Kate Comrie

Okay, hello. Good evening. Welcome to our webinar on breast reduction and uplift surgery. My name is Kate, and I am the Clinical Nurse Specialist for Plastics and Cosmetic Surgery here at Benenden Hospital. I'm joined by our presenter tonight, Mr Simon Mackey, Consultant Plastic Surgeon.

The presentation will be followed by a question-and-answer session. If you would like to share or ask a question during or after the presentation. Please do so by using the Q&A icon which is on the bottom of your screen.

This can be done with or without giving your name. But please do note that this is a recorded session, and if you do provide your name, that will be on there.

If you would like to book your consultation, we'll provide contact details at the end of this session.

So my name is Kate Comrie, and I'm the Clinical Nurse Specialist in Plastics and Cosmetic Surgery for Benenden Hospital. My background is a diploma in adult nursing. I graduated in February 2010, I went on to do the nursing mentorship.

I've also studied aesthetics in foundation, advanced and masterclass. That includes anti-wrinkle treatments and dermal fillers.

In the NHS, I worked in the Surgical assessment unit in Guildford and Frimley Park, as well as working on the wards and A&E. Including nights.

I moved to the private sector in 2015 and then became the Cosmetic Nurse Specialist at another private hospital.

My role involves supporting the Consultant Plastic Surgeons and the patients throughout their whole journey.

I'll now pass you over to Mr Mackey.

Mr Simon Mackey

 So, good evening. Thank you for coming to join us this evening. I'm Simon Mackey, I'm a Consultant Plastic Reconstructive Surgeon.

I've been in plastic surgery since about 2002 now, which is getting on to be quite a long time, and my primary area of practice is cosmetic and reconstructive breast surgery, including surgery of the abdominal wall as well.

I'm a Reconstructive Consultant plastic Surgeon at the Queen Victoria Hospital in East Grinstead, which is still the biggest specialist plastic surgery hospital in Europe and I've been at Benenden for a few years now with an expanding service, and it is a lovely hospital and hospital group, I've got to say.

So I think we can move on to the next slide.

So just going to talk very generally about breast reduction, surgery, breast uplift, surgery. Why they're fairly similar procedures, and we'll just go through the process. What the consultation would involve. What I'd be looking at, how we can optimize things to get the best possible results.

Then we'll chat a little bit about some of the different scar patterns that you can expect with this type of procedure a little bit about hospital stay recovery. And then I think we've got four videos which I haven't seen. I've got to say from some of our previous patients, which I'm sure will be really good to watch, actually.

And then we'll take a few questions and answers, and feel free to answer anything you, or ask anything you want. There is no stupid questions. That's something people are often a bit anxious about. And again, you don't have to give your name, but if you want to, that's absolutely fine as well.

So we'll move on. So plastic surgery is quite closely regulated nowadays. So for any of these sorts of procedures. We'd normally need to see you twice. What I'm looking for at the consultation is your general health.

I want to know what problems you're having with your breasts. I want to know really what your goals of treatment are, because what I want to be able to do is to try and meet your expectations and provide you with a result that you are very pleased with.

Breast reduction surgery, I've got to say, is one of those operations that plastic Surgeons love to do for our patients, because it's not a purely cosmetic procedure. It's very much a functional operation.

Common problems that people have with large breast size would include musculoskeletal issues, often the neck, the shoulders. A lady I saw this morning had significant problems with her lumbar spine because she's constantly balancing her size and large breast size, which those are off balance and causes issues with her lumbar back.

People frequently describe a condition called intertrigo, which is where you get some inflammation and soreness in the fold underneath the breast, where the skin rubs against itself, and additionally with breasts that are larger than around an E cup.

It's very difficult to source bras from high street stores, so people generally have to source their bras from specialist manufactured retailers for larger breasts.

And again with larger breasts, particularly if you've got a relatively small chest. It's very uncomfortable to find bras which fit so it's straps cut in to the shoulders, but also around the chest bound. I see lots and lots of people who end up wearing very, very tight bra straps just to try and support the breasts on the chest.

I get lots of people having issues with high impact sports. So running a lady this morning was talking about difficulty doing star jumps. So it's any of those sorts of movements which put up a high impact on the chest. Very, very uncomfortable.

And again social embarrassment. I get so many poor people coming through saying that everybody talks to my breasts. They don't look at me, they look at my breasts. And actually, you know, people don't need to be feeling that they want to be feeling comfortable and confident and happy to go about their lives.

So at the consultation, I want to know a little bit about your past medical history. I want to know whether or not you're on things like blood thinners which can increase the risks of bleeding. This surgery is really not very good for smokers. So if you're smoking or you're using nicotine would normally recommend that you have to definitely come off cigarettes for six weeks before surgery, and then ideally refrain from smoking until things are nicely healed.

And then nicotine replacement itself. The nicotine can have an effect on the blood flow and nicotine use can increase risks such as loss of the nipple which is a rare but significant complication of breast reduction surgery.

So I'll go through your medical history, chat you about things which you could potentially change, to make your surgery safer to get a better result and a more enduring result as well. It's very difficult with this type of surgery to guarantee a particular cup size.

And actually, bra sizing is a bit of a dark art really, if you go into somewhere like Bluewater and go into four or five different stores, you'll probably find that you're sized up at three different bra sizes, so it very much depends on the style of bra your body shape, so it's very difficult to guarantee a particular cup size, but I've got to say, most of my patients coming through would say they would like to be around the full C.

Certainly, people would prefer to be smaller than an E cup, because actually, if you're smaller than an E cup, it is much, much easier to source bras from high street retailers. They're more competitively priced and less troublesome to seek out.

And I'll really have a good chat to you about what it is that you really want from surgery. So in general it is that people do want to be smaller, lighter, more in proportion for their frame. I get lots of people saying they buy a size 18 dress to accommodate their breast size when the rest of them is a size 12 or a size 10.

So those are the things we'll really be trying to explore other very important things to consider are your weight. So at the moment we have an upper BMI limit of 35 for breast reduction surgery.

And we know that as your BMI creeps up above that, you have a much greater risk of significant wound, healing complications and anaesthetic complications.

So what I want to do is to try to optimize things, to make the surgery as safe as possible for you.

An awful lot of our patients at the moment are on injectables, such as Monjaro and Ozempic. So we've got an awful lot of people who have lost an awful lot of weight, and sometimes it's not a breast reduction that people are after. Really, it's more of an uplift.

Just to deal with excess skin to reposition the nipples and to reposition the breast tissue itself on the chest, but in all honesty a breast reduction, procedure, and a mastopexy procedure are very similar operations.

They both tend to use the same pattern of scars. The recovery is very similar. The major difference is that you're taking more tissue away with a breast reduction.

So if you're more than 40 years of age, we'd normally recommend that you have a mammogram before one of these procedures. So the breast screening program in the UK starts from your fifties onwards, depending on exactly where you live.

So if you've not had, if you're over 40 and you've not had a mammogram within the last two years, I'd normally recommend that we organise a mammogram for you, and it's very important just to produce a baseline of the breasts.

Because the appearances can change somewhat on mammogram after breast reduction, surgery.

And then, of course, lots of these procedures can be combined with other surgeries as well. So very common combinations would be breast reduction and tummy tuck say definitely, a group of patients for whom breast reduction reveals the tummy. People often say I haven't seen my tummy for years.

So there's a reasonably high conversion rate of people who have a breast reduction up front and then realize that actually, the tummy is a bit larger than they were anticipating, and then people come back and have tummy tuck surgery as well, so we can always have a look at your tummy at the same time, and I can advise on the different types of abdominoplasty. But I'm not going to do that today because I'm going to talk about breast reductions and mastopexy.

So breast reduction, very good operation because it's functional. You can combine breast reduction and breast uplift or mastopexy. It's the same, it's the same thing. So for people with significant breast asymmetry. I can perform a breast reduction on one side and more of an uplift on the other, to get you all of the benefits of breast reduction, breast uplift, but also improve your symmetry.

It's not uncommon for ladies to be about a cup size different between the breasts. You can normally, with a bra accommodate a cup size different, really, relatively easily. But if you're straying into being two or three cup sizes asymmetrical, it's very difficult. So this type of surgery is very good at helping to improve symmetry for patients.

After pregnancy with weight, gain, and weight loss, the skin is a little bit like a plastic bag, so if you stretch it a little bit it will recoil back and shrink back. But if the skin is stretched too much, it just cannot go back, in which case you end up with a relative excess of skin, and people describe the breast, dropping the nipple position, dropping on the chest.

And a very common situation people describe is lying flat in bed at night, the breasts go into the armpits very uncomfortable.

So breast uplift surgery, if you're otherwise happy with the volume, then with a breast uplift, I'd use a pattern of scars just to lift the breast tissue, reposition the nipple on the chest and remove some of that excess tissue, and that will often give you a little bit more volume in the upper pole, because the breast tissue is sitting in the right position on your chest, it's much more comfortable lying down at night.

And again it's much more comfortable buying bras and things. People again sort of describe having to fold their breasts up and roll them into their bra, which is not ideal for people really.

But if your breasts are too big. Then again, breast reduction surgery will remove some of that volume.

It also enables me to lift the nipple position, reposition the breast tissue on the chest, and you can get very, very pleasing results if the breasts are too small. Not really going to talk about breast implants today. But you could also combine breast uplift surgery with breast enlargement, surgery, using silicone implants. But that's sort of outside the bounds of this particular talk this evening.

So breast reduction surgery is performed under general anaesthetic. You come into hospital on the day of the procedure. It can normally take between about two and a half and three and a half hours depending on the breast size.

You would normally be in the theatre complex for much longer than that period of time, because the anaesthetists have to say, if you get you off to sleep, wake you up again afterwards, and you need to be positioned on the table, so we take great care to try and avoid issues like compression, neuropathies, and position you very carefully on the table.

With the breast reduction surgery itself, any tissue that I remove we weigh, so it always let you know how much lighter each breast is.

Once I've removed the tissue, I tend to use some temporary staples just to put everything back together temporarily, so that I can sit you up in the operating room and just try to ensure that the symmetry between the breasts is as close as I can possibly get you. Can never get anybody exactly the same. But I'll try.

And of course I do have to wake you up at some point. So, although Plastic Surgeons are a bit fussy about that sort of thing, I do need to wake you up eventually.

And then what I tend to do is to put some special stitches inside the breast, just to try to hold the tissue up on the chest wall, and then I generally prefer to use dissolving sutures that go well.

We'll show you the scar pattern in a moment, but in the anchor shaped pattern on your chest, and those I tend to close with an occlusive type, either spray or glue type dressing.

And then some paper tapes, and I'll come on to recovery a little bit later. But the nice thing about that is that you are able to shower from a couple of days after the procedure which makes you feel a lot more human.

I've got to say it's normally not too painful, this operation in all honesty, and I'll put in lots and lots of local anaesthetic all over the place, just to make you as comfortable as you possibly can be.

Frequently with a larger breast reduction. It may be desirable to put a small drain into the breast just for the first night, but I'd remove the drain before you go home. People get a bit anxious about drains, but I've got to say on the whole, they're not particularly a bother, and they can be useful in some individuals just for helping to reduce collections underneath the skin.

And then we tend to use a medicine called tranexamic acid, which helps to stop bleeding.

So there are all sorts of things. We give you a shot of antibiotics at the start of the procedure to reduce the chance of infection. And normally, by the time you're going home you're on regular paracetamol.

Possibly a non-steroidal such as ibuprofen, and they'll sometimes give you a weak opioid type of medicine to go home with. But that's the one to get rid of first That's the one that can bung you up, make you feel a bit dizzy and unwell. So normally just regular paracetamol is enough pain relief for this.

The hospital also provides you with two bras. Whether you're having a breast reduction or an uplift.

And the post-surgical bras provide very good support, makes the recovery much more comfortable. We avoid or recommend. You avoid underwiring for the first six weeks. So normally, you've got a bra to wear and a bra to wash, and I'd recommend that you use the post-surgical bras full time for the first six weeks, just to get the best possible result.

But the breast tissue that's removed, whether it's a breast reduction or a mastopexy is sent to the lab, and the pathologist will just have a good look at the tissue, just to make sure there are no unexpected findings.

Very rarely one may find something one is not anticipating, in which case you're much better off knowing that you need treatment, and we can get you treated appropriately there.

So breast uplift again, the aim is to reshape and remodel the breast tissue, remove excess, skin, and reposition the tissue on the chest, and it's again a procedure people are normally very, very pleased with.

I think if we go on to the next slide I can show you the typical scars. So the old-fashioned technique for breast reduction used to actually physically take the nipple off. You close the tissues up and then put the nipple back on as a skin graft.

But more modern techniques. I tend to leave the nipple attached to you by something called a pedicle, which I just take the skin off a sort of strip of the skin coursing from the chest down to the nipple, and that should keep the nipple alive. It increases the chances that you'll have some sensation in the nipple as well.

Very rarely for people who have got very large breasts, or in some cases of revision breast surgery. People who've had a breast reduction done 20 years ago and have had some regrowth of tissue. Either they've changed weight or had pregnancies.

Then it might be safer actually to do an old fashioned nipple graft type procedure, as it's often very difficult to know what pedicle your previous Surgeon would have used for you, and if you can imagine, if you try to design a superomedial pedicle, and you've previously had an inferior pedicle that, as I design the pedicle, it might devascularize the nipple, and it increases the chance that you lose your nipple. So I've not yet lost a nipple thankfully.

But it is a known and well documented complication of this type of surgery.

But the typical scars are these anchor shaped scars shown on the right here, so certainly for breast reduction? It's pretty much exclusively in my practice anchor shaped scars, whereas with a mastopexy breast uplift, you may be able to get away with one of these circum areola or lollipop type incisions.

They were very fashionable in the early two thousands, but they actually had quite a high need for revision, because you end up having to cinch the skin in, and it purse strings and ruckles up, and there's a little bit of uncertainty as to exactly how the skin will then settle, so you might be suitable for a circumvertical lollipop type Mastopexy, but overwhelmingly actually, it's the anchor shaped pattern seems to be the best, and these scars will always be visible.

But the way normal scars mature is that they become a little bit red. They can be a bit raised and lumpy initially.

But from six weeks or so I tend to suggest that you take all of your tapes off and then start to massage and moisturize your scars quite firmly with any cream or oil that your skin likes.

So I think, despite the millions spent by the people that produce these various lotions and potions on marketing, I don't think there's any particularly good evidence that any one cream is any better than any other, so I think safest is to use something that you like, and your skin likes, and you're really using the product as a lubricant.

And it's the pressure of the massage. Good. five min twice a day, going backwards and forwards little circular motions that will encourage those immature scars to become soft and flat and pale, and they normally do end up looking very good.

But you would always have visible scars.

So think about age for breast surgery. There's no optimal age, really. I think in an ideal world you would definitely, it's preferable that you finished developing. So got through puberty. I think so for me personally, yeah, from 18 onwards I'd be thinking, but it depends.

It's very variable from individual to individual. Quite when one starts puberty and when you finish developing. But you're best-off waiting, certainly, until you've completed puberty.

I think, with pregnancies in an ideal world. You would wait until you've completed your family before having a breast reduction. It's not always the case or desirable for people, but of course with pregnancy. The breasts can go through all sorts of changes.

Some people who are very small, breasted with pregnancy find they become much larger and stay larger. Some people find the breasts enlarge, and then melt away somewhat and become rather empty, in which case a mastopexy might be desirable, and some people find they don't really change much, and then just diminish in size or flatten.

So in an ideal world you would be as you'd be at your ideal weight when you have the surgery performed. If I perform a breast reduction or an uplift surgery for you, I'll make you look as good as I possibly can when you're at that particular weight. But if you gain three or four stone well, the breast size would increase again.

If you lost a significant amount of weight after having your breast reduction surgery, mastopexy, things might empty out a little bit. So in an ideal world you would be at your about your fighting weight where you'd like your weight to be for the surgery. It makes it safer. You get a better result, I think, and if you're able to maintain that weight. It's a more enduring result as well.

It's about a quarter of ladies can't breastfeed anyway, but there's no doubt that breast reduction surgery can reduce the chance of being able to successfully breastfeed, although I've got lots of ladies who have successfully breastfed after mastopexy and breast reduction surgery. But if that's something that's particularly important to you. Then, again, you might choose to delay breast reduction surgery until after you've completed your family.

I think for a lot of people. We'll go through the recovery in a bit. But there is a bit of downtime to recover, and often with a busy work life. Young family people feel they just can't take the time out to recover.

So there's no, I don't have an upper age limit for breast reduction, surgery, and people's life circumstances for a whole host of different reasons change through their lifetime.

I've performed breast reduction for people in their seventies. I was looking back through. I haven't performed it for someone in their eighties. But I guess if someone was fit and well and was having an issue with their breasts, then if the anaesthetic team are happy, then it could be considered.

But overwhelmingly, I've got to say it's again a procedure people has a very high satisfaction, rating and overwhelmingly. People tend to say. I wish I'd had that done years ago. It's just over and over again, people say that.

And again it's because I would never guarantee that I can't guarantee that it would sort out musculoskeletal symptoms. I can guarantee the breasts are smaller and lighter, but actually overwhelmingly people come back and say my neck pain is completely gone, my shoulder girdle pain's gone, my bra is so much more comfortable, and I think just being able to go and buy any bra from a High Street chain is quite liberating for people I think.

I think the other thing with pregnancy is, if you are considering breast reduction after pregnancy, you'd ideally, it takes a good year for the breast and the body to return to normal after pregnancy.

So I would normally advise you wait for at least a year after the birth of a child, ideally, a year after completion of breastfeeding. Just to let everything just return to normal, and to give us the best chance of obtaining a safe and stable durable result for you.

So risks and complications. There are risks with any procedure, so that's why I'd advise you about things like smoking, and we need to make sure that you're medically fit to have this type of procedure. So you'd have a pre-assessment check with our anaesthetic team normally delivered by Kate and Lexi, our other plastic surgery nurse as well.

But there are complications that are common to all procedures. So things like infection and bleeding and wound healing problems specific to breast reduction and mastopexy is this risk of nipple necrosis, or nipple loss. So this is very rare, but if it happens, you can have a new nipple made.

So in my work as a Breast Cancer Reconstruction Surgeon, I perform nipple reconstruction very frequently for ladies who've had to have mastectomies, and they can look very good. They're just never quite as good as nature had given you initially, but they can be very good indeed, particularly after tattooing, I think changes in nipple sensation are very common. So

I tend to suggest, really you need to go into this thinking that you're going to have a significant change in nipple sensation. I think if you don't, then have a change in nipple sensation, it's a bonus, but I think you need to go in really thinking it will be.

Normally, it tends to be reduced somewhat. Some people find they have oversensitivity, and some people can have some very peculiar sensations related to things called neuroma, which are scars on the nerve you can get electric shock type sensations or a feeling of water trickling down the chest or so, some slightly peculiar sensations.

Often those sensory changes do improve with time, and as the inflammation settles, and with massage moisturisation. But that can be an issue for some people.

Asymmetry of the breast is guaranteed to a degree, and again, quite fussy as plastic Surgeons, so we like to try to get you as similar as possible. But there are so many different variables.

There's nipple, position, nipple, areolar, diameter, scar, position, scar length, volume projections. There are so many different variables. But again, people that do a lot of these procedures.

We're normally pretty good at judging those and getting you a result as symmetrical as we possibly can, and then complications of any procedure. Again, things like blood clots in the legs which can spread to the lungs. That's potentially life, threatening complication of any operational long distance, flight, or long-distance journey.

For this sort of reason, actually, we tend to suggest that you don't go for long distance flights for at least four weeks before this type of procedure, and for at least six weeks afterwards.

My advice is really, if you're planning a holiday after this is to probably not book your holiday ideally until you're happy that you've recovered. I love holidays, and I never want to be in the situation where you're ending up, having to cancel a holiday, because you've got an annoying complication. That's just taking a little while to settle down.

Then occasionally people may require revision type procedures, so common things that people can have is a bit of a lump at the edge of the scar called a dog ear. Some of the phrases used in surgery are horrendous, but everybody in plastic surgery knows what that is, and those are things that are normally, fairly straightforward to sort out under a local anaesthetic if required.

All hospitals have their own terms and conditions of treatment. So it's definitely worth asking Benenden Hospital, whichever hospital you choose. If you have this done elsewhere for their terms and conditions of treatment and they'll tell you what's included within your package of care in general with any of these hospitals, particularly at Benenden. The package of care will get you healed. It will pay for antibiotics. It pays for your dressings if we have to readmit you for an emergency type. Reason related to the surgery, then that would normally be bundled in as well.

But it's definitely worth being very clear with what's covered. And I'm afraid going in eyes open to any of these procedures, knowing that with any self-pay service there's the potential chance. There could be some additional fees, but the packages of care are designed to try to take that uncertainty out of these procedures. It makes it much clearer for the provider, and also for more importantly, for you.

So those are the major risks and complications. Then your hospital stay, might hand over to Kate. She can chat to you a little bit about the hospital, stay itself.

Kate Comrie

 Thank you. So at Benenden we have private single ensuite bedrooms. They're lovely and modern, so you'll have your own space if anyone comes with you on the day they're welcome to stay in your room. That's your space. There are televisions with free view. You've got Wi-Fi throughout the hospital. You can bring anything that you might like a book tablet headphones entirely up to you.

On average, we've said about the surgery time, but, as Mr Mackie has said, you will be away from your room for a bit longer, so tell your loved ones not to panic.

Typically most people stay one night after this procedure. But if you are feeling well, we are happy that you're stable following surgery. Your blood pressure is okay, you've eaten and drunk, and ideally you don't live too far from the hospital, you could go home the same day, but we can assess that on the day and decide. Some people just don't want to stay in hospital, but it does typically feel a bit more like a hotel here. Unfortunately, there's no chocolates on the pillow as of yet.

And we do encourage you to get up and move around after surgery with the nurses, at least for the first time. Make sure that your blood pressure is okay. Low blood pressure can cause you to feel lightheaded and faint. We are trained to get you safely down if you are going to faint.

So with the member of the nursing team, we can get you up and out of bed and get you moving around again to help reduce the risk of you developing any blood clots. We will typically also give you some compression socks which we recommend that you wear for a couple of weeks, or until you're back to normal mobility, and the nursing staff on the ward are here 247. So when myself or Lexi aren't around, there is someone to take your calls. If you have any concerns.

Mr Simon Mackey

Okay and then so post-operative recovery. Thank you, Kate. So post-operative recovery, most people still tend to stay in the hospital for one night. I think if you think you might be suitable to go home the same day. That's fine but bring a toothbrush just in case you're a bit less comfortable than the next person say, but I tend to close as I said, all of these wounds with dissolving stitches and tape dressings.

So any drains if they are used would be removed before discharge home. You can shower with those dressings from two days after surgery. You just have to. Then pat the tapes dry with a clean towel. Use a hair dryer on a cool setting, so don't risk burning yourself if you've got little areas that have reduced sensation.

And then, once the tapes are nice and dry. Just put your support garment back on the first week or so. I normally suggest you don't do too much at all. So I don't really want you putting your blood pressure up so lots of gentle walking around the garden or short walks around the block.

If you've got larger dogs and things. Then it might be worth getting a dog Walker in for a week or so after this type of surgery. From two weeks you could normally start to do a little bit more. And really, from two weeks up to six weeks, people will often get towards normal levels of activity depending on how quickly their wounds are healing up.

I think pain relief. Again, paracetamol is normally the safest analgesic to take, and people tend to tail that off over a couple of weeks or so.

You can normally return to driving from around two weeks in the eyes of the law and the DVLA insurers and the traffic police. They've all got slightly different. Take on things, but the common thing seems to be you have to be safely in control of your vehicle and able to perform an emergency stop.

So I recommend from about two weeks. If you're feeling up to it, you could try in a quiet cul-de-sac or a driveway an emergency stop. Just make sure you're safe and feel comfortable before taking to the wheel. The earliest these procedures would ever recover really is about six weeks.

So from six weeks we normally any tapes we can remove, we can normally get you back into your own clothing as you feel comfortable, and you can take on sort of heavier exercises, running head back into the gym. Work your upper body and do all the things that you might want to be doing.

Again travel for six weeks, you want to avoid long distance flights. They still classify long distance flights as flights of more than four hours just because there's an increased risk of blood clots in the legs which can go to the lungs, and it can take some months for all of the swelling to fully settle off and to get your very final result.

Some people, I guess, some other things to think about. So along the axillary fold some people along the breast have a bit of excess fatty tissue along the anterior axillary fold, so you can combine this procedure with some liposuction to those folds. That's a very nice way of getting a nice shape and also reducing the chest circumference somewhat.

I think some people with a mastopexy might be in two minds as to whether or not they really want an uplift which will increase volume in the upper pole, somewhat reposition their tissues, or a breast implant with uplift. So often. One of the things to consider doing is seeing what's the result you can get with an uplift alone.

I think if that's really nice or nice enough for you. Then, if you can avoid an implant, that's probably the way to go, but you can always have implants put in after a breast uplift procedure at a later date.

And again, these are often combined with so people who have lost a significant amount of weight might combine it with a tummy tuck type procedure or brachioplasties to the underarm areas or thigh lifts. So all sorts of different procedures. You can combine this with.

But safety is the key, so any combination of procedures needs to be safe. And I want to keep the time to less than six hours for any combination. And yeah, ideally, it's combinations of procedures which have similar recovery, really.

So, I think there's all sorts more to talk about with these procedures. But often a lot of the questions people have are very specific to them, but seeing you twice means that we can explore everything, and hopefully by the time. Well, by the time you're having surgery, you should have a very good appreciation of the potential options available, including doing nothing.

The limitations, risks, and complications of surgery, the normal recovery. And it's very important that you communicate to me, and exactly what you're hoping to achieve from surgery, and I can then try and do my very best to meet your expectations.

But again, they tend to be procedures that people are very delighted with. And I'm hoping that these videos are going to show us that, so I'll hand over to Kate, who, I think, will introduce things, and I'll answer some questions a bit later on.

Kate Comrie

Thank you, so we've just got four short videos from a lovely patient of ours who came in and had a rest reduction surgery. So I'll play this for you now.

Angela Miller

Mr Mackey came to visit me, probably around an hour after I'd come round after the surgery. He explained that everything had gone very well, and that he took the compression off to show me the scars.

I was quite apprehensive at first however, I became quite emotional when I saw my shape in the mirror, and I just had feelings of regret that I hadn't had the surgery done a long time ago. They looked perfect to me, although obviously I had tapes on where the scars were. It was such a vast improvement.

I thought I would be in a lot of pain, but surprisingly, I could manage the discomfort with paracetamol that I was recommended to take every four hours. I had two compression bras, that Kate had, before the surgery recommended that I bought, and then I changed them to help with the recovery. I had tapes on the Scarring, which were removed after six weeks, but they stayed on for the entire time.

Every time I would catch my reflection in a shop window or the mirror at home. I just couldn't believe I kept smiling and couldn't believe the new shape. My posture improved; my clothes fitted better. People commented that they thought I'd lost a lot of weight, but they weren't quite sure that I'd had the surgery to reduce my breasts.

At my six-week post-op I was again met by Kate Comrie and went through to see Mr Mackey. He was very pleased with the results, the scarring was symmetrical, very neat, and after the initial surgery they did appear very high and quite firm, but I was reassured they would drop and be more natural, which, once the swelling had subsided.

They certainly did look a lot more natural. Mr Mackie was very pleased with the results. The tapes were removed, and I was told that I could go for a bra fitting to find out my new size.

It has totally changed the way I feel about my body, and I used to be an H cup prior to the surgery, and then I went for a professional bra fitting, and was measured as a 34 D. Now all the underwear in the regular stores are accessible to me. I purchased two swimsuits that are just. They fit perfectly; my body is in proportion.

I go to Pilates regularly. I go on the trampoline with my eight-year-old daughter wearing a regular bra, and it has totally changed my confidence. And the way I dress, and the way I feel about myself.

Kate Comrie

Bless her. Thank you very much to her for providing us with that, and just a note we do now supply you with the two bras.

So that is the end of our presentation. Thank you very much, Mr Mackey. We'll now take some questions.

So, on the lead up to surgery is there better recovery or a better outcome if you have built up muscle in advance through targeted exercise?

Mr Simon Mackey

So good question. Yes, there are lots of prehabilitation programs being introduced for major reconstructive type procedures and there is definitely some benefit to building, protein building muscle, mass preoperatively in specific, patient groups with breast reduction surgery. I think so long as there is a healthy weight and you're not malnourished, you have a stable weight.

If you've lost a significant amount of weight, you've had your vitamins and just make sure that you're well nourished. Basically, then it probably doesn't make a huge difference, although from the major reconstructive procedures if you've because people tend to be slightly less mobile than they are after this type of procedure.

But if you've built up some additional muscle mass, then if you have a period where you're less active you don't notice the muscle loss quite as much so for some procedures. Yes, for this it wouldn't harm. But there's no really good evidence that would make a significant difference to your recovery.

Kate Comrie

Thank you. We've touched on this already. But what happens if you lose weight after a breast reduction? And can the nipple size be reduced?

Mr Simon Mackey

So nipple size can be reduced. So some people sometimes come in with what they feel is very large nipple in proportion to the size of the breast, and that can be reduced with a breast uplift or with a breast reduction.

We have specific nipple size markers in the procedure, so I'll often have a chat to you about what sort of size you might be. The standard British nipple is about 48 millimetres which is the standard nipple mark we use. But yeah, but we can adjust those.

And again, if you've got asymmetry between the areola, I can try to make those more symmetrical. And what was the other part of the question?

Kate Comrie

 Happens if you lose weight after?

Mr Simon Mackey

So it's a good, very good question again. So everybody's slightly different. I saw a lady again this morning who has lost seven stone on Monjaro, and she tells me that her bra size has not changed at all, so her chest circumference has changed and reduced, but her bra size has stayed the same.

Whereas other people I see come in and say, as soon as I put on weight, it's all on my breast, or if I lose weight, it's all off my breast. So to a degree your breast will continue to change, as your weight changes in a similar manner to how they would have done before breast reduction, surgery, but you would have less breast there, so the relative change would be less.

If you've got half as much breast then, if you gained the same amount of weight, less of it would be on the chest. So again, it varies from individual to individual. I don't know if I've made that very clear, but it does vary from individual to individual to a degree, and I think ordinarily one would expect that there would be some change in breast size as your weight varies.

But other people like my lady with the seven stone weight loss. I suspect she's now at her ideal weight, but if she lost another, I don't know if she could lose another stone, if she lost another stone she might find that actually her reduced breast size has not changed significantly.

Kate Comrie

Thank you.

How long after surgery can a patient be exposed to sun?

Mr Simon Mackey

So there's a phenomenon called post-inflammatory hyperpigmentation. So if you have sunlight exposure to an immature scar, so that's a scar normally within the first year or so that is still red and blanch as heavily as you press the scar. Then the immature scar tissue can lay down additional pigment, and you can get permanently darker scars.

So in an ideal world, I'd say lots of people use lots of people use sunbeds and things, but I tend to recommend that if you're wearing thin clothing, or if you're out with a T-shirt with no bra for the first year or so that you use some high factor sunblock on the scars and really try to protect them from sun until they've fully matured and become nice and flat and pale.

Kate Comrie

Thank you. Is the BMI the same for all procedures?

Mr Simon Mackey

So it does vary, I think the upper cutoff for the things like abdominoplasties. Breast reductions is 35, I think, at most hospitals, I think, for some of the orthopaedic procedures. It's higher, is my understanding.

I think it's close to 40, but we know from a host of different audits looking at complications that you get a steady increase in chance of complications as your BMI increases, but that at a BMI of 35 there's quite an inflection point. So the chance of a significant complication whizzes up.

So really, you'd want to try and have this procedure done once and once only, and you'd really want it to be done when you're at a healthy weight that you'd like to maintain. So that's the reason. So it's anaesthetic risk. It's risk of its risk of getting a poorer outcome and then it's you know, your own lifestyle change and ongoing benefit. The various reasons for that.

Kate Comrie

What is the approximate timeframe from time of the first consultation to having the surgery?

Mr Simon Mackey

So again, the GMC and the regulators are very clear. We should be giving you at least two weeks to cool off after an initial consultation.

So ideally, it would be at least two weeks between the initial and the second consultation gives us time to get your quotes and information sheets and things out, and then it's normally it's a bit longer than that until surgery. So I think the fastest we've ever turned things around is about three or four weeks.

But normally, the more time you can give yourself to plan and contingency plan, and people have often got to arrange some childcare or someone to look after the dog or time off work, so probably close to about six weeks, four to six weeks, I think, is a more realistic timeframe.

But again, we can only get you in month by month, but there are odd times of the year get much busier, so get overwhelmed with teachers often at the start of the summer holidays, and so there are various fluctuations, and sometimes are busier than others. But we can normally get you in at a time that's convenient to you.

Even if it's not your absolute ideal date.

Kate Comrie

Thank you. Can the inframammary fold be moved, or will the breast still be based around that staying in the same place?

Mr Simon Mackey

So it can be moved a little bit. So some people with these procedures, if you've got a significant fold, height, discrepancy, I can often lower one and try to raise the other side a little bit, which again makes bra fitting and finding comfortable clothing easier. So you can move things a little bit.

Yeah, so you can.

Kate Comrie

Perfect is silicone scar tape, helpful in the healing process?

Mr Simon Mackey

So it may be. Again, it's one of those things. There's conflicting evidence for it. Looking at the sort of type evidence. Really, the theory is that it's probably the pressure of the tape which makes the difference. So I don't tend to recommend it routinely. I think if somebody is developing what we call hypertrophic scar.

So a scar that, rather than being immature and then maturing, just stays switched on and just keeps being a little bit red and lumpy, then it may be of benefit in those particular people, and things like steroid injections directly into the scar can also help with those.

But for most people it's probably not necessary. It's not necessary, really.

I think the dressing with the best evidence for getting a good scar is actually the paper tape dressing that I tend to prefer, and again, it's cheap and cheerful. We can give you some of that to take home with you. It acts like a big steristrip, so it helps to take the tension off the wound edges, which I think is a big part of why, it's so good at preventing hypertrophic scars.

But also its applying pressure to the scar itself. So yeah, it might be. I certainly don't have any qualms about people using silicone tape if you'd like to, but I'd normally recommend that you wait until six weeks at least. So once the paper tapes are off and you've started to massage as well.

Kate Comrie

 What happens exactly during a consultation. Are you examined?

Mr Simon Mackey

Yeah, so we'll examine you. So I'd have Kate or Lexi there as a chaperone. I'll take a look at you. I tend to discuss asymmetries, because if you cut us in half, none of us is perfectly symmetrical. Often one shoulder's lower than the other, you might have fold, height, discrepancies, nipple, areola, shape or size or height discrepancies. So I'll go through all of those things with you.

And again, most ladies about a cup size, different between the breasts. It seems to be the right side. It's very slightly larger than the left for most people, but it's not always the case.

I'll just point out some of the asymmetries that I can improve, but also some of the asymmetries that I can't improve. So things like chest wall asymmetry. If you've got a very prominent chest rib cage on one side compared to the other. I can't change that.

And then I tend to measure you. So I tend to measure what they call the sternal notch, to nipple distance on each side, and then the nipple to fold distance on each side. I might measure the height and width of the breast.

And it's just useful to have everything documented, and helps me to plan my surgery for you, and then we'll often take consent for some clinical photographs. So Plastic Surgeons are obsessed with images. So I'll generally take some pictures of you before the procedure we weigh any tissue that is removed before it's sent away.

I'll often take some pictures of the material that's been removed, and then we tend to repeat photographs at your six week or three month type clinic appointments for post-operative follow up and documentation as well, and it's quite useful for ladies to be able to look back at where they've come from, particularly if you have something like a minor wound ahiscence, or if you've had a hematoma or a seroma, a collection that needs to be drained, and it's a bit more.

The recovery, then, is a little bit more involved. You might have to come back to hospital a little bit more so, I think, being able to look back to where you've come from can be very, very useful and you're, of course, welcome to have any of the images that I take and they don't go anywhere unless we specifically ask you.

Kate Comrie

Beautiful would a 36-year-old patient require a mammogram?

Mr Simon Mackey

So no, not at the moment. So unless you've had a breast lump, or we'd normally recommend that that's investigated before surgery, anyway. But no, it's a slightly controversial area, anyway.

There's lots of argument within the plastic surgery community about whether or not it's truly necessary to have a mammogram after the age of 40, but I think most plastic Surgeons in the UK at least, think it is good practice to have a mammogram after the age of 40.

Now we don't do mammograms at Benenden Hospital. There are some other providers that we tend to send you to for those. I can't recall how much they are. But I think if you're if you're of the age that you've been invited for breast screening, then often you can have your mammogram performed within the NHS.

I think if there's any difficulty, though, it's faster and easier just to go with one of our other providers, and I think it's in the low hundreds of pounds for a mammogram. I don't recall.

Kate Comrie

I think it's around two to 300. But again, it is an external provider, so don't quote me on that.

Mr Simon Mackey

Yeah.

Kate Comrie

 I live alone. Will I need someone with me for recovery when I come home, or can I manage. Driving won't be a problem. I can get a taxi home from hospital and manage without driving for a few weeks?

Mr Simon Mackey

So it would probably be advisable. Just have somebody with you for a night or so, just to make sure that you're okay at home. I think again, some of the hospitals. I think Benenden might be the same.

They might suggest that you have to have somebody leave the hospital with you. So I think if they're coming in to collect you, anyway, and they've got a car, you might as well catch a lift with them, but otherwise we've certainly had people have a friend get public transport to the hospital and then leave with them in a taxi.

So it's just you have to imagine what would happen if you in the middle of the night you had an issue, and you needed to get back to us. You just you want to have somebody, even if they're not staying with you directly, just close support, and somebody who could come and bare you out and give you a hand if you ran into difficulty. Unlikely as it is, I think it's just contingency planning and trying to make things as stress free as possible really.

Kate Comrie

And actually we won't let you leave the hospital unless you have someone with you for 24 hours following the anaesthetic, and that's the returning to the ward time rather than going down for surgery time.

Mr Simon Mackey

We've had some people opt to pay to stay for an additional night, if it's really difficult to find somebody at home, in which case you can then taxi home.

Kate Comrie

We just want to know you're safe and supported.

Kate Comrie

Do you need to come off HRT treatment before surgery?

Mr Simon Mackey

You don't, so there are certain medications can potentially increase risks of blood clots. But you're taking them all the time, anyway. So I think you're safer just keeping on your regular medication.

What we might do then is send you home with an extra few days’ worth of low molecular weight, heparin to inject yourself with, and would really just encourage you to mobilize quickly, get up and about, and return to normal activities as soon as possible.

Often the side effects of coming off. Things like HRT are pretty awful for people, so we want to make things as comfortable as possible.

Kate Comrie

Perfect. Is there a maximum breast cup size for the option of just an uplift as opposed to a reduction?

Mr Simon Mackey

Not really. I mean, there's no hard and fast rule. I think it would very much depend on your size and shape and the quality of the tissues. So if you can imagine with an uplift, if you've got a very large breast, it's quite difficult to get things to.

You can't defy gravity. So actually, sometimes, in order to stop things from tozing and heading south again more swiftly, it might be advisable to go a little bit smaller than you currently are, but there's no hard and fast rule.

I think we'd really have to just examine you and have a bit of a chat about your goals, and what I think I can do for you.

I think it's not a question anybody's ever asked me before, actually, but and I think it must be because I would normally just. If you're after an uplift and I can do an uplift, I'll do an uplift for you.

Kate Comrie

Right. What happens to high, level breast stretch marks?

Mr Simon Mackey

So any stretch marks that you have below the level of the new nipple position, which is normally at about 21 to 24 cm from your notch would go any that you've got. Some people have got stretch marks in the upper pole of the breast. I can't remove those. I'm afraid.

Now, sometimes with mastopexies. If you've got lots of loose skin, taking away some of the skin and tightening things in the appearance of the stretch marks can disappear somewhat.

So sometimes if you stretch the skin, the stretch marks are less obvious to see, but you can't remove those ones, I'm afraid so any that you've got lower down in the chest will be removed with the skin excision with the reduction, or a mastopexy, and some of the appearance of some of those ones in the upper breast may change, may improve, but you can't get rid of them, I'm afraid.

Which is often disappointing for people to hear. But we've just got to be realistic and let you know what we can and can't do for you.

Kate Comrie

 Absolutely. How does the procedure affect the future ability to detect breast cancer? Is there any effect on monitoring or treatment of cancer if it is detected in the future?

Mr Simon Mackey

No, it shouldn't. So you can still have your regular breast screening as part of your history. When you go for your mammogram, you'd say that you've had a breast reduction. I think you can sometimes get some fat necrosis, so the breast is breast tissue.

There is some fat within the breast as well, and when you cut through the breast to remove tissue, some of the fat cells can devascularize. So as you're massaging, you can often feel a bit of a lump under the skin.

But we know then that's fat necrosis. And as you massage and moisturize, and the swelling resolves they tend to disappear.

But that's why I think it's very important to have a baseline mammogram, because it just gives the team something to refer back to. If you notice a new lump in the future, but it doesn't affect your ability to be able to find breast lumps.

And, in fact, if you imagine, if you're dropping from an M cup breast down to something like an E cup breast. You've got much less breast tissue to have to palpate. So really, the smaller the breast the easier it is to find lumps, and the earlier you could normally have investigation and have things treated.

Kate Comrie

Thank you. Is the scarring much darker for darker skin?

Mr Simon Mackey

So yeah, everybody's slightly different and it tends to be actually younger. Patients are more prone to producing slightly lumpier or darker or more pigmented scars but again depending on the tone of the skin. Yes, some people can be more prone to having things like hypertrophic scars, so there are particular scars called keloid scars, which can be much more common strangely in people with very darkly pigmented skin and in people with very Celtic skin.

So it's the two extremes, very dark and very pale skin, but normally, you know, I'll try to make things look as good as I possibly can. We'll take all of the precautions to try to get you the best possible looking scars. I think if you look as if you're tending towards a hypertrophic scar, I'd want to a bit more frequently, and we might do more, even more scar massage. Think about steroid injections.

So we'd really just try and sit on a scar it looks if it were becoming hypertrophic. But yes, you can. If you've got a more darkly pigmented skin, you can be more prone to forming slightly darker scars.

But it's not always the case. It's just typical in medicine. Surgeons like things to be very sort of clear cut, but they often aren't. They're shades of grey, really.

Kate Comrie

Thank you.

Can this be carried out at the same time as a tummy tuck?

Mr Simon Mackey

Absolutely, so very commonly performed combination procedures. It's quite nice, because the recovery is fairly similar, tends to be one night in hospital, same wound closure, same sorts of dressings. You have to wear compression or Bridget Jones type knickers.

And we've got compression type bands, corset type devices just to get the best possible result. But yeah, the recovery for both is around six to 12 weeks, showering at two days, driving in about two weeks.

So yeah, very commonly performed combination.

Kate Comrie

Absolutely. Can a combined breast, uplift and tummy tuck be done with spinal stenosis?

Mr Simon Mackey

Can do, can be, I think, with the tummy tuck procedure in the operating room I need to flex you to close the wound, so I think I would. So normally, people with spinal type issues, I might get you to see how flexible you are. And I might just recreate the position that I need to put you in on the table in the clinic just to check that. You're going to be comfortable with that.

I think, depending on how your spinal stenosis has presented, and what sort of symptoms you get.

I think you might have to go into this expecting that things could get worse temporarily, because you're going to be relatively immobile, which can affect symptoms.

But I think it's one of those things. We'd have to have a chat, and I think. See how things are affecting you. I think if you had very severe spinal stenosis, then it might make you think twice about this sort of surgery.

But again, I think, was, it combines breast and tummy. So again, depending on the breast size, it may help those symptoms significantly, anyway.

So yeah, it can cause problems. It doesn't necessarily cause problems. And I think we'd have to just evaluate on an individual basis I think.

Kate Comrie

Thank you. Is there a preferred order of surgery if you want to have arms, breast, and tummy done?

Mr Simon Mackey

So it's arms, breast, and tummy. So I think you might then choose. It depends on which is the most troublesome part of the situation for you, but often it's best to think about abdomen and breast first and then think about arms as a separate procedure. That's the commonest way, but I've also done breast and arms at the same time and then come back to the tummy at a later date.

Just trying to think if I've ever done tummy and arms. I don't think I have, so it tends to be breasts and arms, or breasts and tummy. But yeah, so there's no fixed, there's no fixed order, I don't think but and it would depend on quite how significant each of those is, and how long each procedure is going to take so possibly could combine the three. But normally I'll be thinking breast and tum first and then arms as a separate.

Kate Comrie

Good to have your core or your arms to help you move around.

I don't scar particularly well. Is there any scar therapies I can look into post procedure. I have seen silicone dressings and cryotherapy advertised, but wondered if you would recommend them?

Mr Simon Mackey

So lots of things advertised. I think the best thing tends to be the micropore tape in the early postoperative period. Firm massage, moisturisation, using a cream or product that you like.

Silicone may, as I said, have a role for some people but beyond that there are various therapies like microneedling, which can help dry ink, free tattooing, I think, depending on what the scar looks like down the line.

Some of the intense pulse lights or laser type therapies, which we don't do at the moment at Benenden, but you can explore. Those are very good at removing pigment or reducing redness from scars, so it would just depend.

I'm presuming you must know that you've got pore scars. It would be interesting to see what the scars are like currently, and then we might be able to guide.

You know, some tailored advice for you post-operatively. But again, they've got some people, if you, if every single scar you have forms a keloid. Then you might want to think twice about some of these procedures, because they can become very troublesome. It can be very uncomfortable, itchy, painful. More of a nuisance, possibly, than having larger breasts or significant breasttosis.

It's always a bit difficult with some of these very specific questions, because actually it. That's the reason that we like to see you, because you can then tailor the advice specifically to you, just try and stack the cards as much in your favour as possible.

Kate Comrie

Yep. Can surgery take place with family history of breast cancer?

Mr Simon Mackey

 It can.

It can. Again, it depends how strong a family history is, and your individual circumstances, but it absolutely can.

Kate Comrie

And do you recommend the cup size, or do we choose?

Mr Simon Mackey

So most people will come in again. Most people wear the wrong cup size, and most people will come in just wanting to be significantly smaller than they are. Sometimes people say, I want to be A B cup. I want to be a C cup. It's very, very difficult to guarantee a particular cup size, but most people will come in saying they'd like to be a full C or thereabouts.

So I'll use all of my skills to try and get you as close to that as possible. But, I say, look, if you're a smaller C or a D. Don't shoot me. I'll just get you significantly smaller, get you all of those other potential improvements, and hopefully, you'll be very happy. But again, I think most people, as long as you're smaller than an E cup, and can go to high street chains, and it becomes easier to find clothing that fits you nicely. People are normally, absolutely delighted.

Kate Comrie

Absolutely.

Mr Simon Mackey

And I'll try and get, you know if you want to be a C, I'll try and get you to a C. But I just can't, nobody can guarantee it. I'm afraid.

Kate Comrie

I heard you mention you use tranexamic acid. I'm allergic to this, and found out during my C-section, how scary, can I still have surgery?

Mr Simon Mackey

You can, you just tell us that you're allergic to it, and we would avoid it at all costs. In your case.

Kate Comrie

Thank you.

I'm a front sleeper, how soon after surgery could I go back to sleeping on my front?

Mr Simon Mackey

So you are somebody who might want to get hold of a Y shaped pillow, or think about putting some pillows down beside you, just to try and keep you on your back for the first few weeks.

A lot of these things are, there's no absolute, hard and fast answer. But I would normally be thinking, because Surgeons always think in six weeks blocks of probably trying to suggest you try and avoid sleeping on your tummy for at least the first six weeks, but quite difficult when you're asleep and if you're a restless sleeper, that's why things like the Y-shaped pillows just cup you in.

I think you can get those all over the place nowadays.

Kate Comrie

Think you're right. You can, and I always say at pre-op, why don't you try and do it before surgery to get your body used to it?

Mr Simon Mackey

Good idea.

Kate Comrie

Is there a limit to the amount of sizes you can go down to from your original size?

Mr Simon Mackey

Not really, I think we really want the result that's going to be in proportion for your frame and shoulders and the rest of your body, so I wouldn't want to make you smaller than I think would be in proportion for you.

But again, sometimes people who are a K cup or G cup might come in and say, I'd like to be a B.

I can't honestly get you to that sort of size, so there's no hard and fast rule. I couldn't say I can only drop you by X or Y cup sizes but I'll try to get you as close to where you'd ideally like to be as possible, but it's not always possible to get you quite as small.

I think, in general. So with breast enlargement, surgery, the biggest criticism people would have is they wish they'd gone a bit bigger and with breast reduction if they had a criticism it was I wish I'd gone a little bit smaller.

So we just try. And you know we chat to you about all of these things in the consultation. But we'll try to get you significantly smaller than you are.

Kate Comrie

 Brilliant.

Currently a 34 J. Is it advisable to go down to a D?

Mr Simon Mackey

Could be. Yeah, I think if that if that's where you'd roughly like to be again, I think that would make you significantly lighter and smaller than you currently are, it would make it hopefully easier on your posture musculoskeletal symptoms.

If you get into trigo, I would anticipate that should improve things significantly, and I think the luxury of being able to just go and buy your clothes from a regular high street chain rather than having to go to the specialist manufacturers would be ideal. So yes, that's probably quite a nice size change.

Kate Comrie

Lovely. I think that's it. So sorry if we didn't answer your question. If you provided your name, we will answer it via email.

Okay, so I'll go on to the last slide.

Kate Comrie

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On behalf of Mr Mackey and the expert teams here at Bennington Hospital, I'd like to say, thank you for joining us today. We hope to hear from you very soon.

Thank you very much. Goodbye.

Mr Simon Mackey

Thanks for coming.