Breastfeeding after reduction mammaplasty

D. R. Marshall, P. P. Callan and W. Nicholson

Department qf Plastic and Reconstructive Surgery, Monash Medical Centre. Victoria, Australia

SUMMARY. A retrospective study was performed of 30 women who had undergone breast reduction and subsequently wished to breastfeed. Breastfeeding capabilities were assessed by a trained lactation consultant. Findings indicate that in women who have a physiological type of operation then breastfeeding is usually possible (18 patients out of 19), although complementary feeds may be required. We strongly suggest that all functioning breast tissue that remains after reduction mammaplasty be left attached to the nipple in a physiological manner to allow subsequent breastfeeding.

There is considerable confusion amongst patients and surgeons as to whether or not breastfeeding is possible after reduction mammaplasty. Patients presenting for reduction mammaplasty in middle life frequently give a history that although they had breast hypertrophy in youth, they were advised against having a reduction mammaplasty until after they had had their children, on the basis that breastfeeding would not be possible after the surgery. There are some women who want to breastfeed after reduction mammaplasty even though at the time of their operation they thought it not to be important.’

Techniques of reduction mammaplasty have changed considerably over the years. Twenty-five years ago separation of the nipple from the underlying breast with free grafting in a new position was a common procedure. With the advent and acceptance of various pedicle reductions, it is possible to maintain the anatomical and physiological relationship of the nipple with the underlying breast tissue. Thus there appears to be no anatomical reason why subsequent lactation should not be possible after reduction mammaplasty.

The current literature on breastfeeding after re- duction mammaplasty is limited. Much of it is an- ecdotal, consisting of a few case reports,2,3 small series,“. 5 or comments relating to a particular tech- nique with one or two supporting cases.6m8 Strombeck followed up many of his patients and showed that breastfeeding was often possible but capacity was reduced.’ One study recently surveyed a number of patients and found that many could lactate, based on patient survey through mailed questionnaires and telephone interviews.”

Table 1

Patients and methods

Our group studied 30 women who presented to the Royal Women’s Hospital in Melbourne over a 3-year period from 1988-1990, all of whom had previously had reduction mammaplasties. This number was very small relative to the hundreds of women who had no previous breast surgery who presented for lactation advice during the same period. Their breastfeeding capabilities were directly supervised, assessed and recorded for up to 3 months after delivery, and success judged on initial colostrum formation, ability of the baby to suckle, infant weight gain and necessity for complementary feeds.

To establish the breastfeeding rate at the Royal Women’s Hospital a control group was obtained by surveying every woman post delivery (349 in all) in the hospital on three separate days throughout the year of 1990. It showed that 90% of women wished to breastfeed but a few (8 %) failed in hospital for various reasons. 54 % still breastfed at 3 months, 47 % of them exclusively.

When we compare these figures with the results of our study group of 30 patients, we find 28/30 (93 %) of the women wish to breastfeed although their capa- bilities are somewhat reduced. The number breast- feeding on discharge is still 22/30 (73%) but after 3 months this has dropped to 8/30 (27 %) with only one patient able to breastfeed without complementary feeds (this patient was the only one who had a mastopexy performed). These comparisons are shown in Table 1.

These figures do not truly reflect breastfeeding capabilities of our group of operated women as we

Patients

B.F. B.F. on B.F. at 3 exclusively

Wish to B.F. discharge months at 3 months

Control (349) 314 (90%) 279 (82 %) 188 (54%) 164 (47 %) Post Breast Reduction (30) 28 (93 %) 22 (73 %) 8 (27 %) 1(3%)

167

168 British Journal of Plastic Surzn

Table 2 (13 Patients)

.4nlounr of’

hwrrst tissue

cuta&d to the

nipple

Moderate (I 9) Small (4)

Breastftieding upuhilit),

Good Retr.sonrthle Poor

10 8 1 0 3 I

Many patients were told that women with large breasts were poor breastfeeders anyway.‘-’ This is a statement made with little or no justification in the eyes of our lactation consultant.

Although our numbers are small the studied women had no increased incidence of engorgement, mastitis or nipple pain which are occasionally stated to be problems in these patients.

know that at least one woman had an operation which would have rendered it physiologically impossible to breastfeed (nipple graft).

Discussion

The next step was to take as a group those women whose operation we could identify (23 in all). The breast reductions were performed between 1973 and 1986 by a number of different surgeons. In 23 of the 30 cases we were able to trace the type of operation performed by direct communication with the relevant surgeon (21 surgeons in all). We were particularly interested in the amount of glandular tissue left attached to the nipple. Seven of the patients could not recall the hospital or surgeon.

The anatomy and physiology of normal lactation require functioning glandular tissue attached to ducts which in turn are attached to the nipple. Suckling also initiates a reflex arc via the nervous system to the pituitary, causing the release or prolactin necessary for milk production and oxytocin necessary for milk “let- down ‘>.I5

An operation which respects this anatomy and physiology should allow lactation.

Because there are different ways to perform the same operation (i.e. leaving large or small nipple pedicles) we divided the operations into two groups according to the amount of glandular tissue left in direct communication with the nipple. The group with little or no breast tissue left attached to the nipple comprised one Strombeck pattern, two inferior pedicle and one free nipple graft. The group with moderate breast tissue remaining attached comprised four Strombeck pattern,” one McKissock type,‘” one mastopexy and 13 inferior pedicle type in the way described in 1977 by Robbins.13 This information was obtained by direct communication with the surgeons concerned.

If the nipple is dissected free of the underlying glandular tissue, subsequent breastfeeding is unlikely. Providing adequate glandular tissue is left attached to the nipple as in modern methods of breast reduction, breastfeeding after reduction mammaplasty is usually possible.

In a young patient it is important to leave all of the remaining glandular tissue attached to the nipple, as it is pointless to have functioning segments without an outlet.

Breastfeeding capabilities were assessed by our lactation consultant into three levels of success. “Good” means the late introduction of, or little need for. complementary feeds. “ Reasonable” means re- quiring early complementary feeds but still able to provide up to half the infant’s milk intake. “Poor” means little or no milk production. These results are summarised in Table 2.

It is the experience of one of the authors (Nicholson) that big breasted and small breasted women produce comparable amounts of milk and can all breastfeed if correctly instructed. Therefore we would assume that since all women have about 20 lobules, it should be the number of these that are cut away which determines milk production. We would offer the theory that it is the percentage of breast tissue left attached that would determine the adequacy of milk production, not the weight of fat and fibrous tissue resected (which makes up the predominant weight of most breast reductions). There seems to be considerable redundancy of breast tissue, as demonstrated by the fact that twins and even triplets can be successfully fed.16

In the four patients with little or no breast tissue left attached to the nipple, breastfeeding was not always impossible but never sufficient to support the infant. In the others with moderate breast tissue left attached breastfeeding met with more overall success. The benefits of even partial breastfeeding are well known, thus there is incentive to persist.

Conclusions

With the modern physiological operation breast- feeding is highly likely. Patients should be advised with care.

Surgeons’ advice to patients was variable according We recommend that in women who may need to to the patients’ recollections. Reluctance to try breast- breastfeed every effort should be made to preserve feeding was usually easily overcome in those patients physiological function and in particular avoid the use who received negative advice. One patient, however, of free nipple grafts if at all possible. refused to breastfeed despite good colostrum flow and Preoperative advice should parallel the operative full breasts because her surgeon had told her not to expectations, stating that with a physiological op- even bother trying. A few months later she said she eration breastfeeding success is highly probable. would like to try again with a subsequent pregnancy. Breastfeeding capability may be reduced but most Interestingly, the patient who had a free nipple graft women who need to give complementary feeds reach a recalled being told she had “a fifty-fifty chance of stable balance fairly early post partum and this should breastfeeding” but did not produce a drop of be considered a successful outcome. colostrum. These considerations are of value when planning

Breastfeeding After Reduction Mammaplasty 169

and discussing breast reduction in young or potentially child bearing women and may help reduce the anxiety associated with breast reduction, knowing that physio- logical function can be preserved.

References

I. Lawrence RA. Breast feeding: a guide for the medical pro- fession. St Louis. Missouri: CV Mosby Co, 1980: 414.

2. Flack J. Breastfeeding follows reduction mammaplasty. Nurs- ing Mothers’ Association of Australia. Breast feeding Re- view: 21-9.

3. Hatton M, Keleher KC. Breastfeeding after reduction mamma- plasty. J Nurse Midwifery 1983; 28: 19-22.

4. Miiller FE. Late results of StrBmbeck’s mammaplasty : a follow- up study of 100 patients. Plast Reconstr Surg 1974; 54: 664-6.

5. Deutinger M, Deutinger J. Stillen nach Mammareduktion- splastik und Mastopexie? Geburtsh. u. Frauenheilk. 1990; 50: 220-I

6. Lossing C. Holmstrijm H. Briistreduktionsplastik med bevared amningsfiirmlga. Lgkartidningen 1985: 82: 2878.

7. Striimbeck JO. Reduction mammaplasty by upper and lower glandular resections. In: Goldwyn RM, editor. Plastic and reconstructive surgery of the breast. Boston: Little, Brown. 1976: 207-9.

8. Pitanguy I. Personal preferences for reduction mammaplasty. In: Goldwyn RM, editor. Plastic and reconstructive surgery of the breast. Boston: Little, Brown. 1976: 168.

9. Strambeck JO. Late results after reduction mammaplasty. In: Goldwyn RM, editor. Long-term results in plastic and reconstructive surgery. Boston: Little. Brown. 1980: 7267.

10. Harris L, Morris SF, Freiberg A. Is breast feeding possible after reduction mammaplasty? Plast Reconstr Surg 1992; 89: 8369.

I I, Striimbeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg 1960; 13: 79-90.

12. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg 1972: 49: 245-52.

13. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg 1977; 59: 64-7.

14. Schurter MA. Letterman G. Comment on Pitanguy. I. Personal preferences for reduction mammaplasty. In: Goldwyn RM. editor. Plastic and reconstructive surgery of the breast. Boston: Little. Brown. 1976: 181.

15. Lawrence RA. Breast feeding: a guide for the medical pro- fession. St Louis. Missouri: CV Mosby Co. 1980: 58.

16. Saint L, Maggiore P. Hartmann PE. Yield and nutrient content of milk in eight women breastfeeding twins and one woman breastfeeding triplets. Br J Nutr 1986; 56: 49.-58.

The Authors

Donald Marshall, MB BS, FRACS, FACS. Senior Plastic Surgeon. Monash Medical Centre. Melbourne. Victoria. Australia.

Peter Callan, MB B’S, FRACS, Plastic Surgery Registrar. Monash Medical Centre.

Wendy Nicholson, RN, RM, IBCLC, Lactation Consultant. Royal Women’s Hospital, Melbourne.

Requests for reprints to: Professor D. Marshall, Cotham Private Consulting Rooms. 209 Cotham Road, Kew 3 101. Australia.

Paper received 5 October 1993. Accepted 20 December 1993, after revision.