I am being asked more frequently of late (for some reason) whether it is possible to have an explant procedure performed whilst actively breast feeding.
It is an interesting problem to consider. Historically, we (plastic surgeons) have certainly had to consider the impact of the breast surgery we do on the ability to breast feed after the operation. And so whilst there isn't necessarily great data, we can generally answer questions about the impact of breast augmentation, fat transfer and breast reduction procedures on the future ability to breast feed.
But the question of actually operating on a mum who is actively lactating is something else entirely.
I guess it is fair to say that in the past, most surgeons would have dismissed this out of hand. It is also reasonable to say that for someone considering primary surgery such as breast augmentation or breast reduction, it remains the case that offering surgery to a woman who is breast feeding would be a (very) bad idea, for a number of reasons. The most obvious arguments against operating on a lactating woman are the risk of infection, the risk of mastitis, and (perhaps most importantly, when considering elective aesthetic procedures) the risk of poor or unpredictable aesthetic outcomes.
But what about offering explant surgery to someone who has concerns related to their implants? Do the arguments change in that context?
Well, let's break this down a little to look at it critically.
The first question we have to ask is: what procedure are we doing?
The reason that is relevant is that the explant itself is an operation that (in most cases) is "separate" from the breast tissue. Given that most breast implants are placed behind the Pec muscle, a standard explant with capsulectomy involves operating behind the breast gland.
However (!) there are other factors to consider, before we even think about what other operations may be performed. We have to factor a potentially increased risk of both bleeding and fluid collections. This relates to the fact that during breast feeding, the breast is technically in an "inflamed" state, which is relevant surgically as this means there is more blood flowing into the breast. Whilst bleeding risks can in many ways be controlled, we must always consider that any elective breast operation involves some sort of risk vs. benefit equation, and the aim is to minimise the risk in every case.
The bigger questions about what procedure we're doing relate to the additional steps we commonly take to reshape or add volume to the the breast.
The two additions to consider are mastopexy/breast lift procedures, and fat transfer, and each adds risk in its own way if we consider them in the context of someone who is lactating.
Firstly, mastopexy involves cutting through the breast tissue. Cutting through breast tissue which is producing milk is not fun. We do occasionally come across retained milk secretions trapped in the breast in women some time after they have finished breast feeding. When we do, much as when we encounter cysts, we stop and carefully wash and decontaminate the area before proceeding, especially if there will be sutures passing through that part of the breast. This is because the breast glands (and therefore any product of those glands) is technically contaminated. The way to think about this is that by definition, the breast glands and the nipple are in continuity with each other via the breast ducts.
Bacteria do live on the nipple, in the ducts, and in the glands. Conventional wisdom posits that the bugs living in the breast are similar to those living on the skin. We have known for many years that the risks of capsular contracture (which is a process mediated by the presence of bacteria) are higher after operations like mastectomy, at least in part becuase the surgery there involves cutting into and through breast tissue, which creates a "contaminated" environment for a breast implant, when compared to a precise breast augmentation during which the surgeon never enters or passes through breast tissue. Similarly, surgeons have abandoned incisions around the nipple and areola for placing breast implants, for the same reasons.
More recent data would suggest that actually, the breast has its own distinct microbiome, much like the mouth, the gut, and the vagina. The bacteria in the breast seem to vary based on where you live, and your overall health, and there is some suggestion that different bugs are associated with things like breast cancers compared to normal, healthy breast tissue. In fact, as with many common diseases, from heart attacks to gastric ulcers to cancers in every part of the body, scientists are discovering the overwhelming importance of the different bacteria that cohabit in and on our bodies and the ways they can both benefit and harm us.
Anyway, the point of this is to say that there are bacteria in the breast glands. Which is fine, until your cut into them and allow those bugs to enter into the breast tissue itself (where they aren't normally able to get to). Once out of the glands and ducts, those bacteria can then cause infection. So anytime we cut through breast tissue, this is a potential risk, which is heightened by the enlargement of the breast glands during breast feeding.
I guess a logical follow up question is: why isn't this an issue any other time? Perhaps the relevant point is that in young women who haven't been pregnant, and in older women who have finished their families or who may be peri/post-menopausal, the lobules of the breast (the productive components) have "involuted", or shrunk, substantially. They basically collapse on themselves. I would have to assume that this has implications on the nature and the number of bacterial populations in the breast, and therefore the risk of cutting through that breast tissue vs. the tissue of a lactating woman.
I mentioned above that when we do encounter things like breast cysts in surgery, we are careful about how we place sutures within the breast tissue. It is also a well known phenomenon that sutures which become contaminated (however that may happen) are more likely to result in granulomas or abscesses.
Right, so what about fat transfer?
The way fat transfer works is by injecting the fat throughout the breast with a long blunt needle. We lay down tracks of fat which criss-cross the breast tissue in all 3 dimensions. The needle passes through the breast tissue very differently depending on the layer in which we inject, and the age of the patient. For example, fat transfer into the breast of a young woman who hasn't had kids is easy enough when we inject into the fat layer of the breast. But deeper in where the breast glands are tight and thickly fibrous, it is very hard, and in some cases impossible to pass the needle. Contrast this with older ladies who have often experienced replacement of the fibrous breast tissue with fatty tissue, and the injection process is much easier.
As the needle passes through the breast, there is some associated bruising and swelling from the passage of the needle (it is a process you definitely don't want to be awake for!). It is suggested that for some ladies with cystic changes in their breasts (a very common normal variant) that if the needle passes through a cyst, fat can be inadvertently deposited 'into' the cyst, or the needle can create a small bleed into a cyst, both of which don't really cause a problem but can be associated with swelling, pain or small lumps that take time to resolve.
Now imagine that the breast is engorged and swollen with milk production. Imaging a blunt needle passing back and forth through that tissue. Like I said above, the breast is technically inflamed during breast feeding, there is increased blood flow, and the breast glands are larger as they produce milk. The inadvertent trauma and deposition of fat into that environment is going to be associated with bleeding and bruising, and perhaps more worryingly, there is again an increased risk of infection as the needle passes into and out of colonised glands.
So, the summary here is that operating on actively lactating breast tissue has a chance of increasing the risk of infection. Which is bad.
The second thing we have to ask ourselves, which I would have thought would be blindingly obvious, is this: what is our desired outcome?
Some may argue that this should be the first question.
For me, there is only one possible answer that I entertain as a surgeon - the desired outcome is only ever the best outcome possible, within my surgical capabilities.
In a sense, when I see patients, the "interview" is 2 directional - the patient is sussing me out to see if I am the right surgeon for them. At the same time, I am sussing the patient out to see if I think they are realistic, and whether they have what is needed to get the best possible outcome.
So it is probably obvious to say that if a patient asks me to do an operation that is likely to have a higher than tolerable risk, with a chance of a less than ideal outcome, simply becuase they want to continue breast feeding whilst undergoing complex surgery, then we aren't really seeing eye-to-eye.
I want to achieve the best for my patients. If they don't have the same goals, then I am not sure that I am the right surgeon for them.
Electing to operate on someone who is breast feeding is simply not compatible with smart, safe, high quality surgery.
I would suggest that, for 99.5% of women, explant whilst breast feeding is potentially risky, and always associated with a higher risk than for ladies who aren't breast feeding.
Therefore, I don't recommend it, and personally, I don't offer it.
There is a caveat to account for the 0.5%, and that is in the case of a patient who, for whatever reason, experiences an acute complication with a breast implant. Let's imagine for example someone experiences a new onset of sudden swelling and there is a diagnosis of ALCL. Or let's imagine a lady has a spontaneous bleed around her implant. These things are rare, but they do happen. In those cases, there is precedent, and justification for proceeding with explant surgery whilst a woman is actively breast feeding. But in those cases our expectations (particularly with regards to the aesthetic outcome) are going to be altered based on circumstance.
I understand that for some ladies, breast feeding is a really important part of their lives. Obviously some ladies wish that surgery were possible without disrupting their breastfeeding, for whatever reason.
I guess from my perspective, it makes very little sense to feel such a sense of urgency for an elective breast operation like explant that you would have it done in a way that increases risk and compromises outcomes.
There is no evidence anywhere to suggest that breastfeeding with an implant (even a ruptured implant) in place is dangerous to your baby. So I would (nearly) always recommend that the choice to explant be deferred until you are happy to wean your baby. If you want to continue to breastfeed, then by definition you aren't ready to prioritise surgery.