Breastfeeding and Cosmetic Breast Surgery in Israel

Gina Weissman, DMD, IBCLC

The rate of cosmetic breast surgery is growing rapidly in Israel and abroad. But young women and teenagers don’t always consider the impact their surgery will have on breastfeeding. Even though women are often told differently, all types of breast surgery can affect breastfeeding.

At the La Leche League Israel Conference in June, 2009 at Tel Hashomer Hospital/Sheba Medical Center, Gina Weissman, International Board Certified Lactation Consultant/Doctor of Dental Medicine/La Leche League Leader, spoke on the growing rate of cosmetic breast surgeries in Israel. She looked at the impact on breastfeeding of the latest methods of surgery, and gave guidelines for breastfeeding professionals working with mothers with a surgical history. Gina graciously agreed to answer my questions by phone and email.

For more information, see Gina Weissman’s website (Hebrew).

What got you interested in the topic? In the last 5 or 6 years I have seen a huge rise in the number of women with past surgeries. They didn’t even bring it up until I noticed something unusual and asked about it. They would say, “Oh yeah, but my doctor said it would have no effect,” or “Oh, that was years ago.” Some were worried their husbands would find out. These women had breastfeeding issues, and I felt I that in order to help them, I needed to learn more about the effect of cosmetic surgery on breastfeeding.

The two main types of cosmetic surgery on breasts are reduction and enlargement. Breast reduction has benefits for women, including reduction of breast pain and back problems, and patients report a high level of satisfaction compared to other cosmetic procedures. Most of the increase in recent years is in the number of operations to enlarge the breasts, as much as 700% over a two-year period.

Most of the focus on breast surgery and breastfeeding has been on reduction. Diana West has a website and a book on the subject. Women who choose to enlarge their breasts assume they will be able to breastfeed. Breast enlargement is less of a problem, but it does affect breastfeeding.

How did you prepare for the lecture?

I turned to the company providing malpractice insurance for plastic surgery to get statistics for 2005 to 2009. The statistics are important, but I also wanted to know what is behind the scars. I spoke to plastic surgeons and read a textbook. One surgeon said, “After you’ve read it, you can come to see surgery.” I looked at what this poor boob has to go through, whether enlargement or reduction. In a third type of surgery, the breast lift or mastopexy, the nipple is moved upward. The scars and tissue removal are similar to reduction. Skin under the nipple and areola are cut off.

I also talked to mothers struggling, and followed up with mothers I had counseled.

Are silicone implants still used for breast enhancement? Are they dangerous?

Silicon is very popular all over world, and is considered safe. Saline is a more benign option, but considered less aesthetic. They feel different and both must be removed in case of leakage.

Complications:

Implants are often replaced because of ruptures or changes caused by gravity. Most often, though, the woman decides to change the look.

The most common complications are hematoma and capsular contractures, when the body makes a stiff shell over the implant. The implant must be removed. More nerves are cut, causing further problems for breastfeeding later on. In a 2003 study, the mean time for all revisions, whatever the reason, is seven years.

Placing the implant under the muscle reduces the risk of capsular contracture and may slightly reduce the risk of breast cancer. No evidence indicates that silicone implants increase the risk of breast cancer.

What factors determine whether a mother with a history of cosmetic breast surgery will breastfeed successfully?

• Type of surgery.
• Motivation to breastfeed.
• Quality of help received during the first two days when milk calibration begins.
• Whether the mother values less than 100% exclusive breastfeeding. Producing even a small percentage of the baby’s food supply can be a great accomplishment for many.
• Active natural birth.
• Mother-baby togetherness.
• Accurate updated information and support.
• Noting breast changes during pregnancy, in order to get an advance picture of the situation.
• Length of time since surgery, intervening pregnancy and birth, and nursing experience, all of which increase recanalization of the breast tissue.

What techniques help a mother with past surgery maximize supply?

• Being with baby skin to skin, increasing oxytocin levels.
• Putting baby to the breast even if only a few drops are available, aiding the start of milk production.
• Expressing milk within six hours of birth if baby especially if the baby isn’t nursing actively. Mothers with a history of surgery can take the extra precaution of expressing in addition to nursing to increase supply even if she doesn’t know whether the surgery affected her supply.
• After reduction, or if a mother has minimal breast tissue, watching for early signs of milk production and continuing to express 8 times a day.
• Getting skilled lactation help.
• Considering a prescription for medication to increase supply.
• Learning how to give supplements at the breast, if needed.
• Using techniques that all new mothers use: Nurse baby frequently, position carefully.
• Many mothers who choose breast augmentation have minimal natural breast tissue, leading to supply issues unrelated to surgery.

If a young woman or teenager considering cosmetic breast surgery approached you on the subject, how would you advise her?

• Augmentation: Consult with the surgeon about where to insert the implant. The worst location for an incision is peri-areolar. The scar at the border of the areola is supposed to be invisible, but it’s not and the incision severs large numbers of milk ducts. The best and most common location is underneath the breast. She should also get implants of 180 to 200 cc. of breast tissue, about a B cup. Most women put in 300 to 400. Heavy implants can put pressure on the breast tissue and affect supply.
• Reduction: Consult with the surgeon about the method used. The newer vertical incision has been shown to lead to lower breastfeeding rates than the older Wise-pattern, also known as McKissock. The Wise-pattern scar looks like an anchor or upside-down T. With a Wise-pattern incision the lower pedicle (the section under the nipple) is kept intact, and provides the blood supply for the nipple and areola during surgery. The superior pedicle is removed. (Tairych et al. 2000)A surgeon using the newer vertical incision removes the lower pedicle, removing a larger amount of breast tissue and causing more damage. (Lejour)

Is there anything you would like to add?

Yes. Breastfeeding is not just about milk, it’s about the relationship. Today I Spoke to mother on motilium, a medication used to increase milk supply. She was making hardly any milk, maybe 1-2 cc. at the feeding. But the mother is using a supplemental nursing system (SNS) to feed formula while he is also nursing at the breast. So it’s hard to know exactly how much milk he is taking. Recently,she took a medication containing chlorophyll. She was excited that the baby’s stools turned green, because it showed that he is getting a significant quantity of her milk.

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