breastfeeding


I know I am not a pediatrician or a family practice doctor, so some may wonder why I am so focused on breastfeeding.   I am a surgeon who deals a ton with the breasts and the effects of breastfeeding.  I have heard rumblings while being a mom-around-town of women who are choosing not to breastfeed their children because they are concerned about the cosmetic effect it will have on their breasts.  I am a fan of breastfeeding.  Please see the other blogs prior to this and the results of a study which just came out.

For the hypereducated Bay Area women reading my blog, here is another pro for breastfeeding:

MUCH lower risk of SIDS.

SIDS is sudden infant death syndrome.  It affects 2,300 babies a year.  The cause is unknown.  From the sids.org site, risk factors include having a baby as a teen, less than one year between pregnancies, tobacco/cocaine/heroin use during pregnancy, and premature birth.  After the baby is born: have the crib in your room, no bedding/pillows, sleep on the back, use a pacifier, avoid respiratory infections, and do not overheat the baby.  The risk is highest between 2-4 months of age.  90% of SIDS occur in babies less than 6 months.

In Pediatrics June 2011 online edition, Hauck and researchers at University of Virgina did metaanalysis of 18 studies looking at breastfeeding and risk of SIDS.  Findings:

  • 73% reduction in risk if exclusively breastfed
  • 60% reduction in risk if breastfed for any time period
  • 45% reduction when other factors known to increase SIDS were factored out, like smoking, socioeconomic status, and sleep position.

 

Why does breastfeeding lead to lower risk?  Thoughts vary.  Hypothesis include:

  • Breastfed babies are more arousable during sleep
  • Fewer issues with diarrhea and respiratory infections, which may predispose to SIDS
  • Possible boost of their immunity from the breastmilk.

So, pediatricians recommend breastfeeding exclusively for 6 months and then continue to nurse for the first year, as you introduce solid foods.  So bond with your child, lose weight (anyone for an extra slice of cheesecake?), and protect them from SIDS…. Breastfeeding is sounding pretty good.

wish I had a crystal ball.

Every person is different with how their breasts change with pregnancy. Some barely look different, some go up 3 cup sizes.

Breastfeeding adds another layer of change. Are you a producer? Do you favor one side? How big do you get? How long do you breastfeed for?  If you had surgery with an incision at the nipple areola, your milk production may be affected.  I have many blogs on breast milk production after breast surgery.

Each pregnancy is different. As for the droop, it depends on your skin tone, how many pregnancies, how old you are, what your size changes are, and the above.  Keep your fingers crossed.

Advice?
1. SUPPORT SUPPORT SUPPORT. Sleep in a bra. Wear it 24 hours a day.  Wear a good one which looks like Fort Knox.
2. When breastfeeding, alternate (don’t favor one side).  See other tips on my blog.
3. If you see any kind of infection, mastitis, rash, etc, JUMP ON IT EARLY.  Most implants are submuscular, so there is a nice muscle between your implant and the breast.  Most implants have formed a capsule, which protects your implant from your breast.  What you don’t want though is an issue with your breast causing a breast implant infection.  It is rare… but if you are worried about any breast redness, tenderness, or discharge, see a doctor sooner as opposed to later.

And remember to focus on the big picture! CONGRATULATIONS!  Most implants do just fine with pregnancy.

I am a plastic surgeon.  I perform a lot of breast augmentations.  I am lucky- most of my patients come to me after they have children and are done with breastfeeding. 

Any surgery to the breast will affect the breast.  This seems obvious, but it is something I always discuss with patients, particularly if they have not had children yet. 

If someone comes to me in their mid 30s and wants to have kids, I will counsel them to wait to have surgery until they are done having kids.  Your breasts get larger when you are pregnant and breastfeeding anyway.  Your breast changes with pregnancy and breastfeeding–after you are done with kids most women end up smaller in volume, so the size they would choose would change. (Some women do end up larger in breast size after kids, but don’t hold your breath for that one- it isn’t as common.)

So. Back to the title of this blog- if you have a breast augmentation, does it affect your future ability to lactate (ie breastfeed)?

Yes.

A study came out in Breast Journal, Jan-Feb 2007 out of the UK.  I have a few issues with the study, particularly one of their opening lines which I think is really untrue, “It does not occur to most women to consider the possible effects of breast augmentation surgery may have on their future ability to exclusively breastfeed their baby.”  Maybe it is because I live in the hypereducated Silicon Valley Palo Alto area, but I think all of my patients consider the effect of any breast surgery on their future ability to breastfeed, and it is part of my usual discussion, particularly with regards to incision site. 

But back to the study, which I am citing because it did bring out some interesting facts. 

  • Women who have breast augmentation surgery have a greater   lactation insufficiency.  NOTE: This does not mean they do not produce milk, but they may not be able to exclusively feed their child by breast milk alone to meet their parameters of weight gain.
  • Factors related to surgery include impairment/loss of nerves to the nipple areola complex, which lead to reduced sensation and loss of the suckling reflex resulting in decreased milk production.
  • complications in surgery (hematoma, need for additional surgery, capsular contracture, etc) can lead to impairment.

Their conclusion? “With good surgical technique and proper postoperative management, most of the complications associated with surgery that may result in insufficient milk production can be minimized but not always avoided.”

So what does this mean? This study would not change my general advice to women, which is:

  • If you are in your early 20s and have a good decade before having kids, in the pros/cons of deciding to do breast surgery, you need to factor in potential decrease in your ability to breastfeed.
  • I have had many patients who have successfully breastfed after breast augmentation.  This study shows a decreased amount of milk production, and it varied due to multiple factors.  Their final statement was that good technique and proper postop management you can minimize the impairment.
  • IF YOU ARE WITHIN A YEAR OR TWO OF HAVING A BABY, WAIT.  I counsel women to do this all the time. I get that having larger breasts will make your wedding dress fit better, but if your plan is to get married and then start a family right after, wait to do the surgery.
  • IF BREASTFEEDING IS OF PARAMOUNT IMPORTANCE and you would be upset to supplement with formula if needed, WAIT.  I know this is controversial in my plastic surgery world where many doctors have become salesmen for procedures, but you have to look at your life big picture when looking at these things.

Remember also, some women can’t breastfeed for whatever reason who have never had breast surgery.  There are no guarantees.

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.

I saw a patient today in clinic who wants to change her breasts.  She has been unhappy with their size and shape as long as she can remember. 

Perfect candidate for breast surgery! Sign her up?!

Not quite.  She should consider waiting.

Why?  She is in her mid thirties. She wants to have kids.  Even when she said, “I won’t breastfeed because I want to minimize changes in the breast” (which I don’t recommend due to the overwhelming evidence of the benefit of breastfeeding, but those are topics for other blogs), your breasts still change.  She is not a 20 year old who has a good decade before having children.  She is in her mid 30s and will have them in the next year or two.  I could make her breasts perfect- exactly what she wants- and pregnancy and/or breastfeeding will change them. 

What do we see?

  • Loss of volume (Rarely increase in volume)
  • Skin laxity/droop
  • Stretch marks
  • Sensory change
  • Shape change

 

Other thoughts…

Pregnancy is tough.  It is hard to work on making your body look good for decades and then lose control of it in pregnancy.  I don’t want you to ever regret or have negative feelings about having a child and breastfeeding because it is doing “damage” to your breast.  If you are in my office you are not adverse to doing surgery to improve things.  Great! So time your surgery well.  If you are on the cusp of your babymaking years, go have that baby. Breastfeed.  Enjoy it.  When you are done with all your kids, your issues with your breast will have changed.  Your breasts will be different.  Let’s address it then.

If you live in Northern California as I do, women breastfeed.  I would even venture to say there is peer pressure to breastfeed.  When I had my first child I went to a mommy and me gathering for new moms at Stanford.  All these moms from Palo Alto, Menlo Park, Atherton, and Woodside gathered in a circle to discuss their babies.   A mom took out a bottle to feed her child. As people looked, there was almost a hush in the room.  I could feel her discomfort- she wasn’t breastfeeding her baby.  My girlfriend advice (I’m putting on my girlfriend hat, not my doctor hat) is to see how you feel when you have your baby, perhaps even try breastfeeding, before you decide you will or will not do it.

Now if you are 20, flat chested, and self conscious about your breasts, I would advise differently.  For you  it makes a lot more sense.  You could easily have a decade until you even think about babies.  And I have women who understand everything I mentioned above but still want the breast augmentation now.  That is fine. 

I believe in choice.  I am here to educate you and to help you understand the issues.  I will support you (and be honored to be your surgeon) regardless of your choice.

I had a patient who after three kids wants a tummy tuck.  Her belly was blown out after her second child, and she has back pain, so we knew a tummy tuck was in her future to repair it all after her third child.  She wants to do it when her baby turns one.

But she has been reading my blog (Go Bay Area blog reading mommies!) and said, “I know I should wait for 2-3 years until I do surgery, but I don’t want to wait.”   I realized I have not been clear.  It is true, the most common time I see women after babies is about 2-3 years out.  I think that timing is good- you have gotten out of the fog of babydom and given yourself a chance to get back into shape and see what comes back … and what doesn’t.  So the flip of that…

When is the soonest? Should you wait?

  • Normal blood level.  You lose a fair amount of blood after birth.  You need 3 months to rebuild your blood store.
  • Nutrition.  Your baby has spent the last 10 months preferentially getting your nutrients.  You need time to restore. 
  • Sleep.  Surgery is a stress on the body.  I liken it to running a marathon.  If you are sleep deprived you won’t have the reserve to help you heal well.
  • Breastfeeding.  Breastfeeding continues to take calories, energy, and nutrition for your newborn.  I am a HUGE breastfeeding fan.  The benefits to you and your child are immense.  If doing breast surgery, you need the breasts to be empty of milk, which takes about 3-6 months after you stop breastfeeding.  If doing other surgery, you can’t breastfeed at the same time- it would be too tough on your body to devote energy to healing and to your baby, and the medications needed for surgery and healing would get in your milk.  Also, see the nutrition point- breastfeeding can deplete you, so you need time after you stop to rebuild your internal stores.

 

My two to three year window is for women in the dreaded grey zone.  The grey zone? Those women who’s breasts and bellies aren’t like they were before babies, but they aren’t so bad.  In the right time of day, right angle, or if you stand up straight (posture girls!) you look okay.  Those are the women who should wait. 

But some women have things time will not help.  Particularly for the abdomen, horrible stretch marks, a wide diastasis (separation of the muscles), hernias, and hanging skin won’t go away with time and exercise.  Two years will not make these better.

So see your doctor.  Every patient and situation is different.  I get timing is tricky.  Many of you work, have multiple kids, and husbands schedules and other things you juggle.  But this is elective surgery.  And I know, from the title of this blog, you have an incredible responsibility- you are a mom. 

Elective surgery needs to be safe. 

There is a time and place for everything. Talk to your doctor.

Yes, yes.  I am a true believer in the benefits of breast feeding. 

I do not go into this starry eyed.  I know there is a cosmetic hit we breast feeding moms take (it is a lot of what I fix doing my mommy makeover work.)  But if you aren’t going to do it for your child’s health (less infections, etc), or for your health (lowers the rate of diabetes and heart risk), then do it for your country.

Medical costs are soaring.  The government is becoming increasingly involved in medicine.  I saw a recent study published in the news about how breastfeeding for six months could save 13 billion dollars. (!!)  You mean I can make a dent in America’s staggering spending by breastfeeding my baby?

Yes.

This is not new news.  In March 2001, a study of “The Economic Benefits of Breastfeeding: A Review and Analysis” was published for the USDA  (Food Assistance and Nutrition Report (FANRR13):

“A minimum of $3.6 billion would be saved if breastfeeding were increased from current levels (64 percent in-hospital, 29 percent at 6 months) to those recommended by the U.S. Surgeon General (75 and 50 percent). This figure is likely an underestimation of the total savings because it represents cost savings from the treatment of only three childhood illnesses: otitis media, gastroenteritis, and necrotizing enterocolitis. This report reviews breastfeeding trends and previous studies that assessed the economic benefits of breastfeeding”

http://www.ers.usda.gov/Publications/FANRR13/

The recent numbers are an extension of the original study, which only looked at three major illnesses, and wasn’t corrected for today’s economics. 

So.  Breastfeed- For your baby, for your health, and for your country.

Let’s hear it for the girls! 

I love breastfeeding.  We always knew it was good for your heart to snuggle and be close to your baby (awwwww.)  But now science supports it as well.  I know breast feeding doesn’t make the breasts look prettier long term (in the short term it can do wonders though).  I know as a plastic surgeon many of you think we only care about how pretty your breasts are.  And I do care what they look like, but the breasts have a purpose other than looking good in a bikini.

A new study came out in Diabetes  (and was presented by Gunderson’s team on June 6 in New Orleans at the American Diabetes Association’s 69th annual Scientific Sessions meeting).  It was a long term prospective study of 1400 patients.  In it, they looked at the benefit to mom (not babe) of breastfeeding, specifically looking at the “metabolic syndrome” of risk factors which cluster and increase your heart risk.

What increases your risk of heart disease and diabetes?

  • Abdominal obesity (the apple body shape, not pear, especially when the fat is “intraabdominal” behind your belly muscles)
  • high blood pressure
  • cholesterol (low HDL the good one, and high LDL, the bad one)
  • high triglycerides
  •  insulin resistance
  • inflammatory markers
  • a tendency to clot.

 

They found of these 1400 women, 50% had kids.  They followed them at 7, 10, 15, and 20  years. They found the risk of the “metabolic syndrome” was reduced in women who breastfed.  This risk was reduced further the longer you breastfed.  For those who breastfed over 9 months, the risk went down 56% in those with no gestational diabetes (diabetes while pregnant, a marker for those at risk for diabetes later in life) and 86% for those with gestational diabetes.

Yay.

They don’t know why. ? Does it increase your good HDL cholesterol?  Lower the abdominal body fat? Or help with the metabolism of blood sugar and lower your insulin levels?  We don’t know. But it was nice to see these results.

So let’s hear it for the girls.

Don’t worry- if they look bad when you are done, I can help you. But a healthy heart- that looks good on everyone.

I am a huge fan of breast feeding.  The benefits are well known.  For the baby, there is reduced otitis media, respiratory infections, gastroenteritis, rates of SIDS, childhood obesity, type 2 diabetes, and childhood leukemia.  For the mother, there are lower rates of breast and ovarian cancer and type 2 diabetes.  There have even been studies that breastfed children deal better with stress later in life.

It is recommended you breastfeed exclusively for 6 months.  I breastfed all of my children.  Particularly with the dangers in the world of swine flu and other diseases, it is one of the best gifts you can give your child.

Breastfeeding can take a toll on your breasts.  So here are some recommendations:

1. Alternate breasts.  Everyone has one side which is easier to feed on, produces more milk, the baby likes it better, etc etc. Breasts are not symmetric.  They are different sizes and different producers.  Try to use both breasts evenly.  Use a timer and switch to the other side.  Personally, I tried to feed from both breasts with each feed.  When I have patients who exclusively breastfeed on one side, there is a marked difference between their breasts at the end.  The key to breasts is symmetry.  Whatever you do, you want your breasts to look as alike as they can.

2. Support.  Breasts are not a muscle. The infamous ”we must, we must, we must increase our bust” exercises don’t work.  The pectoral muscle lies beneath the breast tissue.  The breast itself is composed of breast tissue, ligaments, and fat.  When the tissue has stretched, there is no way to “firm” it up again with exercises, creams, or lasers.  So wear a bra.  Make sure it fits well and is really supporting you.  Sleep in the bra.  To see if the bra is giving good support, jump up and down in front of the mirror and see how well you are supported.  Everyone has seen a woman jogging who does not have enough support.  A good bra has a defined size, 2-3 rows of hooks in the back, and adjustable straps to transfer the weight of the breast to the shoulder.