Management of Common Complications of Lactation – Breasts Massage

• Myth
  • “Plugging” represents occlusion of ducts by stagnant milk, and “plugs” should be extruded through massage
• Science:
  • The sensation of “plugging” does not represent discrete collections of breastmilk
  • More accurately, a “plug” represents a focal area of congested capillaries, distended alveolar cells, and tissue edema:
    • The root cause of “plugging” relates to:
      • Tissue hypervascularity
      • Edema
      • Ductal narrowing from microbiome changes and luminal inflammation
  • Lactation consultants often recommend massage for “plugs”:
    • However, this recommendation lacks scientific validity and causes tissue trauma that can result in significant complications
  • As surgeons are well aware, lactating breasts have robust blood supply, lymphatic vessels to drain increased interstitial fluid during lactation, nerves, fibroadipose tissue, and functional glandular tissue with a complex network of interlacing ducts:
    • Attempts to extrude a milk “plug” from a duct with aggressive massage will result in tissue trauma, edema, collapse of ducts, and capillary damage
    • All patients report worsened pain with massage
    • As we would injure a thyroid, pancreas, or other functional gland with massage or tissue mishandling during a surgical procedure, it similarly must be avoided in the lactating breast
    • Massage is associated with development of lactational phlegmon (Figure), particularly in the setting of hyperlacta- tion or excessive pumping
• Treatment:
  • Deep manual massage, vibrators, electric toothbrushes, or any commercial breast massage products designed to extrude a “plug” should be strictly avoided
  • Patients with symptomatic “plugging” should be evaluated for:
    • Proinflammatory conditions such as:
      • Hyperlactation and subacute mastitis
  • Patients can use ice for both pain relief and vasoconstriction
  • Therapeutic ultrasound, also used to treat conditions such as radiation fibrosis, can reduce inflammation and pain through application of thermal energy (Figure)
  • If a mass or erythema persists, diagnostic breast imaging should be performed

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