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C. del PilarBérnizLaborda and J. O. Menayo
Fig. 19.13 Both aps joined together under the nipple
base
Fig. 19.14 Drawbridge ap with its widest portion in the
nipple-areola transition
the use of three dermal aps from the areola that
are tunneled under the nipple after cutting the
brous ducts. The procedure is nished with a
purse-string suture at the base. No traction device
is employed. Reported recurrence is 2.8% out of
107 nipples [7] (Figs.19.16 and 19.17).
Perischetti (2011): An incision in the middle
of the nipple below the areola plane is used to
release central brous ducts. In every half of the
nipple, a dermoglandular V-shaped ap is tai-
Fig. 19.15 Tip of the ap turned under the nipple base
after selective duct transection
Fig. 19.16 Three dermal aps based around the nipple
lored. In doing so, this technique would theoretically spare peripheral galactophorous ducts, with
breastfeeding being preserved. Out of 52 patients,
5 women became pregnant and 3 of them could
breastfeed. After 1year, recurrence was observed
in only 1 patient [15] (Fig.19.18).
Suture Based
Serra (2004): After transecting all ducts through
a nipple base incision, a ve-point star suture is
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Fig. 19.17 The three aps transposed under the nipple
base after duct transection
Fig. 19.18 Once the nipple is incised, two VY aps are
raised releasing all central retraction and sparing those in
the periphery
made to maintain projection. A traction device is
placed for 8days. No recurrence is observed in
12 patients [16] (Fig.19.19).
Kolker (2009): This minimally invasive technique uses an 18 G needle inserted at the 6
o’clock position of the nipple base to release the
shortened ducts until good projection is achieved.
A 4-0 monolament purse-string suture and two
crossed 5-0 mattress sutures are placed without
any traction device. Since this is applied for all
Fig. 19.19 Five-point star suture to maintain nipple
projection
Fig. 19.20 18G needle through nipple base incision to
release brous ducts
degrees of retraction, the recurrence varies across
a 0% in I, 27% in II, and 50% in III [17]
(Figs.19.20 and 19.21).
Lee (2003): Through an inferior periareolar
incision, access is gained to the nipple base.
Al brous bands and ducts are released, and
two internal sutures of the nipple sidewalls are
performed near the tip and at the base. This
method reported 0% recurrence in 17 patients
with grade III inversion [18] (Fig.19.22).
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Fig. 19.21 Crossed horizontal mattress sutures and
purse-string suture to maintain projection
C. del PilarBérnizLaborda and J. O. Menayo
• As mentioned before, a combination of quick-
and late-onset anesthetics will prevent any
postoperative pain. Avoidance of adrenaline or
other vasoconstrictor minimizes the risk of
ischemia but also allows for control of any
intraoperative bleeding.
• In cases of severe retraction, the transection of
the ducts by itself usually is not enough to pre-
vent recurrence. Here, interposition of soft tis-
sue helps avoiding new retraction during
wound healing. For a more reliable result,
suture of the ap to the opposite side of the
nipple base maintains the ap in place and
also improves denition of the nipple-areola
transition.
• For a better outcome, horizontal mattress
sutures for skin closure minimize the risk for a
widened or depressed scar, making it almost
inconspicuous.
• The traction device should be maintained
with the suture anchor for a minimum of
15days, but if in postoperative revision a ten-
dency to retraction is observed, the surgeon
should not hesitate to extend this even up to a
month.
Fig. 19.22 Two internal sutures, at the base and at the tip
through a periareolar incision
19.5.4 Technical Tips toImprove
Outcomes andAvoid
Complications
• Before starting the procedure, the nipple-
areola junction must be clearly distinguished
and marked. Anesthetics injection should be
done after this to avoid any distortion that
could mislead the incision placement.
19.6 Postoperative Care
After the procedure, the patient is advised to
avoid any water in the breast area until removal
of the stitches. We maintain the traction device
sutures for 2weeks. During that time, the patient
is instructed to periodically check the operated
area and call in case of redness or swelling. After
the two rst weeks, both traction stiches and skin
stitches are removed. The traction devices are
maintained for two additional weeks with sterile
drape to avoid any compression over the nipples
wearing the bra or during sleep. At that moment,
if the incisions look good, the patient is told to
wash those areas carefully drying the wounds
later (Figs.19.23 and 19.24).
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19.7 Outcomes andPrognosis
Is important to explain the patient that the
swelling of the nipple and the areola remains
for at least the rst month since surgery. This
swelling in the areola can sometimes obscure
the new projection of the nipple achieved after
the correction. Usually, at the second month,
the swelling has completely disappeared.
However, the patient is instructed to take care
of the incisions covering, applying moisturizer
twice a day, and protecting the scars from the
sun for the rst year.
19.8 Complications
Nipple inversion correction is a very safe and
simple procedure, easy to perform, and with good
Fig. 19.23 Inverted nipple (left) and the result 6 months
after the surgical correction (right)
outcomes. However, as any other surgical intervention, it carries a small risk for complications.
The main complications associated are recurrence, infection, and necrosis.
339
Fig. 19.24 Inverted nipple (left) and the result 6 months
after the surgical correction (right)
19.8.1 Recurrence
The most important complication of the procedure is the recurrence of the retraction. This
happens due to insufficient release of the
fibrous tracts or because of new fibrosis during healing of the wounds. The latter is
unlikely to occur since with our technique a
dermofibrous flap is interposed between the
transected tissue. This prevents new scarring
and also adds soft tissue and bulk to project
the nipple.
When the rst signs of recurrence are
observed, conservative measures are taken maintaining the traction device longer. In case the
retraction persists, a new surgery may be offered
to the patient. This is always offered after 1year,
once the result is denitive and to avoid any surgery during the healing process.
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C. del PilarBérnizLaborda and J. O. Menayo
19.8.2 Infection
Galactophorous ducts are colonized structures
prone to be the origin of cellulitis or mastitis to the
breast. The most frequently identied bacteria are
group B Streptococci and Staphylococcus aureus
[19]. During the intervention, these are transected
so migration of these microorganisms may happen. For this reason, we advocate the use of a short
antibiotic prophylaxis. In our clinical practice, we
use a three-dose prescription of amoxicillin/clavulanic 1g for this purpose. In addition, the patient is
instructed to check for detection of any sign of
infection during the rst weeks.
19.8.3 Necrosis
Partial necrosis is a very uncommon complication associated with nipple inversion surgery.
This should be advised in previously operated
and scarred NAC and specially when sutures are
used for eversion in the form of purse-string
sutures at the nipple base. If this is the case, we
recommend close follow-up during the rst 48h.
The patient should be instructed to periodically
check the color and aspect of the nipple and
return in case of any postoperative change.
19.9 Conclusions
Nipple inversion is a very common problem in
women; it may be present since birth or develop
due to postmaternity body changes. Classication
of the degree of inversion and good assessment of
patients’ expectations are essential for the surgeon to choose the best technique for each case.
The surgical intervention we propose here should
be advocated for degree II or III or when the
patient has no desire for future breastfeeding.
This pathology can be treated on a simple procedure, under local anesthesia, and with minor
complications. However, some important technical points must be taken into account. The rate of
recurrence varies depending on the degree of
retraction and the procedure chosen, but with a
thorough preoperative evaluation and an adequate technique selection, good outcome may be
obtained in all cases.
References
1. Bostwick J. Nipple areolar reconstruction. In: Jones
G, editor. Bostwick’s plastic & reconstructive breast
surgery. 3rd ed. St Louis: Quality Medical Publishing;
2010.
2. Nakajima H, Imanishi N, Aiso S. Arterial anatomy
of the nipple-areola complex. Plast Reconstr Surg.
1995;96(4):843–5.
3. Jaspars JJ, Posma AN, van Immerseel AA,
Gittenberger-de Groot AC. The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. Br J Plast Surg.
1997;50(4):249–59.
4. Park HS, Yoon CH, Kim HJ. The prevalence of
congenital inverted nipple. Aesthet Plast Surg.
1999;23(2):144–6.
5. Cooper A.Anatomy of the breast. London: Longman,
Orme, Green, Brown and Longman’s; 1840.
6. Pandya S, Moore RG.Breast development and anatomy. Clin Obstet Gynecol. 2011;54:91–5.
7. Han S, Hong YG. The inverted nipple: its grading and surgical correction. Plast Reconstr Surg.
1999;104(2):389–97.
8. Best CA, et al. Buffered lidocaine and bupivacaine
mixture—the ideal local anesthetic solution? Plast
Surg (Oakville, ON). 2015;23(2):87–90. https://doi.
org/10.4172/plastic- surgery.1000913.
9. Gould DJ, Nadeau MH, Macias LH, Stevens
WG.Inverted nipple repair revisited: a 7-year experience. Aesthet Surg J. 2015;35(2):156–64.
10. Jeong JH, Park I, Han J, Park JU. Correction of
inverted nipples with the double-track sun-cross
running suture technique. J Plast Surg Hand Surg.
2018;52(2):87–93.
11. Yukun L, Ke G, Jiaming S. Application of
nipple retractor for correction of nipple inversion: a 10-year experience. Aesthet Plast Surg.
2016;40(5):707–15.
12. Jeong HS, Lee HK. Correction of inverted nipple
using subcutaneous turn-over aps to create a tent suspension-like effect. PLoS One. 2015;10(7):e0133588.
Published 2015 Jul 24.
13. Durgun M, Ozakpinar HR, Selçuk CT, Sarici M,
Ceran C, Seven E. Inverted nipple correction with
dermal aps and traction. Aesthet Plast Surg.
2014;38(3):533–9.
14. Mathur B, Loh CYY. Sensation-sparing correction of inverted nipples using the ‘Drawbridge’ ap
approach. Aesthet Plast Surg. 2019;43(2):348–53.
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15. Persichetti P, Poccia I, Pallara T, Delle Femmine PF,
Marangi GF.A new simple technique to correct nipple
inversion using 2 V-Y advancement aps. Ann Plast
Surg. 2011;67(4):343–5.
16. Serra-Renom J, Fontdevila J, Monner J.Correction of
the inverted nipple with an internal 5-point star suture.
Ann Plast Surg. 2004;53(3):293–6.
17. Kolker AR, Torina PJ. Minimally invasive correction of inverted nipples: a safe and simple technique for reliable, sustainable projection. Ann Plast
Surg. 2009;62(5):549–53. https://doi.org/10.1097/
SAP.0b013e31819fb190.
18. Lee MJ, Depoli PA, Casas LA.Aesthetic and predictable correction of the inverted nipple. Aesthet Surg J.
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19. Kvist LJ, et al. The role of bacteria in lactational
mastitis and some considerations of the use of antibiotic treatment. Int Breastfeed J. 2008;3:6. https://doi.
org/10.1186/1746- 4358- 3- 6.
Breastfeeding andBreast Surgery
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AndrésRosMagallón andJesúsOlivas-Menayo
20
Take-Home Points
• The function of the breast can be as important
as its appearance for some women. Do not forget to inquire about it.
• Silicone implants are as far as it is known safe
for both the mother and her child.
• Although the ability to lactate is rarely affected
by previous procedures, the rate of exclusive
breastfeeding decreases.
• Breastfeeding alone has not shown any effect
on the shape of the intervened breast. Many
women will not breastfeed out of a misplaced
fear of damaging the results of their surgery.
20.1 Introduction
Cosmetic breast surgery was performed in more
than half million women only in the United States
in 2019 [1]. More than half of those women will
be at reproductive age at the time of surgery, and
of those wanting to become mothers, more than
80% will want to breastfeed [2]. Although it is
A. R. Magallón (*)
Department of Plastic, Reconstructive and Aesthetic
Surgery, Clínica Universidad de Navarra,
Navarra, Spain
e-mail: arosm@unav.es
J. Olivas-Menayo
Department Plastic Reconstructive and Aesthetic
Surgery, MS Medical Institutes, Lisbon, Portugal
e-mail: doctor@olivasmenayo.com
fairly common that mothers do not achieve their
expectations towards breastfeeding—with more
than half of them not breastfeeding as long as
they rst intended—the ability to breastfeed is
important both to the child and the mother [2].
Breastfeeding does have a benecial effect on
infant health. It is reported to reduce the risk of
illness by infectious diseases, the sudden infant
death syndrome rate, the risk of dying in infancy,
the risk of being overweight or obese later on,
and the risk of necrotizing enterocolitis, among
many others [3]. It also improves the health of the
mother, by helping to reduce weight; reducing
blood pressure; spacing away further pregnancies; reducing the risk of postpartum depression
(when the mother had previously the desire to
breastfeed) [4]; reducing the risk of breast and
ovarian cancer, cardiovascular disease, type 2
diabetes, metabolic syndrome, and rheumatoid
arthritis; and improving bone health [3].
Besides the known health effects of breastfeeding, the ability to breastfeed also forms part
of many women’s idea of self. The strong emotional attachment that this entails can be a source
of litigation if the desire to breastfeed has not
been explored properly during patient consultations. Moreover, considering that breast surgery
represents the biggest group of plastic surgical
procedures giving rise to claims [5], any female
patient that consults for breast surgery should be
asked about her prior pregnancies and her desire
for future ones. If she wants to have more chil-
© 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_20
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A. R. Magallón and J. O. Menayo
dren, her ability to breastfeed in previous pregnancies (if there were any) and her expectations
about breastfeeding in the following ones should
be assessed and documented. It is important to
determine the duration of prior breastfeeding
attempts, whether she could achieve at all exclusive breastfeeding or had to supplement it, and
for how much time could she maintain each kind
of breastfeeding. The time since she stopped
breastfeeding should also be documented.
After the obstetric history and the patient’s
plans have been thoroughly explored, the complications of the procedure that has been requested
should be discussed. This kind of approach helps
the patient to reect on her existing desires and
the foreseeable outcomes of her options, thus
building patient autonomy and improving
rapport.
The issues of which the patient should be
made aware when explaining the known complications of each procedure are mainly three: the
effects of the requested technique on her future
ability to breastfeed, the foreseeable changes to
the intervened breast after breastfeeding or pregnancy, and the complications that may arise from
operating on the breast too early on after
breastfeeding.
Of these three, the ability to breastfeed after
surgery will be determined by the amount of disruption of the glandular breast tissue needed to
achieve the desired result. The different outcomes
of breastfeeding after breast surgery will be
addressed later on in this chapter. On the other
hand, the singular complications that appear after
operating on breasts after the patient has stopped
breastfeeding her children may have to do with
the delay between the last time the patient breastfed and the day the surgery is performed.
Lastly, when explaining the changes that may
occur to the intervened breast after pregnancy or
breastfeeding, the principal concern should be
conveying to the patient the message that breastfeeding will not change the appearance of the
breasts, nor put at risk the results of the surgery,
as any change will be more likely due to the pregnancy [6–8]. This is especially important, as
mothers that believe that breastfeeding may
affect the appearance of the breasts will be less
successful at it [9].
Key Points
Breastfeeding is often an emotionally loaded
issue for many women. Be sure to explore the
history and the plans of the patients before taking
them to the operating room, as breast surgery can
impair signicantly their ability to breastfeed.
Women who intend to breastfeed and have
received cosmetic breast surgery should be
encouraged to do it, as it will not have any effect
on the appearance of the breast.
20.2 Breastfeeding After Breast
Surgery
Although the different techniques performed for
cosmetic breast surgery share a common goal—
the improvement of the appearance of the
breast—how they achieve it can vary a great
deal between them. The different needs of volume for each patient, the excess or defect of the
skin envelope, and the concern about visible
scars will make some techniques more suited
than others depending on what has to be done.
However, the way in which these needs are
addressed will affect the ability of the patient to
breastfeed [10].
The glandular tissue of the normal breast contains up to 20 lobules, each of them draining into
a galactophorous duct, that usually opens independently in the nipple. The letdown reex
induces the release of oxytocin needed for milk
ejection. Thus, successful breastfeeding depends
on the number of intact lobules and galactophorous ducts remaining on the breast and the presence of enough sensitive bers to enable the
letdown reex [11]. Additionally, milk excretion
is limited by the compliance of both the breast
stromal tissue and the skin envelope. This
explains the reduced success at breastfeeding
shown by patients with denser and rmer breasts,
such as those with tuberous breasts, whose
breastfeeding success can be as low as less than
half the rate of the general population [12].
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Important Breastfeeding success after breast
c
surgery is highly likely to be related to both
the amount of undisturbed glandular tissue
that is left out and the parenchymal pressure
derived from the relative size of the structures
of the breast cone compared to the skin
envelope.
Even when the loss of functional breast tissue
due to the surgical insult may seem nal, there is
some evidence of regeneration of the galactophorous ducts, both in an experimental rat model and
after nipple correction surgery [13, 14].
Nonetheless, the patients could not lactate up
until 2–3years after the surgery, and the regenerated ducts were narrower and their walls thicker,
which would again decrease the compliance of
the breast.
20.2.1 Breast Reduction
andMastopexy
Approximately a quarter of a million breast lift or
breast reduction surgical procedures in women
were performed in 2019, which account for
38.5% of all cosmetic breast surgeries in the
United States in that year [1]. Approximately
two-thirds of these surgeries were performed on
women under age 50, which emphasizes the need
for adequate knowledge about the consequences
that breast reduction and breast lift techniques
can have on breastfeeding.
Both breast reduction and mastopexy share
surgical incision placement and are often combined to some degree, as it is very rare that a case
requires strictly skin resection to reposition the
breast. Therefore, both procedures will generate
similar issues with the future ability to breastfeed. Firstly, tucking the skin envelope will
stretch it over the breast cone, diminishing its
compliance and making milk excretion difcult.
Secondly, tissue resection will directly reduce the
milk production of the mammary gland [15, 16].
The results reported by the available literature
about this topic are inconstant, as there is no standard denition of the most widespread concepts
about breastfeeding (breastfeeding success,
exclusive breastfeeding, supplemented breastfeeding …) and the thresholds for each one are
often arbitrarily chosen. Once this limitation is
accepted, it is possible to integrate the results of
the different studies.
The overall breastfeeding success after breast
reduction was often described as the ability to
breastfeed at all, and it was reported to be between
43.5 and 81.8% [17–25]. In the studies wherein it
was compared against the breastfeeding success
of the general population, there was some disparity. One did not nd any signicant difference
[19], and in another, both the initial breastfeeding
success and breastfeeding success over time were
lower after breast reduction (58% vs. 94% controls) [25]. No difference between pedicle choice
was found in two studies [17, 18], but in another,
the superior pedicle had signicantly greater
breastfeeding success (60.7% with the superior
pedicle vs. 43.5% with the inferior pedicle vs.
48% with the medial pedicle vs. 55.1% with the
lateral pedicle) [24].
The exclusive breastfeeding rate after breast
reduction does not have a singular denition, but
it can be understood as the ability to provide
enough nourishment only by breastfeeding. The
reported rates of exclusive breastfeeding after
breast reduction were from 21.4 to 53.8% [16,
23, 25–28]. When it was compared with the
exclusive breastfeeding rate of the general population, it was found to be signicantly lower, both
when taken only at a single point (29% vs. 80%
controls) [26] and when considered over time
(21% vs. 70% controls at 1month and 4% vs.
22% controls at 4months) [25].
Supplemented breastfeeding after breast
reduction was usually understood as having the
ability to breastfeed but not being able to produce
enough breastmilk to support the growth of the
newborn. It was reported to be between 21.7 and
68% [16, 19, 23, 26, 27]. In the latest study that
compared the supplemented breastfeeding rate
after breast reduction, it was found to be signicantly higher than in the general population (68%
vs. 16% controls) [26].
Even though they are not directly related to
breastfeeding, there are also some complications
of breast reduction and breast lift described in the
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A. R. Magallón and J. O. Menayo
literature that can impair the future ability of the
patient to breastfeed. These are:
• 0–44.5% of loss of nipple sensation [17–19,
21, 23, 28]
• <2% of nipple necrosis [21, 23, 29]
• 6–10% of nipple retraction/inversion [18, 23]
Additionally, breast ptosis recurrence was
found to be twice as frequent after pregnancy
[22].
Although there are some disparities and even
some contradictory evidence, there is some
agreement that even when breast reduction or
breast lift did not prevent women from breastfeeding at all, they will likely need to supplement
the diet of their children. It is also safe to assume
that there is a chance that the patient will not be
able to breastfeed at all after the surgery. For
breast reduction, if the needs of the patient allow
it, try to resect as minimum breast tissue as possible while preserving the tissue under the nipple-areola complex. And for breast lift, whenever
possible, try not to rely only on skin resection and
gland repositioning to achieve the desired result,
as it will reduce compliance, and opt for combining the skin resection with some degree of gland
resection, also preserving the tissue under nippleareola complex.
Pearls and Pitfalls
Greater corrections entail greater risks for the
ability to breastfeed. If the patient demands a signicant correction of the breast but is not willing
to accept the risk of losing the ability to breastfeed, a better alternative is to schedule the surgery after the patient has resolved her desire to
breastfeed.
20.2.2 Breast Augmentation
withImplants
Breast augmentation was the most frequent
surgical procedure performed in 2019 in the
United States, with a total of 280,692 procedures in that year. 85% of these were performed
on women under age 50 [1]. In addition to its
effect on the ability to breastfeed, it is also
important to consider the possible effects that
the placement of a foreign body close to the
mammary gland may have on the offspring of
the patient.
The different techniques for breast augmentation with implants share the objective of
increasing the volume of the breast cone while
preserving its contour and without overstretching the skin envelope. To fulll this aim, a silicone implant is placed in the subglandular,
subfascial, or subpectoral plane. All these
planes can be accessed through the usual inframammary groove, transareolar, or transaxillary
approaches without needing to disturb the
mammary gland. There is one exception, the
transareolar approach, that can be followed
with a transglandular dissection of the chosen
plane. That being the case, breast augmentation
does not need to directly damage the mammary
gland (except the transareolar-transglandular
approach), but the resulting enlargement of
breast cone will alter the surface-to-volume
ratio. Consequently, the skin envelope will be
stretched, presenting lower compliance, which
in turn will cause lower and more painful milk
excretion through an increase in parenchymal
pressure [30, 31]. Fibrosis around the implant
and gland atrophy have also been identied as
possible factors behind a lower breastmilk production of patients with breast implants.
The overall breastfeeding success after breast
augmentation with implants is high, with a range
between 63 and 93% [32–35]. Three of the articles found statistically signicant differences in
breastfeeding success when compared to the general population (63–93–79% vs. 88–99–89%
controls) [33–35]. There were mixed results
when comparing breastfeeding success by
implant placement, as one study found that retromuscular was better than retroglandular placement (82% vs. 17% breastfeeding success) [32],
whereas another did not nd any difference by
incision or placement [34].
The rates of exclusive breastfeeding after
breast augmentation with implants were consistently lower than those of the general population,
with a range of 47–54% (vs. 80–71% controls)
[26, 34, 36–38]. None found differences by incision or implant placement.
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