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Supplemented breastfeeding rates after breast
augmentation with implants were about twice the
rates of the general population [26, 33, 34]. There
is no difference in supplemented breastfeeding
rates reported by incision or placement of the
implants.
Among the complications described in the literature, the most serious ones are those that
involve the effects of the implant material on the
newborn. About those, the ndings are mixed;
some low-quality papers report rheumatic diseases in children breastfed by women with
implants, and that more children of mothers with
implants had lower birth weight and had to be
transferred to hospitals [39, 40]. There is also one
study that found esophageal motility problems in
some children whose mothers had breast implants,
but it was later found that the study was nanced
by the attorneys of those mothers, who were suing
for compensation against the implant manufacturer [41]. However, many good-quality studies
dispel those statements, as they did not nd any of
those complications in children breastfed by
mothers with implants [42–46]. Other studies
even found that blood silicon levels of women
with implants are not different from baseline and
that the levels of silicon found in breastmilk of
women with implants were 10–210 times lower
than those found in cows’ milk [47–49].
Other complications of breast augmentation
indirectly related to breastfeeding would be loss
of nipple sensation, which happened to up to
10% of the patients intervened but was mostly
transient [33, 50–52]. One study reported less
sensation with an inframammary groove incision
vs. a periareolar one [52], but others did not nd
that difference, giving more importance to the
role of greater implants in smaller breasts [33, 53,
54]. Lastly, the transglandular approach was
associated with painful breastfeeding, which is a
known cause for breastfeeding cessation [50].
The overall breastfeeding success of breast
augmentation patients is close to that of the general population, but taking into account the lower
rates of exclusive breastfeeding and the higher
rates of supplemented breastfeeding, it is safe to
assume that the placement of implants for breast
augmentation has a deleterious effect on the abil-
ity to breastfeed. Moreover, it was found in one
study that women with implants used more galactagogues, which constitutes evidence of lower
baseline milk production. The main issue with
breast augmentation with implants is managing
the increased pressure due to increase in the volume of the breast cone. This can be addressed in
two ways: by choosing the smallest implant that
the patient nds adequate and by placing the
implant under the pectoral muscle, so it can
spread the pressure more evenly across the mammary gland section [55].
Pearls and Pitfalls
Using an implant with a volume greater to which
is advisable by the skin laxity of the patient is
contraindicated when the patient wants to still be
able to breastfeed.
Although the known benets of breast surgery
are plenty [56
volume implant but she also wants to breastfeed
her children, it is better to delay the operation.
], if the patient demands a high-
20.2.3 Other Techniques forBreast
Augmentation
Aside from implant placement, there are other
techniques for breast augmentation, although
they are more seldomly performed. Breast augmentation through fat grafting is, within the rarity of non-implant procedures, the most
commonly performed. There is no specic statistical data about the number of breast augmentation procedures performed, but the total fat
transfers to the breast in 2019 were 24,892, which
is a tenth of the number of breast augmentations
with implants performed in the United States in
the same year [1]. Breast augmentation through
injection of some alloplastic materials is also
possible, but the complications derived from it
are often grievous [57].
As it happens with breast augmentation with
implants, one should pay special attention to the
laxity of the skin envelope and try not to overll
it. Additionally, fat should never be transferred
into the glandular tissue, as it can disrupt its
structure.
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A. R. Magallón and J. O. Menayo
20.2.4 Combined Procedures
All the techniques described above are often performed together, as many cases require mainly
one technique and some degree of others to
achieve the desired result. The main technique is
the one that is often reported, and therefore there
is scarcity in the data about the outcomes and the
complications prole of combined procedures,
but the safest assumption regarding the ability to
breastfeed is to consider that the impairment
caused by each technique proposed for a case is
additive. Moreover, it is known that the combination of procedures in a single surgery is associated with greater needs for revision surgery,
which in turn is associated with greater impairment of the ability to breastfeed [58].
20.3 Breast Surgery After
Breastfeeding
Some patients’ demands will not be easily
addressable before they have fullled their desire
to breastfeed, but scheduling the surgery after
breastfeeding comes with some issues of its own.
A woman can continue to lactate for years after
the pregnancy, but once breastfeeding is stopped
for approximately 1 week, any milk left in the
breast will be reabsorbed, and in theory, no more
milk will be produced even if suckling or pumping is resumed. The problem is then when will
that milk be completely reabsorbed?
20.3.1 The Importance ofProper
Timing
The usual delay when scheduling a surgical procedure after breastfeeding is of about 6months.
This will be enough time for the breasts of most
women to reabsorb the milk that was left after
breastfeeding. There are also plenty of cautionary
tales about what can happen if one decides to
operate too soon [59–61]. Nonetheless, similar
complications have been described in patients
operated up to 10years after their last pregnancy,
although these are simple case reports [62–67].
The expected complications when operating
on a breast that has recently (or not so recently)
breastfed are galactorrhea and galactocele formation, which can by themselves put the results of
the surgery and the patient at risk, as they can
contaminate the implants, burst out sutures, and
become infected [65]. Finding galactorrhea in a
patient that has not breastfed for long may merit
exploration of her endocrine axis [68].
Finding a balance between risk and benet
when choosing a time to operate after breastfeeding is not simple. A year after, breastfeeding
shows a lower amount of cases with complications related to milk production, but it may be
similar to waiting for just 6 months. With the
available evidence, the best policy is to present
both options and their associated risks to the
patient and let her decide.
20.4 Conclusion
Although the available evidence points out that
most breast surgery techniques may not prevent
mothers completely from breastfeeding, it is safe
to assume that their experience will be signicantly different. This may be even more noticeable if they have already breastfed successfully.
Lower milk production can mark the difference between being able to provide exclusive
breastfeeding for enough time to get its benets
for both the mother and the children and not having even enough to provide supplemented breastfeeding. Similarly, a more painful breast due to a
relatively smaller skin envelope, or an impaired
lactation reex due to nerve damage, can preclude both exclusive and supplemented breastfeeding. Furthermore, they can make the mother
stop breastfeeding earlier even when they are
able to, as it makes the process more
uncomfortable.
When the issue is when to operate on a woman
that has just stopped breastfeeding, the usual
threshold of 6 months after the last time she
breastfed is safe enough for most women, but it is
not enough for all of them. Look for lumps and/
or discharge through the nipple when exploring
the breasts, in addition to asking the patient
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whether she had any discharge in the previous
months. A patient without any of these ndings
can still present complications associated with
prior lactation, but the chance of it happening
will be much lower.
As with any surgery that alters the structure of
the breast, obtaining preoperative and postoperative imaging is always recommended, both to
detect if there is any lesion in the breast that
might alter the surgical plan and to provide a reference of the breasts’ structure after the procedure for breast cancer screening purposes.
In general, cosmetic breast surgery will affect
both the structure and function of the breast,
which in turn will affect the lifestyle of the
patient. Enough care should be taken to ensure
that the surgery provides the patient with a benet that is not overshadowed by its downsides.
This is only achievable when the patient is
allowed to discuss her plans and ideals and is
properly explained the possible outcomes of her
decisions.
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Part VI
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Abdomen
Alterations oftheAbdominal Wall
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During Pregnancy
PatríciaMota
21
Take-Home Points
• No risk factors were found for the condition.
However, multiple pregnancies, macrosomic
babies, and twins are associated with severe
diastasis recti in postpartum women.
• Ultrasound imaging is a reliable tool to measure Inter-rectus distance during rest and
under contraction conditions.
• It is essential for women with alterations in
the abdominal wall to be assessed in a multidisciplinary team in order to treat the augmented inter-rectus distance and prevent
pelvic oor muscle dysfunctions after birth.
Attention
Diastasis recti is a prevalent concern in postpartum women.
There is limited evidence to recommend an
exercise program to women with diastasis.
The individual evaluation of the abdominal
wall and pelvic oor function with physiotherapist in women’s health is still the best option to
guide women with diastasis in the recovery
process.
21.1 Introduction
Diastasis recti is an impairment of the connective
tissue causing the two rectus abdominis to separate along the linea alba.
The location of Diastasis recti can be below,
above, or at the umbilicus, and there are several
classications for clinically signicant diastasis.
Women’s health physiotherapists often treat
patients with diastasis both during pregnancy and
after birth, and these patients often present a
combination of other musculoskeletal symptoms,
such as pelvic oor dysfunctions, low back, or
pelvic girdle pain.
It is mandatory that these patients are accessed
in a multidisciplinary team and the elected treatment for the abdominal wall should respect the
musculoskeletal conditions often combined with
the augmented inter-rectus distance.
P. Mota (*)
H&TRC- Health & Technology Research Center,
ESTeSL- Escola Superior de Tecnologia da Saúde,
Instituto Politécnico de Lisboa, Lisbon, Portugal
Univ Lisboa, Fac. Motricidade Humana, CIPER,
LBMF, P-1499-002, Lisbon, Portugal
e-mail: Patricia.mota@estesl.ipl.pt
© 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_21
21.2 Anatomy oftheAbdominal
Muscles andtheir
Aponeuroses
The anterolateral wall of the abdomen has a laminar conguration composed by six layers including, from surface to depth, the skin, the supercial
fascia, fat, the abdominal muscles, the transver-
355
356
Serratus anter
Inter
Exter
Aponeurosis
of the e
ob
or
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P. Mota
salis fascia, and the parietal peritoneum. The
muscular layer comprises four paired muscles
with bers oriented vertically (rectus abdominis
muscle), obliquely (external and internal
oblique muscles), and horizontally (transversus
abdominis muscles) with skeletal attachments
on the thoracic cage, pelvis, and the spinal column via the thoracolumbar fascia [1] (See
Fig.21.1). The aponeuroses of these muscles represent sheet-like tendons that form the sheath of
the rectus abdominis (rectus sheath) and also
serve as the medial insertion of the oblique’s and
transversus muscles, along the anterior midline
of the abdomen, forming a brous structure that
connects the right and the left side of the abdominal wall, the linea alba (Fig.21.1).
The rectus abdominis (RA) and the pyramidalis are the only vertical muscles in the abdominal
wall. The rectus abdominis muscle originates
from the fth through seventh costal cartilages to
insert on the symphysis pubis and crest.
Superiorly, the rectus is wide, broad, and thin,
becoming narrow and thick inferiorly [1].
Segmentation of each rectus muscle occurs by
tendinous intersections that represent attachment
of the rectus muscle with the anterior layer of the
rectus sheath.
The two RA muscles are separated by the
linea alba and each one is invested within a sheath
derived from the aponeuroses of the deepest
abdominal muscles [1]. The rectus sheath consists of an anterior and a posterior layer (lamella)
formed by the aponeuroses of the external and
internal oblique and transversus abdominis muscles. These aponeuroses meet at the lateral edge
of the rectus along a curved line to form the linea
semilunaris, which extends from the ninth costal
cartilage to the pubic tubercle. Above the umbilicus, the anterior and posterior sheaths are composed by the aponeuroses from the internal
Pectoralis major
ior
Linea alba
Te ndinous intersection
Transversus abdominis
nal oblique
nal oblique
xternal
lique
Fig. 21.1 Abdominal muscle. (Adapted from Juarez M.Avelar (eds.), New Concepts on Abdominoplasty and Further
Applications; Springer International Publishing, 2016; with permission)
Rectus abdominis
Inguinal ligament
(formed by tree inferi
border of the external
oblique aponeurosis)
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oblique muscle. In effect, the internal oblique
aponeurosis splits, allowing one layer to pass
anterior and one posterior to the rectus muscle.
The anterior wall of the rectus sheath includes
also the external oblique aponeurosis and the
posterior sheath consists of contributions from
aponeuroses of the transversus abdominis (transversalis fascia). Inferior to the umbilicus, approximately halfway between the umbilicus and the
symphysis pubis, the external abdominal aponeurosis has no contribution to the formation of the
posterior rectus sheath, and all three aponeuroses
pass anterior to the rectus muscle. This anterior
displacement of the aponeuroses creates a curved
line of demarcation, in the posterior lamella of
the rectus sheath, called the arcuate line, below
which only the transversalis fascia separates the
rectus abdominis muscle from the parietal
peritoneum.
The linea alba reaches from the xiphoid process to the pubic symphysis and is dened as the
fusion of the aponeuroses of the deepest abdominal muscles [2]. The linea alba consists of a
three-dimensional, highly structured meshwork
of collagen bers [3] which in conjunction with
both rectus sheaths are regarded as the most
important structures for the stability of the
abdominal wall from a mechanical point of view
[3–5]. The linea alba tension is important to
maintain the abdominal muscles, particularly the
rectus muscles, at a certain proximity to each
other [2, 6] in order to optimize abdominal muscles function both as on abdominal viscera support or producing thorax/pelvis movements.
Tension on the linea alba, particularly below
the umbilicus, seems to be regulated by the
pyramidalis, a small paired triangular-shaped
muscle, present in 80% of people, which lies
between the anterior surface of the rectus abdominis and the posterior surface of the rectus sheath
[7]. The precise function of the pyramidalis muscles is unclear, but together both muscles are
thought to assist in tensing the linea alba [7].
The linea alba compliance is highest in the
longitudinal direction and smallest in the transverse direction [2] which determines the great
resistance offered by the LA to rectus abdominis
transversal separation. Even so, the viscoelastic
properties inherent to the collagen makes the
linea alba prone to increase length when the
mechanical stress is prolonged in time [5],
namely in the case of a long-lasting increased
intra-abdominal pressure, such as that resulting
from pregnancy [8–11].
The mechanical stress on linea alba is highly
associated to the action of the oblique’s and
transversus abdominis muscles. The external
oblique arises from the lower 8 ribs posteriorly to
interdigitate with both the serratus and latissimus
muscles. The direction of the bers is approximately horizontal in the uppermost portion only
to become oblique in the lowest portions. After
contributing to the anterior portion of the rectus
abdominis sheath, the remaining bers insert
onto the linea alba.
The internal oblique arises from the anterior
two-thirds of the iliac crest and lateral half of
the inguinal ligament to run essentially at right
angles to those of the external oblique. The
bers run perpendicular to the external oblique
muscle from the thoracolumbar fascia of the
lower back, the anterior iliac crest, and the lateral half of the inguinal ligament, to insert on
the 10th to 12th ribs inferiorly and the linea
alba (Fig. 21.1). The external and internal
oblique muscles both function in support of
abdominal viscera as well as assist in exion
and rotation of the trunk.
The transversus abdominis muscle is the
innermost of the abdominal muscles, being
placed immediately beneath the internal oblique
muscle from the 7th to 12th costal cartilages,
iliac crest, and the lateral third of the inguinal
ligament. The muscle bundles run mostly horizontally, except the lower most medial bers,
which run a more inferomedial course to their
insertion on the pubic crest and pubis [12]. Their
extensive aponeurosis passes horizontally in the
middle line of the abdomen and is inserted into
the linea alba: the upper portion lie behind the
RA muscle and blend with the posterior rectus
sheath while its lower part pass in front of the RA
muscle [12].
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P. Mota
21.3 Changes intheAbdominal
Wall Morphology During
Pregnancy
Physiological adaptations of normal pregnancy
include among others, and, most notably,
increased fat depot. The mechanisms responsible
for adipose tissue depot-specic structural and
functional differences are unknown [13].
The most obvious morphological change during pregnancy is the increasing abdominal circumference (Fig.21.2). This aspect is associated
with stretch marks or striae gravidarum, a common, disguring, gestational change that affects
between 55 and 90% of women [14]. Stretch
marks present as atrophic linear scars and can
cause distress, often leading to a decrease in
quality of life [14].
During pregnancy, the rectus abdominis muscle, the subcutaneous, and fat tissue undergo
pressure from the inside by the increased abdominal volume. The abdominal muscle and subcutaneous fat tissue become thinner until delivery. A
mechanical force affects the thicknesses of the
rectus abdominis muscle and the subcutaneous
tissue during pregnancy [15]. It is common to
assume that, because of the increased abdominal
pressure during pregnancy, with the increased
abdominal circumference, the stretch marks, fat
depot, diastasis recti, and ventral hernias are
related. However, there is no evidence that these
conditions can be related.
The functional role of the abdominal muscles
during pregnancy appears to be similar to those
in the non-pregnant state [8] and is suggested to
be important for trunk movement, pelvic stabilization, and restraint of the abdominal contents
[1]. However, the musculoskeletal morphology
of the anterolateral wall of the abdomen changes
as pregnancy progresses [16]. The weight and
dimensions of the uterus and its contents increase
from 40 to 1000g, and its capacity from 4mL in
non-pregnant state to 4000mL at term [17]. The
maternal inferior thoracic diameter is increased
[18, 19] as well as the anterior and lateral dimensions of the abdomen. These changes modify the
spatial relationship between the superior and the
inferior abdominal muscle attachments [17]
increasing the length of the abdominal muscles,
particularly the rectus abdominis [19]. At
38weeks of gestation, the length of the abdominal muscles increased a mean of 115% with
respect to the beginning of pregnancy [16]. The
increment of the anterior abdominal dimensions
may alter the angle of the abdominal muscle
attachment in the sagittal plane [16]. Alterations
in the spatial relationship of muscle attachment
and the muscle’s angle of insertion may alter the
muscles line of action and therefore their ability
to produce torque [16, 20].
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