Think You Can’t Breastfeed After Implants? Think Again

Can You Breastfeed With Implants?

Think You Can’t Breastfeed After Implants? Think Again | Johns Hopkins Medicine


If you’ve had breast augmentation surgery and have implants, you might wonder if you’ll still be able to breastfeed.

While having breast implants can make breastfeeding a little trickier, that doesn’t mean it’s completely off the table.

Learn about the factors that determine your lihood of success, possible complications and some helpful tips for making breastfeeding your baby go as smoothly as possible.

When it comes to whether or not a woman with implants will be able to breastfeed, it really depends on where the incision was made and where the implants were placed.

The Incision

If your surgeon made the incision under the fold of your breast or through your armpit, then you should be able to breastfeed just fine. It’s also a great sign if you still have feeling in your nipples.

If your incision was made around the areola, then you may run into some issues, because there is a chance your milk ducts were either damaged or cut.

Implant Placement

If your implants are under the chest wall muscle, then your surgeon most ly avoided cutting the milk ducts and mammary glands. This bodes well for your breastfeeding future. If your implants were placed under any glandular tissue, then you may have a tough time trying to breastfeed.

Possible Complications

Some women who breastfeed after getting implants may have to deal with engorgement and extra-sensitive nipples. You also have a higher risk of developing mastitis, painful inflammation of breast tissue, than women who haven’t had implants.

Breastfeeding moms with implants also run the risk of not developing a full milk supply, especially if the implants were placed under breast glandular tissue.

According to medical experts at The Johns Hopkins Hospital, a woman’s milk supply may be limited if, during surgery, the incision severed nerves in the breast and nipple.

This doesn’t mean you won’t be able to breastfeed, you just may find your supply isn’t full.

Tips for Breastfeeding with Implants

Because women who have breast implants are more prone to developing mastitis, you may want to take some extra steps to try to keep this ailment at bay: Avoid tight bras; do not letting your breasts become overly full with milk; get plenty of rest.

Also, since having implants may result in a limited milk supply, you may want to consider formula supplementation to make sure your baby is getting enough. You can also take some steps to increase your milk supply, pumping after each feeding. This helps empty your breasts, which stimulates milk production.

When in Doubt, Seek Help

If you’ve had breast implant surgery and are either worried about not being able to breastfeed or are currently having trouble doing so, check with a lactation consultant. They are professionally trained to help breastfeeding mothers. If you need help finding one, your OB or baby’s pediatrician should be able to point you in the right direction.


Will Exercise Enlarge Your Breasts?

Think You Can’t Breastfeed After Implants? Think Again | Johns Hopkins Medicine

Some women are blessed with naturally full, sensual and perky breasts. Others, however, may not be satisfied with their breast size and wonder if exercise will enlarge your breasts.

You may have read about home remedies diet, exercise and even “miracle” creams and pills as a natural way to increase breast size.

However, your unique genetic makeup * is the primary factor contributing to your breast size, as well as other factors such as your body weight, age and your pregnancy and breastfeeding history.

Myths and Facts About Exercise and Breast Enhancement

What are your options when heredity didn’t give you the breast size you wanted? Can you really workout to get larger breasts? Even in our modern fitness-crazed era – where more and more women are discovering the benefits of lifting weights – there are still many misconceptions around how exercise affects breast size.

Some women think they don’t need to do chest exercises at all, since their breast tissue covers up their chest muscles. Others believe they can get bigger breasts if they just do enough push-ups. The reality is that neither of these are true.

In fact, chest-focused exercises for women bring a wide range of benefits.

** And, while consistent chest exercises will help build up the muscle underneath your breasts, there are no muscles within your breasts themselves – which is why exercising alone won’t make “your breasts” look bigger or back to your younger state.

However, by working your pectoral muscles, you may make your breasts look bigger and perkier. In other words, the cumulative effects of your chest workouts will be more akin to a breast lift than they will to a breast augmentation.

Understanding Breast Anatomy

If you look at this overview *** from Johns Hopkins Medicine, you’ll see that breasts are comprised of both fat and breast tissue – the lobules and ducts that come into play during breastfeeding.

many women, you may notice temporary breast growth during your monthly menstrual cycle, thanks to the hormonal rollercoaster of estrogen and progesterone. Breast size also increases during pregnancy and lactation to prepare for milk production.

After menopause, a drop in your estrogen levels will cause your breast tissue to shrink and lose shape.

Body Weight and Breast Size

In adult women and men, any increase in breast size often accompanies a person’s weight gain or loss.

When you consume more calories than you burn, you will gain body fat. However, it’s not possible to target these fat deposits in the breasts only. Instead, increasing your caloric intake will lead to overall increases in fat deposits throughout your body. The distribution of the “extra” calories will be dependent upon your genetic profile.

Furthermore, being overweight can increase the risk of several serious health conditions, **** including diabetes, high blood pressure and some types of cancer. Clearly, it would be dangerous to your health to try to gain weight merely to increase your breast size.

Fitness and Weight Training for Women

As mentioned earlier, lifting weights will not promote breast growth, but it will increase the size of the underlying pectoral muscles, which can lead to a more uplifted appearance. Incorporating a regular resistance training routine in addition to cardio can do wonders to tone and tighten your muscles, improving your self-esteem and body image along the way.

For best results, add strength training exercises that target the pectoral muscles – chest presses, push-ups, pullovers and flyes ***** – into your workout routine.

Perform two to three sets of 10 to 15 repetitions of the exercise for optimal results.

Yoga can also be an excellent addition to your fitness routine because it encourages better postural alignment, which will support your core and spine and help you carry yourself better.

Are You a Good Candidate for Surgical Breast Enhancement?

If you are dissatisfied with the size or shape of your breasts, are in good physical and mental health and your breasts have fully finished developing, breast augmentation surgery is still your best option for improving the size of your breasts. Many women with asymmetrical or undersized breasts opt for this procedure, as do women whose breasts have lost volume and shape after pregnancy, weight fluctuation or aging.

In a breast augmentation surgery, a talented surgeon such as Dr. Michael Kulick will place a specially designed silicone or saline implant under your breast tissue or muscle. The result of this surgery will be a fuller, more feminine bustline that still looks and feels very natural.

Are you considering breast augmentation surgery? The first step is to find a board-certified cosmetic surgeon to discuss your unique goals and help you decide how to achieve the ideal outcome for you. For the leading breast augmentation surgeon in San Francisco, contact Dr. Kulick to schedule your consultation today.

* Source:, July 2012

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*** Source: Johns Hopkins Medicine

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Johns Hopkins Magazine

Think You Can’t Breastfeed After Implants? Think Again | Johns Hopkins Medicine

Shockney was 34 when she became director of performance improvement at Johns Hopkins Hospital, measuring and assessing the quality of care delivered to Hopkins patients for the entire institution.

She supervised a team of nurses who reviewed patients' medical records and then identified ways to improve quality by implementing initiatives that reduced post-operative wound infections, and decreased the time it took to deliver test results.

Four years after starting that job at Hopkins, Shockney was diagnosed with breast cancer. She was so certain that her biopsy would be benign, she looked up her own pathology report in the hospital's database while her doctor was town.

She read the words “breast carcinoma” 12 times. She was terrified. “I thought the Grim Reaper was staring back at me,” she says.

As director of performance improvement, she had thought well of the care at Hopkins. “But flipping over to the other side of the bedrail and becoming a patient changed my perspective,” Shockney says. When she woke up in the recovery room after her first mastectomy, unable to feel either breast, she remembers becoming hysterical.

“Please tell me what you've done,” she pleaded with the nurse. “Please tell me you didn't remove both breasts.” The nurse told her she was wearing a binder, a compression dressing designed to prevent pockets of fluids from forming after surgery. “Why couldn't they have told me about the binder before surgery?” Shockney asks now.

She remembers being told that she would feel nauseated after her mastectomy. But the vomiting caused her to rupture her sutures, which made her need pain medication, which made her nauseated all over again. She remembers thinking, I not only lost my breast today but I can't get my head an emesis basin.

“We needed to prevent nausea from the outset,” she says.

After her surgery, she wanted to talk to other women who'd had breast cancer. She says, “I had hope from my doctor, but I needed it from a survivor.

” The American Cancer Society's Reach to Recovery program sent a survivor to talk to her, but it wasn't a good match. Shockney, whose breasts were size 44D, asked the woman, who was a 32AA, whether she should wear prostheses.

The woman told her that she found them unnecessary. Shockney replied, “Well, honey, for you they probably aren't necessary, but for me they are going to be.”

One day, a doctor she knew at the hospital asked her to talk to his secretary, who had just been diagnosed with breast cancer and was devastated.

“I felt really good after I spoke with her,” Shockney says, and remembers thinking, “I've done oncology nursing. I oversee quality of care.

Why can't I combine the two and volunteer so that women who come after me, who wear my bra, have a better experience than I did? It just seemed a natural thing to do.”

There was no model to follow. Shockney simply jumped in.

She volunteered in the just-formed Breast Center 24 hours a week, doing patient satisfaction surveys and writing pamphlets for women on how to read pathology reports and what to expect after surgery.

At home in the evening, she talked on the telephone with newly diagnosed patients. Within three years, she left her job as director of performance improvement and joined the Breast Center's staff, first as its breast health educator.

Caring for patients is more than being empathetic, she says.

Pat Williford, a former breast cancer patient at Hopkins who now works as part of the center's team of Survivor Volunteers, says Shockney has unparalleled concentration: “What impresses me most about Lillie is that she has this ability to make you feel you are the most important person in the world at that particular moment. It's nobody else exists.” Theodore Tsangaris, chief of breast surgery at Hopkins and the medical director of the Breast Center since 2002, says, “Imagine your life is falling apart and here comes this powerful, dynamic woman, and she pretty much takes over your life. She puts out her hand and she grabs you and she walks you through it and gets you over the hump and feeling better. That's a real gift. I used to think I was really good at it. Lillie is better than me.”

Shockney listens carefully to patients and families and has a knack for explaining complex medical information. She is as positive as she can be, given the diagnosis, and s to tell patients that their treatment is “doable.” But she refrains from telling them what they should do.

Instead she looks to the patient for direction. When Gail Shapira was diagnosed last year, she remembers feeling as though everything was her control. “That first visit was so hard,” Shapira says. Shockney was in the exam room with Shapira and her husband.

When the surgeon left, Shockney turned to her and asked, “Now what do you want to do?” Shapira told her that she wanted a bilateral mastectomy, not the lumpectomy the surgeon told her was a possibility, depending on what he found during surgery. Shockney listened to her reasoning.

Then she told the North Baltimore school nurse that she would support her decision in all future meetings with the team responsible for her care.

“Even to be given the smallest bit of control was so important,” says Shapira, a school nurse who lives in North Baltimore. “Lillie gave me that.”

Shockney's devotion to her patients extends long after their diagnosis. When one of them had to be isolated due to a drop in her white-blood-cell count, the woman couldn't hold her young children and became depressed.

Shockney grabbed a pair of pink pom-poms from her office shelf, recruited Deb Stewart, an oncology nurse and breast cancer survivor herself, and headed out to a parking garage rooftop within view of the patient's hospital window.

It was 18 degrees, but the two nurses stayed out there for 30 minutes and cheered for the woman's cell count to rise. “Laughing strengthens your immune system,” says Shockney, citing research studies. “It boosts your T-cells.”


FDA Panel to Consider Lifting Ban on Silicone Breast Implants

Think You Can’t Breastfeed After Implants? Think Again | Johns Hopkins Medicine

Kristen Chase plays tennis, lifts weights and works out on cardio machines — an ambitious fitness regimen for a mother of four nearing 40.

But nursing three sons and a daughter has changed the appearance of her breasts in a way exercise can’t fix, she said. So Chase has opted to have surgery to restore her figure, and she has decided silicone gel breast implants would look and feel better than the saline liquid-filled ones.

Her decision would be a simple one in many countries. But in the United States, the Food and Drug Administration bans the use of silicone implants for cosmetic surgery because of lingering suspicions about health risks.

This week, two California companies will go before an FDA advisory panel to seek a recommendation that could open the way to market silicone implants to the 250,000 American women who each year have surgery to make their breasts fuller.

Chase, who lives near Chicago, will be watching closely. She has delayed having the surgery, hoping the panel will ease the ban on silicone implants and the agency will then sign off on their use.

“I don’t want that top-heavy, unnatural look,” she said. “There are some women that you look at, and it’s flagrantly obvious their breasts are augmented.

I am pursuing a natural, prior-to-having-children look, and saline does not provide that.” Silicone implants have become the choice of 90% of European women who have cosmetic breast surgery, industry figures show.

But in the United States, they remain limited mainly to cancer patients having breast reconstruction.

In 2003, a FDA panel recommended approval of silicone implants for cosmetic surgery patients. But agency officials rejected that recommendation and requested more information from manufacturers.

The two Santa Barbara companies, Inamed and Mentor Corp., have produced data that they say show a low risk of complications, such as ruptures. But it’s not clear that the FDA will agree.

Even if it approves silicone implants, patients may be required to undergo costly MRI scans every year or two to detect ruptures.

Last week, staff reports released before the panel meeting questioned whether the industry’s new data could reliably predict that implants would not rupture after more than a few years in women’s bodies.

“The tone of those FDA documents was more negative than people expected,” said Amit Hazan, an analyst who follows the medical devices industry for the Atlanta investment firm SunTrust Robinson Humphrey.

Wall Street analysts noted that the chairman of the new FDA panel, Johns Hopkins cancer specialist Dr. Michael A. Choti, voted against silicone implants when he served as a member of the 2003 panel. Choti was not granting interviews, his office said.

For Inamed and Mentor Corp., millions of dollars are riding on the outcome of the three-day meeting.

The two U.S. silicone implant manufacturers have spent years trying to persuade the agency to allow them to sell their products to cosmetic surgery patients. Should they succeed, Hazan estimates the implant market would increase by about 20% next year, from $400 million to $475 million.

Market analysts predict that silicone implants, if approved, would quickly outpace sales of the liquid-filled ones.

The safety debate over silicone implants has been going on since the late 1970s. Lawsuits alleging that gel leaking from ruptured implants caused cancer and other diseases forced Dow Corning, a major manufacturer, into bankruptcy. The FDA imposed the current restrictions in 1992.

Since then, repeated scientific investigations have not found a cause-and-effect link between silicone breast implants and illnesses such as cancer, immune system disorders, connective tissue disease or neurological problems. A recent study found an association with fibromyalgia, a syndrome characterized by chronic muscle and joint pain, though that finding remained controversial among doctors.

Medical researchers have documented other kinds of complications, common to all implants. Breast tissue around an implant can contract, causing pain and deformation. Implants can rupture. Such problems require many women to undergo repeated operations.

“Breast implants do NOT last a lifetime,” says an FDA handbook for patients. “You should be prepared for long-term follow-up, re-operations to treat complications and personal financial costs.”

Supporters of silicone implants have concluded that their risks are outweighed by the benefits.

“I’ve never professed that anything man-made in terms of a medical device is perfect,” said Dr. James Wells, a Long Beach surgeon who heads a task force on breast implants for the American Society of Plastic Surgeons.

But Wells said that the task force was going to urge the FDA panel to approve silicone implants for general use.

“Women in 60 countries in the rest of the world have access to them, and 90% of the women choose silicone,” he said. “Why are American women restricted from making the decision for themselves?”

Consumer groups and some women’s health advocates argue that the long-term risks of silicone implants remain unknown.

“I don’t think the science can support approval,” said Diana Zuckerman, president of the National Research Center for Women and Families.

What happens when silicone implants break is of concern because such ruptures are not easily detectable. Saline liquid-filled implants deflate when they rupture, making a failure easy to see. But with silicone implants, the gel stays in the chest area and may be only absorbed into the body slowly.

These silent ruptures account for the majority of cases in which silicone implants fail.

The FDA staff’s conclusions raised concerns about the long-term risks of ruptures, despite the industry’s new data.

Although initial-rupture rates for Inamed implants are in the low single digits, the agency estimated that 10-year rates for cosmetic surgery patients could range as high as 38%. For breast reconstruction patients, facing more complicated surgery, the FDA staff estimated 10-year rates as high as 93%.

The projections are mathematical modeling that the company strongly disputes.

Uncertainties about the health effects of silicone breast implants long have marked the debate over them. Some women who have had the implants later have suspected their health was compromised, even in cases where no ruptures were found.

Brandy Markakis, a 29-year-old mother of two from Menifee, Calif., was never able to get an unequivocal medical diagnosis for the cause of her fatigue and body aches after she received silicone breast implants.

One doctor said she might have fibromyalgia. “My boys couldn’t understand why Mommy didn’t feel good all the time,” she said.

“I am a baseball fanatic, and my 11-year-old would say, ‘Mommy, you never play catch with me anymore.’ ”

She had considered herself lucky when she was able to get silicone implants through a clinical trial in 2001, after her saline implants caused painful contracture of her breasts. But after about a year and a half, her energy plummeted. Markakis said it felt as if she had a flu that she could not shake.

As she researched the problems other women reported about silicone implants, she became convinced they could have caused her malaise. About six weeks ago, she had her silicone implants removed. It turned out they were not ruptured, but Markakis said that her energy had steadily improved.

“I wish somebody had really sat me down and said it’s not a 1-in-a-million chance of problems,” she said.

“Here I am, back where I started, all this money wasted. We must have spent $20,000 our own pockets.”



Surgical choice

Since 2000 cosmetic breast augmentations in the U.S. have grown 24%, while those performed for reconstructive reasons have declined 22%:

Cosmetic: 264,041

Reconstructive: 62,930


Top five procedures

Breast augmentation was the third most popular kind of cosmetic surgery performed in 2004. Number of procedures:

Liposuction: 324,891

Nose: 305,475

Breast augmentation: 264,041

Eyelids: 233,334

Facelift: 114,279

Note: Totals include procedures by physicians not board-certified in plastic surgery but who may perform operations.

Source: American Society of Plastic Surgeons.

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Is It Dangerous to Breastfeed with Breast Implants?

Think You Can’t Breastfeed After Implants? Think Again | Johns Hopkins Medicine

by Guest Writter: Zoe Dobson from

It’s estimated that 5% of all women in the United States have undergone breast augmentation procedures involving implants. If you care to think of that in terms of volume, you’re looking at enough implants to fill an entire Olympic sized swimming pool.

No wonder it’s the top cosmetic surgery procedure in this country. Breast augmentation is one of the best ways to enhance appearance and self-esteem. But there are other things to consider as well. How do implants affect a woman’s ability to breastfeed? Is it safe to nurse when you them? Can you use a breast pump to supplement if needed?

Silicone Versus Saline

To answer these questions, we must first examine the different types of implants and how they affect nursing. The primary concern about breastfeeding with implants is the potential for them to burst and leak into breast milk. If saline implants leak into the milk supply it’s no great cause for alarm, the leakage won’t hurt the baby or the mother.

Silicone implants, on the other hand, are notably more dangerous because they’re made of plastic. However, even cow’s milk has a certain degree of silicone in it. Nevertheless, the chances of implants tainting breast milk are slim.

During a breast augmentation procedure surgeons can place the implants either behind the chest wall or in front of it. Some women still in their childbearing years may want to breastfeed at some point in the future, but this can’t be ensured if the implants are placed behind the chest wall. However, the risk of complications occurring is greatly reduced by approaching the surgery this way.

While there are pros and cons to both types of implants, many women prefer the silicone variety because they look and feel more realistic. Saline implants tend to have a rippled effect, making them more easily identified as artificial.

The Risk of Surgical Nerve Damage

There are three surgical methods to place breast implants. The first method is through inframammary incision.

Those who choose this approach, where the implant is inserted in the fold under the breast, have a greater chance of emerging with little to no nerve damage.

It’s the preferred method for most people as the scar is barely noticeable after it heals. With this technique, the implants can still go above or below the muscle.

The transaxillary incision method, on the other hand, places the implants through the armpit area. A small-pocketed zone is created and the implant is inserted into this pocket. Again, the surgeon can place the implant either in front or behind the chest wall.

Lastly is the periareolar incision. If you want to breastfeed and this method was used, the chances of incidence occurring are more significant. The milk ducts and glands are often cut, and they cannot be repaired. This doesn’t mean a mother can’t breastfeed, only that the chances of damaging these vital components are more significant.

While a loss of sensation does not prevent a mother from nursing, it can indicate other parts of the breast were clipped or altered during surgery. You’ll know if this happened or not if your milk comes in as you get close to your due date.

Using A Breast Pump

Mothers with and without implants face the problem of producing enough milk to fully nourish their baby. The average infant goes through six to eight diapers every day. If your child needs fewer than that, then you may not be producing enough milk. In these situations some mothers opt to use a breast pump.

A breast pump, the Ameda, is great for making sure you always have plenty of milk on hand, that you are always able to produce the volume your child needs. But the question is: how safe is it to use a breast pump after you’ve had implants?

There’s no evidence to suggest that pumping will rupture an implant or cause any other damage. But you need to be careful when placing the flange, especially if the periareolar incision method was used. Scar tissue can build up around the inside of the areola and the flange may irritate that tissue.

Those who have decreased sensitization as a result of this procedure may discover they can’t feel the flange and have to adjust visually instead of through touch alone. But regardless of whether the implants are silicone or saline, there is no worry that the pumping will damage them. The materials they’re made are far too strong for a breast pump to break.

The general consensus is that most women who’ve undergone breast augmentation can still nurse their children without issue. Nevertheless, there are always exceptions. Every woman’s body is unique. Some may have naturally low milk production rates while others may have damage that prevents them from breastfeeding.

People are sometimes quick to blame surgical procedures, but the truth is that some people have milk production issues with or without the implants.

Using a breast pump the Ameda can help ensure you produce the volume of milk you need and provide your baby with the proper amount of nutrition.

Plus, a pump will also help identify any problems you may have with your natural milk production and let you know if you’ll need to supplement with formula.

Ameda strives to present you with accurate and useful breastfeeding information. This article may contain information and ideas that are not necessarily the views of Ameda. It does not constitute medical advice. If you have any questions please contact your healthcare professional.


Breast Surgery

Think You Can’t Breastfeed After Implants? Think Again | Johns Hopkins Medicine

Most mothers who have had breast surgery are able to produce some milk. Some surgeries impact milk production more than others.

Research is limited; however, there have been no recent reports of clinical problems in infants of mothers with silicone breast implants.

In 2001, the American Academy of Pediatrics (AAP) issued a statement regarding the Transfer of Drugs and Other Chemicals into Human Milkexternal icon, indicating that the Committee on Drugs felt there was insufficient evidence to justify classifying silicone implants as a contraindication to breastfeeding.

Learn more about breast implantsexternal icon.

Can a mother breastfeed after breast or nipple surgery?

  • Talk with mothers who have had breast surgery about the type of surgery, placement of incisions, and underlying reasons for the surgery to understand the potential for reduced milk production.
  • Examine mothers’ breasts to identify possible insufficient glandular tissue and provide anticipatory guidance for breastfeeding support.
  • Closely monitor infants of mothers who have had breast surgery to be sure that the infant receives optimal nutrition for growth.
  • When mothers present with insufficient milk production postpartum, inquire about prior breast surgery as part of your assessment.
  • Refer to an International Board Certified Lactation Consultant (IBCLC) to teach mothers who have had breast surgery how to stimulate production and/or how to supplement with pasteurized donor human milk or formula.
  • Ensure that mothers who have had breast surgery and encounter breastfeeding challenges receive appropriate emotional support.

Usually. Most mothers who have had breast or nipple surgery are able to produce some milk, but not all of these mothers will be able to produce a full milk supply for their infants. Having a full milk supply is not necessary for a successful breastfeeding experience because it is possible to supplement in a way that supports breastfeeding.

Breast augmentation, lift, and reduction procedures have the potential to affect the nerves and ducts within the breast, thus impacting lactation. Breast implants below the muscle usually affect milk production less than implants above the muscle.

Incisions around the areola and surgical techniques that include completely detaching the areolae and nipples are more ly to cause reductions in milk production.

Over time, ducts that were severed during surgery may grow back together or form new pathways, and nerves may regain functionality, enabling the mother to produce milk.

A scar around the whole areola following breast reduction does not indicate complete detachment because it may have remained connected to tissue containing nerves, ducts, and blood supply.

The amount of milk made will depend on the number of connected ducts and functionality of the nerves that enable lactation, as well as other factors apart from the surgery, such as hormones and milk removal. Babies of mothers who have had breast surgery should be carefully monitored for adequate weight gain. Mothers may need support to increase milk production and/or to supplement with pasteurized donor human milk or formula.

Some mothers may have had underdeveloped (hypoplastic) breasts prior to having breast surgery.

Mammary hypoplasia, or insufficient glandular tissue, is characterized by breasts that appear tubular, widely-spaced, or significantly asymmetrical, leading some women with this condition to seek reconstructive surgery.

Mothers who have had hypoplastic breasts may not be able to produce enough milk (primary lactation failure) and will need lactation support to learn how to stimulate production and/or how to supplement with pasteurized donor human milk or formula.

Can transgender parents who have had breast surgery breastfeed or chestfeed their infants?

Yes. Some transgender parents who have had breast/top surgery may wish to breastfeed or chestfeed their infants.

Healthcare providers working with these families should be familiar with medical, emotional, and social aspects of gender transitions to provide optimal family-centered care and meet the nutritional needs of the infant. These families may need help with the following:

  • Maximizing milk production
  • Supplementing with pasteurized donor human milk or formula
  • Medication to induce lactation or avoiding medications that inhibit lactation
  • Suppressing lactation (for those choosing not to breastfeed or chestfeed)
  • Finding appropriate lactation management support, peer support, and/or emotional support

Learn more about how to support transgender persons.


Restless Leg Syndrome, a Clinical Diagnosis

Think You Can’t Breastfeed After Implants? Think Again | Johns Hopkins Medicine

The Johns Hopkins Associate Professor spoke about the current therapeutic landscape of restless leg syndrome, an often misdiagnosed disorder. 

Rachel Salas, MD Restless leg syndrome (RSL), a disorder that has become much more recognizable in recent years, is still often misdiagnosed. While there are treatments available for patients with RSL, many of times they come with side effects that lead to an increase in augmentation.

Aside from dopamine agonists, opioids are another viable option for treatment of RSL, however, in the current opioid crisis, it’s quite difficult for physicians to prescribe them.

Rachel Salas, MD, Associate Professor, Neurology and Nursing at Johns Hopkins Medicine, spoke with NeurologyLive in an interview to provide further insight into the current therapeutic landscape, hopeful that additional treatment strategies will soon be available for patients.

Rachel Salas, MD: For restless leg syndrome (RLS), there are medications out there that are FDA approved and work, but they come with side-effects and can actually cause worsening of symptoms. For example, the dopamine agonist can cause augmentation and people can have these impulse compulsive behaviors, so these are things at our center that we’re constantly seeing in patients. A good example for restless leg treatment, beyond the dopamine agonists, are opioids which, right now, in the current opioid crisis, is very difficult for us, because we know opioids at a very low dose work really well for RLS. The problem is, with the opioid crisis, and because our peers and medicine aren’t familiar with our practice parameters for RLS, you don’t see the connection there, but in reality, RLS is a different type of beast from chronic pain. We don’t see dependence, we don’t use high doses, so that is a pretty good treatment strategy for RLS, however, sleep centers are not set up as a pain center and it’s been more difficult to initiate and maintain these patients on even low dose opioids. One of the issues I see is that even though it’s in our practice parameters, for people who have been augmented or other medications have not worked, opioids while they’re a viable option, it’s very difficult for us to start patients. In fact, we’re really not able to do it, so we’ve combined with our colleagues in pain clinics that are comfortable, familiar and educated on those with RLS, and we have a partnership with some of the pain specialists. I see this as really a step back for RLS patients because opioids are a serious problem it’s negatively impacting our patient population.  With the dopamine antagonist, there’s the risk of augmentation, so this is where the dopamine agonist works, it helps their symptoms, but then over time the RLS gets worse, so you increase their medication, but it doesn’t get better. It’s this pattern and that’s what augmentation is, that the symptoms are actually worsening not because of the disease itself, but because of the medication.   When treating with dopamine agonists it’s important to be aware that augmentation can happen and does happen, and these patients can also develop compulsive impulse behaviors, usually not to the degree of people with Parkinson, because these are on higher doses of dopamine and so they can get into these compulsive impulse behaviors gambling. RLS patients can develop this too, but usually to a less degree where it might be under the radar with family members. With RLS there’s certainly behavioral modifications, I try to send several of my patients with severe RLS to the sleep behavior psychologist as well, to try and improve bedtime practices. All of these things can positively affect sleep and we try to make that part of the management, some patients may also try meditation, acupuncture, massage, things that can be helpful. We also use antiepileptic medications quite frequently for chronic RLS and those can work well, but again, they have side effects too, so we have to work with them. Often in our clinic, people have tried medications in the past, but both patients and providers need to be open to trying therapies that were tried previously and maybe didn’t necessarily work. Many times, it’s not just about taking the medication, but it actually has a lot to do with the timing of medication. I find that many times patients were taking the medication at suboptimal times, so I’ll try medications that they think didn’t work, but we just time it more appropriately the symptoms and I can have more success doing that. In talking to my colleagues who have patients with RLS, I think before switching medications, if it’s because the medication isn’t working, we need to look at the timing, because you want to make sure that the medication is on board before the RLS starts, because once RLS starts, taking medications may not be as helpful. It’s important to look for exacerbators, people take medicine over the counter all the time, especially cold season, so antihistamines are huge exacerbators for RLS and not many people aren’t aware of that, not only patients but health care providers. There’re dopamine medications that we’ll see for nausea or some of the antipsychotics that have dopamine blockers and those medications if given to an RLS patient can be very bad, they can exacerbate their RLS. I trained under Richard Allen, PhD, and Chris Earley, MD, PhD, who have done a lot of work in iron and RLS, and so we often check iron status and we have patients that will even receive iron infusions a couple times a year and that’s all they need. I think looking at all of these other potential causes or exacerbators is really key and it’s something that I really try to let my peers in other fields who are taking care of RSL patients be aware of.

We just completed a large study using transcranial magnetic stimulation to better understand the neurobiology in patients with moderate to severe RLS. We weren’t looking at therapy in this study, but the study does show that those with RLS actually have differences in cortical excitability.

When looking toward the future, hopefully, there’ll be opportunities to perhaps target have this excitability as a potential treatment strategy with stimulation.

There’s a lot of interest, not just in sleep, but in other medical disorders even with medical marijuana and things that, so I think we’re going to see at least more studies come out, I certainly know patients are trying that on their own, but I think it needs more research behind it, because at the moment there’s no quantity or frequency.

I think while patients are very interested or sometimes desperate to try these therapies, we really don’t know the long-term consequences, what type or how often to use it. I think there’s going to be more research in those areas and potentially, there may be some opportunities there, but maybe not, we still have to see. That’s where we are with RLS.

RS: RLS is something that I think a lot of health care providers are maybe not too familiar with or maybe don’t see. One of my big messages is to remember that RLS is a clinical diagnosis, so sometimes health care providers may order a sleep study and in the sleep study we report this patient has periodic limb movements during sleep and just that, may be diagnosed with RLS and that is not correct, and that’s actually common. One of my points to my peers would be to remember that RLS is a clinical diagnosis, patients have to meet all of the criteria for RLS, and if they have leg movements on a sleep study and poor sleep, then you should evaluate, ask them questions to see if they meet the criteria for RLS, or refer them to a sleep specialist or a movement neurologist for further evaluation. I can’t tell you how often I see patients with just leg kicks with no RLS symptoms that were initiated on dopamine agonists, and again these medications come with side effects and may even trigger RLS. The other thing is that if you’re concerned a patient has RLS and it’s happening more than 3 times a week, then you’re moving toward someone that could probably benefit from potentially treatment—before initiating anything it may be worth referring that patient, so we can look for treatable causes. For example, iron deficiency, it’s not just about checking a quick iron panel, we have specific things and levels that we’re looking for, so even though they might be normal, they may be low normal, but we still could treat them. If you feel this patient probably has RLS, it may be worth referring at least 1 time to confirm the diagnosis and then to do a thorough evaluation, so that way there may be things the patient has taken over the counter, or there may other things that can be addressed before actually starting medication. In terms of opioids, sometimes we’re recommending them and sometimes people live in small cities where there’s not a sleep specialist or a pain center and a lot of times the primary care physician since they have a long-term relationship with the patients, can initiate low-dose opioids. Sometimes patients will come and see us at Hopkins to diagnose or confirm the diagnosis and we see that the patient has tried every therapy, low-dose opioids are a great option for this patient. In those cases, the primary care physician should really try to work or connect with the sleep center and experts in RLS to have guidance. Now with telemedicine picking up more momentum, we’re going to be able to really better maintain these relationships with a lot of primary care physicians under our guidance for next steps, and I think this is going to provide better care. One of the things I wanted to say with opioids is with RSL, you have to remember to reassess for things apnea, because low-dose opioids and sleeping pills Ambien or Lunesta, which we often see given to patients with sleep problems, weren’t adequately assessed for apnea. Any sedative is going to worsen apnea and I think people need to be aware of that, plus, we know from studies that our RLS patients if they have untreated apnea, that’s negatively going to impact their RLS. You have to remember to identify if the patient is at risk for apnea; maybe they’re not right now, but in 5 years that could be a different scenario, peoples risk factors do change. This is definitely a new point that I’m trying to get out to my colleagues. If you want to try a sleeping pill or something sedative wise for patients that may be appropriate to try, especially if there have a trigger a death in the family and it’s acute insomnia, you might want to at least screen for apnea, because a patient may get into trouble at night.

Transcript edited for clarity.