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E. Moreno-Artero and L. Aguado
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Part V
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Breast
Mammary Tissue Changes During
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Pregnancy andBreastfeeding
TatianaCostas, MónicaGomes-Ferreira,
andJesúsOlivas-Menayo
14
Take-Home Points
• We should consider breasts not only as a
breastfeeding organ but also as an aesthetic
one. The second function is as important as
the rst, and it must not be overlooked.
• Breasts are dynamic organs that change during a woman’s life. Hormone variations during pregnancy and breastfeeding cause
changes in the physiology, shape, size, and
vascularization of these organs.
• There are particular conditions in this period
such as mastitis or nipple ssure. Moreover,
changes in breast tissue make it difcult to
diagnose breast pathology.
• These changes may revert over time or require
surgical procedures to recover the aesthetic
function of the breasts.
T. Costas (*)
Obstetrics and Gynaecology, Complejo Hospitalario
Universitario de Salamanca, Salamanca, Spain
e-mail: tcostas@saludcastillayleon.es
M. Gomes-Ferreira
Department Obstetrics and Gynecology,
MS Medical Institutes, Lisbon, Portugal
e-mail: info@drmonicagomesferreira.com
J. Olivas-Menayo
Department Plastic Reconstructive and Aesthetic
Surgery, MS Medical Institutes, Lisbon, Portugal
e-mail: doctor@olivasmenayo.com
14.1 Introduction
Breasts are an important organ in the woman’s
body, not only for breastfeeding but also because
of their important aesthetic function. Both of
them are crucial, and the latter must not be
overlooked.
During pregnancy and breastfeeding, the
mammary tissue is exposed to critical changes
due to hormonal activity. Depending on multiple
factors, these changes may persist over time or
disappear after the breastfeeding period.
There are also typical pathologies in this stage,
such as mastitis in the puerperium. Also, there
may be other common lesions, such as broadenoma, which are more difcult to detect and
diagnose due to changes in the mammary tissue.
14.2 The Breasts
14.2.1 Anatomy
The breasts are a bilateral organ in the thoracic
area. They are usually close to the sternum,
between the second and sixth ribs. In addition,
there is mammary tissue in a triangular extension
close to the axilla called axillary process or tail of
Spence, which has several implications in breast
cancer.
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_14
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T. Costas et al.
The breasts are afxed to the chest through the
Cooper’s ligament, which joins the breasts to the
pectoral fascia.
They are made up of glands, fat tissue, fascia,
and skin. The mammary tissue composition
changes during the different stages of life due to
hormonal mechanisms [1] (Fig.14.1).
14.2.2 Tissues
14.2.2.1 Glands
The gland is formed by gland lobules (between
15 and 20) that are connected to the lactiferous
sinus through the lactiferous ducts.
The milk is produced in the glands by secretory cells, and it is carried through the lactiferous
ducts to the sinus. When the nipple is stimulated
or the sinus completely lled, the milk comes out
from the breast through the nipple.
The mammary gland is extremely exposed to
hormonal changes. During pregnancy and breastfeeding, the glands are stimulated and their structure changes. This concept will be explained
below [2].
14.2.2.2 Fatty Tissue
The mammary fat tissue is different from other
body fat tissue, such as the one in the thighs, for
example, due to its inherent characteristics.
In the breasts, fat is essential for the development of mammary glands and their changes during pregnancy and breastfeeding, since fat creates
the structure in which glands may develop [3].
Moreover, it plays a crucial role in carcinogenesis due to the special microenvironment that
fatty tissue creates. Adipocytes have aromatase
activity, which increases the effect of estrogen
(also important in pregnancy) [4], and these cells
secrete many other factors such as adipokines,
involved in cancer development [5]. On the other
hand, the latest research shows that the growth of
these tissues (not only mammary tissue) has an
inammatory component, and it could also be
connected to cancer [6].
From an aesthetic perspective, the mammary
fat tissue is the one most affected by weight
changes and weight loss, because breasts only
have fatty tissue (with no muscle or bones), and
they have an elevated amount of estrogen receptors (Fig.14.1).
14.2.2.3 Vascularization andLymph
Drainage
Irrigation of the anteromedial zone is provided by
branches of the internal thoracic artery (specially,
the branches of the second to fourth intercostal
spaces), which perforate the chest wall close to the
sternum. In the lateral external zone, irrigation is
provided by axillary vessels [1] (Fig.14.2).
Fig. 14.1 Basic breast
anatomy. Redrawn with
permission of Olivas
Menayo J.Available at
https://www.
cirugiasdelamama.com/
anatomia- de- la- mama
b
Pectoralis major
muscle
Perforant vessels
Intercostal muscle
Sixth rib
Fatty tissue
Areola −nipple complex
galactophore reservoir
galactophore ducts
gland lobules
Internal thoracic
14 Mammary Tissue Changes During Pregnancy andBreastfeeding
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249
Fig. 14.2 Vascularization of the breast. Redrawn with
permission of Olivas Menayo J.Available at https://www.
cirugiasdelamama.com/anatomia- de- la- mama
internal thoracic lymph nodes and the lateral
zones to axillary lymph nodes. The union of both
of them is located in the area of the nipple, and it
is called subareolar plexus (Fig.14.3).
nerves, specially fourth to sixth, in their lateral
and anterior branch.
14.2.3 Physiological Changes
Breast continues to change since prenatal life to
menopause.
mones involved in that) during all women life are
going to be explained, since prenatal life, menarche, puberty and adult life, pregnancy, and
breastfeeding and the end of that.
ized skin). They are exocrine glands that are able
Axillary vessels
Internal thoracic
vessels
The lymph vessels drain the medial zone to
The skin sensitivity is provided by intercostal
andBreast Development:
Hormone Function
In this section, changes in breast (and the hor-
Breasts are an ectodermal derivative (special-
lymph nodes
Subareolar plexus
Fig. 14.3 Lymph drainage of the breast. Redrawn with
permission of Olivas Menayo J.Available at https://www.
cirugiasdelamama.com/anatomia- de- la- mama
Axillary lymph nodes
to secrete milk thanks to a differentiation process. Hormones and protein factors such as prolactin, aldosterone (responsible for duct
differentiation), and placental lactogen are
involved in the fetal breast development, and progesterone and estrogens also participate.
At the end of the fetal life, the breast is completely formed with a minimum size (no fatty
components, and lactiferous ducts at their minimum). During infancy, breast development takes
a rest due to a reduction of placental hormones
and lack of hormones from the body itself.
Before menarche, the levels of ovarian estrogen increase in response to gonadotropin levels.
Due to this, thelarche appears: an increase in the
fat and gland differentiation due to hyperplasia
and hypertrophy. Before that (more or less 2years
prior), the nipple-areola complex starts to grow.
During puberty and adult life, the breasts
develop without interruption until reaching complete structural and functional development. It is
well known that during the menstrual cycle, the
mammary tissue changes due to the hormonal
differences that are registered during this cycle.
During pregnancy, the breasts have to be prepared for their function: breastfeeding.
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T. Costas et al.
Nowadays, the inherent mechanism involved is
still a mystery.
It is known that the increased levels of estrogens, progesterone, and placental lactogen
induced by pregnancy (due to the corpus luteum
and placenta) are involved in breast changes due
to their mammotropic effects.
During the rst weeks of pregnancy, there is
simply growth of ducts and lobules. In the third
trimester, due to an increase in the level of hormones, the breast undergoes remarkable changes:
it grows further, with proliferation of the duct
epithelium and creation of new lobules, and the
lumen of the ducts dilates due to an accumulation
of secretions. The involution of fatty and connective tissue to allow this enlargement is mediated
by progesterone. The rst colostrum is formed.
Also, the nipple-areola complex grows.
After childbirth, the levels of estrogens, progesterone, and placental lactogen decrease dramatically and, for that reason, prolactin can carry
out its function: lactogenesis. During pregnancy,
levels of prolactin are similar to those of the puerperium stage, but the other hormones were previously inhibiting it.
Lactogenesis has two phases:
The rst one is called lactogenesis I or galactogenesis, and it is the rst milk production promoted by prolactin.
Lactogenesis II or galactopoiesis is the second
one. Its function is the maintenance of breastfeeding. In this stage, not only prolactin is important (every time that milk is evacuated, prolactin
is stimulated), but also the suction and pressure
of the baby, which maintains prolactin and milk
ejection reex (an autonomous reex that acts on
the smooth muscle).
There are also other hormones such as insulin,
oxytocin, or thyroid hormones, as well as local
and microenvironmental factors, which allow the
epithelium to secrete milk and which also modify
its properties.
At the end of breastfeeding, the spacing of
baby breastfeeding intake stops the stimulation
of prolactin and breasts gradually come back to
normal.
In menopause, the hormonal decrease also
causes changes in the mammary tissue, which
involutes and loses rmness. However, there are
other anatomical factors, such as changes in the
connective tissue or in ligaments, which also
have an inuence on this process [7].
14.3 Changes During Pregnancy
andBreastfeeding
inMammary Tissue
In order to prepare the body for lactation, the
breasts undergo signicant changes during pregnancy and breastfeeding afterwards.
Anatomical changes are due to tissue modications: gland tissue should proliferate. In return,
the rest of the tissues, such as a fatty tissue or
connective tissue, have to allow this change
through involution. The mammary glands grow
signicantly.
During breastfeeding, ducts should be completely lled with milk, and changes similar to
those of pregnancy may be observed.
This change may be observed with ultrasounds. During pregnancy, mammary tissues are
usually hypoechoic. In the lactating woman,
breasts are generally hyperechoic, with more vascularity and bigger ducts [8] (Figs. 14.4 and
14.5).
Fig. 14.4 This image shows pregnancy in a primigravida
woman at week 26. It should be noted that the hypoechoic
area is due to proliferation of breast tissue and disruption
of the layered architecture. Image courtesy of Dr. Martín
Esquilas (Salamanca)
more
14 Mammary Tissue Changes During Pregnancy andBreastfeeding
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In contrast, Rauh etal. described in 2012 [10]
several factors that could have an inuence on
breast stiffness and size after pregnancy and
breastfeeding. A decrease in breast volume was
reported in 21.8% of the women, and an increase
in 35.1% of them (no changes were reported by
the remaining women). The following variables
were predictive factors for an increase in breast
size: a younger age at rst pregnancy at term,
time elapsed from that pregnancy (more time was
Fig. 14.5 This image shows a lactating woman on her
15th day after labor. Differences should be seen with an
increased hyperechoic area (with many vessels and ducts).
Image courtesy of Dr. Martín Esquilas (Salamanca)
a better predictive factor), weight before pregnancy, and weight gain. In addition, predictive
factors of greater breast stiffness were age at rst
pregnancy at term, time from that pregnancy,
weight before pregnancy, breastfeeding status,
14.3.1 Changes inVolume, Position,
andDensity: Symmetry
14.3.1.1 Volume andDensity
Tissue changes modify the shape of the breast
during pregnancy and lactation.
The breasts grow and become less stiff due to
the increase in gland tissue and the decrease in
connective and fatty tissue during pregnancy
and number of pregnancies [10].
Moreover, some studies reported that women
with a larger increase during pregnancy are more
likely to carry inside a male fetus [11]. There is
not enough evidence on this aspect, and further
studies are needed.
Finally, no correlation was found between breast
size during pregnancy and milk volume [12].
Figure 14.6 summarizes the main changes.
(they grow by one to two sizes). During breastfeeding, the breasts may feel heavy due to milk
content and the volume could also increase. After
breastfeeding, the breasts may be bigger or
smaller than before pregnancy. It depends on the
breast tissue recovery or fatty and connective tissue after glandular involution.
There is no clear factor involved in the change
of size of breasts:
Bayer etal. carried out a study in Germany in
which they assessed breast volume during pregnancy using a three-dimensional surface technique. They discovered that the average increase
in volume was 96 mL, regardless of the initial
size. Factors such as age, previous pregnancies,
and BMI did not seem to have substantial effects.
However, during pregnancy and breastfeeding,
breast changes are related to progesterone, which
is involved in carcinogenesis. There could be a
relation between breast enlargement during pregnancy and cancer development [9].
Fig. 14.6 Main changes in volume and density in breast
during pregnancy. Redrawn with permission of Olivas
Menayo J. Available at https://www.cirugiasdelamama.
com/anatomia- de- la- mama
251
Less stiff
Connective
and fatty tissue
Gland tissue
Milk content
Volume: 1 or 2 size
Ptosis
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T. Costas et al.
14.3.1.2 Ptosis: Position
oftheNipple- Areola
Complex
The position of the breasts is inuenced not only
by tissue changes, but also by alterations from
gravity induced by this extra weight.
Breast ptosis occurs when the supportive
breast tissue cannot attach to glands and fatty tissue, causing a stretch of breast skin that allows
descent of the parenchymal mass and changes in
the shape and position of the nipple-areola complex. Hormonal changes during pregnancy and
breastfeeding, together with the fast change in
volume, may cause sagging breasts after this
period in a woman’s life [13].
This situation may be classied as ptosis when
the nipple-areola complex is more than 21 cm
away from the suprasternal notch.
In the 1970s, Regnault proposed a ptosis classication that is still useful nowadays. Although
there is a subjective component, it is the best tool
for ptosis classication for surgery (mastopexy)
[14] (Fig.14.7):
There is no correlation between lactation and
ptosis. In fact, the main factors that affect ptosis
are being overweight, weight changes, number of
pregnancies, breast size before pregnancy, age,
and smoking habits [15].
Ptosis can be treated surgically (see reshaping
after breastfeeding).
14.3.1.3 Symmetry
As a double organ, breasts can show differences
between them. The volume could be different if
the amount of estrogen and progesterone receptors is different. The mechanism behind this is
unknown.
Different studies have tried to correlate symmetry with the fetus’ sex without results [16], as
well as with the child’s weight, head, or chest circumference, without success [11].
14.3.2 Changes intheNipple-Areola
Complex: Skin
andPigmentation
– Grade 1: Slight ptosis: nipple-areola complex
just below inframammary fold and above
breast contour
– Grade 2: Moderate ptosis: nipple-areola com-
plex further below inframammary fold and
above breast contour
– Grade 3: Severe ptosis: nipple-areola complex
below inframammary fold and no tissue below
the inferior pole
– Pseudoptosis: Inferior pole ptosis with nipple
in correct position
Fig. 14.7 Ptosis classication. Redrawn with permission of Olivas Menayo J.Available at https://www.cirugiasdela-
mama.com/elevacion- de- la- mama
14.3.2.1 Nipple-Areola Complex
Allowing suction will be the function of the nipple-areola complex during breastfeeding. In
order to achieve this, it may change.
The width and depth of the nipple increase in
order to become adequate for the newborn’s
mouth. Similarly, the areola undergoes the same
process.
Montgomery glands appear. They are hypertrophic sebaceous glands scattered on the areola
[17]. Their function is not completely known.
14 Mammary Tissue Changes During Pregnancy andBreastfeeding
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253
They may emit a smell that could attract the newborn to lactation (Fig.14.8).
14.3.2.2 Pigmentation
Hyperpigmentation is the change in the coloration of the skin (or part of it), which becomes
darker. It may happen due to the facts that estro-
Fig. 14.8 Montgomery glands on the areolar surface.
Black arrowheads signal Montgomery glands
gens are melanocyte stimulating and human chorionic gonadotropin (HCG) is biochemically
similar to melanotropin. However, there are no
consistent studies in this eld.
More than 90% of all pregnant women
reported some type of hyperpigmentation during
gestation. The most common one is enhancement
of normally dark areas [18]. Typically, hyperpigmentation affects the middle abdominal wall skin
(linea alba), which forms the linea nigra, and also
the areola and nipple on the breast.
The areola and nipple are darker during pregnancy than in nonpregnant states (Figs.14.9 and
14.10).
Darkening of the region surrounding the areola is called secondary areola. The mechanism
behind this process is unknown (Fig.14.11).
14.3.2.3 Skin
The breasts go through the same process as the
rest of body skin regarding weight changes during pregnancy. It may be even worse in these
organs due to their dramatic changes.
If the increase in breast size is extensive during pregnancy, stretch marks may appear. They
usually turn up after breastfeeding due to the
quick breast weight change (Fig.14.12).
Figs. 14.9 and 14.10 (Left) and (right): The image on
the left one is a nonpregnant woman with a pink areola.
The image on the right is a pregnant woman at week 29
(not the same patient). The hyperpigmentation and
darkness on the right image can be seen
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Fig. 14.11 Secondary areola in breastfeeding patient
T. Costas et al.
14.3.3 Vascularization
Increasing blood volume is necessary for breast
gland development. Breast blood vessels are full
due to the hormonal effect. In sum, the fullness of
the vessels and the fact that the skin is thinner due
to breast enlargement may make little veins
slightly noticeable on the breast surface during
pregnancy.
Ogawa etal. tried to measure the tissue concentrations of oxyhemoglobin, deoxyhemoglobin, and total hemoglobin and their saturation in
the breasts. Values were higher during pregnancy,
but in the breastfeeding period, they decreased
during the newborn suction time. This could be
because during suction, oxytocin not only binds
to lactiferous epithelial cells but also affects the
vessels of smooth muscles. There is also a compression mechanism of multiple ducts above the
blood vessels that can explain this situation.
There are not many factors that affect the volume of breast vessels. The only one with which
they found a negative correlation was BMI [19].
Fig. 14.12 Stretch marks after 6months of breastfeeding
in a 29-year-old primigravida woman. Her breasts
increased two sizes during pregnancy and breastfeeding.
White arrowheads show two stretch marks
14.3.4 Paresthesia andPain
Tenderness and paresthesia appear in breast tissue from very early stages of pregnancy.
This could be explained by two causes:
The rst of them is breast enlargement.
Mammary tissue grows into the skin and the
breast is perceived as full and stimulated, which
causes tenderness.
Also, changes in estrogens and progesterone
could stimulate neurological receptors that may
explain the paresthesia in the rst weeks of pregnancy. Moreover, anatomical changes can have
an inuence on the receptors by applying pressure or crushing them.
Breast tissue may feel painful during pregnancy but also during breastfeeding. It is important to take care of the breasts and try to alleviate
pain by applying heat or cold, for example.
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