Question:

I am a IBCLC at Stanford and my co-worker asked me a question that I could not answer for sure.  She asked: Can a mom who had breast augmentation with incisions under the areola or under the breast pump as a mom would without a history of augmentation?  I have had many new moms with such histories pump without a problem, meaning no apparent damage, and most were able to get colostrum.  Some moved on to pump transitional milk.  I think her question was more in regards to risk of breast damage with pumping?  What are your thoughts on this?

Barbara Dodson, IBCLC

Answer:

In general, a mom should be able to pump normally after breast augmentation.  However there really is no such thing as an “in general” answer when it comes to patient care. Ethical patient care is specific and individualized.  This means we have to understand the issues ourselves, and then we have to take a careful history so that we identify each mom’s specific challenges. It has been my experience that when a mom asks this kind of question, something is worrying her.  It is wise to ask why she is concerned and then give her accurate information so she can make informed decisions.  Your colleague will appreciate the same thorough response so she can most effectively interact with her patients.

Here are some issues to consider:

Research documents that any kind of invasive breast surgery elevates lactation risk factors.  While none of the research specifically discusses breast augmentation with regard to pumping, I think we can extrapolate to see how pumping might also be impacted.

Periareolar incisions are associated with more risks than incisions under the breast, or under the arm.  The periareolar approach improves the cosmetic appearance because it “hides” the scar in the color change at the edge of the areola.  But it also increases the risk that important nerves or ducts have been severed.  If nerve damage has occurred, both breastfeeding and breast pumping may be affected in various ways.  I have seen, for example, clients with both reduced and increased nipple sensitivity.  Moms who are pumping and who have altered levels of nipple sensitivity may need more guidance in selecting safe, effective pumping pressures.  Selection of a properly sized pump flange would also be crucial both to comfort and effectiveness of milk expression.  In the worst case scenario, if there has been severe damage to the nerve pathways, the milk ejection reflex (the milk letdown) cannot occur.  In which case, prolonged “dry pumping” may irritate the nipples.

The US Federal Food and Drug Administration (FDA) website has a section describing the risks of augmentation surgery.  They mention implant hardening and/or rupture and abscess formation at the incision site as common side-effects.  We describe such a case in The Breastfeeding Atlas, 4th Edition (see attached photo of Fig 200 showing an abscess at the implant incision site, in this case under the breast in the mammary fold).

To prevent bruising, moms who are using a breast pump should be routinely cautioned not to dig the pump flange into their breast tissue  This advice may be even more important for the mom with breast implants, particularly those with a periareolar incision.  It is possible that rubbing from a pump flange on a periareolar scar might irritate the scar tissue.  LCs can teach moms to lubricate the flange or the breast with something safe such as olive oil.  Caution them to be gentle about placing the flanges.  Hormone changes owing to pregnancy and early lactation make skin more vulnerable than normal.  Any increased inflammation of scar tissue should be reported to the woman’s health care provider.

Finally, we must always remember that many women seek augmentation surgery to correct breast deformities that may be markers for insufficient glandular development.  If the pre-surgery breast was abnormally developed, that, more than the surgery itself, may impact milk production.  If milk production does not progress in the normal, expected manner, moms may blame the pump or pumping technique when the problem is physiological.  It is appropriate to describe what normal volumes of milk production look like and help the patient determine if she is producing a normal supply.

Being a good LC is a lot like being a good detective.  Counseling skills come into play, too.  Information should be delivered factually and in a calm, straightforward manner, with time allocated for the mom to ask questions.

References:

Hurst N: Lactation After Augmentation Mammoplasty, Obstet & Gynecology 1996, 87(1):30-34.

Neifert M, Seacat J, Jobe W:  Lactation failure due to insufficient glandular development of the breast, Pediatrics 1985, 76:823-28.

Wilson-Clay B and Hoover K:  The Breastfeeding Atlas, Lactnews Press, Austin, Tx. 2008.