Q  Is it possible to breastfeed after breast or nipple surgery?

A  Yes! Depending upon the type of surgery that was performed, most women can produce some amount of milk. Every drop is greatly beneficial for your baby.

Breast reduction surgery tends to affect lactation capability the most, although augmentation, lift, diagnostic, and nipple surgeries also can reduce the amount of milk a mother can make.

We've found that far more women are forced to abandon breastfeeding in favor of exclusive formula feeding because no one around them knew enough about the issues involved to be able to educate them or fully support their efforts, than because they were physically incapable of producing milk. There are so many issues that surround breastfeeding after breast or nipple surgery and so many feelings that women who have had it can experience. It is seldom as easy a process as for women who have not had breast or nipple surgery. But if you are dedicated to providing the benefits of breastmilk and breastfeeding for your child, there are now many resources available on this website to provide the information and support necessary to enable you realize your breastfeeding goals.

If you do not have a full milk supply, it is important to know that many mothers breastfeed very successfully without a full milk supply by supplementing in ways that are supportive of breastfeeding. There are also many ways to increase milk production using a variety of methods that can include (depending on the individual circumstance and preferences) pumping, breast compression, deeper latching psychological conditioning, and galactagogues (substances that increase milk production).

When supplementation is necessary, some mothers supplement with at-breast supplementation products like the Medela SNS or the Lact-Aid, which are containers that hang around the neck with tubes that supply formula or pumped milk as the baby nurses from the breast. Using the at-breast supplementer is the ideal way to prevent nipple confusion and flow preference while maximizing milk production, but it does pose some challenges. It is not a device that works well for every every mother and baby, particularly when baby is not able to latch well or remove milk effectively.

For these and various other reasons, some mothers choose to use bottles to supplement. Contrary to the warnings about bottle use in the BFAR book and elsewhere, we now know that using them does not necessarily impact breastfeeding negatively. Many mothers have used bottles to supplement and have continued to have successful breastfeeding experiences. We now understand that there are ways to use bottles that minimize their impact. Click here for more information.

Realistically, it's important to understand that not having a full milk supply and needing to supplement, while at the same time taking measures to increase milk production, can be a lot of additional work. However, it is certainly well worth the effort for the tremendous benefits of breastfeeding.

Q What is the definition of "successful breastfeeding"?

A  Here is an excerpt from Defining Your Own Success: Breastfeeding After Breast Reduction Surgery:

It is also important to remember that nursing is so much more than nutrition. By breastfeeding our babies, we meet a whole range of emotional needs as well. When we understand success in this way, we are aware of the power we have to make breastfeeding possible and to be wholly satisfied with whatever unique direction our breastfeeding relationship may take. It is this empowerment that gives us strength in vulnerable moments and keeps the knowledge uppermost in our minds that we alone determine what success will mean for us.

Q How will pregnancy and breastfeeding affect the size of my breasts?

A  Any lactation tissue in your breasts will enlarge during pregnancy, which enlarges your breasts, possibly to about the size they were before your surgery. This can be worrisome to women who do not want to go back to their previous size. Keep in mind, though, that it is pregnancy and not lactation that increases breast size, so without surgery your breasts would still enlarge during pregnancy, becoming even larger than they are now. And they will enlarge whether you breastfeed or not. Fortunately, most women find that their breasts return to the pre-pregnancy size after weaning.

Q What factors of breast and nipple surgeries impact the amount of milk that can be made?

A  Many factors directly affect the amount of milk a mother can make after breast or nipple surgery.  The condition of her ducts is very important, however, that the state of the nerves that affect milk release is equally critical.   Fortunately, the ducts and nerves can regenerate through processes known respectively as recanalization and reinnervation, which are critical to the impact of breast surgery upon milk production and release.

Recanalization

Recanalization is the process during which previously severed ducts reconnect or new ductal pathways develop.  The most extensive instances of recanalization have been seen in direct response to lactation.  Any duration of lactation seems to prompt the mammary system to reestablish new ducts.  The extent to which recanalization will occur seems to correspond directly with the extent of the mother’s previous lactation experiences.   A mother who had an incomplete supply with her previous baby may find that she has more milk with her next baby.  In some mothers, recanalization has resulted in a complete milk supply for subsequent children.  A slight amount of lactation tissue is also formed in response to the hormones that are secreted during each menstruation.  Therefore, the longer the mother has lactated and the more menstrual cycles she has experienced, the greater the potential for recanalization, although lactation potential is limited by the extent of the surgery.

One other angle regarding what happens to ducts during surgery is how many ducts the mother actually has. It has recently been discovered that the number of ducts that actually open out to the nipple can vary much more widely than we have thought. Researchers found an average of nine ducts that came all the way through the nipple, but as few as four were also observed. A woman with nine ducts can afford to lose a couple, but a woman with only four really can’t afford to lose any. Though she may still have enough milk-making ability, if the milk can’t get out then baby can’t get it and that area of the breast will stop producing.

Reinnervation

The critical nerve to lactation is the fourth intercostal nerve, which is located around the 4:00 position on the left breast and the 8:00 position on the right.  This nerve is the primary messenger to the brain for the release of prolactin and oxytocin, the latter of which triggers milk ejection.  When this nerve pathway is injured, milk ejection does not happen as easily.  Fortunately, nerves can regenerate and reconnect through a process called reinnervation.  The process of reinnervation is not influenced by the process of lactation or previous lactation events, but occurs at a consistent growth rate of 1 mm per month.  When normal response to touch and temperature is regained, it indicates that the nerve infrastructure is improving in its ability to conduct the appropriate sensations to the pituitary gland for the release of prolactin and oxytocin.  Of course, how well the mammary glands are able to respond to baby’s demand is dependent upon the state of both the glands and ducts.  Nonetheless, the more time that has elapsed since the surgery, the greater the chances that the nerves critical to lactation have regenerated. 

In addition to the impact of ducts and nerves, the functionality of the milk glands prior to surgery, the healing process, the amount of time since the surgery, other lactation experiences between the surgery and current baby, breastfeeding management, and the mother’s attitude toward breastfeeding also directly impact breastfeeding success.

Q What can I do to maximize my milk-making potential when my baby is born?

A  The best thing you can do to maximize your breastfeeding experience is one simple thing (that isn't always so simple):  remove as much milk as possible in the first two weeks.  This is because the amount of milk the breasts are programmed to make is determined in the first two to three weeks.   The more milk that is removed during that time, the more milk-making capacity your breasts will have.

The way this happens is that milk removal establishes as hormone receptors in the breasts.  The more milk that is removed, the more hormone receptors that are established.  Hormone receptors are necessary to maximize the body's ability to use the hormones that are produced.  The more receptors you have, the more effective the hormones will be to make and release milk.  Even if you can't pump much volume, just *asking* your body to remove milk by pumping and nursing establishes receptors. 

Q What is it like when the milk first comes in on the third or fourth day after birth when a mother has had breast or nipple surgery?

A  Engorgement when the milk first comes in (transitions from colostrum to mature milk) on the third or fourth day after birth can be a significant first hurdle when breastfeeding after breast or nipple surgery.  Despite the extent of the engorgement and no matter when it is experienced, it is important to remove as much milk as possible to avoid damage to functional milk-making cells. If milk is not removed, a protein called the Feedback Inhibitor of Lactation (FIL) builds up in the milk and signals the cells to slow down milk production. When production has slowed down significantly, they shut down permanently and stop making milk. This reduces how much milk can be made for this baby (new milk-making cells are developed with each pregnancy).  

Most mothers with surviving lactation tissue will experience some degree of engorgement following delivery of their first babies.  It is often after delivery of the second baby, though, that engorgement becomes pronounced enough to cause serious discomfort and interfere with breastfeeding.  This is because the first lactation experience prompted growth of additional lactation tissue, which is then subject to engorgement.  

The extent of new growth is directly related to the degree of the first and subsequent engorgement episodes.   Mothers who have lactated longer with the first child will usually experience more engorgement following the next delivery as a result of regrowth than those mothers who lactated for only a short time.  Engorgement following the third and subsequent births tends to be at least as pronounced as it was the previous time, and may even be more extensive as a result of further regrowth.

If you don't experience any fullness at all when your milk comes in on the third or fourth day after birth, this can indicate that her prolactin levels are too low or the prolactin has not been able to affect milk production.  Or, it may mean that you do not have many viable, intact lobes to produce milk.  Occasionally, some mothers experience unequal engorgement between their breasts, again indicating that the viable lactation tissue is present in greater quantities in one breast than the other.  Less frequently, some mothers find that they have engorgement only on portions of one or both breasts, but that other areas of the breast remain soft.  This means there is little or no viable lactation tissue in the non-engorged areas.

The most important priority for breastfeeding after breast or nipple surgery is to maximize milk removal in the first two to three weeks to ensure maximum milk production.  This may require a lactation consultation to ensure that your baby is able to remove milk adequately. It may also be helpful to pump after each daytime feeding for the first two to three weeks to remove as much milk as possible.

Q My milk has come in and I'm very engorged. I'm very uncomfortable. Does this mean that I have a lot of severed ducts?

A  Your discomfort is not likely to be clogged ducts, so much as FULL ducts -- the milk is being produced, but not enough milk is being extracted.  The hard part to determine when a woman has had breast or nipple surgery is if the engorgement is because baby is having trouble latching and/or suckling, he is not being brought to the breast often enough, he is not staying on long enough, or there is a problem with severed ducts or nerves.  Or it could be any other number of issues.  Or baby may be getting plenty of milk and the only problem is that the milk is being made more quickly than he can drink it.

So in order to narrow things down, it helps to know a few things: 

• How many stools did your baby have in the past 24 hours, how large are they, and what color are they? Stools are more important that urine in determining milk intake.  (They should be 2 stools on day 2, 3 stools on day 3 and thereafter, each bigger than a US quarter.)
• Have any weights been taken? (After the milk comes in, baby should begin gaining an ounce a day for the first four months.)   If so, what percentage of baby's birth weight has been lost? (Be sure to compare weights taken on the same scale as scales can be calibrated differently.)
• How is baby acting? 
• How has latching been going? 
• What was the birth like -- any medications? 
• Are you having sore nipples? 

There are many more questions to consider, but knowing how baby is doing, diaper output and weight loss are the most telling factors.  Of course, even with those, there are mitigating factors, like being weighed on different scales that are calibrated differently.  But those are the starting points to consider. If diaper output and weight loss are at least the minimum levels, then we know baby is getting enough milk, which indicates that enough milk is being made and removed. Click here for more information on how to know if baby is getting enough milk

To make things better right now, make sure your baby is fed and make sure as much milk as possible is being removed. It may be helpful to use ice packs to reduce the swelling so the milk can flow. It also may be helpful to use Reverse Pressure Softening.

The important thing to understand is that this discomfort will be much better in another day or so.  During this time, your baby will be fine so long as do your best to breastfeed him as much as possible, paying close attention to diaper output and weight gain.  Don't hesitate to supplement with expressed milk or formula if you feel it is necessary.  If it later turns out that you really are not making enough milk, there are many effective ways to increase milk production. Don't hesitate to contact a local lactation consultant if you need help working through uncomfortable engorgement.

Q If there are ducts that are severed and they become engorged when my milk comes in, will I get a breast infection (mastitis)?

A  Apart from the pain and discomfort of engorgement, many mothers find that the engorgement experience is made more difficult by healthcare professionals who tend to refer to the swelling as an inevitable result of severed ducts rather than as proof of functional lactation tissue.  Instead of being reassured by the evidence of recanalization, the mother is incorrectly warned about a risk of breast infection due to the mistaken belief that the engorgement will take longer than normal to resolve since the “milk has nowhere to go” and can become infectious. This is incorrect from the standpoint of both general lactation principles and post-surgical physiology.   From the general lactation perspective, engorgement is not a result of a large volume of milk so much as it is swelling of the tissues that surround the glands and ducts in response to a rapid influx of mature milk.  Thus, the presence of milk in severed ducts is not responsible for the majority of the engorgement, and so will not have a bearing upon its progress.  When the milk is not removed, the severed ducts atrophy rapidly, so they do not become distended with “backed up” milk and do not progress to infection or abscess.

Q Is there anything a mother can do to increase her milk production?

A  Yes! Increasing the milk production is a very critical concern of many breastfeeding women. Fortunately the human lactation system is very flexible and can be increased in most circumstances, although not always to a full supply.

There is no definitive recipe for making more milk.  There are different causes of low milk production, so the techniques that work for one mother are not necessarily the best methods for another.  This is because the effectiveness of the techniques used to increase milk production depends on the actual cause, such breastfeeding management, something the baby is doing, a physiological cause in your body such hormones, or damage to your ducts and nerves, such as from breast surgery.

Techniques to increase milk production are most effective when they specifically target the causes, which are not always a single factor. For instance, a woman may have had breast augmentation using the periareolar incision, which can damage nerves critical to milk release, but she also may have underlying insulin-resistance that inhibited the development of lactation tissue, which was why she had small breasts in the first place. Addressing her insulin-resistance in addition to traditional methods of increasing milk production is likely to result in more milk production than just following the traditional methods alone.

There are many techniques to increase milk production, both physical and medicinal. These include pumping, breast compression, relaxation techniques, and the use of galactagogues (herbal and prescription medicines that increase milk production). But in order to have the best result, it is important to understand as completely as possible why you do not have a full milk supply. Even if you think you know for sure, it doesn't hurt to consider the possibility of additional causes, because only when all causes are addressed can you make as much milk as possible.

Click here for more information

Q Is the amount of milk I can pump indicative of my milk supply?

A  It depends on the type of pump she is using. A rental-grade automatically cycling pump, such as the Medela Symphony pump, the Medela Lactina Select pump, or the Ameda Elite pump, is usually able to extract milk very efficiently, as long as the mother is using the correct size shields. A small electric or battery-operated pump, on the other hand, can usually only extract a small portion of a mother's accumulated milk. If a hospital-grade pump is not available, a manual hand pump can often extract milk more efficiently than a small electric or battery-operated pump, although they can be tiring to use. A consumer-grade pump, such as the Medela Pump in Style or the Ameda Purely Yours are generally not able to remove milk adequately for the purposes of increasing milk production because they are designed for use 3-4 times a day with an established milk supply.

Don't worry if you are not able to pump much more than drops in the first few days after birth. Even for women who have not had breast surgery, milk is made in very small quantities until the yellow colostrum transitions to mature milk around the third or fourth day.

Q Is it normal for nipples to turn bright white after nursing when a mother has had breast or nipple surgery?

A  It seems to be common for mothers who have had breast or nipple surgery to experience blanching or nipple vasospasm, which is otherwise rare among breastfeeding mothers.  Blanching occurs when either the tip of the nipple or the entire nipple becomes rigid, squeezing out all blood and turning completely white.   After some time, it may turn blue, and then the nipple will relax and a deep purple-red color will flush the entire nipple as the blood returns.  It is very painful, often including numbness, burning, tingling, and stabbing pain deep in the breast.  It can last several minutes and occur frequently, even in between feedings.

It is not known why mothers who have had breast or nipple surgery experience blanching so commonly.  It may be a result of blood supply disruption or nerve trauma to the nipple/areola complex during the surgery. 

Blanching can also be caused by many factors that are unrelated to surgical trauma.  At one time, it was thought that the phenomenon was a psychosomatic disorder (a manifestation of psychological disturbance).(1) It is now a well-known medical disorder, and is believed to be caused by physical factors, as well as external physical or chemical causes.(2)

Some cases of nipple blanching have been identified by numerous clinical studies as a manifestation of Raynaud’s Syndrome, a disorder that causes blanching in the extremities.(3) Raynaud’s Syndrome usually affects extremities such as fingers and toes in persons who are not lactating, but it can also affect coronary, pulmonary, ocular, gastrointestinal, penile, placental, and cerebral blood vessels. In nursing mothers, though, it seems to affect the nipples.   Mothers who experience true Raynaud’s Syndrome have experienced this disorder before breastfeeding as blanching in other parts of the body.  They may have Primary Raynaud’s Syndrome with no other symptoms or Secondary Raynaud’s Syndrome, which is caused by an underlying autoimmune or connective tissue disorder.

In mothers who do not have Raynaud’s Syndrome, blanching may be caused by either external physical or chemical factors.  A vigorous suckling technique, with a tight jaw and clamping, can precipitate blanching, as can poor latching and positioning techniques.  Exposure to cold can also precipitate nipple blanching.  Some drugs, such as thophylline, terbutaline, epinephrine, norepinephrine, serotonin, nicotine, and caffeine are known to cause vasoconstriction, which can manifest in the nipple.(4) 

The treatment of nipple blanching depends on the cause of the blanching.  When it is caused by Raynaud’s Syndrome, blanching can be improved by the use of food supplements such as calcium and magnesium, as well as evening primrose oil (gamma linoleic acid), and fish oil (eicosapentanoic acid and docosahexanoic acid) eicosapentanoic acid and docosahexanoic acid).  Unfortunately, it can take up to six weeks to see improvement with these supplements. 

When the discomfort from nipple blanching is severe, a prescription medication may be warranted, despite the original cause of the blanching.  The most commonly prescribed drug for the treatment of nipple blanching is nifedipine, which is a calcium channel blocker.   It has been shown to be clinically effective in reducing nipple blanching fifty to ninety-one percent of the time.  It passes into the milk at a rate of under five percent, which presents virtually no risk to the nursing child.    The side effects that are most commonly seen from use of this drug are headache, flushing, dizziness, rapid heartbeat, and edema in the extremities.(5), (6)

Nipple blanching that is caused by poor positioning, latching, or suckling techniques is resolved by improvements to those techniques. In some cases, nipple trauma is caused by tongue-tie, which can be resolved by clipping the tissue tying down the tongue (the frenulum). Some cases of tongue-tie are not obvious, but can cause severe nipple damage.

Nipple blanching caused by exposure to cold can be prevented by keeping the entire body warm at all times as it is not enough to keep just the nipples warm.  When it has already occurred, however, applying warm compresses to the nipple and gently squeezing blood back into the nipple can relax the spasm enough to stop the blanching.

Q Is it possible that the pain I'm feeling during nursing is from adhesions or scar tissue from the surgery?

A  Adhesions formed after breast surgery are frequently discussed in the medical literature and are often attributed as the cause of breast pain in mothers who have had breast or nipple surgery, particularly reductions.  The number of cases where adhesions could be clearly identified as the cause of breast or nipple pain is exceptionally low; none have been documented in medical journals to date.

Nonetheless, some breast pain felt by mothers who have had breast or nipple surgery, especially during their first lactation experience, may be attributed to adhesions.  Adhesions are comprised of scar tissue that forms connections between layers of tissue after surgery.  The binding together of the tissue layers that would normally move independently is painful.  The adhesions can vary in severity, from thin, filmy adhesions, to thick, vascular adhesions, to dense cohesive adhesions.  The thinner the adhesion, of course, the less pain it causes and the easier it is to break by exterior or surgical methods.  Over time, adhesions shorten, and depending on the type of adhesion, can introduce pain that did not previously exist.  This pain can significantly inhibit milk ejection, and thus reduce milk production.

When an adhesion is suspected, the first remedy is to try to move the layers of tissue by frequent, gentle massage, which will break the adhesions if they are not too dense.   In the case of nipple adhesions, the nipples can be gently pulled outward.  With time and active use of the breast, the adhesions will usually diminish in severity.

Unfortunately, when mothers have a sharp, stabbing breast pain, it is very common for their physicians to mistakenly attribute the cause of the pain to adhesions.  The mothers are frequently told there is nothing that can be done about it and the pain is something to be suffered through.  In fact, however, in many cases the actual cause of this type of pain is either shallow latching due to latch technique or tongue-tie, or a bacterial or fungal infection, which is treatable.  For this reason, it is important to rule out the more common causes of breast pain before attributing it conclusively to adhesions.

Q Are there any books on this subject that would be helpful to read in preparation for breastfeeding after breast or nipple surgery?

A  Yes! Diana West, IBCLC, a mother of three who has had the surgery herself and has successfully breastfed three boys wrote Defining Your Own Success: Breastfeeding After Breast Reduction Surgery. It is a comprehensive discussion of all the factors that surround breastfeeding after breast reduction surgery, including basic principles that apply to all breast and nipple surgeries.

A new, comprehensive book about low milk supply, by Diana West, IBCLC, and Lisa Marasco, IBCLC, will be published very soon. Watch this site for more information!

It is also important for mothers to learn about the normal course of breastfeeding. The following books are excellent resources for this purpose:

• Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers By Nancy Mohrbacher and Kathleen Kendall-Tackett
  
  
• The Womanly Art of Breastfeeding by La Leche League International
  
  
• The Nursing Mother's Companion by Kathleen Huggins
  
  
• Bestfeeding: Getting Breastfeeding Right for You by Mary Renfrew
  
  
• The Ultimate Breastfeeding Book of Answers by Jack Newman and Teresa Pitman
  
  

Q What resources for support does the woman who has had breast reduction surgery have?

A  The main BFAR forums are the primary source for support for the woman who has had breast reduction surgery. She need not be currently breastfeeding to participate. Click here to join. Many mothers also find that local breastfeeding support groups like La Leche League are excellent ways to meet other breastfeeding mothers for support, even though these mothers may not have had breast reduction surgery themselves. For personal breastfeeding help, though, a board-certfied lactation consultant, ideally one who has experience working with low milk production, will be your most helpful resource.