Breast Augmentation History Breast Augmentation History · PDF file(Breast Implants) Breast...

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

[email protected]

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



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



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



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



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



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



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



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.


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


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



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


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


Breast Augmentation

Surgical Photos

Warning: The following slides display breast

augmentation surgery in graphic detail

Liposuction

AugmentationMammoplasty

Periareolar Technique




Augmentation MammoplastyInframammary Technique



Inframammary Technique


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



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



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



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



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



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



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



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



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



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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