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by Diana West BA, IBCLC
Predicting a mother's ability to breastfeed after breast reduction or augmentation surgery would be much simpler if we could say 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. The range of experiences is extremely diverse and dependent upon myriad factors, including the type of surgery and how the surgery was performed, e.g. a surgeon sensitive to women who will have children and want to breastfeed and the mother's state of mind, attitude, environment, support structure, and what she was able to do to prepare. Each mother's experience will be different; some may be able to breastfeed exclusively, while others may need to supplement the baby's entire nutritional requirement. Of course, the amount of the milk supply does not at all preclude any woman from having a deeply satisfying breastfeeding relationship because there are many ways for a mother to supplement in ways that are supportive of breastfeeding.
Any surgery upon the breast carries the inherent likelihood of affecting lactation. Fortunately, the mammary system is comprised of many co-operative, redundant networks of glands and ducts and damaged nerves repair themselves over time. Even with the most invasive surgeries, it is possible that some portion of the original number of glands and ducts will remain intact. It is even possible that some of the glands and ducts that are damaged by the surgery will reconnect, which is known as "recanalization," and some of the nerves critical to lactation will regrow, which is known as "reinnervation." 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.
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. The starting place to determine the baseline lactation capability is to know what type of breast reduction surgery a mother experienced because some surgical techniques preserve more lactation tissue and critical nerves than others. Also relevant is the number of intact ducts. A woman will almost certainly have milk, but there will need to be ducts to move that milk to the nipple. The mother may require recanalization to help this happen.
The reduction 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 while still attaching to a wedge of tissue, called a pedicle, which contains the lactiferous change to ducts and remains attached to the ducts and primary nerves.
There are breast reduction surgical techniques that do completely sever the areola and nipple from the breast, which more severely reduces lactation. 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 have such large breasts that the pedicle technique would not provide satisfactory results. Only very rarely have women with completely severed areolas and nipples produced a significant milk supply.
Similarly, breast augmentation surgeries that result in the best lactation outcomes are those in which the incision for the implant does not sever the nerves near the areola, such as incisions in the armpit, under the breast and at the umbilicus. Implants placed under the muscle tend to result in better lactation outcomes than those placed over the muscle.
The length of time between the surgery and the subsequent pregnancy is also important. Research has shown that women have a better milk supply when the surgery occurred five or more years before pregnancy. This is likely to be the result of recanalization and reinnervation, as well as the hormonal influences of each menstrual cycle that foster mammary gland development. A longer length of time between the surgery and the pregnancy enables this process to redevelop more mammary tissue.
Many mothers who have had breast surgery 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 experience of breastfeeding after breast surgery.
Most mothers who have had breast surgery 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 experience.
Many new mothers wonder whether or not they want to face the challenges involved in breastfeeding after breast 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 surgery. If supplementation is necessary, the efforts can sometimes seem very arduous and time consuming. Expressing and managing galactagogue intake can also be a lot of work. But the efforts expended in supplementing are usually no more than that expended by other bottle-feeding or partially breastfeeding mothers. After the initial learning curve when mother and baby are working out their optimal system, things can run very smoothly. It is also important to remember that breastfeeding is so much more than nutrition. By breastfeeding our babies, we meet a whole range of emotional needs as well.
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.
Diana West, BA, IBCLC, is a La Leche League Leader and a lactation consultant in private practice. She is the author of "Making More Milk: A Nursing Mother's Guide to Milk Supply" (La Leche League International, available 9/05), "Defining Your Own Success: Breastfeeding After Breast Reduction Surgery," (La Leche League International, 2001), and the "Lactation Consultant Unit: Breastfeeding After Breast Surgery," (La Leche League International). She is also the administrator of the BFAR.org and LowMilkSupply.org websites. Diana mothers her three charming, breastfed sons in partnership with her husband Brad in their home in New Jersey, USA.
