Barbara wrote:

>Also, it's my impression that the surgery has begun to be more careful
>with regard to protection of the function of the breast.  15 years ago
>when I saw my first cases, the breasts were just not delivering milk to
>the outside; today, I see many more successful experiences.

This is largely a result of the improvements in the surgical techniques,
rather than improvements in surgical skill or better attempts by surgeons
to preserve lactation tissue, although surgeons are increasingly aware that
a large proportion of their younger customer base desires to retain the
ability to breastfeed.  Twenty years ago, the free-nipple graft technique,
in which the nipple is completely severed and rests on a saline sponge
during the surgery, was widely used.  Today, the inferior pedicle technique
accounts for 80% of all techniques in North America (source: the American
Board of Plastic Surgery).  It is somewhat less prevalent in Europe, but is
widely used in Brazil and Australia.  The inferior pedicle technique
interrupts the function of the fourth intercostal nerve far less and the
leaves more of the ducts attached than do any of the other reduction
mammoplasty techniques.  As was recently discussed, breast liposuction is
gaining in popularity and it will be very interesting to see how our BFAR
clients fare who have had the liposuction surgery.

Jean responded:

>I saw a mother yesterday who commented early on in the consult that she
>had asked her surgeon what would happen if in the future she should have a
>child and decide to breastfeed.
>
>His answer: "I didn't interrupt anything. I think you should have no
>problem." I hope he was referring to lymphatic pathways as well as nerve
>and ductal pathways.

I doubt he was.  And I wonder if he considered the innervation issues,
which are nearly always impacted when incisions occur around or near the
areola, as in most reduction surgeries.  In my experience (and at the risk
of denigrating an entire medical specialty, which is not my intention), few
plastic surgeons have a thorough understanding of lactation, especially
with regard to the interrelationship of the nervous, lymphatic, and
parenchymal systems.  I have also learned that it is very difficult for
surgeons to differentiate among the types of tissue as it blanches during
the surgery.

With regard to the client having "no problem," well, that is unlikely to be
true, as many of us who work with BFAR mothers have experienced.

When speaking to post-surgical lactational capabilities, most surgeons
think in terms of any lactational capability as being full lactation.  They
often think that any lactation is full lactation.  So when they give
prospective clients odds of lactation at "50/50" -- they mean that there is
a 50% chance that *some* milk will be produced (and hopefully
expressed).  In those terms, I think the odds are actually significantly
better than 50/50.  Most BFAR mothers that I have worked with have been
able to produce express some milk.  But it is *how much* milk they can
produce that matters when it comes to the breastfeeding relationship.

Karleen wrote:

>I also say that all they need to do is breastfeed for long enough and if
>their babies demand and
>their supply does not match up to start with it will eventually!

Sadly, this has not been my experience at all.

Diana West
http://www.bfar.org

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