Kate Comrie

Good evening, everyone. We're just going to give it another 30 seconds or so to let the final people join.

Hello and good evening. Welcome to our webinar on breast surgery. My name is Kate, and I am the Clinical Nurse Specialist for Plastic and Cosmetic Surgery. I’m joined tonight by Consultant Plastic Surgeon, Miss Anita Hazari. This presentation will be followed by a question-and-answer session. If you would like to ask a question during the presentation, please do so by clicking on the q&a icon, which is at the bottom of your screen. This can be done with or without giving your name, but please be aware that the session is being recorded if you do leave your name. If you would like to book a consultation, you'll be provided with the contact details at the end of the session.

So, a little bit about me: my background is in adult nursing. I did a diploma in higher education at the University of Surrey. I also studied the nursing mentorship degree at level six. I have also done aesthetic practitioner practice in foundation advanced and master classes in anti-wrinkle and dermal fillers. I’ve worked in the NHS in the surgical assessment unit in A&E; those were royal surreys in Guilford, and I also went and worked at the surgical assessment unit in Fleet. Following that, I moved into a private hospital as a ward nurse, and shortly after joining, I moved to the cosmetic nurse specialist. I then came to Benenden just over a year ago as the Clinical Nurse Specialist. I support our cosmetic and aesthetic consultants and all of the patients throughout their journey, including pre-ops and post-up follow-ups and just being on the end of the phone if they need me. I’m going to hand you over now to Miss Hazari.

Miss Anita Hazari

Good evening, everyone. My name's Anita Hazari, and I’m a consultant plastic surgeon. I work in the NHS, the private sector, and the NHS. Many of you would have heard of Queen Victoria Hospital in East Grinstead, which is the regional plastic surgery centre for Kent, Sussex, and Surrey, and I’m one of the surgeons there. I’m probably now one of the senior ones because I’ve been there for about 18 years, so I’ll be talking about breast surgery, which includes reduction enhancement uplift and a bit about male breast reduction at the end as well.

I just thought I’d put in a couple of slides about to just say that plastic surgery is not so anyone can be a cosmetic surgeon but plastic surgery is a proper specialty such as orthopaedics general surgery and on average for most plastic surgeons including medical school takes about 19 years now we would think that plastic surgery is a new phenomenon in the last century or so it's not actually so where I’ve put this slide on history of plastic surgery as you're looking at it on the left is a pattern which people in the past used to use to reconstruct the tip of the nose and on the right you can see a picture of an Indian gentleman who's had what's called a forehead flap so skin and on its blood supply taken from the forehead to construct the tip of the nose and that's from 700bc when it was written in a document called the Shush Samita and essentially people used to have nasal tip amputation done as a punishment for various crimes and the cobblers at that time used to reconstruct because that time there were no such thing as surgeon 700bc they used to actually reconstruct using the forehead tissue the picture in the middle where the where the figure shows the nose sort of attached in a fashion to the upper arm is something called a tube flap and that's we what also known as the Italian rhinoplasty or reconstruction using the same sort of flap using tissue from elsewhere to reconstruct the nose performed somewhere in the 1800s so all of this has been around if you dig far enough has been around for a long time this is East Grinsted Queen Victoria Hospital when it was first located to this site in 1936 and this is a picture of it when I became a Consultant in 2006 and you may think well nothing much has changed but believe me these are the corporate offices but the main hospital a lot has changed inside we have state-of-the-art theatres and stuff and we cover all reconstruction for 16 hospitals all the way from Margate to Guildford so if anyone has hand trauma you generally end up coming to us and it is down to this man Archibald McIndoe and you may have heard about Archibald McIndoe and his guinea pick so he was a kiwi and he started at the hospital in 1939 pretty much when the war broke out and he did a lot of pioneering surgery for the allied air crew so from the British Canadian air forces and Australian air forces and there was an inherent fault with these spitfires planes where when they caught fire the hands and faces of these young pilots would get burned and when I say young they were 19 20 21 year old so they were young men and this is one of the guinea pigs and you can see when he initially presented a young lad who's got significant burns on the face and then the nose needed reconstruction and what Archibald McIndoe did is used some of that skin from the shoulder formed a tube out of it to preserve its blood supply and joined the other part of the nose and then divided that at about a few weeks after the connection and detached it so that the nose tip had suddenly good quality skin from the shoulder whereas the rest of it was put back and that's him when he's much older he did come visit east grad quite frequently for several years and what's absolutely remarkable about what Archibald McIndoe did with the guinea pig is these were young lads who got burned so he made sure that in all the public houses in east Grinstead no mirrors were allowed so these young men could never actually see what they look like and some of them went on to marry the nurses who treated them as well so that's where I have been I have actually danced with the guinea pigs during my training because I was at East Grinstead doing my research so I have been a Consultant plastic surgeon since 2006 I am on the specialist register on the on the General Medical Council register so any doctor who practices in the UK has be has to be on the General Medical Register but if you are a specialist then you have to be on the specialist part of the register and like I said earlier there's no such thing as cosmetic surgery specialist because there's that's not a specialty plastic surgery is so we have to obviously do our training over several years do the qualifying exam and that's when we get our qualifications. The last line just says about various associations, such as the British Association of Plastic Reconstructive Aesthetic Surgery and Breast Surgery, various organisations of which I’m a member, which just means that I have to adhere to a certain standard. My basic qualifications are set right in front of you: MBBS, just to sort of decode all of this as a basic medical degree. I did my research in nerve regeneration as a as a young trainee and I on the basis of that thesis which was an MD thesis I got a Hunterian professorship from the RCSE which is the Royal College of Surgeons of England in 1999 feels like a long time ago and that's where the higher degree md is and then FRCS is Fellow of Royal College of Surgeons and that's the basic surgical degree and the ENG stands for England because there's four colleges England Scotland there are two in Scotland and one in Ireland and then there's the specialty which is the FRCS Plast so Fellow of Royal College of Surgeons Plast stands for plastic surgery so if you went and saw an Orthopaedic Surgeon for a hip or a knee operation they would have orthopaedics orth in in that bracket and so on and so forth so what are my special interests plastic surgery involves a lot of parts of the body but my own specialty interest in the NHS is breast reconstruction where I do a breast reconstruction using the skin and fat from the tummy which you normally would chuck away in a tummy tuck so I use that take it to the chest and make a breast out of it by rep plumbing the blood supply and at Benenden I do cosmetic surgery and body contouring and the cosmetic surgery is pretty much restricted to breasts tummies and a few other parts of the body and body contouring which is tummy tugs arm reduction and thigh lifts so in breast surgery which is the remit of today's webinar.

I’m going to speak about a few different types so reduction which is making breasts smaller uplift is well bringing them north implants is making them bigger or restoring the volume as we may say and male breast reduction for those men who feel they have something called gynecomastia which is extra breast tissue which does not look for of which they're embarrassed so here's one of my ladies she was a 34 double h and those of you who have got large breast you totally will understand the problems this lady had which is a lot of upper back ache neck ache straps digging into the shoulders and where it gets really hot and sweaty in the crease underneath the breast you can get red and sometimes a fungal infection called inter trio and the breast reduction operation involves making the nipples smaller but moving so you don't take them off completely you move them north but it is a big operation it takes about 3 hours 2 and a half to three hours to do and it takes about you're in hospital for one night and it is about making the breast in proportion with the rest of the body so often my ladies will ask me so what size should I be or what size I will end up being well I can't guarantee you a cup size you go to M&S the sizes are completely different to the Fenwick brand and completely different to the you know the queen's ones which is Rigby & Peller so there is and Victoria Secret which is an American company you come out really small so there is no standard brass size but what I look at is to see whether I can make you in proportion with the rest of the body so it's about balance shoulders hips and breast and the idea is that when you wear a dress afterwards it fits at the top fits at the bottom so the surgery involves moving the nipple north and it is a bit like those of you who have done dress making may actually recognize some of this pattern where the pattern is like how you see on the screen at the moment the nipple and the nipple is the bit in the middle the areola is the pink bit around it that's made smaller so some women have very large areola so those are made smaller and it's a standard 4 5 cm diameter and the reason I can say that is because we have an instrument called in nipple marker which looks a bit like a cookie cutter and what I do is I dip that in some sterile ink and place it on the breast and then I’ve got a perfect circle and I cut around it the nipple area is still attached to the breast tissue but the breast tissue is then isolated in a tongue of breast tissue with a nipple attached to it through which the blood supply comes in and then it's moved north so if the nipple further south it's moved north and then the lower breast tissue is taken away which leaves an anchor shaped sky as you can see on the screen so here it is where there's a pedicle which is the nipple is still attached to the breast tissue which is shown as yellow and it's isolated on a tongue of breast tissue but we don't call it a tongue we call it a pedicle and then it's swung up like you see on the picture as you're watching it on your right and then the lower crescent of breast issues taken away sent off to be looked under the microscope to make sure there's nothing unusual in it or sinister are in it and therefore before this operation for those who are 35 or over we do insist on a screening mammogram because in large breast it's very difficult to feel for minor changes so one just wants to make sure from the safety point of view there are no surprises afterwards from the breast tissue.

This is another of my ladies well into her 60s actually who had over a kilo taken off from each side and she was a lot more comfortable afterwards so why do women have it it's really for neck ache and back ache sometimes some of you who may be going to a chiropractor may actually say to you well actually why don't you have the breasts reduced because when the breasts are large one tends to stoop a little bit the centre of gravity moves forwards the shoulders roll forwards so and then it starts to hurt the back so it's for relief of those symptoms weight does come in it's a good idea if you're planning to lose weight to try and get to your target where before because once if you have the surgery and then lose weight then the lovely operation where I’ve done and I’ve hyped the breast up and they're small and per well they do then become floppy again when you lose weight so it's a good idea to reach your target weight beforehand and I’ll briefly mention here quickly about smoking and nicotine and that'll apply to almost all operations that I do so nicotine as in smoking or using in any cigarette or lenes or patches all of these nicotine is a vasa constrictor which means it makes the size of the blood vessels smaller and therefore there is an increased risk of wound healing but specifically in uplift and breast reductions well where the nipples relying on that blood supply coming through the pedicle so it might be that that is jeopardized because the sizes become too small the blood supply so then you can have something called nipple necrosis when bits of the nipple is affected and can actually die so that is really important to stop smoking vaping using any nicotine replacements for at least six if not 8 to 12 weeks before surgery to give yourself the best chance possible because with all these operations you're spending a lot of money so it's nice to have you coming out at the other end with no complications preferably or the least amount of complications an uplift so the pattern is exactly the same.

Now this is a slightly older way of doing up lift where the nipples move north and then if you look at her sideways it's still the slope is still there and it's an anchor shaped scar again so one of the problems with both the breast reduction and uplift is the scarring which is significant an anchor shaped scar round the nipple vertical and a horizontal scar in the crease and like all scars no matter where they are on the body from whatever type of surgery all scars remain red and lumpy for six to8 months and take 18 months to fade and same with this lady now her areola is quite large and I’ve done an uplift and I’ve made them smaller and the shape is a lot better.

Now you look at this lady she's had exactly the same operation and you might say my god I can't see any scars well she does have the scars so when the same surgeon does the same operation in 100 patients 90% of patients would say they have a reasonable scar 5% would say you can hardly see it like this lady here and 5% would say it looks awful because some women just develop very lumpy red race scars so some people are just not such great scar for so again that's important to bear in mind now with an uplift you can have it when the when the nipple and the tissue is very strong and you just want to rejuvenate it and bring it up and the same thing applies for those ladies who are wishing to have implants which they may have had for several years and the breasts have dropped to actually finally come to a point where they just want the implants taken out so obviously whatever uplift you have the residual volume of the breast depends on how much breast tissue is there and how much do the implants contribute towards the size of the breast because as women what we want from our bodies when we are in our 20s is very different to our 30s very different to how we feel about our bodies in 50s and I hope by the time I’m 70 I don't really care what anyone thinks so it's very different so different things are right for you depending on how you feel and what confidence you need just to you know have it done so I’ll come to the question about breast implants in a moment someone's asked is there a risk of getting stretch marks from a reduction as the skin is being moved no if anything the stretch marks which are below the level of the nipple usually end up with that tissue in well good to pathology in the b really in a way but any stretch marks above the level of the nipple I’m afraid they're going to stay I can't change the quality of skin in the upper half of the breast that does stay we come to implants and I’ll answer that other question in a moment another lady where she had implants in her 20s then as she got older hid the menopause the breast became you know fuller because you put on weight and then we took the implants out but her residual volume was quite a bit may not have been like that when she was young and had it done but as one gets heavier the breast tissue is increased as well so that again has the implants have been taken out and I have basically moved the tissue I haven't taken any breast tissue away I’ve just moved it around and remoulded on the inside to do an uplift some women prefer to have their implants removed and here this lady decided that the implants were too large done elsewhere all I did was take them out and I’ll she came with a specific problem called breast implant illness and I’ll cover that in the next couple of slides including how frequently implants need to be placed so for those ladies who are considering implants remember that I can't change the quality of the overlying skin or the tissues or the thickness of breast but what I what we can do with breast implants is basically it's like a filler where're we're increasing the volume of the breast we're restoring the volume the feel is different implants feel a bit stiffer and a lot of the implants we use these days are high cohesive gel which means if you take a knife and cut through it maintains its shape like a jelly implants 30 40 years ago were more liquid silicon and they are not great to deal with actually the high cohesive gel ones are more form stable and most implant manufacturers say implants last 10 to 15 years but I say to my ladies if they're in break don't fix it and the two main reasons why implants need changing is for ruptures or leaks and that will be detected when the implant changes a little bit you may feel it but also when the only sure fire way of knowing if it's leaking is to have an ultrasound scan or an MRI and then they need changing and the second reason is capsular contracture implants are put usually through this inframammary crease so an incision in the crease and if somebody's very slim if you now just this cross-section here that's the ribs that's the muscle your pec muscle which is dep depicted here in this cartoon and then the breast tissue so if the tissue that you have in the upper half is very thin and you can see your ribs then it's a good idea to have the implants partially under the muscle known as dual plane because otherwise you can see the edges and folds so for a smoother more natural look it's probably a good idea to have partially under the muscle or dual plane over here and implants as you know they can be teardrop or they can be round I’m going to show you a couple of pictures and then we'll talk a little bit more about the long-term problems of breast implants as well there's a question about risks of on breast reduction I’ll come to the nipple losing sensation in a minute but let's just go back to the augmentation.

So this lady had teardrop implants which are flat at the top fuller at the bottom in the dual plane which means partially under the muscle she had no children so her quality of skin is very different it's a tight skin envelope and obviously when one has not had any children you need to be a little bit more sort of you need to consider a moderate or a modest increase rather than going too large because if you go too large very quickly well it's like putting a 9-month old baby into somebody's stomach this collagen just breaks and then you end up with loads of stretch marks which can be quite distressing.

This lady had three children and she had implant round implants put under them in the dual plane partially under the muscle so I’m just going to mention here couple of things about implants long-term implant problems we've talked about ruptures leaks capsular contracture but there's also the fact that if you can see your ribs you'll be able to see or feel the edges of the implants especially near the scars on the sides and if it's put on top of the muscle then potentially even in the upper part of the breast now you may have read and I think it was in the tabloids in the daily mail some years ago about implants causing breast cancer they don't cause breast cancer in fact we use implants for breast reconstruction after mastectomy but they do cause or is a causative factor for a for an uncommon type of cancer of the immune system known as anaplastic lymphoma and there are about 1,600 cases worldwide and one got one has that usually the breast becomes quite large one side five six years down the line and if there's fluid that fluid has to be sent for looking under the microscope and if it's positive for lymphoma cells then the lining capsule implant everything has to come out and sometimes one requires chemotherapy and in the same manner there is an aggressive form of that of which there's only 30 cases worldwide called squamous cell carcinoma we don't know very much about that one and you may have read on the patient forums about breast implant illness which is where some women feel a lot of the problems they're getting is from breast implants things like fibromyalgia multiple joint pain feeling tired all the time hair loss memory loss there's no diagnostic test itself s diagnosed by ladies and then they often request for the implants to be removed I’ve shown you pictures of uplift and I’ve shown you pictures of implants so what if someone needs an uplift because the nipples are very south but also requires volume to give it that to restore the volume.

So this lady the breasts have emptied out the areola are quite large she obviously requires an uplift but ideally she would like some volume so she's had implants placed partially under the muscle with an uplift performed on top and the same with this lady as well I’m showing you this picture because this is a reconstruction patient she's born with a symmetry which is one side which is too small and the other side is quite large and I’ve done a combination of these where on the left side she's got an implant and on the right in the left breast and on the right breast she's had an uplift with a small implant put in so to even things up so anybody who has an uplift with an anchor with a scar round the nipple or a breast reduction for example the risks are that you may you will lose sensation in the nipples and whatever sensation you have at the end of six months to a year you're going to end up with that in the long term and what about breastfeeding so if someone has a breast reduction where a lot of that tissue is removed then I say to my ladies if you have very strong feelings about wanting to breastfeed then I would suggest that you complete your family for bonding purposes with the baby and defer the surgery until breast reductions complete until beg your pardon until the family's complete and then have breast reduction so with breast reduction yes you will lose sensation in the nipples how much you'll end up with on either side I don't know it's whatever you end up with at the end of six months to a year and breastfeeding we've discussed and then the final thing with implants for example is that yes you can still have screening mammograms you just have to tell the mammographer you've got them in place and they do special views to make sure they can visualize the tissue with breast reduction it makes no difference to screening mammograms I’m going to move on so some ladies we can do a combination which is to put implants and uplift and it's not in just those ones where the breast may have emptied out.

This young lady had something called tubous deformity and a bit of asymmetry so she's had implants with an uplift uh performed all in one go so you can sort of make them a little bit more equal I mean most of women and I think the same says for Kate and for me you know one side might be slightly larger and one slightly smaller but that's within the variation you find in most women so I can never give you a pair of twins up there I can give you a pair of close sisters I can never make them identical now as part of this I thought I’d put in this as well which is nipple inversions some patients have inversion for years and years and it's all been investigated but if you ever have a new inversion inverted nipple suddenly happening then you must see your GP and get referred to the breast screening unit because that could be an indication for potentially breast cancer changes within that breast so any retraction and inversion but if someone like this lady has had inverted nipples for several years and there are various grades if they come out on their own that's fine but if they remain inverted sometimes keeping them clean is very difficult they end up you know sort of collecting stuff and get a bit smelly in the depths of the inverted bed so it's easy enough then to do this op usually under general anaesthetic takes about 60 minutes half an hour per side to actually do this operation to get them out and the problem with this is that sometimes they do retract again so you have to wear this dressing for a couple of weeks afterwards somebody's asked me can you make the nipples smaller as part of a breast reduction and uplift when I say nipples smaller we need to make sure that we know what we're what we're trying to get at here nipple is the knobbly bit in the middle and the aerial is the brown bit around so if the aerial is very large it's like I mentioned earlier you can make that smaller by reducing the diameter of the areola but a nipple which is the bit that pokes out generally if that's really large yes you can make it smaller but majority of women don't opt to have that done it's relatively uncommon so I hope that answers the question that one of you have put on that we come to male breast reduction so what I say to the men who come for wanting their breast reduced to me on what's known as gynecomastia all men and all women have breast issues some women have very little and they may wish to therefore increase the breast volume or restore it by having implants some women have too much and therefore you may wish to have a reduction to improve the symptoms of neck egg back egg all men have breast tissue as well some men have too much and then they find it visually embarrassing and it shows under clothes and therefore they may wish to have it reduced.

Now if you have teenage boys a lot of teenage boys including my own son actually that everybody dur going through the hormonal changes during puberty all girls and boys will have breast growth but majority of the boys a lot of that breast growth the puffiness the nipple in the nipples the breast tissue underneath or gynaecomastia as it's called will reduce and become almost normal by the time they are 20 21 so for a lot of young men who come I say look if it's still there when you're when you're 21 or so then come back but you know you may save yourself an operation if you just wait a bit longer but when it's still there and it's not gone then it depends on the type of breast tissue there is if it's soft flabby fatty sort of breast tissue then you can just do liposuction like this young man here where here he's got sort of an a to small b cup and I have liposuction it like you would normally liposuction fat anywhere and reduce the size and obviously the success of liposuction depends on the ability to shrink of the skin to shrink back so it's better in younger people where the skin does has that elasticity for it to shrink back and one has to wear a vest for about six weeks or so like a lyra vest to help with that this young man on the other hand he has got a lot more and when I felt the breast tissue it was almost like a gristle ball behind the nipple which no matter how much you liposuction isn't going to come out so in addition to liposuction what I’ve had to do with this young man is do like a little half-moon cut at the junction of the areola the nipple areola and the surrounding skin to take out that gristle ball underneath and leave him with a tiny bit of breast tissue behind there but what you can't do is take every ounce every fat bit out because then it looks really weird the skin and the nipple stuck straight down onto the pec muscle so you do need to leave some tissue behind there for it to look natural this gentleman was actually in his 4s and he always felt embarrassed always used to put a towel over his right breast and that's almost like a be up but if you look at the areola which is the pink bit round the nipple that's much larger than the other side so I used a combination of lip suction made the area a lot smaller so he's got a scar now going right round but to reduce the size and take some excess skin away he has actually got too short horizontal scars on either side so a different procedure for this compared to this side which was just liposuction alone so it depends what is required and therefore it has to be tailored to that patient I think that sort of wraps it up it's sort of been a little bit of a whistle stop one whenever you decide to have any surgery I’ll come to the Q&As again in a moment whenever you decide to have the surgery do check the qualifications it's like I said at the beginning there is no such specialty or training of cosmetic surgery anybody can be a cosmetic surgeon a GP  any specialist can be but to be a plastic surgeon you do need to undergo that training and take that exit exam to become a Consultant after the finishing your training at the end of 18 19 years so check the qualifications they'll usually have FRCS Fellow of Royal College of Surgeons and in brackets clast which says plastic surgery check whether they have affiliations to some of the major sort of they're not really unions but they're memberships of specialist organizations which means there is a certain standard that has been met that they are on the plastic surgery register specialist register on the GMC not just on the General Medical Council register because any every doctor has to be and never ever rush into this type of surgery it's not life-saving surgery it's quality of life improving surgery so you must do your research well and always avoid having the operation I say to my patients at three points in the lifetime one is if there's a bereavement if you're going through a separation or divorce and then if you're in the middle of buying a house because you have to actually move house and do a lot so not in the middle of buying a house but more in the middle of moving a house because there's a lot of stress involved in that so it's just the whole thing is that it's just about choosing a point when you feel you can cope with the surgery and the stress because these are big operations and very important for the surgeon to understand your goals and what your desired outcomes are because if you if the surgeon understands and you're both on the same page then there is a pretty good likelihood you'll have a happy patient and a happy surgeon at the end but if there's a mismatch then there is obviously room for dissatisfaction and a bit of unhappiness either on one or both sides so important to do that I’ll just take a few more questions and then we'll go I’ve got a couple more slides explaining about what how what the consultation process etc is involved so there's a question about how frequently implants need to place I think I’ve answered that that they need manufacturers say 10 to 15 years but if they haven't ruptured aren't leaking and the capsu contracture which is the hardening around it isn't causing you a problem then you can potentially leave them alone I have another question could you explain the recovery from a reduction I’m 52 and worry if my skin will take longer to heal and I’m still working no you can have surgery whenever you feel but you do need two to three weeks off work you know it depends on your job if you are working from home online then I don't see the problem in you going back to doing your few bit of work online say a few days afterwards but do take at least four five days off because it's a general anaesthetic the 2 and a half hour 3 hour so just give your body a chance to get rid of all the anaesthetic and life to come back to a little bit of stability before you go back to online working if you're traveling into work you won't be able to drive for but I would suggest you don't drive for two weeks so it's a good idea to avoid that but if you're in in a heavy duty job like cleaning lifting heavy things stacking stuff good idea you can go back to work at two weeks but see if they can actually put you on to light work and do somebody else's light job rather than lifting he everything heavier two weeks I wouldn't want you doing hoovering and lifting heavy things for about four weeks or so age is no barrier I showed you a lady that she was she was in her 60s when I did the breast reduction took a kilo off each side so it really depends what symptoms you're getting from the large breast and then some women when they have them done in their 50s and 60s or 70s wish they'd had it done several decades earlier because it just improves your life so much in terms of neck ache back ache but also when you wear clothes they fit you don't get that gaping when you wear a shirt or you have to put little poppers in between buttons you know all of that clothes just fit better and it's easier to find bras that fit you don't have to spend absolutely oodles of money buying them from Bravissimo how do I know if I have good elasticity is another question well elasticity is very much dependent well to some extent on age but it's not really that age dependent depends things that give rise to poor elasticity when sudden weight loss which is significant the skin sort of gets stretch marks on it and when you pick it up it's got that slight crepe feel to it slightly thinned out and you may find that on your breast and the rest of the body is fine or you may find it in certain specific areas so elasticity is easy you know when the stretch marks and it's thinned out that's when you know your elasticity is not brilliant but if it's got no stretch marks it's nice and t skin and elastic as one always presumes that's young skin but not always then you know you've got good elasticity there's a question here I had a reduction 30 years ago and would like to have an uplift now if possible yes it is possible it depends how north that nipple needs to move so where it is on the on the on the on the chest and how much how droopy it is and how much further north we want to move it so it depends on that and depends whether you want to maintain the volume then there are certain techniques possible what you see on the outside is the same scar pattern which is round the nipple vertical and horizontal scar the only caveat I would put here is it depends on your reduction what technique was used because sometimes with an uplift if the nipples moving north a long way and a previous operation happened if we don't know what technique has been used inside the breast then there's an increased risk of the blood supply to the nipple being jeopardized so that's the only caveat I would say and the sensation yes nipple sensation won't come back I think I’ve answered most of the questions on the screen so I’m going to go on to a couple of other things about your consultation when I take it I do go a lot into detail about medical conditions because you know things like diabetes means that you have a slightly higher risk of having wound problems and we have to make sure that the anaesthetic is safe for you so you always have a preassessment with a specialist nurse to gauge the fitness for anaesthesia if you on blood thinners for example that creates a little bit of an issue so I may have to write to your haematologist to see whether we can find an alternative or have a bridging type of blood thinner for the time for the duration of the surgery and in the preoperative meaning period meaning around the time of your surgery psychological suitability is just about making sure that your what your expectations are from the surgery is something I can deliver if I can't deliver your expectations then I’m probably not the right surgeon for you and it's about you know it's just making sure that you have the confidence after the operation you know from what the operation has done for you really if there are significant underlying mental health issues and we do see that a lot in the younger generation like self-harm anxiety dep a lot of patients have anxiety depression that's not an issue but any other things like suicidal attempts or uh personality disorders then it's a good idea for me to involve your treating counsellor psychiatrist into that pathway because then as clinicians we work together to get you from point a to b without then having a spiral down into a problem after the operation because the anaesthetic things can throw you off a little bit and realistic goals obviously so the whole idea is that when I see you the first time I do show you some pictures some of those will be the ones you've seen today there are lots on my own personal website before and afters but you see the photos I give you an information booklet summarizing pretty much all the complications the long-term squally what is involved and then I write to you summarizing everything we've discussed at the consultation including my findings you know like chess circumference d l nipple distance etc and I copy that to your GP  and then if you wanted to go ahead you charge for that consultation but if you wanted to go ahead you do have to come back and see me for a second consultation that consultation is free of charge to you that's for me to make sure you know what you're letting yourself in for because it's all about making sure you're fully informed in this process and that you don't just go in without knowing what is actually involved and especially being prepared for the post-operative period and the potential complications so fully informed so it's a 40-minute consultation written letter and an information sheet to you and a copy of your letter to your GP  time to think cooling off period so important you wouldn't buy a house or a car on the whim of a moment well this is something we're doing to our bodies so we need to make sure it's the right thing for us that we understand the implications for that so I would like you to think it through and that's not just me being difficult or anything it is a general medical council which is our regulator advised that there is a minimum to two weeks sometimes up to four weeks cooling off period before you actually proceed to surgery so the days in the past when you had your consultation and then went ahead and had your surgery the next week we don't tend to do that anymore I haven't done that ever but it's something we don't even at this hospital and then you have your operation and on the whole you have three to four follow-ups which are included in your package price which involves you coming back for your dressings to most of the stitches are dissolving ones and we do the dressings we tell you know change them and then you shower etc all of that is taken care of in your first dressing change and then you come back 6 8 weeks later to see me and then again 3 to four months later I’m a data protection license holder with the information commissioner's office so I will be doing photos on the day of the surgery in the morning and then some at six weeks and three months and therefore your protection and mind and if you fancy it you can have all those photos before and afters on a little USB stick and take them home when your whole process is finished with me and I do involve your GP  like I said if if there are some of you who don't want your GP  involved I’m afraid maybe for the first consultation to see your suitability but if you did proceed with surgery I will insist that the GP  is involved and the reason is very simple if your GP  is not involved then I am holistically responsible for all of your care whereas a GP  is responsible for your whole care meaning you know your whole body whether it's hips knees asthma diabetes whatever whereas I am really responsible just for the bit I’m operating on so it's about joined up so that's why I like to keep the GPs informed of what's happening with you.

I think you want to take over. Kate

Kate Comrie

Perfect thank you very much really interesting so I think we've covered most of the questions but we do have one here so; maybe a silly question, no such thing, front sleeper very good point and worry this would impact recovery if I accidentally sleep on implants?

Miss Anita Hazari

So for most breast surgery or for that matter even for tummy tucks and stuff we would like you sleeping on your back for the first two to three weeks at least and initially you're slightly with a raised head and then you sort of go flat and then after the 3 four weeks period you can go on your side but remember you're going to be wearing a supportive brow or a garment for the first few weeks anyway as far as sleeping on your front is concerned you can do that but not soon after surgery I think you're looking at about two to three months before you can sleep on your front so I hope that answers your question about being a front sleeper. So it may be a question of having propped up lots of pillars behind and next to you sometimes a lot of my ladies find the v pillow really useful that's the one that most have used during pregnancies well I did and it's just useful it just sort of keeps you a bit lined and helps you so that's useful.

Kate Comrie

There's another question how many nights did you say in hospital for a breast reduction?

Miss Anita Hazari

So in my practice usually you come on the morning a surgery you have your surgery stay one night and because I will leave drains in which I normally overnight drains is like a tube attached to a bottle and that's just to drain anything that might be collecting in there overnight next day usually about lunchtime or after that we take them out and go home but this is just as a broad view you know just a general practice but if we find that no you're draining a lot more then you may have to stay in an extra night but that's something I discuss with you and if it's a medical indication then obviously whatever price you're quoted by Benenden it's a package price which means it includes all to do with your surgery your preassessment and all your follow ups.

Kate Comrie

So someone said can I fly 3 weeks after surgery?

Miss Anita Hazari

Well it depends on the surgery you're having it's minor surgery yes you can but there are certain things with all of these operations known as DVT or PE deep vein thrombosis or pulmonary embolism and basically clots in your legs and lungs so I’m afraid with breast reductions and uplift and with implants up implants uplift you're going to get a blood thinning injection that night when you're staying overnight and you also get these calf pumps which pump your calves during surgery and then you get your sexy nylon stockings to stop clots in your legs and lungs I’m afraid you're going to wear them for three to four weeks, so when it comes to short-haul flights before the operation, that's fine, but for long-haul flights, which are over 4 hours, it's advisable not to have long-haul flights for about four to six weeks beforehand because there is an increased risk of you forming clots in your legs and lungs, and the same thing applies afterwards as well if you're having an implant reduction uplift. I don't want you can fly to short hall or somewhere like that but if you're going and sort of laying in the sun sea sand I don't want to I’m a worrier I don't want to be worrying down here thinking my god are the scars okay is the wound okay is something opening up so ideally I want you in this country if possible for about four to 6 weeks 6 weeks ideally after the operation because I see you at a six week period before you fly away on holiday and certainly if you're going for a long haul and going to a really hot country I would advise definitely six weeks in this country before you plan any holidays so just work that around

Kate Comrie

Can you do a breast reduction and tummy tuck at the same time?

Miss Anita Hazari

Indeed you can actually so it lengthens the operation and on the whole as a rule of thumb I’m willing to do maximum two procedures at the same time which is I the breast and the tummy and yes you can have a breast reduction and a tummy tuck but if you have had massive weight loss for example you've gone from something like 20 stone to eight stone then it's a question of where the concerning areas are and what two procedures I can combine because I have to think about the blood supply so I can't combine tummy tuck with this for example because I’m worrying about the blood supply to the skin in between and so it really needs to be tailored to you but straightforward breast production and tummy tuck yes it's done quite frequently. Lovely I think that's all.

Kate Comrie

I hope that was useful thank you. I’m sorry if we didn't answer all of your questions.

Miss Anita Hazari

I think we have actually Kate so if anyone feels that a burning desire to just pop another question feel free like Kate said there's no such thing as a silly question so please do put it on because it's just easier we're just in a forum so we just say it isn't it absolutely that's what we're here to do.

Kate Comrie

Please could we move to the last slide Yeah, sorry, okay, so as I thank you for joining the session, we are offering 50% off your initial consultation using the code as indicated, a call back from your dedicated private patient advisor, and an email tomorrow with a recording of treatment information, loyalty reward points, and updates on news and future events. We would be grateful if you could complete the survey at the end of this session, which will help us shape future events. If you would like to discuss or book your consultation, our private patient team can take your call until 8:00 p.m. This evening, their normal hours are 8:00 a.m. 6:00 p.m. Monday to Friday, using the number on the screen in the purple circle, our next webinar is on varicose veins, which you can sign up for via our website. On behalf of Miss Anita Hazari, our expert team at Benenden Hospital. I’d like to say thank you for joining us tonight. We hope to hear from you very soon.