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.

OUCH!

I have a friend who lives in LA who just had a tummy tuck and breast augmentation.  She is on her first day after surgery.  She is a tough cookie, and her words to me today were, “This really hurts!!”

One of the most common mommy makeover surgeries is breast augmentation and tummy tuck.   These by themselves are the two most painful surgeries we do as plastic surgeons.  These surgeries hurt because of the muscle.  For tummy tucks, I like to put in a pain pump which drips numbing medication internally to help.  In addition we give you pain medication and some of us use muscle relaxants as well.  Even with all of this, it still hurts.

For planning how to deal with your family life (as you are a mom, hence the mommy makeover):

  • the first 2-3 days you are OUT. You will be on medication round the clock.  Someone else should care for your kids.  And you. 
  • The first one to two weeks you will be very sore.  No driving until you are off pain medication.  As for when you will feel normal again and be doing your daily life things, people vary.  Every person is different as to when they get over the “hump” and feel better. 
  • No heavy lifting (yes, this includes your adorable children) until much farther out.  Exactly when you can lift something over 5-10 pounds is not a hard rule.  Some of it depends on you and your tissue.  Your doctor will know what that means.  Here plastic surgeons differ on their recommendations for activity level, so defer to your doctor.  Tensile strength of your wound (how strong your repair is) is weakest at three weeks out from surgery.  Usually you can’t do any exercise until at least 6 weeks out.  For core body exercise (pilates, crunches, that favorite daily method place in menlo park, etc) I extend that until 3 months.

Give yourself time.  It took you 9 months (and for those of you with multiple kids, multiply that time) to get into this mess, it will take you a while until you feel normal again.  This is normal.

Where to cut?

When you choose to do a breast augmentation, we must get the breast implant inside. (Unfortuantely, it is not magic.)  This is the scar you will see when you are done.  There are pros and cons to each incision.

There are three basic common incisions:

  • Armpit (also known as axilla)
  • Periareolar (at the bottom of the areola, the colored portion of the breast skin)
  • Inframammary fold (also called IMF, the under part of your breast where an underwire goes)

There are other incisions  you hear about such as through the umbilicus (TUBA), through an abdominoplasty incision, and through the base of the  nipple. These are not as common (for real reasons).

IMF: This is the most common incision used.  The scar can go in the crease of the underwire or just above the crease on the bottom curve of the breast.  PROS: On the breast, so only someone seeing you naked will see it.  Preserves ability to breastfeed.  Can use as an open door- when you need a revision surgery due to deflation or capsular contracture, you can fix it through the old scar.  CONS: If you wear a bikini which doesn’t hug your underwire, you may see the scar.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

AXILLA: Scar goes into the armpit.  PROS: Preserves ability to breastfeed.  No scar on the breast.  CONS:  Scar in a place visible when you wear tank tops or bathing suits.  Usually more of the pocket is done by blunt dissection, so may get more bruise.  More difficult pocket dissection, may lead to implant malposition and upward migration of implant.  Difficult to place gel implants.  Usually need to make a second incision when you need revision surgery for implant replacement.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

PERIAREOLAR: Scar is at the transition between the areola and the breast skin.  It does NOT go all the way around the areola.  It is at the bottom of the semicircle.  If you see a scar going 360 around the areola, then a breast lift was done.  PROS: I find this incision hides the scar the best, particularly in my patients with darker skin tones: Asian, Phillipino,  Latina,  and Black.  If your scar turns darker / brown, then it tends to blend with the areola.  It is an open door- you can reuse the old scar for any revision surgery.  It does NOT interfere with sensation. (Will go into sensation details below.) The scar is on the breast, so only someone seeing you naked will see it.  It gives the best access to making an accurate pocket dissection, important for smaller implant sizes, which is important for my natural aesthetic in my Bay Area patients.  It allows access to have meticulous bleeding control, important to limit bruising and potentially capsular contracture.  This is my favorite incision as I find the scar fades in most patients to nothingness.  I like it particularly for women who are done with pregnancy and breastfeeding, women with constricted or tubular breasts, and women who may need a lift down the road, so you limit future scars.  CONS: It does cut through some of the breast ducts, so for women who have not had children yet and want to breastfeed, it may impair breastfeeding.

The biggest issue women bring up when discussing breast augmentation incisions, tends to be sensation.  Will my breast sensation change? What affects it?  There is a common perception that cutting at the areola will cause more sensory change.  This is not true.  Funny.  It seems like if you cut at the areola then the nipple sensation should change more than if you cut at the armpit, eh?  A study published in our white journal (the plastic and reconstructive surgery journal- a big deal in my world) showed there was no difference in sensation based on where you cut, but there was a difference based on how big you go.  The sensory nerves come up from the sides.  As you stretch the skin the nerves stretch.  This is what causes the sensory change.  Think about how your breasts feel when you are pregnant- or better yet -when your milk comes in.  That tingly, numb, or hypersensitive-don’t-touch-my-breasts sensation.  Many women report right after augmentation feeling like they did when their milk came in.  This feeling goes away, though your final sensation may be the same, less, or more than prior to surgery. I tend to find sensory change is less for women after having kids, and my thought is they have essentially “prestretched” their breast skin.

SO. Bottom line on sensation? The bigger you go, particularly if you are stretching the skin, the more sensory change you will get.

For photos, check out my gallery.  Most of the incisions you see are periareolar, and most photos are 6 weeks out.

Implants come in all shapes and sizes just like we women do.

It gets confusing when you surf the internet and see photos of websites and patients.  How do you choose?  This is a place where your surgeon really will guide you.  Every surgeon has their method of choosing an implant for a patient.  This includes size, profile (width, projection), and type of implant. 

I see many women come in confused by what implant to get.  There is so much information out there, and you cannot become an expert by reading.  You can pick a surgeon who is right for you.  I repeat myself often on this point, but the two most important decisions when you decide to do breast augmentation: find a board certified plastic surgeon (by the Board of Plastic Surgery), and like the aesthetic

What does “the aesthetic” mean? Look at the photos. Do they look pretty to you? Do you like the shape? Do you want to look natural or augmented?  Every doctor has what in their mind’s eye looks like a “pretty breast.”  You and your plastic surgeon should have the same eye.  At my practice in Palo Alto, and throughout the Bay Area, most patients seek what I would call a natural look.  They want it to look like nothing was done, these are the breasts they were born with.

Major categories of implants:

  • fill:    gel / silicone  or saline
  • profile:    low, medium, or high
  • shape:  round or anatomic / shaped
  • shell:   smooth or textured
  • volume

Profile has to do with the width and projection for a given volume.  In general, the low profile implants are flatter and wider than the high profile implants.  I have some patients who think to have a natural result you must have a low profile implant.  This is not true.  The profile of the implant varies depending on the patient: how broad are they? how much natural breast tissue do they have?  how big are they going? If you look at my photos, you will see all three profiles of breast implant. 

In general, if you are between two profiles, the lower profile implant will give more of a salt of the earth natural look, the higher profile a little more perky look.  Width is important.  If you go with too narrow of a breast implant, you will look fake and have a wider gulley between your breasts.  If you pick too wide of an implant, you will be fuller into your armpit, a particular problem if you are a tennis player or golfer.

My general rule of thumb is to have the patient pick volume first, profile then follows.  If you are at an extreme: a very small size or very large size, then your breast implant width may not be ideal.  This is something I review with patients during their consultation.

If you have further questions, please email me through my website: http://laurengreenbergmd.com