Article: Mandy Collins from True Love
Image: plastic surgery

"By the time I turned 20, my savings from holiday jobs and birthday presents had resulted in a good sum of money and my parents paid for the small shortfall. I found a good plastic surgeon and had my breast reduction without giving it any further thought. It had been my dream for so long, and I was the happiest person alive after the operation. My self-esteem soared."

Seven years later, however, Khetiwe had fallen in love and was getting married. She and her fiancé decided they would start trying for a baby on their honeymoon. Khetiwe fell pregnant and began attending antenatal classes halfway through the pregnancy. "After we'd covered pregnancy and labour, we discussed breast-feeding,"she recalls, "and I went stone cold. It suddenly occurred to me my surgery might mean not being able to breast-feed my child. This was something I really wanted to do, and it was also an economic necessity – breast milk is free, you know!"

A few months later, Khetiwe gave birth to a beautiful son and her struggle began. "I was producing some milk, but it never seemed to be enough,"she remembers. "However, I was determined to do this. The breast-feeding expert at the hospital was very helpful and encouraging – she kept telling me about other women in the same position who'd managed to breast-feed successfully."

After six weeks of constant struggling, and a baby who was perpetually hungry, Khetiwe finally gave in and started to supplement the breast-feeding with bottle feeds. "At least he was still getting some of his nutrition from me,"she says, "but I had to think about his health, and he was obviously always hungry. I just couldn't produce enough milk to keep him satisfied."

Brenda Pierce, a lactation consultant in Johannesburg, says this is quite a common scenario. "Many girls have cosmetic breast surgery around the ages of 18-20 and while they don't regret it in terms of the psychological benefits, they often regret it in terms of feeding their babies in later years."

Pierce, a mother of four children (all of whom were breast-fed), is internationally certified as a lactation consultant and has seen all kinds of problems with breast-feeding. On the surgery front, however, she says things have improved a great deal. "These women are learning they can breast-feed quite successfully now,"she says. "In the past, it was out of the question, but there's a lot more hope these days."

To understand what problems might crop up, you need to know how breast reductions and augmentations are performed. Professor Alan Widgerow, a Johannesburg plastic surgeon, explains the difference between the two operations. "When you do a breast reduction,"he says, "you're removing actual breast tissue, but it has to be done in such a way that you keep enough tissue to provide an adequate blood supply to the nipple, which remains attached. Many people think we take the nipple off, put it in a bowl and then re-attach it after we've re-shaped the breast. That's really not true anymore. The nipple remains attached. I like to leave the central part of the breast there, and remodel the outside before hitching it up to the chest.

"A breast reduction also involves more cutting and scarring than an augmentation, and the surgery is performed over the pectoral muscles that lie beneath the breast." An augmentation, however, is performed under the pectoral muscles. Prof Widgerow explains: "We insert silicone implants beneath the muscle to augment the breast. I like to use silicone because it has a more natural feeling than saline, and patients generally find it a better implant to live with – they're less aware of it."Despite the ongoing controversy surrounding the use of silicone in breast implants, Dr Widgerow believes its safety has been adequately established. "Any perceived health hazards were disproved in 19 independent studies, so silicone implants really are safe."

He adds that while the vast majority of women undergo these operations for cosmetic reasons, there are occasionally medical indications for performing them. "We sometimes have to do massive reductions on 13- or 14-year-olds who have breasts that have just outgrown them and become huge. We may even have to do the reduction twice – I'm talking about young girls with size G, H and I cups. Otherwise, having very large breasts might cause certain physiological problems like backache or headaches.

"On the augmentation side, some women have a congenital absence of breasts, or even marked asymmetry of the breasts, in which case we would perform augmentations. However, these really are very occasional cases." The key to breast-feeding problems lies in the way the operations are performed. Because breast tissue is removed during a reduction, Prof Widgerow says only about 50% of patients will be able to breast-feed after the operation. Patients who've had an augmentation, however, generally have no problems, because the breast tissue is completely unaffected and therefore behaves normally.

Pierce says the degree of breast-feeding problems in general varies from woman to woman, but agrees that those who've had cosmetic breast surgery are more likely to experience problems. "Any interference with the breast will affect breast-feeding in some way,"she says, "because to breast-feed, you need a good nerve supply and good breast tissue. Usually those with an augmentation don't have any problems.

"When it comes to reductions, however, it depends on how much of the breast tissue was removed and whether the milk ducts were cut or not – which they generally have been. As a result, these women have to supplement the breast-feeding they can manage with bottle feeds, to ensure their babies receive adequate nutrition. "I tell the women I teach, however, that breast-feeding isn't just about feeding – and what little milk they do make is good for the baby."

Pierce is referring to other benefits of breast-feeding apart from nutritional value. These include good jaw development and strengthening of the baby's speech muscles, as well as improved bonding between mother and child. "Some women have managed to breast-feed fully after a reduction because of their persistence and commitment to feeding their babies,"adds Pierce. "I tell all of them breast milk comes from their brains, not their breasts! My advice to anyone in this situation is that it's really worth giving it a good try."

So what do you need to know if you're contemplating having a "boob job"? In terms of pain, Prof Widgerow says the surgery is painful, but not excruciating. "The pain for an augmentation is normally a bit worse – but, then, ‘no pain, no gain'!"he says. "Generally, pain is personality-driven – it depends on individual people's pain thresholds."He adds that the first week after the operation is usually the worst.

There's very little to exclude most people from this kind of surgery, except for general health problems which would put them in danger from an anaesthetic, for example. "Heavy smokers are bad news,"says Prof Widgerow, "because their wound-healing isn't as good. However, on the whole, the contra-indications are few and far between. We have to consider if patients are taking St John's Wort, for example, which would have to be restricted or stopped a couple of days before the procedure.

"Generally, though, these are the happiest patients in the practice – it really is liberating surgery for most of the