Events

Elena

Once again, good evening and very warm welcome to our webinar on Plastic Surgery after significant weight loss. My name is Elena, and I'm hosting tonight's session. I'm delighted to be joined by our expert speaker, Mr Christopher Macdonald, Consultant Plastic Surgeon.

Tonight's session will begin with the presentation from Mr Macdonald, followed by a live Q&A. If you have any questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen. You are welcome to ask anonymously, or include your name. Just a quick note that the session is being recorded, so any names shared may be visible in the recording.

To help us get through as many as possible, please keep questions brief. If you're interested in booking a consultation, we will share all the relevant contact details at the end of the session.

Now I will hand over to you, Mr Macdonald.

Mr Christopher Macdonald

Thank you so much, Elena. So, welcome to this evening's webinar, where we'll be discussing, plastic surgery after significant weight loss, which is something that we are seeing more and more demand for.

So my name is Chris Macdonald, I'm a Consultant Plastic Surgeon. I trained at UCL in London, but I then continued working across London, Essex, the South East, Hertfordshire, Midlands, where I trained in advanced techniques, I undertook competitive fellowships in skin cancer reconstruction and aesthetic cosmetic surgery.

I am a fellow of the Royal College of Surgeons in Plastic Surgery, and I undertook some advanced training in both Boston and San Diego in America.

So, most of my cosmetic practice is based around breast and body contouring, particularly after massive weight loss, and I have a special interest in treating people who have undergone significant weight loss, or who are dealing with the complications that we see in a post-pregnancy body.

I am a member of the British Association of Plastic Reconstructive and Aesthetic Surgeons, as well as a member of the British Association of Aesthetic Plastic Surgeons, and I've recently been admitted into the International Society of Aesthetic Plastic Surgeons also.

So most of my research focus is based around combining patient safety and improving surgical outcomes in these sorts of cases.

So the session that we're going to run is going to go through what to expect if you were to come and see me or one of my colleagues, talk about the consultation assessment, and I'm going to talk a little bit about the most common operations we carry out with people after they've lost significant amounts of weight. I presume, because you dialled into this, this is something you're interested in.

We have been seeing for decades and decades people who have significantly put on large amounts of weight, then lost it again. And more recently, we have seen the shift from people who are doing it with diet and exercise, or with bariatric surgery, like sleeves.

Who are now using, injectables like Ozempic, etc. But there's always been a huge demand for this. It's become more and more of a problem for people.

Because as they've gained significant amounts of weight, their skin is stretched to accommodate all the tissue underneath it. But once they lose the fat, they're left with skin that doesn't really retract back together, and all the problems that come with it. So the majority of the operations that we talk about in this way are dealing with skin excess.

I might briefly touch on liposuction at the end, and then we're going to go into the question and answer.

So, what should you expect when you come and see myself or one of my colleagues at Benenden? So, we offer a 45-minute consultation, just as a starting place. It is broken up into three main sections.

So, the first part of the consultation is really based around you telling me what your concerns are, and telling me what it is you're trying to achieve.

Once we get past that, it's then a more focused series of questioning for myself about what it is you're trying to achieve, what things you're bothered about, what things you're not bothered about, and then we talk a bit more about your medical health and previous operations, and medications etc and then I will, carry out a detailed examination of the area you're concerned about and then we'll sit back down, and we'll go through a personalized plan designed to deal with the things that you are concerned about, and we then will go through an individual presentation that I prepare for patients, where we talk about before and afters of lots of people who've been through similar sorts of things. We talk about what's involved in the recovery, we talk about what to expect as you heal afterwards.

And then I, allow you to go away, take some time to think about it. We provide you with a detailed, individualized quote for what to expect, and what to expect to pay for any sort of surgery.

I put everything that we have discussed into a letter that comes through to you, that allows you to go through all the information at home.

With no pressure, and then I ask you to come back and see me for a second consultation, which gives us an opportunity to go through everything again, and for you to, ask any questions you've had from all the time that you've been able to think things through. That's how the first appointment runs.

We will most commonly look at people's tummies, breasts, arms, and thighs.

And it's quite common, but it's very unusual for someone to have one area they're concerned about, so it's really, really common for people to come and say, well, actually, I'm really bothered about my chest and my tummy, or my tummy and my arms, and we talk about options for combining these surgeries, or staging them, so that we deal with the one that's most problematic, and then move on to others in the future.

So we're going to start off talking about abdominal surgery, which has lots of different names, so people refer to it as tummy tucks. The medical term for it is an abdominoplasty. Basically, it's around dealing with someone's abdomen after it's undergone significant changes, which in this webinar, we're going to be talking about the changes that we see after someone has lost significant amounts of weight.

There's lots of similarities between that and someone whose abdomen has changed because of multiple pregnancies, or sometimes just the aging process.

And what we find is that as the abdomen fills with fat and weight, it stretches out the muscles that are there, it stretches out the skin, and then once you recover, the skin doesn't have the natural ability to recover and become taut again. So you're left with stretch marks where the dermis has been damaged by the way it's stretched.

You're left with skin excess, which then hangs, and it can become moist and problematic underneath. It could be an issue for you when you try and run or exercise.

And there will sometimes be some remaining fat as well, and so that could be removed at the same time.

This section here talks about muscle gaps, which I'm going to come back to when we've got a diagram in a minute, but basically, the six back muscles in the front can become detached because of pregnancy or weight gain, and actually, if they don't heal back together, that can cause real functional problems.

So why would you have a tummy tuck? So most of this we've already covered, and it's about removing excess skin and fat after pregnancy, or weight changes, or the aging process, and it's designed to make you feel more confident about your shape and about your body.

Most people we find that actually they will insist on wearing baggy clothes all year round, because they don't want anyone to be aware of their shape. They'll wear jumpers to hide their shape. You won't ever see them in swimwear or anything that's tight-fitting.

And that can really cause problems in relationships as well, because lots of patients become so dissatisfied with their body that they won't even like their loved one to touch them or cuddle them, and it can cause real problems. So, by being able to deal with this, we can actually make a really positive impact on the way that people feel about themselves, and improve their relationship with themself, and with others around them.

Who can't have a tummy tuck, so it's really designed to remove small amounts of fat and to tighten up skin. So it's not really something that we do for people who are still extremely heavy. So if you still carry a lot of weight around.

Usually, it's not a tummy tuck that you're after, because it's much more likely if you have problems with wound healing or infections.

We would normally encourage someone to get their BMI down to below 30, if possible, before undertaking any surgery. It's also not ideal if you're planning on either gaining weight again in the future, or becoming pregnant, because it will essentially undo all of the hard work that you've put in so far.

So this is the most common type of tummy tuck or abdominoplasty to perform. It's what's referred to as a standard. There are other people who will put terms like Brazilian or LIPO-assisted to this, and they're all just slight variations on a core principle.

Which is basically where a cut is made all the way across the low abdomen, from the front of one hip to in front of the other, low enough that the scar that's left there at the end could be easily hidden either by underwear or by a bikini.

And, we raise all of the skin and the fat off the lower abdomen. We leave the belly button attached where it is, so it still comes out at you. And then once we've freed up the skin, we pull it down as far as it'll go and remove all of the excess skin, and then stitch everything back together, and then make a small hole that we deliver the belly button

So this is the original belly button, and we deliver it through the skin, and stitch it into place with some fine dissolvable sutures.

It is an excellent operation for getting rid of skin. In fact, it's a really good way of giving you taut, good skin. It will remove all of the stretch marks between your pubic area and your belly button in most operations.

But it won't remove stretch marks from above the belly button. That's something to bear in mind, if that is something that bothers you.

And it does leave you with two scars. One that runs all the way across, like I've said, very low, and then one that sits around the belly button, that's designed to be very inconspicuous. Most people will have this scar on the beach, and people won't notice.

There is an operation called a mini abdominoplasty, which is actually not something that we can do that commonly, because not that very many patients have the problems that this addresses.

So this is an excellent way of removing a small amount of skin and fat from below the belly button, from this area here. So if you are carrying a small amount of weight in that area, which is quite common in the post-pregnancy lady.

Then this can be easily addressed with a mini abdominoplasty, and we simply snip that away and repair it back together and leave you with a small scar here. It's also excellent at dealing with,

Problematic caesarean section scars that people don't like, we can remove that in the same operation.

It won't address anything else. It won't address the skin above the belly button. It can sometimes pull the belly button down by a couple of centimetres. So there's only a small number of people that really benefit from this.

If you have more skin than we'd be able to easily remove with a standard abdominoplasty, the first operation I talked about, then you would often be a candidate for a fleur-de-lis abdominoplasty. So this is very similar, but will you also take away a big triangle from the front, so that we can pull everything from the sides around.

And this is an excellent, really powerful way of removing huge amounts of skin and fat, but also really helping recreate an hourglass figure and tightening the waist. This is an excellent operation.

The only downside of this is that it does leave you with a midline scar that runs all the way down, but is much harder to disguise in swimwear, or a bikini, or a pants and bra. So this is something that you do have to accept if you do have an operation to remove that much skin.

There is an extended abdominoplasty, which is similar to the very first one, but rather than the scar stopping here on the front of the hips, it actually goes around the side, so some people refer to this as a 270, so a 270 degree abdominoplasty, so it goes three quarters of the way around the body. Kind of removes more skin than the first option would have done.

Or a 360 abdominoplasty. This is where people have lost very large amounts of weight.

And they are left with skin excess on their front, and on their flanks, and on the back as well. So this is an excellent way of removing the whole tube of skin all the way around someone's body. So at the same time as tightening up the front, you can also tighten up the back.

And it will give a bit of a lift to the buttocks as well. This is a really good operation, but it's quite difficult to recover from, because you don't only have a sore area on the front, you also have a sore area on the back, and it can be a little bit tougher to recover from.

So this is the diagram I was talking about earlier on. So, when we talk about muscle gaps, this is what we see. So here on the left, we have someone who has got their six-pack muscles, their rectus abdominis, which runs from the bottom of the ribcage here to the pubic bone, and they're responsible for flexing the core.

When the abdomen has blown up like a balloon, either because of pregnancies or because of fat, what happens is these have to separate to allow the organs to expand forwards, so you end up with a big gap forming here.

And then once you have de-volumized the abdomen, either through weight loss or through pregnancies, these should stick back together, and in some cases, they do. But in a lot of cases, they don't ever really heal, and you're left with these slightly lax muscles sitting to the side.

And because they don't form a strong sheet at the front, actually, the abdominal contents that you're left with can bulge forward or you can be left with problems because the core muscles of your abdomen don't work anymore. It's quite easy to end up with lower back problems, difficulty sitting up, so we can repair those at the same time as any of these tummy tuck operations.

So it's an extremely safe operation to have a tummy tuck, but there are a few small things that can happen. So you can suffer from bleeding underneath the skin, something that's called a hematoma. This so each one of these only happens in less than 1 in 100 patients, so they are very uncommon, but it could end up with a hematoma.

If that happened, it'd be very obvious to us, because we'd have a large swelling, and it'd be uncomfortable, and there would be a reason to put you back to sleep, find out where the bleeding's coming from, stopping it, and then putting everything back together again.

It's unusual people to be left with obvious scars or bulges under the skin, but if you were left with any problems like this, these could be easily treated with a minor revision under local anaesthetic.

And skin numbness is a problem, after these sorts of operations, where the skin has been stretched, and the nerves are temporarily put to sleep by the stretch on them, but it usually recovers really well over the following 6 to 9 months. It's very unusual for someone to be left with an area that's completely numb afterwards.

And with any operation, whenever we make a cut in the skin for any reason, then bacteria from the outside world can get inside and cause an infection. And because you are slightly less mobile than you normally would be, you can develop blood clots, and these are incredibly rare, and actually, I haven't ever seen a patient of mine with blood clots in many hundreds so far.

Benenden is an excellent hospital, it's very clean. They haven't had any cases of bacteraemia or septicaemia from MRSA in over 20 years, and they've had no cases of Clostridium difficile, another infection that you see in some other hospitals.

They have three fantastic modern operating theatres with the laminar flow technology, which is a way of describing the way that the air moves through the theatre in the most, the most clean way to make sure that it's all coming through fresh and isn't stirring up dust off the floor or anything like that.

So what to expect when you're recovering for an operation like this? So, you'll be in hospital just for one night, and go home the next day. For the first week afterwards, you need to have someone around to help look after you, as you'll be quite limited in what you can do.

For the first two weeks, you'll be walking slightly stooped over, as we've tightened everything so much. You may feel slightly bloated. It'll be a couple of weeks before you can return to office work, and it's normally two to three weeks before you can comfortably drive a car.

And then it's really 6 weeks before we say we sort of sign you off and say you can go back to all your normal levels of activity. Maybe 6 weeks before you can return to exercise or the gym.

And it's usually 6 weeks before I'd be happy for you to leave the country or go away on a holiday. I like to keep my patients closer by, just in case there were any problems at all.

This is a gentleman that we're actually gonna, play a little testimonial from him, so I won't talk about him too much, but he lost a very significant amount of weight, both from his abdomen and from his chest.

And then he had two operations. One to deal with this skin excess, and you can see that actually the skin comes all the way up underneath here, so she has this huge floppy amount of chest skin that just hits his chest every time he moves, and then he had all this skin hanging down here.

And this is him at, I think it's probably about   months afterwards. So his scars are still maturing, but they're really good at this stage. He's got a completely different shape to him. His skin has been retightened to give him a better figure. He's had an extended abdominoplasty, so when I said the scar comes all the way up around the back.

You can appreciate here that actually he's still got quite a lot of loose skin in this area here, so that's what has to be dealt with by having the scar coming further around. Completely life-changing for him.

And actually, I'm just gonna let him tell you about his experience.

Paul

My name's Paul. I live in Hastings in East Sussex. I had a chest reduction and tummy tuck surgery at Benden in January 2025. My weight had increased to the point that I was 26 stone.

And I was told that I was pre-diabetic. At that point, it was apparent that I needed to make significant changes in my life.

With support from Benenden I was able to lose 14 stone. That meant that I went from a 46-inch waist to a 30-inch waist and a significant amount of excess skin developed.

That was both on my stomach and on my chest. Again, with help from Benenden speaking to the team there, they recommended the two surgeries that I had earlier this year. Part of the journey to lose that weight, I took up a number of activities, one of which was triathlons and running. Running would cause that skin to bounce, to flap. I could literally hear it as I ran. It was not a pleasant thing.

There was also the issue of during the summer, where it was effectively sagging, it would effectively become unpleasant. Despite having lost the weight, I still had a bulge, around my stomach that was unsightly. I chose to go ahead with this with Benenden over a cosmetic clinic or some of the options you see abroad.

For a number of reasons. The first, quite frankly, is the degree of confidence that Mr Macdonald and the team gave me, and the level of support, and care that I felt I would get.

You know, the hospital is unbelievably clean. It it just is impressive. This is the bit which, sort of leads me to go on and say, I can pretty much do everything that I would want to do, that I can do things such as you know, go to the beach without having to always wear a rush shirt, or go swimming without always wearing a swim top, or whatever.

Two and a bit years ago, I weighed 26 stone. You know, there was just absolutely no way I would have done anything like that. It's the final piece of quite a complex puzzle and it's definitely been worth it.

Mr Christopher Macdonald

And so, that's it. So, I won't be talking about abdomens anymore, but there will be plenty of time to go through questions if you want to put any in the box. Not quite second most, but one of the operations that we do a lot of is removing skin and fat from arms.

Most commonly in those who've lost significant amounts of weight for exactly the same reasons, this is what's usually referred to as a brachioplasty.

People will often sit down, and when I say I'll give them the opportunity to tell me about their problems, they will often talk about their bingo wings and how much they really impact on them psychologically. And people will, always wear clothes that hide them. People will avoid vest tops, or even a short-sleeved t-shirts, or wear very long-sleeved, items or clothing to try and hide their arms.

It makes it very hard to exercise, it can be very difficult when the weather's as nice as it has been this summer, and so it's one of those areas that people really benefit from when they've had it treated. And it's designed to try and give you a much better silhouette by removing skin and fat.

The way that it's carried out is a combination of liposuction and then skin removal. So the more modern technique of dealing with this is actually to use a special liposuction machine to remove the fat from the inside of the arm, and this is the safest way of doing it without injuring nerves and blood vessels or lymphatic channels.

And then once we've taken away all of the fat with that technique, we then remove any skin excess, and then stitch everything back together.

Meticulously, with very fine and dissolvable sutures, and most common way of doing this leaves you with a scar from the level of the elbow to the level of the armpit. And there's a couple of options about where we place that scar, depending on what's most important to you.

So most patients that come and see me choose to have it put all the way down the inside of their arm, so that when their arm is down next to their body, which is where it most commonly is, the scar is completely hidden, but it does become more obvious if you are someone that swings or plays racquet sports.

And in which case, some patients will choose to have it placed down the back side of the arm, running down the back, which means it will never be obvious to you, and you'll never see it in a mirror, but anyone who's behind you may be able to see that scar. The goal is for the scar to be a faint, pale white line.

That's all I need to say about that. So, what to expect from the surgery? Again, you stay in hospital for one night afterwards. It's normally a couple of weeks before you can start to return to, work, or three weeks before you're driving, very similar to abdominal surgery.

We don't want you to do anything that gets your blood pressure up, because we don't want you to run the risks of bleeding.

One of the main, well, not really issues, but problems with this operation is that the area can swell, so I tend to wrap it up in a very tight bandage for the first week afterwards, and then after that, you go into a compression, bolero, which is an item that squeezes the arm and stops fluid accumulating in it, and it helps keep patients more comfortable, and allows them to recover faster and better.

And again, it's usually 6 weeks before you return to all your normal levels of activity.

Thigh lift is another really common operation, which is, in many ways, is very, very similar to the brachioplasty I was talking about, and it's where your thighs have been expanded by fat, and then when the fat has disappeared through weight loss, you're left with all this skin redundancy.

The problem in the thighs is that it can become very sweaty, your thighs can chafe, and they can rub together, and they make it very difficult to exercise. People can be bothered by the cosmetic appearance as well, and the goal is always to have smoother, more contoured thigh shape, that people can be more confident about, and they can exercise, move, and get on with their life without worrying about the problems that come from having so much new skin there.

It can also be a big impact on intimate relations as well.

So this is carried out under a general anaesthetic. There are two real ways of carrying it out. So one is where we just remove a patch of skin from the groin and tighten everything, but in patients who fall into this massive weight loss category, that's never really quite enough.

So we have to do a T-shaped incision that comes all the way down the inside of the thigh as well, and can really tighten up everything fantastically. It's a really good operation, but it can take a little while to recover from.

And again, exactly as with the arms, you spend one night in hospital, you need to wear compression shorts to squeeze the area, and it's about six weeks before you can really return to all your normal levels of activity.

That's right, I'm trying to speed up, because I want to make sure everyone's got time for questions, so we'll just skip this.

And here's a patient who's had the first option that I was describing. So she has had just a very large slice of skin taken away from the air, sort of a wedge removed, and all of the skin has been lifted up. And you can see that the mole that was here has now become much higher up.

All the looseness here, the creepiness, the folds that are here, even when she's just standing, let alone when she's sitting down, have all been smoothed out really, really nicely. So, a fantastic result for that patient.

And then this with, tummies is the is the most common area that we treat, and this is a breast reduction, for a reduction mammoplasty. And there are there are two parts to this. So there's the patients who have lost significant amounts of weight, and they've lost huge amounts of volume off their chest.

Which means they're left with very deflated areas, like we've seen in the man, sorry, both men that we've talked about. Or we also see the same thing in women, where the huge amount of fat's been removed by the weight change process, and they're just left with a very small amount of breast tissue that isn't the way they want it to be.

Or this is a very similar operation in those patients who just have very large breasts, even after massive weight loss surgery, and they want to have their breasts reduced and allow them to get on with their lives.

We see in patients who've got large breasts, huge rates of shoulder and neck and back pain. It's quite common for people with very large breasts to suffer from migraines or problems with posture.

It can leave, deep grooves in the neck, sorry, in their shoulders where bras sit. They can end up with skin infections and irritation where the breast sits over the chest wall.

And so the operation's designed to remove skin, fat, and breast tissue, and tighten everything, and lift the breast up to where it belongs before the weight change process.

So this is what we normally plan to see. So this is a combination of a reduction to make the breasts smaller, and to lift everything up to where it was before all the weight changes.

What you normally see with this is that as the breast becomes larger, the weight stretches all of this skin, and the nipple that was here once upon a time has fallen much lower.

The other changes that you see is that the areola becomes larger and stretched out, and normally the nipple tends to either fall outwards to one side or fall towards the middle here, and you lose the sort of normal, traditional cosmetic breast.

And so the operation is designed about reducing it to whatever size the patient wants, to reducing the nipple size to a more aesthetic size, and to lift the nipple back up to where it belongs here, at the same time as repositioning what we call the inframammary fold, so the fold where the breast meets the chest wall.

Up here, and often times we find that by lifting a breast back up to where it belongs, we can really significantly lengthen out someone's torso and abdomen and improve the appearance of their abdomen without even touching it. It's a real benefit of this kind of operation.

There are various scar patterns that you see, so if you do any online research, you'll find there are a few different ways of doing this. There is an option where we just leave a scar around the nipple, what we call a peri areola reduction, or mastopexy.

So that's very good when dealing with very small changes, or we're just trying to move the nipple up by approximately 1.5 to 2cm, just tighten a very small amount of skin.

But if you're someone who's been through massive weight loss, and there's very large amounts of skin, that little scar will never be enough to deal with it. And so, the middling option is to have what we call a lollipop, or vertical scar, which is where we combine that with a scar that runs all the way down to the chest wall, which means we can tighten in this direction as well, and bring the skin around underneath to lift the breast. Or the most powerful one is what some people call an anchor scar, or a wives pattern, or a T, which is the combination of the lollipops, the nipple with the vertical scar, and then a cut that goes all the way across here. And then, depending on how much skin we're removing, sometimes it has to come quite a long way around the side of the chest wall.

So what do you expect to recover? So, this can be done as a day case operation, but most of my patients choose to stay overnight. It'll be two weeks worth of feeling a little bit uncomfortable, a little bit swollen, maybe having to have some occasional painkillers, but nothing too bad.

After two weeks, people will return to normal levels of office work and driving, and again, like everything else I've said so before, it's normally six weeks before they can return to heavy levels of exercise, remove their garments, and go on long-distance travel.

Excellent, so we're just drawing, drawing to the end, so I'll just talk a little bit about liposuction.

So liposuction is something that we normally carry out as part of nearly all the operations I've talked about so far. It's a really good way of removing any areas that are problematic.

All by thinning out areas, so in a tummy tuck, where we're carrying out the operation to thin out and tighten the skin on the front of the abdomen, it's quite a good way of thinning out the love handles, or flanks, or trying to accentuate things like the waist.

And in breast surgery, it's a really good way of thinning out the chest wall to try and accentuate all the volume towards the chest.

That's a really crucial way of taking away the fat that remains both in the thighs and arms safely when removing skin. So liposuction can also be carried out entirely on its own, without any of those, we can just have liposuction. It's not so common in the patient who's already had massive weight loss.

Because all it does is further removes fat. It's not any it's not a way of removing skin or tightening skin at all.

So we tend to not see it in our massive weight loss patients, and it's really good for people who have lost some weight and have got a particular area where they're unable to lose weight from, but they're now at a healthy goal weight. So we can take away fat from somewhere like a lower abdomen or their love handles, or their back, and we can use it to shape and improve body contours. And the way it's carried out is you make a tiny incision, just a few millimetres in size and we put a little cannula in, so a little, basically metal straw inside, and we use, so this is a microwave, which is power-resistant, and it vibrates. It just breaks up the fat and allows you to suck the fat out.

It can be driven either by a vacuum or a syringe, but here at Benenden, we have the benefit of this device, which is all self-contained, and it basically sucks the fat and any fluid out, allowing you to see an immediate difference in the way that this is in the impact this has on the body.

The area will swell a little bit after the surgery, and like everything else I talked about, we would encourage people to wear a compression binder or garment to squeeze the area, keep more comfortable and allow things to heal. The recovery from this tends to be much faster than any other surgery, as there's no wounds to heal. I think that's all I need to say about that.

So, talking about a hospital stay, although this slide does say one or two nights stay, it's very uncommon for someone to need more than one night in hospital, and the times when I've had patients stay for two nights, it's usually when they've chosen that as they live alone, and they just need extra night to stay and recover before they can feel ready to go back to the house.

In the situation of a tummy tuck, because we really tighten up the skin and the muscle, we actually slightly bend the bed in the middle to try and keep you comfortable while everything's healing.

You'd be standing up definitely on the same day of the surgery, and I'd expect you'd be getting up and walking around and going to the toilet, and then you find that as the first couple weeks go past, you'll be able to straighten out.

And, I think that's everything that I wanted to cover today. I hope you found it useful, and I intentionally left us 15 minutes to try and go through some Q&As. I'll hand over to you, Elena.

Elena

Thank you. Let's move to our Q&A session. We are really pleased to have so many of you with us today, and while we may not be able to answer every question, we will do our best to cover as many as we can. On this slide, you can find information on arranging treatment, and also you can call us or book appointment online.

So, let's go to our questions.

First question is, what are the additional challenges with surgery and recovery for patients over 60?

Mr Christopher Macdonald

So, so actually, we, you know, in the last couple of decades, we've shifted away from finding age as an important factor in this at all.

So I don't really consider age as a part of any sort of problem with recovery or with the surgery. We do find that patients who are over the age of 50 or 60, they are more likely to have medical problems that need some extra level of thought, so if you are if you have some age-related changes, or you're hypertensive, or you have a degree of ischemic heart disease, or anything like that that sometimes comes with age, they may need a little bit more thought about the operation, or about the anaesthetic.

But actually, there's no real impact on the surgery itself, there's no impact on the recovery, and there's no real impact on the results.

And actually, we find that, patients who are over the age of about 50 tend to heal better and have finer, paler, whiter scars than those who are younger. So, to my personal opinion is that actually age should be a consideration in these sorts of cases at all.

Elena

Thank you. And the next question, the combined operations, is it possible to have more than two done at a time? For example, tummy tuck, upper arms, thighs, and breasts in one?

Mr Christopher Macdonald

So that I wouldn't normally offer to do all four of those in one go. There's a few different parts to the recovery, and the surgery itself, so we know that every area that we add on adds some time during the operation.

And although anaesthetics are extremely safe, we know that in patients who have very long anaesthetics and very long operations, they are more likely to have complications, and they are slightly more likely to have problems with wound healing.

Because they've been asleep for so long. So we tend to try and restrict the amount of time they're asleep, and because of that, we usually only treat two areas at a time.

Sometimes we will treat three, and sometimes that will mean having to combine surgeons. So, rather than me doing the whole operation on my own, I'd get one of my colleagues to come and help me to try and get through the surgery faster, and make your recovery smoother. Some of the operations actually lend themselves very well to going together, so things like breasts and tummy go really well.

While arms and tummy go really well together. There are some that are more difficult to combine. So if you have a tummy tuck and a thigh lift, it can mean that you have the tummy tuck operation, which is trying to lift everything up.

And the thigh operation that's trying to do the opposite. And you can sometimes find that the scars are slightly more stretched out, or the cosmetic result isn't quite as good because of the way that you've combined them.

So I would normally offer to separate an abdomen and thighs, for those reasons.

Elena

Healing process can be challenging in this case.

Mr Christopher Macdonald

Exactly.

Elena

Okay, I see. Thank you. Can you use for tummy tuck the scar that is already there from C-section?

Mr Christopher Macdonald

Yes. So usually a C-section scar is too short to do the whole operation through, but we would normally remove a caesarean section scar with any of those operations.

So sometimes, if you are having just a mini abdominoplasty, we'll remove the scar with a little bit of skin above it and below it, and that's what we will tighten up. But normally, if you're having a traditional abdominoplasty, we will be so low that we will take out a caesarean section scar.

Elena

Okay, thank you. How high is the risk of spitting stitches?

Mr Christopher Macdonald

So very low. So, we use well, so I certainly use a monochril-type suture for the skin closure. It's uncommon. I would probably say that one in every 20 or 30 patients will have problems with their stitches spit out.

But it's definitely not something that we see very commonly at all.

Elena

I see. I have a number of hard, fatty lamps in my legs after losing a significant amount of weight. I've been told that harmless lymphoma lamps. Can this be removed as part of thigh lift?

Mr Christopher Macdonald

Yeah, so it would, to know for certain, I would need to examine you. It's quite common for people to have, lipomas, and it's quite common for people to have lipomas that you don't know about when they're covered by other fat, and then as you lose the fat, the lipomas become more obvious. You usually can, remove them as part of a thigh lift.

The problem is, if they are not in the area where we would normally go, I would be quite reluctant to go and chase them. So if they were on, say, the outside of your thigh, which isn't somewhere that we normally operate in during a thigh lift.

I wouldn't want to remove them in that operation, but they can be removed either separately, or they can be removed through a separate incision. So you could have a thigh lift and remove lipomas from the outside, but we probably couldn't do it through the same cut.

Elena

I see. And the next question, I saw an episode of Botched where someone was having a reshape and reduction, but there wasn't enough fat to maintain the shape, so they put an implant in unplanned. Is this common?

Mr Christopher Macdonald

No, I would think that's an awful thing to do to someone, no. So when we go through the consultations in advance, the reason that we have, you know, a minimum of two of them, sometimes we have more than two, is to really make sure that we've had excellent communication, and we know what the goal of the operation is, and everything is planned out in advance.

You know, and having breast implants put in is a really big decision for someone to make, because once breast implant's put in, they do have some drawbacks on their own, they don't live there forever, and I think you could only ever possibly put breast implants in someone where they understood what they were signing up for, they knew that that was part of the operation.

And, you know, I would think that if someone had that, that would count as assault. It's a terrible thing to have happened. I can't I have heard of this case before, because it was in the press, but this is, you know, not even not common. This must be the only person this has happened to in the world. This is a terrible thing for a doctor to have done.

Elena

Thank you. Do arm leaves require drains during the healing process?

Mr Christopher Macdonald

No. So I, so the only time I could possibly consider would be if you took, blood thinning medication. So if you had, something like atrial fibrillation, or you had strokes, and you had to have blood thinners.

Then that can increase the risk of you bleeding after the operation, and I would possibly consider putting drains in, but I really dislike drains, and actually it's very, very uncommon for me to use drains in any of the operations that I've described.

Because I find they are problematic. Patients don't like them because they're uncomfortable. They can leave additional scars, they can be a route for infections and other things to get inside. So I tend to do all of my operations in a way that means I can avoid drains. And in all the arm lifting brachioplasty operations I've done, I've never yet put a drain in someone's arm.

So I'd be very surprised if I ever did one day.

Elena

Okay, thank you. And can you extend the hospital stay longer than one night?

Mr Christopher Macdonald

Yes, yeah, so it's uncommon, but occasionally people will stay for two nights. It tends to be people who either live a very long way away, who've travelled across the country, and they just want the extra reassurance of being here for another 24 hours.

Or someone who doesn't have any support at home for that sort of 48-hour window, because they just choose to stay an extra night.

Elena

Okay, very interesting, next question. With the breast reduction, is there a way to use any excess tissue from underneath the armpit, or combine it with having an arm lift?

I have been told that I have minimal breast tissue, but wouldn't be candidate for artificial enhancement. Would there be an option to try and preserve as much volume so the breasts look proportional to the body size?

Mr Christopher Macdonald

Yes, so there's various, various ways of doing that. You can't you can't just take a block of tissue from the arm and then put that into the breast, if that's what you were suggesting.

Because all tissue needs to have a blood supply, and if you take a block of fat from one part of the body, it doesn't have a blood supply anymore, you've removed it. And if you just put that into someone's breast, which people have tried in the past.

What you find is that there's no blood getting into it, and it slowly dies. And although you may be very pleased with it for a day, within a few days, all that fat would start to die, and it would cause problems. So you can't you can't just take a block from one place and put it somewhere else.

What we can do is sometimes take some skin and fat from the upper abdomen, just underneath the breast, and we can if you have got loose skin there, we can slide that up and behind the breast.

And use that to volumize it. Or the final option is something called fat transfer, or fat transport, and that's where you have something like liposuction, where we suck the fat out, and then do some various things to it, so that we have, kind of like a fat smoothie.

You can then inject that in very small really well-controlled doses. So we put little spots of fat into a well-vascularized blood breast tissue. Vascularized means it's got a really good blood supply. So you can then put it in in small volumes in a way where the blood vessels in the breast will grow into it and feed it and keep it alive.

But that only works when you put in lots of, lots of lots of little small spots. You can't just transfer one block in. So that's a fact transfer. We could discuss that if you wanted to come and see me.

Elena

Okay, thank you again for your questions, and for being part of this evening session. If we haven't covered your question, and you've provided your name, we will follow up you with email. And, let's see, the final slide.

We are pleased to offer 50% of the value of your consultation.

A callback from your dedicated Private Patient Advisor, an email with a recording of this session, treatment information, and loyalty reward points. Updates on future events and health news.

We'd really appreciate if you could take a moment to complete the short survey at the end of the session. It helps us to improve and tailor future webinars to your needs.

If you'd like to speak with someone to book your consultation, our Private Patients team is available today until 8.30, or from 8am to 6pm Monday to Friday, and Saturday 8am to 4pm. You will find the contact number on your screen. Alternatively, you can book online. Don't forget to use code PLASTICS50 to get 50% discount for your appointment.

And we also have upcoming webinars on a range of topics, including glaucoma treatment, shoulder pain treatment, hip and knee surgery, and arthrosamid injections. You can sign up for this on our website.

Thank you from all of us here at Benenden Hospital for joining us, and thank you, Mr. Macdonald, for such an interesting presentation.

Mr Christopher Macdonald

My pleasure.

Lexie Otana

Once again, good evening, everyone, and a very warm welcome to our webinar on tummy tuck surgery. My name is Lexi, and I'm the senior staff nurse in plastic and cosmetic surgery here at Benenden.

I'm delighted to be joined by our expert speaker, Mr Adam Blackburn, Consultant Plastic Reconstructive and Aesthetic Surgeon.

Tonight's session will begin with a presentation from Mr Blackburn, followed by a live Q&A, and if you have questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously or include your name and just a quick note that the session is being recorded, so any names shared may be visible in the recording.

To help us get through as many as possible, please keep these questions brief.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session.

So, as I said, my name is Lexie. I've been a nurse for about ten years. I spent five years in intensive care in Bristol and London. I joined Benenden in 2025.

I've worked in London as a director at a hearing clinic, and I have a master's in international marketing and consumer psychology.

Mr Adam Blackburn

Thank you, Lexie, and good evening, everyone.

Thank you for joining us. My name's Adam Blackburn, and I'm a consultant plastic reconstructive and aesthetic surgeon, and I'll be talking you through tummy tuck surgery and liposuction this evening.

My background is that I'm on the GMC Specialist Register for Plastic Surgery. I trained at Imperial College School of Medicine in London.

And then went on to do higher surgical training in the northeast of England before coming back down south to do fellowships at St Thomas's Hospital and the Queen Victoria Hospital in East Grinstead, along with trauma fellowships in India.

Now, I've been a consultant for about 14 years, and my practice is focused primarily on breast and body contouring. So, in my repertoire, I do breast augmentation, reduction, mastopexy, and abdominoplasty, and I have a particular interest in functional abdominoplasty.

Which is more than just being about appearance; it's about improving posture, restoring core strength and sometimes even pelvic floor symptoms.

I also do a lot of microsurgical breast reconstruction, where I transplant tummies to make breasts. So, the sort of aesthetic side of my practice feeds into my reconstructive one, and vice versa.

Yeah, next slide, please.

So this is to, sort of, just summarise what we're going to go through this evening.

We'll start off describing what happens when you come in for a consultation, and then I'll go through the nature of the surgery itself, whether that's a tummy tuck or a combination of both.

We'll quickly go through what's involved with your hospital stay and recovery and show you a typical, good average result and then have a question and answer session.

So the consultation starts with a full 45-minute consultation, and this should be an unhurried appointment where we discuss your goals, and I then assess your anatomy and work out what I can realistically achieve and what's likely to work best for you.

We'll go through lots of pictures of before and afters, hopefully with patients who have previously consented for photos being used, so I can show you what's a typical sort of result for somebody with your body shape.

And we'll try and make a personalised plan that's particularly tailored to you, because even though everyone's got a tummy, not every tummy is the same.

Sometimes what becomes apparent is that you may benefit from a combined procedure, whether that's a little bit of liposuction to refine the tummy tuck or whether it's a mummy makeover type procedure where breast surgery is performed at the same time as the tummy tuck to improve your silhouette overall.

So, tummy tuck surgery is also known as an abdominoplasty, and everyone knows it's about improving the appearance of the abdomen, but it's also about improving core strength. Most people who come for a tummy tuck will have had children before.

Some will have just lost a significant amount of weight and have loose skin. But if you've had children and pregnancies, the six-pack muscles are often separated, which is known as 'rectus diastasis', and that stretching weakens core strength and can affect pelvic floor strength.

So part of the procedure is to put the muscles back together to give you a strong tummy, so you can get back to planking or sit-ups if you want, and also improve how things look by getting rid of some of the stretched, loose skin that overlies it.

So, tummy tucks work for people who have lots of loose skin and would like to achieve a flatter tummy. It significantly helps with confidence and helps with clothing choice. Many women who haven't worn a bikini for many years. We'll feel confident enough to wear a bikini afterwards.

And often, feeling strong in your core makes you feel younger. You know, you can trampoline with your kids again, if that's what you wanted to do, and you can get on to proper fitness regimens with the PT, which you wouldn't otherwise have been able to do.

Tummy tuck surgery isn't a weight loss tool, I'm afraid. You need to be at your happy weight before it, and by happy weight, I mean the weight that you'd want to be for the next ten years.

If we do the surgery and then you lose weight, you'll end up with loose skin that could hang over the scar again.

If you put on weight, that may stretch the repair of the rectus diastasis apart, and getting pregnant is a bit like putting on lots of weight, so it's best to have had your family complete before having this type of surgery.

So most of what we do is a standard abdominoplasty, which involves a cut around the tummy button and a hip-to-hip scar.

If you want to know how long that hip-to-hip scar needs to be, sit down and let your tummy hang out over the top of your underwear.

There'll be a crease, and where that crease ends on the side is how long the scar needs to be to avoid dog ears, which is an unflattering sort of bunching of skin at the end of the scar, which can occur if you try to make the scar too short.

During the surgery, the skin between the tummy button and the top of the pubic hair is excised and thrown away, and then the skin above the tummy button is lifted all the way up to the edge of the rib cage and then stretched down to be sewn up just above the pubic area.

Before doing that, if the six-pack muscles have separated.

That separation is repaired with permanent sutures, so you have a nice, strong repair that can't stretch too easily again.

So, to emphasise, with a standard tummy tuck, there is a scar that goes around the tummy button and a hip-to-hip palm, and that's slightly different from a mini tummy tuck, which I think we'll talk about a bit later.

So, with a mini tummy tuck, this is for ladies who predominantly have loose skin below their tummy button and their pubic area, and it works best for just getting rid of that, sort of the fold, often over a caesarean scar.

During the procedure, it is possible to elevate the tummy button without a scar, so the stalk of it is detached from the sinews between the six-pack muscles. One can still repair the gap between the six-pack muscles, but the skin isn't pulled quite so tight.

And that avoids the scar around the tummy button, though it does lower the position of the tummy button by a couple of centimetres.

It's not very good if you've got a lot of skin laxity between the breastbone and the tummy button area.

So if I were to do tummy tucks, probably only ten of them would be mini tummy tucks. The rest would either be a standard or an extended tummy tuck, which are much more common.

This is an even more aggressive tummy tuck than a standard one in that skin is excised in a horizontal and a vertical direction. So if you've lost lots and lots of weight, you will have not only a vertical excess of skin but also a horizontal excess of skin.

And this is a really powerful technique for narrowing somebody's waist and improving their silhouette. However, it does put a scar that goes from the bottom of the breastbone all the way down to the pubic region, as well as the hip-to-hip scar.

And this is an extended tummy tuck for people who have less of that vertical laxity but do, when they sit down, that roll that goes over their underwear goes all the way around towards their buttocks. And so, as you can see, the scar goes probably two-thirds of the way around the circumference of the body.

And it can be a very powerful technique to improve some of the fullness in the, sort of, outer hip area.

A 360 tummy tuck is talked about quite a lot on social media, and that's where somebody has the other name for it: a belt lipectomy, because you excise all the way around the body.

I'm not a fan myself of doing this in one go in that you've had a tummy tuck and the skin on the front of you is pulled nice and tight. I normally want you walking slightly stooped for about ten days.

But if you're walking stooped, you're then pulling on the skin on your lower back.

So, this operation can have quite a high complication rate in that the wounds can either fall apart at the back or the front, or the surgeon then doesn't pull the skin tight enough.

And the skin becomes loose and needs a small revision.

I often think if you need one of these, it's likely that you probably would benefit from multiple surgeries, whether those are breast reductions or uplifts, or arm lifts, otherwise known as brachioplasties.

So it'd be best to do an extended tummy tuck in the first instance with another procedure, such as a thigh lift, or an arm lift, or a breast reduction. And then, at a second operation, you can then do the

Excise the skin from the back, and you're much more likely to get a result without a complication.

So, as I've mentioned earlier, rectus diastasis, or diastasis recti, just means the separation between the six-pack muscles. And in the left picture, you can see there's just a separation around the tummy button region, and on the right there's a separation that goes all the way from the breastbone to the pubic area. And I know from doing research with army doctors that if that gap between the two six-pack muscles is over about four to 4.5 cm for an average-sized woman, she will get symptoms of lower back pain and pelvic floor weakness that are improved with repairing that gap.

And having worked with patients in the armed forces, we know that ladies who were pre-operative, well, pre-pregnancy, high-performing athletes, whether they were on the Great Britain bobsled team or Commonwealth sprinters or even had a lacrosse player for GB.

Once they had kids, they weren't able to get back to their usual exercise regimens, and their fitness fell off a cliff, and they became quite depressed. But having put their six-pack muscles back together, they were able to get back to training, and their quality of life was significantly improved.

So, as well as improving how they looked and getting them back to wearing bikinis, if that's what they wanted to be doing, they felt strong and able to keep up with their male colleagues at work for physical activities.

Here's a sort of a good average result of a lady who's had combined surgery, and she's had a breast reduction and then extended abdominoplasty, and you can see that the scar around the belly button is slightly inside the belly button dip, so it's difficult to see, and the hip-to-hip scar would be hidden by a slightly fuller bikini bottom.

So liposuction, like an abdominoplasty, is also not a weight loss procedure. What it's brilliant at is eliminating stubborn areas of fatty disproportion.

And it relies on making a few small holes and then putting in a cannula, which is a tube with holes at the end, and attaching that to suction so I can suck out fat from underneath the skin.

And if you've got good skin quality, the skin will then retract, and you can get a very good improvement in your contour without the need for long scars.

So, it does rely on having good skin quality.

It's not a weight loss technique but just good for refining stubborn areas of fat that won't go with diet and exercise.

And, yeah, so this is just to remind me, to remind you that Benenden is a brilliant little hospital that hasn't had any significant infections, whether that's bacteraemia, which is bacteria in the blood, nasty MRSA septicaemias, or Clostridium difficile, but I'm very proud of this record.

The operating theatres are nice and big and clean, with all the latest operating tables and liposuction equipment, and it's a real pleasure to be able to work there.

After a tummy tuck, you may have a drain for the first night, depending on how much tissue's removed.

Sorry, we've got one. Apologies. Team Blackburn just locked the dog in the room with me.

Yeah, so tummy tuck surgery is really good surgery for improving quality of life. The way we do it, it's very safe. Patients are in hospital for one night in my practice.

Many will have a drain, because I think it's a really good way to know that there hasn't been any bleeding under the skin, which can sometimes get missed.

The drain comes out the next day, and patients go home in a post-operative girdle and wear stockings for ten days. The girdle they'll be wearing day and night for six weeks, and that compresses the

The tummy skin is back onto the six-pack muscles to stop any fluid collecting there.

I like patients to walk in a sort of a T-Rex position, so they're slightly stooped.

For the first ten days, Lexie and I will see you at about a week to ten days postoperatively, and everything's healing beautifully. We can then get you walking straight, and at that time, you can then go from sleeping on your back to sleeping on your side.

It's not uncommon to feel quite bloated initially after surgery, and what I like patients to do is to buy their girdle or get the girdle off Lexie preoperatively and wear it for three or four nights and three or four days consecutively. So they get used to the tight feeling of wearing it preoperatively.

So there aren't any surprises from the discomfort just from wearing a girdle after surgery.

Putting six-pack muscles together can be quite tender, and when I was training, patients would be in hospital for three or four days.

But we now know that by using lots of dilute local anaesthetic, I can make sure that you wake up completely comfortable with just a mild feeling of tightness, rather than a feeling of a nasty pulled muscle.

Patients, when they are still, should be very comfy. When they get up and move, they will feel like they have got a mild pulled muscle. So patients will go home with paracetamol and ibuprofen and may need occasional codeine, but that's not the norm.

Patients potter about in TED stockings and their girdles for a couple of weeks; they're driving after about three to four weeks, and then they're back doing gentle exercise, like starting Couch to K or a beginner's Pilates class, at six weeks.

I tend to use dressings that will survive a gentle shower so patients can shower from day one.

But it is six weeks before patients are back, sort of picking up children, and doing heavier activities.

With this type of surgery, we'll need you not to have had a long-haul flight for six weeks before surgery.

I would really want you to be in the country for another four weeks afterwards to make sure there are no issues if you were planning any holidays.

Lexie Otana

Thank you, Adam. So, now we can move on to our question and answer session. We're really pleased to have so many of you with us today.

We may not answer all of your questions, and we'll do our best to cover as many as we can, and on the slide after, you can find information on arranging treatment.

So, Adam, we have a question asking that if I have excess skin around my lower back, would a standard tummy tuck be able to target some of that skin, or what would be able to tackle that area if not?

Mr Adam Blackburn

So that's probably not the answer.

A standard abdominoplasty just deals with loose skin on the front of the tummy.

Then, when that is turned into a belt lipectomy or a 360, that tends to sort of lift the buttocks more than treat the lower back.

Depending normally, what I'd probably be thinking is a thing called a 'bra line back lift', where there's a horizontal cut at the level of the bra, and the skin is excised, which then pulls things nice and tight over your back, and the scar is then hidden in the bra strap.

So that's a slightly different area of body contouring surgery, but it can be done as a combined procedure or as a separate procedure, depending on where the area of concern really is.

Lexie Otana

Thank you. And another question: does this surgery impact or support pelvic floor prolapse repair surgery?

Mr Adam Blackburn

So, this is a really interesting question, and you would think that if you reduced the distance between the six-pack muscles, that would increase the pressure in the abdomen and make pelvic floor prolapse potentially worse.

However, the urogynaecology colleagues that I talk to about this say that many ladies will find it difficult to properly engage their pelvic floor if they've got a weak core.

So I think it's easier to do pelvic floor exercises after you've had this surgery.

So in theory, it could make it worse, but in reality, that's not what we often see.

We ladies often tell me that they get a stronger floor afterwards.

Lexie Otana

Thank you. Another question is around whether we give Fragmin after a tummy tuck.

Mr Adam Blackburn

Yes, while you're in hospital, you'll have a Fragmin injection.

That's right, but unless you've had multiple miscarriages or are known to have a sort of a clotting disorder, we wouldn't normally send you home on fragment after this type of surgery.

Lexie Otana

Okay, thank you very much.

Thank you again for your questions and for being part of this evening's session.

If we haven't covered your question and you've provided your name, we'll follow up with you via email.

And as a thank you for attending, we're pleased to offer 50% off the value of your consultation, a callback from your dedicated private patient advisor.

An email with a recording of this session, treatment information and loyalty reward points, and updates on future events and health news.

We'd really appreciate it if you could take a moment to complete the short survey at the end of this session. It helps us to improve and tailor future webinars to your needs.

If you'd like to speak to someone to book a consultation, our private patient team is available until 8pm this evening and from 8am till 6pm, Monday to Friday.

You'll find the contact number on your screen.

We also have upcoming webinars on a range of topics, including diabetes management, urology and orthopaedics. You can sign up for these on our website.

Finally, a thank you from all of us here at Benenden Hospital for joining us. We hope to hear from you soon. Take care and goodbye.

Lexie Otana

Good evening, everyone. Thank you for joining us.

We'll just give it another moment or two to allow everyone to get settled.

Once again, good evening and a very warm welcome to our webinar on breast enhancement, reduction, and uplift.

My name's Lexie: I'm the senior staff nurse here in plastics and cosmetic surgery.

I'm delighted to be joined by our expert speaker, Mr Adam Blackburn, Consultant Plastic Reconstructive and Aesthetic Surgeon.

Tonight's session will begin with a presentation from Mr Blackburn, followed by a live Q&A.

If you have questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously or include your name, but just a quick note that the session is being recorded, so any names shared may be visible in the recording.

To help us get through as many as possible, please keep questions brief.

If you're interested in booking a consultation, we'll share all the relevant details at the end of the session.

As I said, I'm Lexi. I've been with Benenden for about 18 months now and previously worked in intensive care in London and Bristol.

I was a former director in a London hearing specialist clinic and has a master's in International Marketing and Consumer Psychology.

Mr Adam Blackburn

I'm Adam Blackburn; I've been a doctor for over 26 years, and I've been on the specialist register for plastic surgery for 16 years.

I trained at Imperial College School of Medicine in London and then went on to complete microsurgical fellowships, which started off as trauma but ended up transplanting tummies and thighs to make breasts after breast cancer.

And at St Thomas' Hospital in London, and then the Queen Victoria Hospital in East Grinstead, where I was a consultant for 13 years.

Because of this day-to-day work, transplanting tummies, and thighs to make breasts, it was only natural that I would go on to develop an expertise and an interest in all things related to breasts and tummies, whether that's breast reduction, breast uplift, or augmentation.

And often these are combined with things like abdominoplasty.

I'm passionate about research and evidence-based practice.

And I've done a lot of work on enhanced recovery and reducing complications to make sure patients get the

Best possible care with the fewest number of complications.

Tonight, I'm going to go through what happens at your consultation and assessment, because that's always the first step, and it's worth understanding what to expect.

We'll then move into detail about what breast reduction surgery and breast uplift surgery are, whoop.

What's involved with those procedures?

Because they have subtly different aims. And then after that, Lexie will talk you through the hospital experience and what recovery looks like in the weeks following surgery.

We'll then go through a patient story, and I'll show you some of my own before and after photographs.

So, the consultation starts with a 45-minute meeting, where I take a thorough medical history, which not only determines what your motivations for surgery are, and your level of fitness, and what your expectations are.

But it involves a thorough examination to make sure that I can actually meet those goals.

And we then work out a personalised plan that's tailored to you.

And many ladies, I'm not sure whether they want a breast reduction or an uplift.

If breasts have lost lots of volume and are droopy, many patients think that they want to

A reduction, when in fact, they just may want an uplift.

Making breasts

is a bit like making cushions. You need the right amount of cushion cover for the right amount of stuffing.

If your breast skin has been stretched following breastfeeding.

You can have the right amount of volume in the wrong size or in the wrong amount of packaging, and by lifting the skin, it can restore the volume, which would be an uplift. Whereas if there's too much skin and too much volume, you're likely to be more suitable for a reduction.

So a lot of the determining about what you want is about how happy you are in your bra.

If you like your silhouette when you wear your bra, then it's likely that you're a candidate for an uplift.

If you find that you're still too big and bulging out of your bra and are wearing clothes to disguise it.

You have a large chest, then it's likely that I'll be recommending a breast reduction.

And obviously, if you don't have enough to fill your bra, that's when you might want an enhancement, whether that would be with

Fat, so liposuction elsewhere to add a subtle amount of enhancement to the cleavage area.

Or an implant to give a more dramatic, immediate result.

Sorry about that.

So breast reduction is one of the most rewarding operations I perform.

Because the impact on quality of life can be transformative.

And the improvement is it results in improvements psychologically and often functionally as well.

In the NHS, the primary aims of breast reduction are explicitly functional for rationing, and the commissioners deliberately ignore the psychological benefits of surgery.

And what's interesting is when you ask women about why they really come and see you in an NHS practice.

They've learnt to emphasise the chronic back, shoulder, and neck pain, which they may or may not yet have developed if they're very young.

So they will, they've learnt to get through the commissioning to emphasise neck pain, shoulder pain, shoulder grooving, and rashes under their breasts.

But often it's the psychological element of being very young, developing early, and somebody talking to their chest, which they find

It's sort of socially debilitating.

So then they start wearing baggy tops to disguise their chest.

They don't like anything that draws attention to their breasts and will stop exercising.

They may even put on a little bit of weight to hide the disproportion between their chests and their tummies and their thighs.

They all say that. All these poor ladies say that they have difficulty finding bras that fit.

And they and their self-consciousness can even be around people that love them, including their partners.

And by reducing the size of their breasts and the weight of their chest, both the psychological and functional aspects of their condition can be significantly improved.

From a technical standpoint, the procedure involves removing excess

skin and breast tissue. This tissue is always sent for histology to make sure that

All the tissue is benign, and then the remaining tissue is then reshaped and repositioned to make a breast that looks natural and proportionate.

On the whole, the scars go around the nipple and then down vertically and then are hidden in the crease underneath the breast, making an anchor-shaped scar.

And the length of the scars depends on the amount of tissue that needs to be removed.

Crucially, all breast reductions end up with an uplift.

So you're getting a smaller, better-shaped, and better-positioned breast in one procedure.

A breast uplift is also known as a mastopexy.

And it's subtly different to a breast reduction, though the scarring can often look very similar.

The key difference is that with an uplift, we try and keep all the volume and reposition it higher on the chest wall.

However, over time, all breasts will naturally lose their firmness and sit lower on the chest.

And this can be accelerated by pregnancy, breastfeeding, or significant weight changes.

A mastopexy will address this, removing the excess skin that's causing the drooping and reshaping the breast tissue itself.

And moving the nipple to a higher, more natural position.

The result is a press that sits and looks more youthful and projected.

And patients often describe feeling their body has been returned to how it used to look and feel.

As I've said previously, the incisions are similar to a reduction, again, around the nipple, vertically down, and along the fold. Though, again, the extent depends on the degree of the droopiness of the breast that we're correcting.

For patients who also feel they've lost volume, a mastopexy can sometimes be combined with either a small breast implant or fat grafting.

And this is particularly useful for ladies that have lost volume in the upper half of their breasts, which often occurs after breastfeeding.

For completeness, here's a quick mention about breast augmentation.

Because it's often a procedure that patients are curious about alongside reduction and uplift.

Particularly when you've lost volume through weight loss, pregnancy, or following breast cancer treatment.

The aim of enhancement is to reshape and fill the breast, increasing fullness and helping patients feel more

Comfortable and confident in their own body.

A simple breast augmentation procedure using an implant will take about 90 minutes, and the incision's normally relatively short in the crease underneath the breast.

The implants are then inserted either above or below the muscle.

And sometimes this can be combined with fat grafting as well to try and reduce rippling, where the implants can be seen under the skin in very slim patients.

And if this could be something you're interested in, it's obviously something that would be discussed at the consultation.

And so on the left side of your screen, you can see a breast that's been marked up for a reduction or an uplift.

And the nipple and areola complex is going to move up on the blue pedicle, which is a vascularised bit of breast tissue that we leave behind.

And in a breast reduction, the green area is excised and in a mastopexy, that green area will be sort of tucked in underneath the breast to keep all the volume.

And on the right side of the screen, you can see how you end up with a lifted breast and the classical anchor-shaped scarring.

Sometimes we don't need to have the bit in the crease underneath, and the patients can end up with a lollipop-shaped scar.

But most of the time, it's around the nipple, down, and in the crease underneath.

The timing of breast surgery can be quite nuanced because there's no optimal age.

Ideally, you want somebody who's at their happy weight.

Which means the weight they're going to comfortably keep for their next 10 years.

And when their breasts have stopped growing, because what I don't want to do is to make a patient a double patient.

I want to do the right operation once for that patient so they have the best-looking chest for as many years as possible.

Most breasts will have done most of their growing by the age of 18.

And most women by the age of 18 are very sure in their minds that they want a breast reduction if they feel top-heavy.

So that's the age that we sort of say is the youngest, we'd want to do a breast reduction surgery, though there are always exceptions.

There are conditions, like gigantomastia, where you know, 14 and 15-year-old girls can have 2kg breasts.

That gets in the way and stops them from doing everything. And you, as plastic surgeons, would perform a breast reduction at that age.

Knowing that they would need another operation in a few years. Thankfully, that's something that the NHS will often look after.

You know, having a breast reduction at a very young age.

Can potentially interfere with breastfeeding at a later time.

So that if you become pregnant, many of the milk ducts will have been cut.

Which may mean you won't be able to breastfeed afterwards.

Also, when the milk comes in once the baby's born, and the breasts will still become quite swollen, and this will stretch the skin and may undo some of the benefits of the previous breast reduction surgery.

So, as you'll see later on, there are some patients that have redo operations, and if you've had a breast reduction at a young age and then have had either a weight change or pregnancy later on in life, you may want another reduction or an uplift.

Breast reduction is a very safe operation, and it's one of the best operations we do as plastic surgeons. It's got a fantastic patient satisfaction rate.

The risks are relatively low.

Though it's a big operation for your chest, it's a small to medium-sized operation for the patient herself.

The most common issue can be minor wound healing issues, particularly at the T-junctions. By that, I mean where this scar joins that scar, and that scar joins that scar.

Those T-junctions there and there, can occasionally take a little bit longer than everywhere else to heal.

With all surgery, there's a small risk of bleeding and infection.

But the chance of needing to go back to the operating theatre for bleeding or an infection is exceptionally low.

You know, in the region of 1%.

It's possible that when nipples get moved a long way, they could die. I've done hundreds of these operations and haven't had that complication yet.

But if you were to have a haematoma that wasn't managed quickly and things were then to get infected.

It is very possible to lose a nipple, and I've certainly helped manage nipples that have been lost after the patients have had surgery with other surgeons.

What I can't predict is what nipple sensation will be after surgery.

If erogenous sensation is particularly important for you.

You will probably lose it, and you may end up with numb nipples, especially initially, but after some degree of time, often sensation does come back, but I can't guarantee to what extent.

Many women will start off with a degree of breast asymmetry, and I attempt to correct that during surgery.

and so people will end up more symmetrical than they end up.

But there is always some degree of breast

Asymmetry afterwards if you were to be an absolute perfectionist.

Thankfully, the risk of deep vein thrombosis and pulmonary embolism is very rare with this procedure. I do ask that ladies wear TED stockings for a week after surgery, until they're back mobilising normally.

And thankfully, the need for revision surgery is very low.

The types of things that could potentially be revised are the ends of scars if they're a bit puffy, sometimes known as dog ears.

Or if there were some abnormal healing with a wide or thick scar.

That could be revised at a later date.

But on the whole, it's a brilliant operation with lots of very happy patients, and it's one that, as plastic surgeons, we love to do.

I'm going to hand over to Lexie for this bit, because she knows more about the hospital's rooms and the but on the whole, I'll just finish by saying that the surgery normally takes about 3 hours, and I don't use drains, and patients go home the day after surgery.

Lexie Otana

Thank you, Adam.

So, your hospital stay here at Benenden will be very lovely and will include seeing lots of Adam and me. You'll have a private ensuite room.

With lots of light, lots of natural light, and very clean, it's an extremely clean environment, Benenden Hospital, with lots of really incredibly friendly and knowledgeable staff.

On average, surgery will take 2-3 hours, although implant surgery does take less, as Adam has already said.

You may go home the same day, particularly if you've had implants, but most of our patients choose to stay one night, to be safe and to rest.

And, to enjoy the lovely hospital that we have at Benden.

You can get out of bed and move around the same day as surgery, generally.

You will have minimal pain immediately after surgery, as Mr Blackburn will use a lot of local anaesthetic.

And you can be driving within 2-3 weeks, usually.

Mr Adam Blackburn

Yeah, so the recovery is I ask patients to have what I call T-Rex arms for the first

10 days. So their elbows are in by their sides, and keeping there when they're getting dressed, being careful not to get their elbows above the level of their shoulders when putting on t-shirts.

And things, because what we don't want is the scars underneath the breast to be pulled apart.

Patients will have dressings, which are splash-proof, and will survive a gentle shower.

They come back to the hospital for a wound check at about a week, and if everything looks good then, they can then start sleeping on their side and get back to driving if they feel comfortable.

But that's a decision between them and sort of their insurance and the DVLA. If everything looks good and they're not too sore, then it's absolutely fine for them to start driving.

But it's 6 weeks before they're back in the gym doing beginner's Pilates or yoga or starting Couch to 5K if they wanted to get back to running.

That was afterwards; all patients are in a compression bra, which is provided by the hospital.

And you wear that day and night for 6 weeks.

The final result?

Because of everything, it's almost slightly too high and a bit swollen on the chest wall to start off with.

And the breast sort of rounds out to where we want it to be for the long term, at about 8 weeks post-op.

I think I've covered all of that in the previous slide.

So here's a patient who's describing her experience of having a breast reduction at Benden Hospital.

Audio shared by Mr Adam Blackburn

I feel like I'm the person that I should have always been.

Not just a person with big boobs. My name's Kelly Walsh, from Hornchurch in Essex, and I had my breast reduction surgery in November of last year. Physically, I had back pain, shoulder pain, neck pain, and divots in my shoulder from bra straps, really low confidence and self-esteem, and the feeling that

That was the first thing that anybody saw was the size of my breasts. I would wholeheartedly recommend the cosmetic process that I had and the service that I received.

In fact, I've already recommended somebody. Mentally, I've got more confidence in myself.

I can wear what I want; I can even go without a bra if I want to and feel perfectly comfortable. One of the big things as well, which people don't often realise when you've got larger breasts, is the cost of buying bras.

It can be really, really expensive, and just to be able to go into a normal shop and buy a normal bra and not have to buy it anywhere, you know, go anywhere, specialist shop or anything like that, that's made a difference, and that's made me feel more normal as well. My advice would be

To not continue and struggle, reach out and speak to somebody, even if you don't have the confidence to go through with the whole procedure, to speak to somebody and get information for yourself, and

Be brave about it, because having a cosmetic procedure, for yourself, to make yourself feel better, to alleviate physical issues, is a no-brainer.

You know, it's going to help you just knowing what is available, what you can have done, and what things can be like afterwards.

Mr Adam Blackburn

As you can see, she had an exceptionally positive experience.

And so this is one of my patients I looked after last year.

And this picture here is how she presented to me.

She'd lived in the Northeast, and one of my old mentors had performed a breast reduction on her in 2016.

Which, when she was 34, took her from a 34H cup to a 34DD.

Since that time, she'd put on weight and came to see me for a redo breast reduction and a tummy tuck.

We had a long chat about how she felt about her breasts, and her tummy, and her level of fitness, and whether she was at her happy weight.

And she was exceptionally motivated to have surgery very quickly.

And after our consultation, she realised the importance of being at her happy weight prior to surgery. So she went away for 3 months and lost 20 kilograms in weight.

She then had her weight stabilised for another 2 months before I performed surgery, which was a redo breast reduction, which took her from a 36E cup down to that sort of large C, small D cup with an abdominoplasty.

Which absolutely transformed her figure and her confidence.

And you can see the benefit of being at your happy weight prior to surgery can't be underestimated.

This next lady also went on a weight loss journey and she lost 20 kilograms.

And as you can see, she's got a degree of breast asymmetry, with one breast larger than the other.

And during the operation, I took off an extra 150 grams off the left side, so she's much more balanced afterwards, and she also had a breast reduction and tummy tuck.

Again, improving her confidence, her clothes fit, getting rid of the sweatiness under her breasts and her shoulder grooving from her bras.

Another lady who was already at her happy weight, she told me, and she had

I think it's 780 grams of tissue removed off that breast and only 420 off that breast to give her the symmetry you can see afterwards.

And she's absolutely thrilled to be a much more comfortable size that improves her confidence.

And looking at these patients, it's all about what if you look at where moles are? You can see how much things have moved.

So, so this young lady hadn't. her complaint was the discomfort and sweatiness and the attention.

She hadn't really developed too much shoulder grooving or back pain but was devastated by the size of her breasts from a psychological standpoint.

And again, you can see her nipple's closer to that mole than that mole, but at the end.

It's almost level with the top one. It's made a massive difference to how she feels about herself and she's a very happy person.

And that's approximately a 350-gram reduction.

So I think this is sort of coming towards the end of the procedure, of the talk today, sorry.

Lexie Otana

Yes, thank you, Adam. So, we can move on to our question-and-answer session now, and we're really pleased to have so many of you with us and asking many questions.

And we'll do our best to cover as many as possible. If we don't answer your question, and you've left your name, we will respond via email.

So we have a question relating to somebody having secondary cancer in their lungs with no symptoms and having started hormone tablets, and they're asking if they can get a reduction.

Mr Adam Blackburn

So, the answer is potentially.

That lady will need a more significant, sort of, anaesthetic workup.

And as part of it, we'd need information from her oncologist about how they feel about her having surgery.

All surgery is a little bit immunocompromising.

So, one of the risks of surgery is it will slightly put, you are a little bit under the weather because your immune system gets distracted from fighting cancer to healing wounds.

And what we don't want to do, you know, the number one priority is always to cure the patient.

And make sure that the breast cancer is being properly managed and the lung cancer is being properly managed.

But if someone's been very stable for 2 or 3 years.

The chance of that coming back is actually relatively low.

So, if the oncologist is happy and the patient's got good lung function and is fit and healthy for an anaesthetic.

Then the answer is we probably would be able to help her.

But it's making sure that everything's done as safely as possible.

And the patient's health is optimised. And we understand all the risks of surgery, not just of the surgical procedure, but the implications performing surgery could have on her lung cancer.

That makes sense.

Lexie Otana

Thank you; that was great.

Another person who is asking if, at the age of 74, having had very large breasts since they were 14, they are too old for help.

Mr Adam Blackburn

Absolutely not. I've operated on many ladies late into their 70s who have wanted breast reductions.

And interestingly, some of those ladies have wanted to be much smaller than average.

Because some of them have found it difficult to do up bra straps.

And asked deliberately if they can be made maybe a B cup, so they might never need to wear a bra again.

And it's all about just being fit for surgery. You know, if you can walk up two flights of stairs without getting too short of breath.

Then the answer is you probably are fit enough, and

It wouldn't be an unreasonable operation to perform.

But it's, but it's one just needs to make sure that things you're not smoking, you're in good health. If you're diabetic, it's very well controlled.

And if you're on blood thinners, we've got a management plan for how to look after them.

I know from the research I've done into complications that complication rates do go up for patients over 60.

However it's about optimising patience and controlling for everything else so that you can do an operation as safely as possible.

And most for most women if they really want an operation, and they understand the risks, and we've done everything to mitigate them; you can have a very safe breast reduction well into your 70s.

Lexie Otana

Thank you, Adam. Somebody else is asking about what level of increase they can expect from fat grafting, and do you use a specific type of lipo, such as Lipo 360, or just standard lipo?

Mr Adam Blackburn

So, with regular liposuction and fat grafting, the answer used to be about half a cup size, would be the most could expect in the long term.

So for a meaningful enlargement, you'd need 2 or 3 sessions of fat grafting to the breast.

There is another technique using water-assisted liposuction, called the Bewley technique.

Where, for a straight, you can expect about 70% of the fat to work in one operation, which for most women means about three-quarters of a cup size to a cup size.

If they've got a donor site to be able to get enough fat.

And the fat grafting's one of those procedures where, the first time, you may lose 30% of the fat that's injected because the body absorbs it, but 70% takes

But the second time you do it, you can always get more fat into the breast, and the take rate is higher, so you might only lose 20%.

So, when you're trying to work out whether fat grafting or an implant is right for you.

With an implant, it's just one operation. For fat grafting, it can sometimes be two.

But with implants, they're always going to need a revision operation at some point in the future anyway.

Just with fat grafting, if you want, say, a cup size and a half enhancement, you'll be spending all of your money up front, whereas with implants, you'll need

To have them revise on separate occasions throughout their lifespan and your lifespan.

Lexie Otana

Thank you. We have another question. Someone is saying, 'I've had galactorrhea since I was 16, with fluctuating prolactin levels but normal MRI and CT.' Would this increase my risk of infection or healing complications with breast implants?

Mr Adam Blackburn

It shouldn't do. When we do breast implants, we're staying away from the breast tissue.

And with galactorrhea, the stuff that comes out of the milk ducts is clean.

So breast implants should be okay.

You know, if you had mastitis or something related to your galactorrhea, then that would be a red flag.

But I can't see; galactorrhea is a particular issue.

Obviously, putting an implant behind your breast tissue that then is pushing everything forward.

Could make your galactorrhoea temporarily worse if your ducks are full of milk.

I have to say, I have no experience of doing breast augmentation with patients with galactorrhea, but I can't see how that would be a problem.

Lexie Otana

Thanks again.

Another lady is asking what the optimum time postpartum to have breast augmentation surgery is, and they mention that they've had acute mastitis and skin stretching also.

Mr Adam Blackburn

So, so, it depends on whether ideally we want patients to not be breastfeeding.

At a happy, stable weight that they're going to be for a long time afterwards.

If you have the thing, you've mentioned skin stretching, which often means the nipple is then very low on the breast mound.

So it's unlikely a simple breast augmentation will be the right solution for that patient.

The patient's likely to need an uplift and then may need more volume, either with fat grafting or an implant.

And the answer is when they're at a I mean, if you've got a young person in the house.

They will need someone to take lots of care of their little one and a little bit of them after surgery.

And it will stop them picking up their baby for, sort of, 4 to 6 weeks afterwards.

So probably when the baby's a little bit bigger and the patient's back has got a stable weight for 6 months that she's happy with would be the time to do it.

So we're often looking at over a year after the baby's born.

Lexie Otana

That's great.

Another lady is asking whether they're still a good candidate for breast reduction, having had occult breast cancer, with a 5-year all-clear mammogram in 2025.

Mr Adam Blackburn

So it is, so I'm guessing she's had a wide local excision of her breast cancer, i.e., a lumpectomy with some radiotherapy.

Because that's normally how that would be managed.

Radiotherapy can play havoc with the blood supply to the nipple, so

that I have done breast reductions on people who have had lumpectomies with radiotherapy.

And sometimes we need to modify the technique.

And accept that the complication rate is much higher.

Radiotherapy makes life much trickier because

It continues to reduce the blood supply to the breast, and we know that

Over 15 to 20 years, the breast that's had radiotherapy will end up

Much firmer and more fibrotic and smaller than the other breast.

So planning for that patient for the long term.

It's really quite nuanced and tricky.

Because if you make somebody symmetrical today, in 5 years, the side of the radiotherapy will probably be smaller than the other side.

And won't have as much droop.

But it can be done, and if there is what's a more common thing to do is, if someone's had a lumpectomy with radiotherapy, it's that size or a bit smaller.

And a bit sort of shrunken because of it, then to do a lift and a reduction on the other side for symmetry is something we tend to do more commonly, and that's a very straightforward thing to do with a very low complication rate.

I'm not saying I wouldn't make the side of the radiotherapy smaller, but I may not.

Move the nipple on a pedicle.

That nipple may move on or may be transferred up as a free nipple graft.

Because that can be more reliable in that situation.

Lexie Otana

Thank you very much.

So, I think that's all we've got time for today, and again, I'll say if we haven't covered your question and you've left your name, we will follow up via email.

And as a thank you for attending, we're pleased to offer 50% off the value of your consultation.

A call back from your dedicated private patient advisor.

An email with a recording of this session, treatment information and loyalty reward points, and updates on future events and health news.

We'd really appreciate it if you could take a moment to complete the short survey at the end of this session. It helps us improve and tailor future webinars for your needs. And if you'd like to speak with someone to book your consultation, our private patients' team is available until 8pm this evening.

And from 8 till 6, Monday to Friday.

You'll find the contact number on your screen.

We also have upcoming webinars on a range of topics, including heartburn and acid reflux, hip and knee pain, and tummy tuck surgery with Mr Blackburn and me.

And you can sign up for these on our website.

Finally, a thank you from all of us here at Benenden Hospital for joining us this evening, and we hope to hear from you soon!

Take care, and goodbye!

Mr Adam Blackburn

Have a good evening, everyone.