Breast Reduction Surgery/ Reduction Mammaplasty

Breast feeding requires:

• Glands to produce the milk
• Ducts to bring the milk to the nipple
• An interface for the child's mouth - nipple
• Emotional component

Breast reduction surgery can leave intact the ability to breast feed. This depends on the type of surgery. Breast reduction mammaplasty normally:

• Restores the nipple and areola to a higher position - excess skin may need to be removed or redraped.
• Lessens excess mass and weight by removing:
  • Breast glandular tissue
  • Fat

The aim is to remove the excess, yet keep the remaining tissue alive with a good blood supply and sensation. To maintain function, the gland - duct - nipple connection must remain intact.

Pedicle Flap

There are many types of breast reduction sculpture that keep glandular tissue attached to the nipple and areola. When blood and nerve supply are left attached, the tissue moved is called a pedicle flap. Each of the many types of flaps has its own characteristics for sensation and amount of remaining attached gland. The choice of flap design is part of the surgical sculpting and what is the best depends on your specific problem. Not all methods are suitable for every breast.

All pedicle flap breast reductions have less gland than before surgery. The ability to breast feed after surgery will depend on

• how much milk producing gland remains
• how well the gland attachments to the nipple have been preserved
• sensation
• healing

Free Nipple Graft

In cases of massive breast reduction mammaplasty, there may be just too much tissue to preserve the nerves and blood vessels to the nipple and areola. Using a "free nipple graft" means that the nipple and areola are disconnected from the underlying gland, blood vessels and nerves. The breasts are then reduced. The areola and nipple are attached to the skin as a "graft" that needs to reestablish their blood supply to the superficial tissues of the breast. Sensation can restore to a degree from the local nerves but may not be as strong as with the "pedicle" techniques.

Remaining glands in the breast enlarge with hormonal stimulation. Since the connection to the ducts and glands is divided, milk production that gets to the nipple is very uncommon with a free nipple graft reduction. This operation is best reserved for the unusual case of massive breasts when breast feeding is no longer a concern.

Breast Feeding without Sufficient Milk Production

There are ways to breast feed without producing enough of your own milk. There are lactation consultants who specialize in showing you how to optimise what ever milk production is possible. Your child can then still get nutrition, and you can still enjoy the bonding of the breast feeding. One method is to tape a tube to the skin from a bag about the neck. You will need to ask your doctor for such help or explore several web sites that can direct you to resources. See our article on “optimizing milk supply”.

Breast Reduction - procedures

Breast reduction is one of the most common procedures performed by plastic surgeons in North America, South America, and Europe. It is the surgical treatment of macromastia, a condition that comprises the presence of enlarged and heavy breasts.

The weight and size of breasts can be reduced by using various surgical techniques. Two main technical aspects have to be considered when detailing surgical options for reduction mammaplasty. The first one is the pattern in which to incise the skin in order to gain access to the breast parenchyma that will be removed. These skin incisions, and the skin area that is to be excised, ultimately define the location and extent of the final scars. The second aspect to be considered is the segment of breast parenchyma to be left in the patient after the glandular excision is performed. This defines the vascular and nerve supply to the remaining breast (parenchyma, draping skin, and nipple-areola complex), as well as its shape, since each area within the breast has different attributes. This second issue pertains most importantly to the postoperative ability to breastfeed.

The purpose of breast reduction surgery is to reduce the volume of the breast. There are many breast reduction surgical techniques, nearly all of which are likely to reduce milk production capability. (1), (2) The surgeries that have resulted in the least negative impact are those in which the areolae and nipples were not completely severed (even though they may have been moved),(3) and the lower portion of the nipple and areola remains intact.(4)

The most common techniques in Ireland are the pedicle techniques in which the areola and nipple are moved to a higher position while attached to a mound of tissue called a “pedicle” that contains the still-connected ducts, nerves, and blood supply.  This technique is called "inferior" or "McKissock," "Robbins," or "Moufarrege" techniques, if the main part that remains attached is below the areola (where the nerves that are important to milk ejection are). It is called "superior" if the main part that remains attached is above the areola. The superior pedicle technique, also known as the "Lejour" and "Lassas" techniques, has been shown in studies to result in less favorable milk production outcome, due to the location of the incision on the lower part of the areola, which severs the primary nerve that affects sensation and milk release.(5) There is also the medial pedicle technique, with the attached portion on the inside side of the areola. The lateral pedicle technique preserves the portion on the outside side of the areola. A combination of superior and medial is also used and this is known as the Superomedial pedicle technique.  There are also variations on each of these techniques. Although there is a scar completely around the areola with each of the pedicle techniques, the nipple and areola have not been completely detatched and remain attached to the chest wall throughout the procedure.

The Free Nipple Graft technique does severe the nipple and areola completely from the breast. This technique is usually only required in women with extremely large breasts when the pedicle is too long to sustain the nipple were it left intact. Even with this technique, however, some women have regained nipple sensitivity and some milk production and release capability.(6) 

The scars from breast reduction surgery vary widely according to the technique that was used, but can include a scar around the areola; a scar in a vertical line from the areola to the inframammary fold (the fold below the breast); a very small half-inch horizontal scar at the base of the breast; a short horizontal scar of about two inches somewhat above the inframammary fold; or a long horizontal scar along the inframammary fold.  Some scars are hidden on the areola, some resemble an inverted T, and others resemble an anchor. 

Breastfeeding after breast reduction surgery is certainly possible. With advances in surgical techniques for breast reductions (reduction mammoplasty), surgeons are increasingly able to preserve milk-producing tissue so that women who have had breast reductions are able to produce significant amounts of milk.

The techniques that have resulted in the most milk production are those in which the nipple was not completely severed, even though it may have been moved. Through our extensive experience with BFAR mothers, we have also learned many means of maximizing the milk-producing capability of any portion of the mammary system that remains intact and functional.

Breastfeeding, then, is a very attainable goal if you have had a breast reduction, assuming that you have at least one breast with a nipple and areola.

Want to know more?

Details of operative techniques that are used:

• Breast Amputation
• Central Pedicle
• Inferior Pedicl
• Lejour
• Liposuction
• Vertical
• Superior Pedicle
• Vertical Bipedicle
• Poland Syndrome

References

• Breast-feeding, self-exam, and exercise practices before and after reduction mammoplasty.
• Ann Plast Surg. 2008 Oct;61(4):375-9.
• http://www.ncbi.nlm.nih.gov/pubmed/18812705?ordinalpos=3&itool=EntrezSystem2.
• Widdice, L. The effects of breast reduction and breast augmentation surgery on lactation: an annotated bibliography. J Hum Lact 1993; Sep 9:3 161-7.
• Souto, G., Giugliani, E., Giugliani, C. et al. The impact of breast reduction surgery on breastfeeding performance. J Hum Lact 2003; Feb 19:1 43-9; quiz 66-9, 120.
• Marshall, D., Callan, P., Nicholson, W. Breastfeeding after reduction mammaplasty. Br J Plast Surg 1994; Apr 47:3 167-9.
• Sandsmark, M., Amland, P., Abyholm, F. et al. Reduction mammaplasty. A comparative study of the Orlando and Robbins methods in 292 patients. Scand J Plast Reconstr Surg Hand Surg 1992; 26:203-9.
• Tairych, G., Worseg, A., Kuzbari, R., et al.  [A comparison of long-term outcome of 6 techniques of breast reduction].  Handchir Mikrochir Plast Chir 2000 May; 32(3):159-65.
• Ahmed, O. and Kolhe, P. Comparison of nipple and areolar sensation after breast reduction by free nipple graft and inferior pedicle techniques. 

www of interest:

Breastfeeding after Breast Reduction Surgery:

www.bfar.org

Kellymom: