January 2011


I love science.

I do a ton of breast surgery.  I have 3 kids.  I am a huge fan of breastfeeding.  How can I advise my patients about breast surgery and the relationship to breastfeeding?   I know a lot from being in practice for over a decade, and I read a lot of studies.  Every piece of information helps in the decision making.

There are women who are going to have a hard time breastfeeding.  Some of these women have had breast surgery, others did not.  Is there some way to predict who is whom?  Who will have a harder time?

A study came out in Birth, Sept 1990 looking at the influence of different factors on your ability to breastfeed a baby.  The study followed 319 women who were pregnant with their first baby who intended to breastfeed.  These women were evaluated in their last trimester for their initial measurements.  They looked at:

  • surgical incisions
  • size
  • symmetry
  • nipple protuberance (do you have inverted nipples?)
  • and the woman’s estimate of their breast increase during the pregnancy

At two visits after the first 2 weeks postpartum (all were term babies), the infants were weighed and the moms estimated how big their breasts got when their milk came in.  Breastfeeding was evaluated and help was given when there were problems, looking particularly at how to maximize the amount of milk made.

“Sufficient” milk production related to an average weight gain daily of 28.5g between visits.  If they had to supplement with formula this was noted as well. 

What was related?                                                              

  • 85% of mothers had sufficient lactation
  • 15% had insufficient lactation, despite intervention
  • 7% had some kind of breast surgery prior to their first pregnancy.  If a periareolar incision was used, these women had a 5x rate of lactation insufficiency compared to those without any surgery.
  • Insufficient lactation was significantly associated with minimal prenatal breast enlargement
  • Insufficient lactation was significantly associated with minimal postpartum breast enlargement when the milk came in
  • Inverted nipples were more likely to have lactation insufficiency (not statistically significant)

 

So. How can you anticipate?  If you have inverted nipples, or prior breast surgery with an incision in the periareolar area, you may have decreased milk production.  15% of women in this study had insufficient milk production, and many did not have any prior surgery or inverted nipples.  If your breasts get much larger with pregnancy and when your milk comes in, signs are good you will produce enough milk. 

What I have seen in my plastic surgery practice here in Palo Alto, where there is positive peer pressure to breastfeed, is prior surgery does not mean you can’t breastfeed.  What I found in practice and these studies is your milk production may be lower.  But any breast milk is good for you, your baby, and your bond.

This will be the first in a line of blogs about this topic.

Let me start first with an email I received from a patient,  “I just want let you know that I have had no problem breastfeeding.  I am grateful that nothing was damaged during my breast lift surgery.  Nice job to you!!  We had a beautiful girl.  I was worried about breastfeeding but it is going great.  I have a ton of milk supply on both breasts.   I just wanted to let you know. “

All breast surgery affects the breast.  Seems like a simple concept, but we forget it sometimes.  A 20 year old woman who wants a breast reduction may be more focused on getting her breasts smaller and somewhere above her waist, not the bonding and nutrition she may give with breastfeeding 10 years down the road when she decides to have kids. 

So I discuss it. 

Any woman who has not had children and wants to do any surgery of the breast needs to consider the effect surgery will have on the breast and your ability to breastfeed.  Thankfully, for most women, they are able to make milk.  The studies show there may be a decreased amount of milk, but I have had many patients who have had breast augmentation or breast reductions and lifts who have successfully gone on to breastfeed.

If you are a decade away from thinking about kids or you have a lot of issues with your breasts (backpain, droop, asymmetry, etc), then know there are techniques which help maximize your future ability to breastfeed.  If you are on the verge of having kids, wait to do the surgery.   It will totally preserve your ability to breastfeed among other advantages:
Anectode:  I had a friend who was 38, newly married, who wanted a breast augmentation.  I am a straight shooter, so I told her, “You are older.  You can’t wait to have kids.  Have your kids.  You’ll need to have them in the next year or two.  Your breasts will get bigger with pregnancy.  Your breasts will get bigger while breastfeeding.  When you know you are done, then do the surgery.  Pregnancy and breastfeeding changes the breasts a lot- shape, volume, symmetry.”  She did not listen, and went to someone else for surgery.  She has now had two surgeries within 3 years.  Had she waited until done with kids, she might have had just one surgery, and the results could have been better. 
 
I am a huge fan of breastfeeding.  I am not saying to do surgery or not do surgery.  I am not dictating the timing of your surgery.  This is all about educating you to make the right choices for you.

Many women who come to me have gained weight.  Particularly after babies, and the more babies the merrier, you may not be able to get back down to the svelte self you once were.  Some of it is from pregnancy- did you overeat? not exercise? Some of it is from young motherhood- are you sleep deprived? eating to stay awake? nibbling on all of the goldfish and mac n cheese? going to the umpteen million kiddie parties with cupcakes? or finishing the tidbits on your kids plates while cleaning the dishes (guilty as charged)?

So what am i going to say?  Eat broiled fish and salad?  Lose the weight by “chasing your children” and breastfeeding??

NO!

I love to read Men’s Health magazine.  The articles are great.  Here are some good rules of thumb, and he focuses on the tiny changes- not the “I am going to exercise for 2 hours every day” kind of programs, but the “I am going to not put the extra food on the table” kind of things. So I am not going to write this article again- I think he did a great job.  But I will post it here because he cites some interesting studies.  And much of the body work I do as a plastic surgeon has everything to do with weight.

7 Habits That Make You Fat
By David Zinczenko of Men’s Health


FAT HABIT #1: Putting the Serving Dishes on the Table
Researchers at Cornell University found that when people served themselves from the kitchen counter or the stove, they ate up to 35 percent less food than they did when the grub was on the kitchen or dining room table. When there’s distance between us and our food, the scientists theorize, we think harder about whether we’re really hungry for more.

FAT HABIT #2: Getting Too Little (or Too Much) Sleep

A sleep schedule is vital to any weight-loss plan, say Wake Forest University researchers who tracked study participants for 5 years. In the under-40 age group, people who slept 5 hours or less each night gained nearly 2½ times as much abdominal fat as those who logged 6 to 7 hours; also, those who slept 8 hours or longer added nearly twice as much belly fat as the 6- to 7-hour group. People with sleep deficits tend to eat more (and use less energy) because they’re tired, says study coauthor Kristen Hairston, M.D., while those who sleep longer than 8 hours a night tend to be less active.

FAT HABIT #3: Not Multitasking While Watching TV
We don’t need to tell you that too much TV has been linked to weight gain. But here’s what you may not realize: You can have your TV and watch it, too. Just do something else at the same time. Washing dishes burns 70 calories every 30 minutes. So does ironing. Here’s another thing to keep in mind: Cutting TV time even a little helps you burn calories, say researchers at the University of Vermont. In their study, overweight participants who cut their viewing time in half (from an average of 5 hours to 2.5) burned an extra 119 calories a day. “Nearly anything you do—even reading—uses more energy than watching TV,” says study author Jennifer J. Otten, Ph.D.

FAT HABIT #4: Drinking Soda
Researchers say you can measure a person’s risk of obesity by measuring his or her soda intake. Versus people who don’t drink sweetened sodas, here’s what your daily intake means:

½ can = 26 percent increased risk of being overweight or obese

½ to 1 can = 30.4 percent increased risk

1 to 2 cans = 32.8 percent increased risk

More than 2 cans = 47.2 percent increased risk

That’s a pretty remarkable set of stats. You don’t have to guzzle Double Gulps from 7-Eleven to put yourself at risk—you just need to indulge in one or two cans a day. Wow. And because high-fructose corn syrup is so cheap, food marketers keep making serving sizes bigger (even the “small” at most movie theaters is enough to drown a raccoon). That means we’re drinking more than ever and don’t even realize it: In the 1950s, the average person drank 11 gallons of soda a year. By the mid-2000s, we were drinking 46 gallons a year. A Center for Science in the Public Interest report contained this shocking sentence: “Carbonated soft drinks are the single biggest source of calories in the American diet.”

FAT HABIT #5: Taking Big Bites
Dutch researchers recently found that big bites and fast chewing can lead to overeating. In the study, people who chewed large bites of food for 3 seconds consumed 52 percent more food before feeling full than those who chewed small bites for 9 seconds. The reason: Tasting food for a longer period of time (no matter how much of it you bite off) signals your brain to make you feel full sooner, say the scientists.

Fat Habit #6: Not Eating Enough Fat
You don’t have to go whole hog on a low-carb diet to see results. Simply swapping a few hundred calories of carbs for a little fat may help you lose weight and reduce your blood-insulin levels, according to researchers from the University of Alabama at Birmingham. People in their study who consumed just 43 percent of their calories from carbohydrates felt fuller after 4 hours and maintained their blood-sugar levels longer than those who ate 55 percent carbs. Carbs can cause blood-sugar levels to spike and then crash, leading to hunger and overeating, says study author Barbara Gower, Ph.D. Fat, on the other hand, keeps you satiated longer. Some easy swaps: butter instead of jam on toast; bacon instead of potatoes; low-fat milk instead of a sports drink.

FAT HABIT #7: Not Getting the Best Guidance!
Signing up for e-mails (or tweets) that contain weight-loss advice can help you drop pounds, a new study reveals. When researchers from Canada sent diet and exercise advice to more than 1,000 working adults weekly, they discovered that the recipients boosted their physical activity and ate smarter. People who didn’t receive the reminders didn’t change.

EAT RIGHT RULE: If your food can go bad, it’s good for you. If it can’t go bad, it’s bad for you.

A lot of us have back pain.  And kids, in addition to being a pain in the neck at times :), can also lead to a pain in your back.  

That tummy tucks help with back pain is not new news.  When you have babies you will stretch out your abdominal muscles.  Frequently this leads to separation of the rectus muscles, what is called a diastasis.  This midline separation cannot be fixed with situps.  The only way we have of fixing it is to corset the muscles back together during a tummy tuck. 

So why would fixing your belly help your back?  Your back and your abdominal muscles work to stabilize your body and help you stand up straight.  If your abdomen is blown out or loosey goosey (I know, highly technical terms here), then your back must work overtime to stabilize your body.  This can lead to pain.

What is common folk wisdom in plastic surgery often leads to scientific papers which support it.  A multitude of papers have emerged which support that tummy tucks are not a just-to-make-you-look-pretty surgery, but a functional one.  The latest appeared in the January 2011 issue of Plastic & Reconstructive Surgery Journal .  It is a study out of the University of Michigan, “Wide Abdominal Rectus Plication Abdominoplasty for the Treatment of Chronic Intractable Low Back Pain.” 

In it, they point out some ideas I would like to reiterate:

  • Most surgical treatment for chronic back pain is directed at the spine.  In a study by Toranto, who first championed the wide abdominal rectus plication, he gave relief to chronic back pain in 24 of 25 patients by addressing the belly, not the back.
  • A tummy tuck for back pain is only useful in patients who present with significant abdominal wall weakness and laxity.  All of the patients in this study had one or more pregnancies. 
  • Conservative treatment is always good first. 
  • For those with neurologic damage of the spine, you need to make sure there is no radiographic or clinical evidence of the damage being caused by an identifiable structural lesion in the spine.

 

The study postulates that the rectus muscle forms a “sheath” of tissue connecting to the thoracolumbar fascia.  “This forms a structure that biomechanically influences the mechanics and stability of the lumbar spine.”  The “wide” abdominal plication doesn’t just realign the rectus muscles, it brings it in tighter.  The thought is to increase the intraabdominal pressure and put the muscles at a more efficient place in the force-length curve to increase their force generating capacity. In this small study of 8 patients, all were improved. 

Small studies can be discounted, but this study had a very thorough evaluation preoperative and postoperatively by a physical medicine and rehabilitation specialist with specific expertise in management of chronic low back pain.  100% of them were better.