Transcript:
Maureen: Hey everybody, welcome back to the Milk Minute Podcast. Today, we have a very exciting interview for you.
Heather: Yes, we have Dr. Katrina Mitchell, who is a board certified general surgeon, and she is actually a fellowship trained breast surgical oncologist, as well as an IBCLC and a perinatal mental health provider.
She is also the founder of the Physician’s Guide to Breastfeeding, which is just The chef’s kiss of lactation information on the internet. Most of us professionals refer to this as an excellent resource when we are troubleshooting complicated issues, or we want refreshers on how to manage things in general when it comes to lactation.
Also enjoy listening to me, trying to keep it really cool and not. Fan girl, like while talking to, while talking to Dr. She’s just, she’s the coolest. She’s like from California and she’s like always championing women’s health and she just gets it. You know, she’s like, she’s like the leader of the pack. Okay.
Maureen: Absolutely. She’s just like, she’s, she’s like, she’s a surgeon and she’s really cool. You know, she like spends time on the beach and goes camping. And anyway, we love her. And so we’re like so delighted to bring her to, actually today, Heather, I was almost late. And I looked at my husband and I was like, I’m going to be late if we don’t do this right now.
And he was like, why is it a big deal? I was like, we have a really important breast surgeon coming on the show and I can’t be late.
Heather: Yeah. I mean, but also in addition to her breast surgery work, Dr. Mitchell sees patients daily in her breastfeeding medicine practice. And so it keeps her very fresh, you know, like she understands the ins and outs of what people are going through in day to day lactation. It’s, and is a surgeon. It’s just like, she hits, It’s all the things when it comes to lactation.
Maureen: Yes. And this is a long episode, but I promise you it is good all the way until the end. And actually, like, just, just stick with it, everybody, because this is incredible.
Heather: Also, you won’t be able to see her, but let me just tell you what the vibe was like.
Her hair is gorgeous and blonde and like salt licked from the ocean and thrown up in a messy bun. And she’s got these really cool glasses and boob earrings that are dangly. And it’s just everything you could possibly imagine. So that’s what you’re picturing while you’re hearing this surgeon speak. Okay, let’s do a quick question before we jump into the interview.
This question comes from Pam Mallory, who is one of our sweetest patrons, who also emails me on the side from time to time just to say hi and talk about my cute baby, which obviously makes me happy. But Pam says, Quick question. Does donor milk need to fit the baby’s age? If I have a mom who has a 13 month old and a full term baby that is in need of donor milk at two weeks of age, is it okay to use?
Maureen: The short answer is yes, it’s okay, it doesn’t have to match age, like, especially when we’re looking at donor milk, we’re already kind of not going with the absolute, like, ideal food, right, which would be, like, milk from the mother if possible, so. Donor milk from a baby of, you know, almost any age is going to be acceptable.
Now, if we’re looking at a milk bank, they are going to have age restrictions on donation for, for a couple of different reasons. So typically after 18 months, they’re going to stop taking donations from folks, but that would still fit even within those stricter guidelines.
Heather: Right. And it kind of depends how you’re using it.
Also, you know, if it’s, this is a medically, well, I’m assuming term baby. And most of the time with those kids, I would say we’re only using the donor milk for a little bit of time, you know, if possibly, and now if this is like a long-term thing, where we’re going to only be using donor milk, then we might look a little bit more diversifying and trying to find a couple other donors as well.
But if you’re just using it for like a week, it’s not going to matter.
Maureen: No, and if you’re going through a milk bank too, they go through a process of essentially like equalizing calories from samples so that milk is appropriate for like any baby.
Heather: Love that, and great question, Pam.
Maureen: Alright, well we are going to have a really quick break here, and then we’re going to hop right into this incredible
Heather: interview.
Yeah, we just jump right in, because we had so many questions for her, there’s like no warmup, but she’s a surgeon, so she should be used to that. Be ready though, it’s good.
Maureen: Have you guys ever been listening to our show, and thought to yourself, man, I really want to work one on one with
Heather: Maureen? I do every day that I sit here podcasting across from you. Well,
Maureen: lucky for you and everybody at home, I offer both in person and virtual support through my business. And in my business, Highland Birth Support, I’m dedicated to mentoring you guys through your childbearing year.
So that could start with fertility, all the way through pregnancy, childbirth, postpartum. I offer home birth midwifery services, doula services, lactation support, herbal support, anything you guys
Heather: need. You even do miscarriage support. Absolutely, I do. That’s one of the biggest things that is so hard to find and I think that your people that are local to you are so incredibly lucky to have this service.
Maureen: Thank you and I just feel really happy to serve everybody and I’m so happy I can expand my services virtually as
Heather: well. Yeah, telehealth for lactation has been really important through the pandemic and I think we just about got it. Perfected at this point. So if you guys want to work with me, head over to
Maureen: HighlandBirthSupport.
com and check out what I can offer
Heather: you. That’s h i g h l a n d birth support. com.
Welcome back to the Milk Minute podcast, everybody. We are super excited to have Dr. Katrina Mitchell here with us today. And we have so many questions about breast surgery. Unfortunately for Many people we end up either with a history of breast surgery or breast surgery during breastfeeding. And there’s a lot of really confusing research about that.
And I, I think that different providers from what I’ve seen in the downstream of care kind of feel differently about it if you’re breastfeeding, depending on the surgery. So welcome Dr. Katrina. How are you feeling this morning?
Dr. Mitchell: Good. How are you?
Heather: I am good. Do you mind if we just jump in because we have so many questions for you?
Dr. Mitchell: Sure. And you guys had really good questions too. They were all really good ones.
Maureen: We’ve been sitting on these questions for a long time, so I’m so excited we finally have somebody knowledgeable enough to ask.
Heather: Yeah, we do.
Okay, so first and foremost, there are plenty of people out there that are looking into getting breast reduction surgery before they have children, and oftentimes they come to me and they ask me as a lactation consultant, you know, if I’m their friend or their midwife, and they say, you know, if I’m planning to have a breast reduction, can I breastfeed later?
So are there any special considerations that these folks would need to make to protect the possibility of breastfeeding in the future?
Dr. Mitchell: Yeah, that is such a great question and it comes up very frequently as you know and the one of the main surgical considerations is that you want to avoid a free nipple graft if possible.
That is when someone does the breast reduction and they actually amputate the nipple areolar complex and replace it by just Simply tacking it on after the actual reduction of the breast, so we call it parenchyma, so the, you know, the breast gland is done. I will say that is really very unusual to have happen as a surgical technique in this point in time.
I think that was done more commonly. Probably 20 or 30 years ago, and the vast, vast, vast majority of people having breast reduction surgery today are getting what’s called a Wise Pattern technique, or a pedicled technique reduction where you keep the nipple areolar complex connected To its parenchyma underneath, so the gland underneath, the blood vessels, the nerves, and the pectoralis muscle, which is where all the blood vessels and the nerves emanate from to begin with.
So I would say for the average cisgender woman undergoing a breast reduction, that is what she’s going to get. If you have someone who is looking for gender affirming surgery, that may involve, that becomes trickier because sometimes people want a completely flat chest wall and you can do a reduction technique with that.
But Very often, that may involve a free nipple graft. It really just depends on the surgeon and the size of the breasts to begin with that are being reduced. Whether someone just does a simple mastectomy and literally removes all of the breast tissue with none left and has a free nipple graft or even free or even nipple tattooing.
I think people tend to have those surgeries more that completely ablate the breast tissue when they may have like a BRCA mutation. And so it’s a risk reducing mastectomy and a gender affirming procedure at the same time. But again, those are really, statistically, it’s, you know, that’s probably less than 1 percent of, or is less than 1 percent of the breastfeeding population.
And the far more common is, is, Just a, you know, say a 19 year old woman that has very large breasts and has bra grooving and Neck pain and back pain and just is unable to play sports without two or three sports bras So that’s kind of a long answer It’s just a surgical aspect of it. But otherwise when I meet people asking about that that question I basically I don’t discourage people from it unless they really are sure that they’re kind of wavering about it.
But most people come in wanting a breast reduction and it is a completely life altering procedure for people. And I just find it hard to, you know, take a woman that is really suffering psychosocially, physically. And just say, well, you may, this may impact breastfeeding in the future. And so you shouldn’t have this done.
Because it really is a, very much a medical procedure. And not an elective procedure necessarily. So yeah, it’s hard. And I think the other thing that I talk to people about is that we have such poor data on it. It’s just the most confounded, muddy, unclear data that the only way you could actually make very clear Recommendations that are very accurate would be if we had, you know, a control for basically a prospective study or very clear retrospective study, which is retrospective.
It’s impossible at this point. You know, you’d have to control for. Exactly what kind of operation they had, which pedicle, i. e. inferior, medial, lateral, like what kind of blood flow pedicle you preserved, how much, how many grams of breast tissue were removed, what was the person’s BMI before the procedure, what were their comorbidities, what was their counseling, they’d have to have standardized counseling while pregnant Standardized follow up, postpartum, a very clear definition of what is breastfeeding and what is not breastfeeding.
Is it pumping? Is it partial breastfeeding? Is it full breastfeeding for how long? And so that’s why I’d say I’d never tell someone not to get a breast reduction. So it’s a long answer to a complicated question.
Maureen: Absolutely. That, that’s a great answer, though. And that sort of, you know, data complication is what we deal with all of the time in breastfeeding, where we’re like, well, we would love to have a study on that, even one.
And we basically have nothing. We have, you know, some data that we can look at. That’s sort of confusing and might give us some correlations. And that’s where we’re at. And it really does. It makes it difficult often to, you know, provide that counseling in what feels like an accurate way.
Heather: Definitely. This is Marty, by the way.
Marty has joined us. She was like Nobody has decreased the size of my mommy’s breasts today. They are quite large and I would like to eat them. So the lollipop procedure. So this is the, the word that gets thrown around. So that’s what you were just talking about.
Dr. Mitchell: No, I wasn’t. Okay.
Heather: So perfect. Okay. So tell, tell me what the lollipop is because this is what the lay people talk about where they’re like, Oh, I want to get a breast reduction, but I’m not going to get a lollipop.
So I’ll still be able to breastfeed.
Dr. Mitchell: Yeah, and that’s really important to clarify because the lollipop is just the name of an incision and It has nothing to do with whether you can breastfeed or not. It’s an incision That’s around. I mean if you imagine the shape of a lollipop, it’s around the areola with an inferior extension, but I Wonder if people throw that around more because that is an older procedure again, along with free nipple grafting, and we know that the most durable, best reduction is the wise pattern.
So that is where you have that lollipop, that all the way around the areola, the inferior extension, plus you have that whole incision under the breast and the inframammary fold. So that, yeah, maybe people are calling it a lollipop and they think that there’s, it’s true that there’s probably less tissue dissection with a lollipop, but that’s also why it’s not as good of a breast reduction.
It’s kind of, it’s kind of doing some surgery without getting a great breast reduction and possibly impacting lactation. And it’s like, you may as well get your breast reduction for real.
Heather: I think so we have a lot of lactation consultants that listen to our podcast and I, I think when they are assessing a patient for the first time and, you know, we’re reviewing the history and we’re reviewing surgeries and they see the incision around the areola and they see the, the line, they’re like, Oh, I don’t know if you’ll be able to breastfeed because of this particular incision.
So I’m really glad that we’re clearing that up. So what you’re seeing on the outside doesn’t necessarily reflect what happened inside the breast.
Dr. Mitchell: Yes, and any breast reduction, any kind, whether it’s a lollipop or a Y’s pattern or, it’s going to have an incision around the areola and an inferior extension.
Unless you’re doing a very, very small, Lift that would be called a donut mastopexy, but that would still be around the areola So you’re not gonna have a breast reduction without an incision near the nipple areolar complex around it.
Heather: Cool Well, thank you so much for clearing that up. I think that’s really gonna help a lot of people do a better History and intake on patients.
Maureen: Absolutely. I would love to chat a little bit about like smaller scale removal of tissue like in the case of severe abscesses or galactoceles or some kind of other like acute complication that we, we do really often see for breastfeeding parents where we’re having to have a small piece of breast tissue cut out.
You know, what, what are the considerations for breastfeeding that we’re looking at? What does breastfeeding look like after that? You know, just sort of, if you can give us a little bit of a rundown.
Dr. Mitchell: Yeah, I mean, any kind of smaller procedure, like a lumpectomy, that shouldn’t impact breastfeeding unless you’re just doing what’s called a central duct excision, where you’d be behind the nipple and just removing all of, all of the ducts.
But, I guess the first thing is I wouldn’t think anyone should be having tissue actually surgically excised for a galactocele or an abscess. That means that probably someone should be getting a second opinion with a different surgeon because those should be a small percutaneous drain procedure. And what you’re maybe describing is seeing people that have had a complication and they go to the OR and they end up with what looks like a chunk out of their breast and they may have packing in there.
So it’s not that it’s going to impact lactation from the actual procedure itself it’s more like someone shouldn’t be having that procedure and they should just be having a drain and probably all the things that led up to them getting that galactocele or abscess is what is going to be Prohibitive with lactation and not the procedure itself so were they you know pumping and massaging and causing all kinds of tissue damage and cell death and You know, just all the swelling and blood flow disruption and capillary injury.
That’s, that’s what’s going to impact lactation more than A procedure, right?
Maureen: Yeah. And unfortunately, Heather and I work in a region where we don’t see a lot of up to date medicine globally in this region. You know, and, and we do still see a lot of recommendations like that. We’re, we’re, we’re trying to recommend folks get second opinions because it doesn’t sound to us like it meets those up to date guidelines of yet using a drain versus excising a whole bunch of tissue.
But it absolutely still happens for sure.
Heather: Well, and also I will see, I will see that some people are recommended to cease lactation just on that breast so they can have the procedure done. And then continue breastfeeding on the other side. And they think that’s their only option. And that’s why they come see me.
They’re like, how do I stop my milk on one side and keep it going on the other side to make sure my supply is good. And I’m like, wait, what’s going on? So, okay. And then what about the people that have had a history of surgery where they have, Those may be chunks taken out of their breast, and then they want to breastfeed with a subsequent child scar tissue.
Does that play in a lot? Are there certain things that that patient is going to have to watch out for? I’ve had questions where they’re like, should I just not even attempt to breastfeed on that one side? Because I don’t want to have that happen again. You know, they’re traumatized from the from the injury the first time.
Dr. Mitchell: Yeah, that’s a good question to the let me think of how to answer. So the, you know, scar tissue itself, the breast is pretty resilient. So I, sorry, I was distracted by the fact that I watched you feed your baby in a really reasonable way and you knew when she was done and it was like a quick five minute feed where, you know, people are, are putting the babies on for like 30 minutes and then burping them and then putting them on the other side and then they wonder why they’re spitting up and having blowout diapers.
And I was like, wow, she. She just had a really normal, like, five minute feed and the baby’s done and you’re not burping her and waking her up and you’re just holding her.
Maureen: We have to give some kudos to Heather because she has had a rough last two weeks of breastfeeding and pumping and getting to that normal, so.
Dr. Mitchell: Okay, well, yeah, you look great. Sorry, so, I, yeah, and I have a new bird feeder outside my window and so I’m watching, like, 20 birds that I’m really excited about. My cat is excited, so. I’m sorry. So, yeah, exactly. So I would say just having, I see a lot of patients that have had complications before like that, that involve surgical intervention.
And, You know, I, I say every, it’s just like anything, like any kind of previous breast surgery, any, it’s really kind of supporting the trauma because most people are very traumatized by having had these painful complications and conflicting messages and lack of support and told to stop breastfeeding, most of the time they do stop breastfeeding or there’s just a lot.
to unpack there. But I, I mean, countless, countless patients that have had some kind of thing like that before. And I’d say the biggest issue is preventing it. So the prevention is the fact that most of these people were, again, they develop a little lump, then they’re told to pump and massage and keep pumping and keep their breast empty and massage more.
And You know, heat up their breast and create a breast soup. And so really it’s just about seeing them very early and setting them on the right track and saying, Hey, this is just a lot of breast tissue. You’re just feeling normal breast tissue. It’s engorged. It’s not a plug. There’s no such thing as a plug and we’ll support you and you’re going to be fine.
But you bring up a good point about scar tissue in general, because I think there’s this myth in lactation that, you know, if you, if you would disrupt the fourth intercostal nerve, then, then, you know, you don’t have the milk ejection reflex, and it’s just like, the breast is so much more complicated than that, and nature protects it, and innervation’s very overlapping, and that’s just a reminder when people have very bad neuropathic pathways.
You know, nipple nerve pain or basal spasm, why it is so exquisitely painful because the nipple is just highly, highly innervated with multiple overlapping, crossing nerves. So The point about the scar tissue is that there’s far more to, to milk production than one nerve and there’s blood vessels and there’s, you know, there’s lymphatics and there’s scar tissue from surgery.
But that usually comes into play again more if you’ve had a reduction or, you know, a procedure that’s really, really disrupting. The retro aerial or space and not just a random access drainage.
Maureen: Yeah. Well, I love that you really kind of hone in on our body’s resiliency and an ability to heal and, you know, restructure and move on because really we’re dealing only in that like time of our body in the postpartum when we’ve just had a major body event, a trauma, regardless of how easy the birth was.
And then we’re. You know, moving on to this entirely new phase of body function, and I think it is an incredibly encouraging way to frame this for people who’ve had past traumas around breast surgery or emotional experiences around breastfeeding and just reminding them like we, we do have the ability for our bodies to adapt to new structure and to adapt around scar tissue and to you know, adapt pathways for nerves and things like that.
Heather: What about correcting scar tissue? Is, is that so say we have a history of surgery. We have some scar tissue. They decide to go ahead and attempt lactation again and lean into the body’s resiliency. And they find that the scar tissue is impacting their supply on that side. Maybe like they’re only able to get like 10 cc’s of milk each time they pump compared to the other side, which might be like four ounces.
First of all, that would be fine supply wise, but, you know, people have asked me, can I get this scar tissue removed? Like if I get it removed, will it actually help my lactation on that side?
Dr. Mitchell: No, that’s, that is often the more you operate, the worse it gets. And it’s very different. There’s one kind of scar that we would revise like a capsule or contracture with breast implants where that’s scar tissue right around the implant though, so you would actually just excise, and you wouldn’t be excising breast tissue, you would just be excising kind of the body’s reaction to the foreign body, but the idea that you would have, say, had a, a nipple procedure, like a nipple eversion or, you know, reduction procedure that your, it involves a lot of scarring and disruption of the tissue going in there, I mean, it’s just going to make it worse.
Maureen: Well, you know, you bring us to our next big topic about breast augmentation surgeries. We’re going to take a quick break to thank one of our sponsors. And then when we get back, I would love to chat more about that.
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Welcome back everybody. We are super excited to jump into talking about breast augmentation, which if you missed it, I actually just did a whole episode on my breast augmentation, which we will link in the show notes if you’re interested to hear about my personal journey with that. So I did get a breast augmentation after my first son and my breast size had always been a hindrance to me and my self-confidence from the time I was a kid.
And the size of the implant I ordered was not the size that I woke up with after surgery. And the doctor came in and he told me that he had to choose a larger size so he could fill the pocket that I had, because it was larger than he thought, because I had breastfed before. And he wanted to do this to prevent capsular contracture.
So now I have ginormous boobs and now when I breastfeed they get even bigger and so now it’s kind of like the joke is on me because now I’m walking around like Dolly Parton and I used to be a double A so it’s like this whole situation. So do we have any control over the size implant that we get after breastfeeding or do we just always have to fill the pocket?
I just need to know for my own peace of mind. You can be honest.
Dr. Mitchell: I mean, that’s a reason to have a female surgeon and not a male surgeon. I Yeah. Yeah, if you have a choice. I mean, it’s actually true that I’m sure, I don’t know if you’re aware of the data that That patients in general have better outcomes.
They live longer with female physicians compared to men and in particular, female patients have better outcomes when they’re cared for by female physicians. So, yeah, I can’t, I can’t really speak to interoperative Decisions though I, it depends on, I, did he do a sub glandular implant or submuscular or the dual plane?
Submuscular. Okay, did he do the dual plane? Like where he releases a little bit of the muscle so it doesn’t animate, like when you contract your pectoralis it doesn’t move? When
Heather: I contract my pectoralis it definitely moves.
Dr. Mitchell: Okay. Then he did just a plain old sub muscular, which that, I mean, again, I don’t want to speak to someone else’s surgery, but there’s a muscle sub muscular that wouldn’t have anything to do with your gland.
You know, there’s a, there’s a, it’s a place between your ribs and your heart. Pectoralis muscle, and maybe he just thought Cosmetically the place your nipple areolar complex was gonna end up or where your implants were going to sit or But yeah, it’s not the only thing I could think of is I mean you’re your gland at its base doesn’t change because of breastfeeding.
I mean, if anything, it’s more like the, you know, the nipple can change.
Heather: Yeah. I guess in, in the layperson’s mind, it’s like you’re breastfeeding and you’re full of milk. The milk goes away. It leaves a pocket. We have to fill pocket up with silicone. And what you’re saying is that’s not how it works.
Dr. Mitchell: No, and I mean, it’s actually not breastfeeding that changes ptosis or, you know, skin laxity, it’s pregnancy.
Maureen: Yeah, we, we talk about that a lot because it is such a common misconception. You know, and, and I think, one way that breastfeeding gets a pretty bad rap.
Dr. Mitchell: Yeah, and it’s also just age, too, right? Exactly. I mean, it’s like, no matter what you do, you’re, you’re gonna have mortises, whether you have Kids or you don’t have kids or you have one pregnancy.
Yeah I mean by pregnancies, obviously you’re going to have different changes in pregnancy, but yeah, it’s not breastfeeding That’s to blame and I think the other reminder too is that if you’re thinking of it like oh, there’s milk in the breast it’s really the gland like the alveolar cells that and the blood vessels that are going to expand during lactation and you have like a tablespoon or two of milk hanging out in your ducts like if you if anything at all and it’s really just the and the stroma like the supporting tissue of the breast that changes so yeah i don’t know what he was maybe thought your submuscular pocket was But it’s also like how you dissect it too and like how much tissue you open up and I, I don’t really know.
Heather: So he made the big pocket and then he filled it up. Cool. Cool. Cool. Cool. Cool. That’s what I thought.
Dr. Mitchell: Yeah, I, I know you suspected that for a while. No, no, it’s not a good idea to ever, yeah, comment on anyone else’s surgery because we all have our ways of doing things. But I just like to point out whenever given the opportunity the statistics about female physicians having better outcomes.
Absolutely.
Maureen: And I think in this case for you, Heather, it is a little bit reaffirming to know that there, there, you’ve had suspicions about this and there were possibly other ways to go about it.
Heather: I mean, lucky, lucky for him, I’m pretty chill. I’m like, well, I did ask for big boobs.
Maureen: You do look great. Listen.
It’s fine.
Heather: It’s fine. And the, the bigger joke is that my husband’s not even a boob guy. So
Dr. Mitchell: yeah.
Heather: Whatever. So if someone is trying to decide on or they have decided, I should say, on a breast augmentation and the question of silicone or saline comes up, you know, I have heard, and I have, I’ve read this actually, in some lactation, Things that silicone leaks into the breast milk.
However, there’s also silicone in formula. So, what gives? Like, do we care about this? Do we have to pick saline if we want to be responsible breast augmentation folks?
Dr. Mitchell: No it’s really, I think, patient preference, and I more and more see, to be honest, I think it’s more unusual if I see a saline augmentation now, just because silicone does have a lifetime.
I guess technically warranty, you know, they’re meant to last. Whereas it’s the saline ones that you technically are supposed to replace. And we’ve gotten past the, you know, the, the implant associated lymphoma with the textured implants and those were recalled years ago. So I think people understand that silicone is safe.
And yes, we know that. There’s far higher levels of silicone in formula, in cow’s milk, people take simethicone for gas, they give it to babies orally all the time for gas. So you know, even with a, with a rupture of silicone in general, it would be contained within the capsule and wouldn’t be directly contacting the breast milk to begin with, or someone like you that has implants.
behind the muscle, they’re not even contacting, you know, they’re behind the muscle. They’re not contacting the gland. Again, it depends exactly on the, the surgical technique, but it’s not something that I would have anyone, you know, go through or, you know, have a saline implant when they wanted a silicone implant just because of, of lactation.
There’s, there’s nothing to suggest that that is some kind of contraindication, absolute contraindication. So
Heather: it’s nice.
Dr. Mitchell: Collective sigh of relief. Yeah. I mean, countless, countless patients. Yeah. Nothing, nothing that, I mean, and again, there’s just, there’s silicone in our food, in our environment, naturally. I mean, there’s and I mean, in California, we have patients that get procedures in Mexico and that includes things like direct silicone injection into the breast parenchyma.
And I’ve had people breastfeed. I, and I have a good mammogram picture of that on my website. under plastic surgery. I have to go look at it. That sounds fascinating. Yeah, because it’s just, it’s, it’s just not a, not a, not a concern, but yeah, nothing to worry about. Nice.
Maureen: Well, I’m wondering, you know, as we just talked about, there are many different techniques for I’m sure all of these surgeries.
If somebody is planning an augmentation, what considerations for surgical techniques should they be thinking about if they’re planning to breastfeed in the future?
Dr. Mitchell: Yeah, as I’m sure you know, there’s lots of different incisions. There’s axillary, you know, under the armpit, and there is peri areola around the areola.
There’s inframammary underneath the breast in the inframammary fold. There’s trans umbilical. Probably the most common at this point in time is the inframammary fold because they think that it causes less capsular contracture. And if that’s the, the reason why people have pain or even distortion cosmetically of their breast implants, that’s a reason to have that incision.
And it’s probably just that it involves less dissection and less just tissue. Kind of reactivity when you’re just slipping in an implant from the inframammary fold. I guess that’s also Why I it’s probably I again There’s countless people that have breastfed without an issue with having had peri areolar incisions And again, our data is so poor.
There’s just not a lot. You can’t make absolute statements about anything, but technically in terms of common things being common, if you do an inframammary fold incision and do a submuscular implant, you’re really not even touching the breast tissue and certainly not the nipple areolar complex.
You’re just putting it in behind the muscle.
Heather: Well, that’s been my experience. I haven’t had any issues breastfeeding. In fact, I can breastfeed in more fun positions because I just have so much to work with now. I mean, I can, I can dangle over the car seat if I want to, you know, in a, in a parking lot without removing the baby, you know, so that’s an, actually, I think it’s made my let down a little bit stronger just because when I’m super full plus the implant, just like pushing on the back there, this is really, I could shoot this thing across the room, but Okay, cool.
Well, I think everybody so far is feeling really positive and good, whereas before this interview, they were probably very nervous and feeling like it’s going to be a bad decision or something bad’s going to happen or, you know, so I think responsibly, you know, getting this information and then at least learning what questions to ask your surgeon and picking the right surgeon is probably
Maureen: I, I think that last part is important because I’ve definitely had feedback from a lot of patients where, you know, it’s like, oh, how did your consult go?
And they’re like, they just told me to wait till I was done having children. Yeah, that sounds like not a very good consult.
Dr. Mitchell: Yeah, I mean, it depends. I think it really is sort of nuanced. I mean, again, I probably. Wouldn’t recommend anyone have an augmentation before they finish having kids if it was an option But again, everyone is different and if it’s something that you’re living your life and you’re like, I feel really self-conscious about this I this is really not something I want to live with great You know, but if you’re kind of like on the fence or like maybe not I don’t know Yeah, I mean if you don’t have to have a surgery don’t do it and that the same goes for the reduction.
So It’s, it’s just really kind of individual. I don’t think there’s like one answer.
Maureen: And you know, I think we’re always just advocating for patients to, to make sure that they get enough information to make a decision that they feel confident in, whether that choice is to delay surgery or to get it now or, you know, whatever that
Dr. Mitchell: might be.
Exactly.
Heather: Well, now that I have these implants in my body, one thing I didn’t think about beforehand was imaging. So if I need, well, when I need a mammogram, you know, do I have to have an MRI? So these, these are the questions like, is a mammogram going to be out of the question for me? What if I do end up with this pregnant or with this new baby I have, what if I end up with an abscess?
Hope not, you know, and they need to do Ultrasound is the implant going to affect that so I think a lot of people have questions about imaging.
Dr. Mitchell: Yeah, another good question they may Do an MRI to survey your implants to look for the integrity and to look for any kind of rupture But that would not be for breast cancer screening, just because you have implants, you get a regular mammogram, they do what’s called an implant displaced view.
It does not impact breast cancer screening to have breast implants or not. But again, the MRI would be for, if they were talking about a routine MRI, that would be for looking at the implants themselves. Okay.
Maureen: Yeah. Well, I have a follow up and I know you’re not a radiologist, so, you know, if you don’t know, that’s fine.
But when we do have to refer people for like breast anomalies and breastfeeding, you know, lumps, abscesses, whatever, and imaging is recommended, we have gotten a lot of mixed messages about whether it’s preferable to have A breast full of milk for certain imaging types or to empty the breast before imaging and it seems very inconsistent based on where I refer people to.
I don’t know if you, if there’s like an overall rule we’re following based on the type of imaging or if it’s just kind of people making it up.
Dr. Mitchell: Sounds like people are making it up because Even the American College of Radiology, we know that you want to pump or feed a baby to try to get milk out of, you know, empty the alveolar cells and clear out any scant drainage in the, the ducts to, i.
e. it’s to reduce the parenchymal density. So that is the, the idea that the alveolar cells are not, you know, bursting full and You know, I, I describe it to people as like grapes, you know, you have like a really full pack of grapes, or you have like some kind of deflated grapes. Like raisins. Yeah. Yeah, I mean, that’s basically what happens.
Yeah, the, the alveolar cells, yeah, they be, they become more like raisins. But it’s, it’s just it’s just getting people to have consistent messages. And a lot of times, even if you’re teaching the text, the radiologist may not be getting the recom, the recommendations, or you teach the radiologist and then.
They have new staff and the person answering the phone didn’t get the recommendations. And that’s why I was just say breastfeeding patients. It’s, it’s a healthcare disparities issue. You know, it’s like if men had breasts and, and breastfed and got breast imaging, we would not be all over the place. You know, it would be very well defined exactly what we’re doing and there’d be no questions and no contra, contradictions.
But it’s just, it’s just a process and, and trying to get thing, you know, get people to pay more attention to women and babies. Absolutely. Preach.
Heather: Yes. So, just to clarify. Emptier is better.
Dr. Mitchell: Huh. Yeah. I mean, even like every radiology office that I’ve worked with, you know, we’ve gotten a pump that, so if someone doesn’t have their own pump and the Anderson, this is what I’m getting to.
Yeah. The biggest the biggest cancer center in the world where I trained. And one of my surgical colleagues who stayed there. who completed her lactation consultant, IBCLC, she just got pumps for them. But again, it’s just, it’s a huge, huge process to change culture.
Heather: Well, and you know, you were talking about healthcare disparities issues.
I mean, some people don’t have breast pumps. They, you know, and like your appointment was at three o’clock, so they fed the baby right before they left, and now it’s 4. 30 at five o’clock because you had to wait that long.
Dr. Mitchell: Right, yeah.
Maureen: I had this happen exactly to a patient, Heather, where they told her to empty before she, but they told her she couldn’t bring her baby.
So she did, she gave her baby to her husband, then they were an hour late, so that was no longer the case by the time they got around to imaging.
Heather: And then the dude is mean to her. And they rescheduled. He’s like, I thought I told you to empty your breasts,
Dr. Mitchell: and it’s like, I did! Yeah, it was ridiculous. Yeah, yeah, no, that’s why I always say bring it to the imaging center, or if they have a pump.
there because it’s just pointless to do it at home and sit in traffic and then wait. I,
Heather: I couldn’t agree with you more. And I, I feel like you should be able to bring your baby anywhere if you’re breastfeeding, just period. They’re, they’re whole people, you know, it’s not like a medical device that I’m bringing here that has to be cleared.
Maureen: If it were actually, we’d probably be able to bring them anywhere.
Dr. Mitchell: Yeah. Right. Right. I mean, yeah. If yeah, if big farm was in charge of babies, we’d have, yeah, it wouldn’t be, wouldn’t be a question. Yeah. No, I mean, I routinely, I mean, my visits are always with babies and you know, I was the only person seeing babies and moms in person in our community during COVID.
And it’s like, you can’t see a mom without seeing a baby and the other way around, you know, post op. It’s, it’s really important. And. Yeah. Yeah. I mean, I just, I just put a bunch of for breast cancer month on my Instagram, a bunch of educational images about this, like, you know, pump at the imaging suite and things like that.
So
Heather: cool. That’s great. And that seems like such low hanging fruit. Like we could take care of this.
Dr. Mitchell: Yep. Yep.
Maureen: Yep. Well, we’ll keep it in mind for our projects on the backlog of, you know, trying to change medicine in West Virginia.
Heather: Yeah. We have a running Google spreadsheet of just like shit we were trying to get done here.
But you know, I, I was going to ask a couple other things, but I kind of want to change script a little bit. And. Really kind of ask you more personally, like how did you end up being this amazing boob doctor and you know How did you end up in this position because you are? You are incredible the things that you are doing the physician’s guide to breastfeeding And you know just the way you advocate for patients and your Instagram and all of these things like how did you get called to this?
specific
Dr. Mitchell: career Yeah, a long winding path. I mean, definitely not a straight path at all. I mean, I, I think I yeah, I mean, I would have thought I was going to be a writer when I was growing up, and, you know, was a history major in college, and then ended up work, working for a women’s health clinic, and then decided to go to med school, and then started med school, and then took time off to write for a magazine, and thought I was going to drop out, and then And then did surgery and found something I loved and then did surgery residency and then did research in East Africa And then I was like, okay I want to do something that I can work Anywhere in the world and it’s not like robotic surgery that you can only work in the West And then I said this seems like a perfect blend of women’s health and surgery So yeah, I feel like it’s more lucky that I just kind of ended up On this path, winding path and ended up here.
And, and yeah, I was a breastfed kid. And I honestly, my mom always talked about breastfeeding when I was growing up and what’s funny is I just kind of went down some rabbit holes of, of images from when I lived in, I lived in Africa for four years and one of my patients was going to Zimbabwe and I just.
Like, went down this rabbit hole the other night of, like, gorillas and, and, you know, like, elephants, and I, I had collected a bunch of those photos because I realized how much, how many pictures I had of breastfeeding animals throughout, throughout my life. And that’s, that’s also on my website under, I have it like under things I love and like nursing and nature.
And then people have also sent me pictures of like various, you know, my friend in Australia, like a kangaroo on the golf course, nursing. And so it’s like my favorite thing. And I was like, wow, this is pretty amazing how anywhere I’ve ever been I had like One of our friends growing up has a house in Nicaragua and I had like a cow nursing on the beach in Nicaragua.
I was like, what? One of my, one of my mom’s friends is doing some really epic trip to see the polar bears in, in the Arctic Circle, I guess. And there was one, I was like, look, that baby’s going in for bamboo! I was like, did you see that?
Heather: You’re gonna have to up your game and go deep sea diving so you can watch a whale breastfeed off of its little fin.
Dr. Mitchell: Whale! Totally! Yes, yes. I actually had a patient from Hawaii who said she saw that and I was like, did you get a picture? She’s like, you know, it was a long time ago. I was like, oh man. Yes. We want to totally we want to go to see the whales and in Baja, you know, just a couple hours south of us. I was like, I gotta see a whale breastfeeding.
Heather: It is so funny to me that anytime we meet a kindred spirit in like the, the birth work circle or the breastfeeding circle, and we ask like, how’d you get here? It’s never like, well, A plus B equals C. It’s always like, well, this weird thing happened.
Maureen: And I, I think that’s why we all connect. And like the, having Such diverse, like circuitous backgrounds.
I think it really makes us all better professionals, frankly, to have such a breadth of experience to draw on that when you first look might have nothing related to what we’re doing now, but truly, I mean, just any, any experience of human life is, is useful in our fields.
Heather: Absolutely. Totally. And by the way, I have a minor in history
Dr. Mitchell: and yeah, you know, I
Heather: was an
Maureen: art major to begin with,
Dr. Mitchell: you know, totally, totally.
It’s all the right, the right brain of just medicine and yeah. And, and breastfeeding it’s totally true that I think if you’re, if you’re too kind of black and white and left brained, it’s just not. And certainly, I mean, you guys probably have it too, but the, yeah. I have a lot of engineer patients from our university here and we have a lot of tech transplants here and I’m like, you’ve got to shut off the app.
And you know, the dad’s like, but I like the graph. And then I’m like, no, no, no, no. And then they’ll like hand me, you know, see, look, and I’m like, when did the baby last feed? Well, they don’t really know. Cause I have to look at the app. I’m like, okay, I need you to be able to tell me that without looking at the app.
And then they like show me and they show me this like graph. And I’m like, I’m like, look, I am very left handed. I, I need you to speak in words and describe it to me because I can’t understand that and I barely passed physics and statistics and you know, I, I need it to be explained.
Heather: Well, thank you for saying that because I have been a little insecure as a professional when people hand me like the huckleberry app.
And I go, okay. I don’t know what this means. No, I get a mini panic. I’m like, wait, oh, like it’s making my heartbeat fast. I’m like, whoa, please take that away.
Maureen: Well, and I feel like it requires me to like do immediate calculations on like how long it’s been, how long that was. And I’m like, if we’re doing an app, it should already say this.
It should give me this and it doesn’t. Yeah.
Dr. Mitchell: No, no. I say you have to delete the apps. You have to delete the apps because you have to be able to pay attention to your baby because even there with Heather, you know doing that very efficient feed that we just saw and as she described us She has a fast letdown now.
This is not first baby She has more and more milk with each baby and so a baby is going to feed a third baby is going to feed differently than a first baby or a fifth baby and that baby may get on and just you know, gulp it down in five minutes and be done But the app is going to tell you there’s a problem with that and then you’re going to be like, oh wait But she fed for four minutes and then did eight minutes the other time and it’s been one and a half hours instead of two hours and you know it’s like you can’t actually learn that your baby’s done in a natural way if you’re just plugging it into plugging it into an app that’s taking your data and I don’t know this is a whole different podcast because I could go on and on and on and on maybe we’ll get back
Maureen: on here about breastfeeding apps because we You have lots of feelings about them.
Heather: I think it is so funny that you mentioned engineers because I actually just I actually just told my team this the other day because I had an engineer patient who emailed me an Excel spreadsheet prior to the meeting for me to review.
She was like, this is
Dr. Mitchell: your Yes, I’ve had that. To review prior
Heather: to our appointment so we can get the most out of our appointment.
And I was like, Yeah.
Maureen: Heather, I think this is why my sister did not ask me a single question about her pregnancy and breastfeeding, she’s a robotics teacher. And I was like, we just don’t, our brains don’t meet anywhere except when we discuss our parents. There’s like nothing else we can talk about.
Dr. Mitchell: Yeah, yeah, totally. I mean, and it’s really hard. I mean, it’s challenging because if you’re growing up in this world of, of, you know, plug and play and swipe, swipe and swipe, swipe, swipe, swipe. You know push this button push that button and then you’re forced to learn how to parent that has nothing to do with that and you know, we were I said we’re at the shoe store yesterday and It’s the one I try not to go to but you know My son like of course doesn’t have any shoes that fit and we go I’m like, I don’t really know what size It’s maybe like is he a two?
Is he a three? I don’t know and the girl goes in the back Because they’re all these young college students goes in the back and, and then brings us back this like one shoe that’s, you know, I’m like, okay, maybe I think this probably fits, but do you have it in a, like a three to, it sounds like, you know, my, my interpretation was that she didn’t cause she didn’t bring back a three, even though I’ve speculating on these various sizes and she’s like, Oh yeah, we have a three in the back.
Like I’ll go get it. I’m like, Wouldn’t you use your reason that this person isn’t quite sure. And so they’re like, okay, I was told to like push the button to instead of, but it’s really a lot of critical thinking and reading people and listening and understanding nuances of communication and making inferences about, Hmm, that probably makes sense that I bring this mom with a kid.
She doesn’t know the shoe size more than one size. Yeah. A
Maureen: lot of people. We are disconnected from intuition
Dr. Mitchell: for sure. Intuition. And yeah, it’s the same thing with like nipple sizing and like, I’m like, I don’t know. It’s what fits at that point in time. Like just, you know, your nipples could be different sizes at different times of the day.
Just like different brands of shoes have different sizes and our feet are swollen at the end of the day and maybe not at the beginning and nothing is black and white. This sounds like me,
Heather: me two weeks ago, I called Maureen and I said, All right, do I need to quit my job as a lactation consultant because I literally can’t figure out what flange size I am because I’ve measured like six different times and they’re, they’re different and I think it’s because they’re swollen because the baby’s got a tongue tie.
I said, do I need to quit? And she was like, no, you just need to like, let your nipples calm down and then pump with whatever’s comfortable. And I was like, thank, thank you. Yeah, right.
Dr. Mitchell: And it’s true. I mean, they’re dynamic. Your nipples are not the same size every day. They are tissue.
Maureen: They’re, they change.
Yeah.
Dr. Mitchell: I, I, I, I tell people all the time, the three tissues in the body that are the same are the clitoris, the penis, and the nipple. They’re the same tissue under the microscope. And if your husband, you know, or thinks his penis is the same size. all the time. I’m sure he’ll probably tell you, well, no, like, you know, look at this or, you know,
Maureen: I think we’re going to adopt that analogy.
Dr. Mitchell: I, yes, for the clitoris, right? I mean, people have such a poor understanding of the clitoris and how, you know, what tissue you see on the outside and what the, the other parts of clitoris, you know, and it’s just, it’s not, it’s an It’s an org, you know, it’s part of a dynamic organ and it’s not going to be the same size every hour of the day.
Heather: No, we don’t need to know what size it is. We just need to know how to find
Dr. Mitchell: it. Right.
Maureen: Perfect. This is a great note to leave
Heather: on. I think it’s been loads of fun. And I have so many more questions, but for people that also have more questions and want to learn more about you, can you tell us how to find you and how can we support you in, in whatever you have going on in your career, your
missions?
What can we do for you?
Dr. Mitchell: Yeah, I mean, just share my website because truly it makes, makes my life easier when people aren’t coming, you know, with it. Like yesterday, I just drained an abscess out, like a friend of a friend from L. A. And I was like, this wouldn’t have happened if someone had given her good advice to begin with that she shouldn’t have been, you know, massaging and pumping, like, and heating up her breasts too with a Crock Pot, you know.
So, yeah, KatrinaMitchell.org or PhysicianGuideToBreastFeeding.org, it goes to the same place, but I think the more you can share, the, the better it is for patients and patients getting breast imaging and, and mostly preventing complications before they start, because I always say, You know, it’s like one person isn’t, you know, it doesn’t matter if I, you know, go off to Mars, but it’s like, if you can help change like a system and like a culture of education, that’s what is going to actually make a difference.
So, absolutely. Well,
Maureen: we will share that in our show notes and on our social media. For this episode and yeah, we, we love all the stuff you’ve been putting out there. So I hope everybody listening today goes to check that out, bookmarks it on their computer so they know where to look next time.
Awesome. Well, thank you so, so much. We are very appreciative of your time.
Dr. Mitchell: All right. Thanks for the invite. Take care.
Heather: Do you have a baby that struggles with excessive gas, fussiness, colic, and general sleep problems?
Maureen: Well, I did, but then I used Evivo Probiotics.
Heather: Evivo is a pediatrician approved probiotic for babies that’s even used in NICUs on the gentlest tummies all over the United States. It is an
Maureen: amazing, unique product that contains a specific strain of B.
Infantis that we need. To digest human milk, oligosaccharides,
Heather: that’s actually 15 percent of breast milk that your baby will then be able to utilize. Whereas if you don’t have the bacteria, there’s so much extra in the gut, which is why American babies poop like 10 times a day more than babies that are colonized with B.
Infantis. I have personally
Maureen: seen this probiotic help my baby and the babies of many of my clients. And frankly, if we’re dealing with any of these symptoms, it is the first
Heather: thing I go to. And the best part is, it’s not like any other probiotic that we would take when we’re sick or taking antibiotics where you take it every time you go through antibiotics for the rest of your life.
If you give your baby Evivo in the first hundred days of life, it actually colonizes in their gut and becomes a part of their immune system, which then they can pass to the next generation. And this is how we make change, y’all. Evivo is amazing because it’s going to safeguard your baby’s health today and give you peace of mind in the future.
Maureen: Check out Evivo Probiotics through the
Heather: link in our show notes. And enter code MILKMINUTE for 10 off.
Alright, well that was really helpful. That was helpful for me. I know it was helpful for listeners. I know it was helpful for other lactation consultants and how they manage patients and the recommendations that we give. The things to kind of expect when we’re looking at breast surgery and breastfeeding.
Maureen: And we actually continued our conversation off air for like another 20 minutes and got into a really good chat about like nipple wounds, so I am going to throw a link in the show notes to Her protocol on that, which is a little bit different from what we’ve been using. But she’s got excellent evidence behind it.
And I think we’re just going to adopt that.
Heather: Yeah. Yeah. Nipple wound healing is another thing that we could have an entire podcast about, but so you don’t have to wait. We wanted to make sure that you could access what she has to say on that as well.
Maureen: Excellent. Well, Heather. I just feel great after that, and I would love to give someone an award.
Do we have an award today?
Heather: Of course we have an award. Let’s see, this award is gonna go to Laurel. And Laurel says, Hey Heather and Maureen, I’ve been listening to The Milk Minute since my baby was a couple weeks old, and now he’s nine months. I love it, and I’ve kind of become a lactation nerd, so I finally became a patron.
I’ve been loving Beyond the Boob, and also getting early access to episodes of The Milk Minute. You guys are so great. Hey, thanks Laurel. Also, I want to nominate myself for an award. Just recently, I had my first work conference since my son was born. I didn’t have to travel out of town, but I was away from my baby for 10 plus hour days and I knew I wouldn’t have access to a fridge like I do at work.
I checked the conference center’s website to scout out lactation spaces ahead of time and I ordered a series chill. I was also lucky enough to have a pair of Elvie wearables that a friend handed down to me. So much more portable than my regular pump. I was weirdly nervous on day one of the three day conference.
It felt kind of like my first day back at work figuring out my pumping setup for the first time, but it went swimmingly. I felt so proud of myself. Thanks so much for your work on the podcast. I’m a librarian and I’m really big on fighting misinformation on Facebook, Reddit. And in my due date group on the What to Expect app, I frequently reference Oh, those are tough.
I frequently reference the Milk Minute and resources you’ve cited. It feels good to share solid information about something so important. Anyway, thanks for being awesome, Laurel. Oh my goodness,
Maureen: Laurel thank you so much for that nomination, because absolutely you deserve an award.
Heather: Yeah, I think we should give her the Conference Queen Award.
Yeah.
Maureen: I love that. And also how it’s like almost alliteration, but not quite. And it’s kind of perfect.
Heather: Yes. Yeah. Conferences in general, like hit or miss, right. They’re either like awesome and like invigorating or they’re like, Oh my God, when is this going to be over? And like, why are all these amenities not up to par that they listed on the website?
Yeah. So good job rolling with the punches there. And I hope it was a good. What was it a librarian conference? Like
Maureen: that sounds fun. Well we’re super proud of you, Laurel. And thank you so much for your supportive message. We love that too. Yes.
Heather: And thank you all for listening to another episode of the Milk Minute podcast.
Maureen: The way that we change this big, complex system that we’re a part of is by educating ourselves, our friends, our family, and sometimes our healthcare
Heather: professionals. Definitely. Definitely. Especially in an arena where the patriarchy reigns supreme. And we are still trying to get good studies, good evidence, good, good research in general for recommendations and you know, be like Dr.
Mitchell and fight the good fight. Yes, and
Maureen: reminder, we are going to have a bunch of resources in today’s show notes, so scroll down and check those out.
Heather: Yes, please. And if you’re considering breast surgery, you know, make sure you ask all the right questions.
Maureen: All right, everybody, we will see you next week. All right. Bye bye.
