregnancies, but they should still be present to some degree.
Recanalization and Reinnervation
Recanalization is a very exciting physiological phenomenon for BFAR women. It is the process wherein breast tissue actually regrows, reconnecting previously severed ducts. On occasion, completely new pathways that permit transportation of the milk from the glands to the nipple may be formed. The most profound instances of recanalization seem to occur in direct response to lactational demand. This means that any efforts to lactate encourage the mammary system to reestablish the mammary ductule system. Of course, at this time, the process of recanalization is not well enough understood to be able to predict the extent to which recanalization will (or can) occur. Because it 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. As a general rule, the longer the lactation experience, the greater the extent of recanalization will be.
Reinnervation, on the other hand, seems to occur in response to the passage of time and the body’s normal regenerative process, rather than as a result of previous lactation events. Reinnervation is the process whereby the nerves that serve the nipple and areola that were damaged by the surgery are regenerated. The nerves of the nipple and areola are critical to the process of lactation, so regeneration of such nerves would be a key component of increased lactation capability. Many BFAR women wonder if the sensitivity currently present in their nipples and areolas is indicative of the state of the lactational nerve connections. The answer is that if they are once again responding normally to touch and temperature, it may indicate that the nerve infrastructure is functioning well and would therefore conduct the appropriate sensations to the pituitary gland for production of prolactin and oxytocin. Of course, the ability of the mammary system to fulfill the demand is dependent upon the state of the glands and ducts. Nonetheless, the longer the length of time since the surgery, the greater the chances that the nerves critical to lactation have regenerated, which is an important factor for lactation.
Each woman is capable of an inherent lactation capability that existed before her surgery according to her own unique physiology and anatomy. Some women tend to have copious milk supplies, perhaps even to the point that it presents a problem. A certain percentage of BFAR women would have had this "problem" had they not had the surgery. What this means for them, though, is that their lactation system will compensate very well for surgical damage and they will have better milk supplies because of their greater inherent yield.
Many surgeons have told prospective breast surgery patients that because their breasts were so large, they would never have been able to successfully breastfeed anyway. This is patently untrue and unjustly shifts the responsibility for lactation insufficiency from the surgery to the woman’s inherent physiology. The truth is that the size of a woman’s breasts does not bear any impact upon her ability to lactate. An incomplete milk supply following breast reduction surgery is almost invariably a direct result of that surgery. It is not a result of the woman’s natural breast size.
There is a natural fluctuation to a woman’s milk supply over the course of breastfeeding that is unrelated to the surgery, but is rather a normal process for all lactating women. Contrary to common belief, mothers do not initially produce eight ounces of milk at a feeding, nor do newborns need such a large amount of food. Instead, their bodies begin producing milk in much smaller quantities that are perfectly suited to the needs of their babies at the particular age they may be. For instance, even in women who have not had reduction surgery, colostrum is produced in mere teaspoons during the first few days after birth. When the milk matures over the next few weeks, it is normal and appropriate for a mother to only produce a few ounces per feeding. As the baby progresses through the standard growth spurts at about three weeks, six weeks, three months, and six months, the milk supply is correspondingly increased by the baby’s increased demand so that a mother begins lactating in greater quantities. After the baby begins solids and begins nursing less, the milk supply decreases to produce only as much as the baby requires. This process continues in diminishing quantities until the baby no longer takes any milk and weaning has occurred.
Many BFAR mothers increase their inherent milk supplies by manipulating them with herbal and prescription galactagogues (milk-inducing substances), special massage techniques, and pumping. These actions can be effective and can increase milk supply. Taking galactagogues in particular is a very common component of the average BFAR experience.
Most BFAR mothers find that they have a greater milk supply with each subsequent baby. Although recanalization and reinnervation certainly play a significant role in this, so does the increased experience, information, and support that she may have with subsequent babies. Each of these factors contribute to a woman’s perspective about her BFAR experience.
Combinations of Feeding Methods
Because there are so many variables to consider, it is unrealistic to attempt to portray a "typical" BFAR experience. Yet reviewing the options, benefits, and challenges of various types of BFAR experiences can help present a clear illustration in your mind’s eye of what each scenario may entail. A mother may find that she will want to use different techniques as her milk supply fluctuates and needs or priorities change.
When a baby requires full supplementation because a woman has no (or nearly no) milk supply, but still desires to breastfeed, she has several options:
- Feed baby exclusively at the breast with an at-breast supplementer
- Feed baby at the breast with at-breast supplementer plus use artificial feeding devices;
- Nurse at the breast for comfort plus use artificial feeding devices.
Mothers who are able to lactate, but still need to provide part of their baby’s nutritional requirements with a supplement, have several choices:
- Feed baby exclusively at the breast combining active lactation with at-breast supplementing;
- Feed baby at the breast with at-breast supplementer, combined with active lactation, plus use artificial feeding devices;
- Feed baby at the breast plus use artificial feeding devices;
- Pump milk supply and feed baby with artificial feeding devices.
Even a mother who is producing a full milk supply has certain options as to how she will feed her milk to her baby. Some of these options may be influenced by the BFAR experience; others are choices available to all lactating mothers.
- Feed baby exclusively at the breast;
- Feed the baby at the breast and also pump and feed with an artificial feeding device.
- Pump and feed with artificial feeding device.
The Effort and Rewards of BFAR
Many new mothers wonder whether or not they want to face the challenges involved in breastfeeding after breast reduction surgery. It can be said with reasonable certainty that breastfeeding will entail more work and probably more worry for a mother who has had breast reduction. If supplementation is necessary, the efforts can sometimes seem very arduous and time consuming. Pumping and managing galactagogue intake can also be a lot of work. And it is certainly time consuming to learn about BFAR in order to be able to do it as well as possible. But the efforts expended in supplementing are usually no more than that expended by other bottle-feeding or partially breastfeeding mothers. And after the initial learning curve when mother and baby are working out their optimal system, things can run very smoothly.
If a mother is able to maintain breastfeeding, she will always have that special breastfeeding bond. She will be able to nurse to comfort and soothe her child.
If a mother supplements completely at the breast without lactating at all, she will be rewarded by an intimate breastfeeding relationship, as well as many of the structural benefits of breastfeeding, such as better facial development.
If it turns out that a mother can’t have a breastfeeding relationship and decides to provide her child with human milk in a bottle, she will always have the satisfaction of knowing that her body provided a priceless gift at each and every feeding.
No matter how things turn out, as long as a mother continues to give her child any human milk at all, it will be well worth the effort. Every drop of human milk is a precious, enduring treasure for a child, and feeding him at the breast even if there is no milk at all will be deeply satisfying.
Keep in mind, though, that even when a mother has prepared in every way possible, her baby is likely to have a mind of his own. He may have very different ideas about how he wants to go about things. After all, when entering into a relationship, compromise is necessary.
The most important thing to keep in mind when preparing a mother for BFAR is that the reality will probably be much more intense than ever imagined. Reassure her that this is not because of her breast reduction surgery; it’s because she is having a baby, and babies tend to turn the world upside down in an amazing way.
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Riordan, J. and K. Auerbach. Breastfeeding and Human Lactation, 2nd edition. Sudbury, Massachusetts: Jones and Bartlett Publishers, 1999; 494.
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