Would of course begin by recommending Diana West and Lisa Marasco's most wonderful book, Making More Milk, as well as the website, Breastfeeding After Breast and Nipple Surgeries.  For those who are new to our field:  When this book first came out in 2008, there were dances of joy in our profession from one end of the planet to the other.  http://www.bfar.org/index.shtml

I have never experienced nor had the need for breast reduction surgery, but speaking as an RN IBCLC for decades, my current perspective is that I would want to interview more than one breast reduction surgeon from more than one practice to ask about their surgical techniques for breast reduction in regard to functional outcomes.  

In consults, I've quietly observed varying cosmetic results ranging from nearly natural appearances with minimal scarring, to out-of-the-ordinary appearances that include off-centered nipple-areolar anatomy, off-centered to the extent that babies have marked difficulty with the oral grasp.  In two instances, the entire nipple-areolar tissue was removed and then replaced higher than usual, to the extent that the nipples were pointing slightly upward, and the infants had great difficulty with motor learning and motor control for the oral grasp, with and without the support of a nipple shield.  

I've assisted some post-reduction mothers who state that their nipples were protractile before surgery ("My nipples used to really stick out"), and the nipple appearance after the infant's birth had minimal to no protractility. If I were contemplating breast reduction today for myself, given my experience as an RN IBCLC, I would want to ask prospective surgeons these questions:   

Are you educated and trained to maintain the functional connection between the nipple and ducts?  Are you trained to maintain or remove some or all of the nipple-areolar complex during the surgery?  If the latter, how much of this anatomy is removed and subsequently restored during surgery?  

What percentage of your breast reduction patients report decreased sensitivity and/or increased sensitivity of the nipple/areola/breast?  Some women report experiencing hypo- and/or hypersensitivity post-reduction, and some women report that the hypersensitivity is so intense that they have been unable to tolerate having their breasts touched, with this hypersensitivity lasting for years and even decades after breast reduction.  In these instances, mothers often share concerns with a lactation consultant that they may not be able to tolerate having their infant at the breast, or in fact cannot tolerate having their babe at breast at all, with similar responses to milk expression.  Some mothers deny any diminished sensation in the nipple area post-reduction, and during a lactation consult, report feeling no nipple pain at all, even when presenting with visible nipple damage, and even when active bleeding has just occurred.  

Do you follow-up with your breast reduction patients over the years to inquire and learn about possible hypo- and hypersensitivity issues, and how these sensations may change over time?  Some women report either hypo- or hypersensitivity in the early days/weeks/months post-op, and also report changes in sensitivity over time, such as initial hypersensitivity in the early weeks/months/year(s) after reduction, followed by subsequent hyposensitivity thereafter.  

Do you maintain a professional relationship with the lactation community in order to continue learning about possible post-operative effects on breastfeeding and lactation?

What percentage of your reduction patients who lactate are able to build a full milk supply of 25 to 35 ounces daily by one month postpartum?  

For your lactating patients who are able to build a partial milk supply, to what extent are the volumes produced?     

In post-reduction mothers who wish to breastfeed their children, what percentage of these infants are reported to have learned the oral grasp for breastfeeding? 

In post-reduction nursing mothers, what percentage of their infants do not need supplemental milk feedings in order to gain adequate weight?   

From my perspective as a clinician, if I were contemplating breast reduction and hoping to nurse a baby at some point in my future, I would also want to interview IBCLCs in my area for their discreet recommendations of plastic surgeons who are both experienced and skilled in breast reduction.  

Many years ago, a mother (post-reduction) poignantly described to me the gratitude she felt to her plastic surgeon in regard to her ability to exclusively breastfeed her baby for several months (at that time of our discussion).  She described the surgeon as an older gentleman who was nearing retirement at the time of her surgery, and that pre-operatively, he had asked if she ever wanted to have children and breastfeed.  She laughed in telling this part of the story, saying that she was highly offended that he would dare to ask her such a question, since having a baby was the last thing on her mind at that much earlier time in her life, and she very much wanted and needed the reduction.  She said that this surgeon advised her that he would do everything he could to ensure that she would be able to breastfeed in her future, should she become a mother someday.  I am sending my own gratitude to this kind gentleman, from my location to wherever he might be.   

With warmest regards,

Debra Swank, RN BSN IBCLC
Ocala, Florida USA
More Than Reflexes Education
http://www.morethanreflexes.org

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