Top Surgery and Lactation: What You Need To Know
by Jacob Engelsman, IBCLC
When the subject of lactation after top surgery comes up, I’m usually speaking to one of two groups of people:
people in their late teens or early twenties who want top surgery but also feel like they may want to give birth and one day and are concerned about their ability to make milk and feed their baby, or
people in their late 30s to early 40s who had top surgery several years ago and now either are, or want to be, pregnant and have questions and concerns about making milk.
My goal in writing this article is to cover the information in such a way that it benefits both groups of people.
For lactation professionals reading this article, there is much more that goes into these surgeries than what I’m presenting here — this is a simple overview of the available information.
In one sense top surgery is very much like a mastectomy or a reduction mammoplasty that a cis woman might get, but in another sense, it is very different. I’ll start by clarifying what I mean when I use certain terms:
Mastectomy is used to denote complete removal of the chest tissue. This is usually out of medical necessity when there is a growth of some sort.
Reduction mammoplasty is a more general term used to denote surgery to reduce or reshape the chest. These procedures are most often done for cis women who want a reduction in size or cis men who have gynecomastia, a condition where they have enlarged chest tissue due to a hormone imbalance. This is very similar to what we’re talking about when we talk about top-surgery.
Frequently asked questions
How can I ensure future lactation?
If you’ve not had surgery yet and are concerned about your ability to make milk in the future, the best thing you can do is let your surgeon know about this well beforehand. There are certain things the doctor may be able to do (depending on your personal anatomy) to maximize the chances for future successful lactation. These include: making sure your nipple stays as intact as possible/never entirely removing your nipple, and mainly removing adipose (fatty) tissue instead of glandular tissue.
What if I have (or need to have) a lot of tissue removed?
If you had a lot of chest tissue removed and you are or want to be pregnant, you may have concerns about whether or not you’ll be able to make milk for your child.
This is a perfectly reasonable concern, however it’s important to note that the hormones that control lactation are regulated by the pituitary gland. If your body makes and expels a placenta, you will produce milk. How much milk you will produce if you’ve had a significant amount of tissue removed is impossible to predict, so it would be beneficial to adjust your expectations accordingly.
If you had been counting on producing 100% of your baby's needs, you may need to acclimate to the idea that donor milk or formula is necessary and strategize accordingly.
What if I don’t have nipples?
If you had a lot of tissue removed, you probably won’t be making much milk.
While the pituitary gland has no idea that you cannot express that milk, the fact that you do not remove the milk will lower the demand (supply and demand is what builds lactation production). You will likely end up with swelling and discomfort, but using some cold compresses should help.
We can also dip into the list of things we tell parents who are concerned about low milk supply to avoid: mainly mint tea and OTC decongestants.
Of course you’ll want to check with your doctor before taking anything off-label, just in case you have any conditions or medications that these may negatively influence. Still, as a general rule, if something is suitable for a runny nose, it’s bad for milk supply.
There are also some prescription medications that can be administered at the hospital (if you gave birth in a hospital) which will immediately cease lactation. Cabergoline works by decreasing the amount of prolactin your body is making.
Neither of these scenarios means that you can’t feed your baby at your chest, and even latch them if you would like to.
Feeding options
Supplementer
A supplementer is a device that assists the baby with milk production during a feeding.
Many people who have kids wish they’d known about this sooner, so I’m excited to get the word out to as many people as possible.
These devices go by a variety of names (some of which are not very inclusive) — At-Breast Supplementer and Supplemental Nursing System — but a few companies are making more of an effort (Haaka, for example, calls it a Supplemental Feeding Combo).
Regardless, they’re generally the same thing: a container with a few ounces of milk or formula, either a bottle or special bag; which is connected to a nipple shield (silicone nipple you can place over your own or tape to your chest) via a special narrow feeding tube.
If you have a nipple, you may not even need the nipple shield and can just tape the feeding tube to your chest, or with some practice, you don’t even need the tape. The benefit to this process is that it allows you to have the experience of latching your baby and having them feed in the traditional positions, as well as the warmth, closeness, and skin-to-skin time that comes with it.
Bottle
However, if all of that seems a little too elaborate for you, or if it sounds like it may cause dysphoria, but you still want to get as close to your baby as possible, there’s no reason you can’t bottle feed them skin-to-skin as well.
And this isn’t an all-or-none scenario; you can try the supplementer and switch to a bottle if it doesn’t work for you.
If it works, but you can’t use it all the time, use it as often as possible. Do remember though, that once your baby knows there are options, they may display a preference, and that shouldn’t be taken personally.
What should we be putting in the bottles?
Donor milk
Donor milk can be a tricky topic because so much of it depends on your community and what is available around you.
Do you have friends or family that you trust who are currently making milk? Or friends of friends?
How many degrees out you’re willing to go in that regard is a decision that only you and the other parents can make. Some organizations vet donors and test milk for health and safety, but that milk is usually either reserved for hospitals or sold at a very high price (in the range of $3.00-$5.00 per ounce).
Formula
A few days ago, I had an interview about lactation for obstetric and neonatal nurses.
One of the questions was about why human milk is so important; since I’m usually speaking with or to lactation professionals, this question rarely comes up and I don’t often have to spell out the reasons.
The first answer that came to my mind was that, although formula provides calories and nutrients that babies need, it lacks the key antibodies generally provided by an individual’s milk.
Fun fact: if you get a flu shot while you’re providing milk for your infant, they will get the same antibodies through your milk! I love that. Don’t get me wrong, antibodies are also transferred just through physical closeness though, so don’t worry if you can’t make milk for whatever reason.
I imagine a lot of people reading this are those interested in both top surgery and lactation. Hopefully, this article will get you started on your research so that you can make whatever decision is right for you.
Jacob Engelsman, IBCLC (he/him)
If you would like to learn more, feel free to reach out to me on instagram @jacobibclc or through my website: jacobengelsmanibclc.com. You can also order my book, Lactation for the Rest of Us: A Guide for Queer and Trans Parents and Helpers.