Types of Breast Surgery

Breast Reduction

Breast Reduction

 

What is breast reduction?

 

Breast reduction is an operation whereby breasts are made smaller by removing breast tissue and then reshaping the breast.

Who will the operation help?

As any woman who has very large breasts can tell you, large breasts cause significant problems. They can cause severe ache in the back, neck, shoulders and in the breasts themselves. The shoulder straps from bras dig in to such an extent that they create permanent grooves over the shoulders. In warmer months a sweat rash often develops beneath the breasts.

In addition to these functional problems ladies with large breasts encounter social difficulties. It is usually impossible to buy clothes “off the peg” as they need much smaller tops than bottoms and choice of clothes is usually limited. Exercise is usually severely limited due to heavy breasts bouncing, whilst self-consciousness often prevents activities such as swimming. One particularly irritating effect of large breasts is unwanted sexual attention. Men often talk to large breasts rather than making eye contact, or pass rude comments. As a result women with large breasts will often keep themselves overweight, preferring to appear fat rather than being slim with obviously large breasts.

A breast reduction operation may improve or solve all of the above problems. In several recent studies looking at the improvement in quality of life of all surgical procedures undertaken in the NHS (including open heart surgery, cancer operations, hip and knee replacement surgery amongst many others) breast reduction surgery came out top. It improves your quality of life each year for the rest of your life.

What size will my new breasts be?

The size of breast you will be reduced to is a personal decision, but there are certain limitations that apply. It is very difficult to reduce a very large breast to a very small size (eg to an A or small B cup) as there needs to be some breast tissue left to form a natural breast shape. The most commonly requested cup size is a C cup. However, it is not always possible to exactly predict what size you will end up with and I will ask whether you wish to err on the smaller or the larger side of your ideal cup size.

Is breast reduction available on the NHS?

As a result of the above it is not surprising that many breast reductions are undertaken on the NHS. However, women seeking breast reductions are increasingly being turned down for NHS treatment for financial reasons. At the current time, you should discuss your problem with your family doctor and enquire whether they are still making NHS referrals for breast reduction.

Before and After photos

 

 

 

How is the operation done?

The operation is done under a general anaesthetic (with you asleep). The ideal position for a nipple is level with the crease under the breast. In large breasts, the nipple is often much lower than this ideal position. Therefore, the first thing to do is to move the nipple upwards to its ideal position. The skin of the upper breast is cut to accommodate the nipple, and the nipple is moved with a block of breast tissue in order to keep a blood vessel (and hopefully a nerve) with it, to keep it alive! Once this has been done, a block of skin and breast tissue can be removed in order to make the breast smaller. Following this, you will be sat upright on the operating table to ensure your breasts are of equal size. A drain is then usually placed in each breast which emerges from your skin close to your armpit. The remaining skin is then tailored, trimmed and closed using buried, dissolvable stitches. Your wounds are then dressed and surgical tapes are applied all around your new breasts. The tapes help to support your new wounds and shape your breasts until they have healed a little.

Which incision is best?

                     Anchor scar                                    Vertical scar

Two different scar shapes are commonly used (see picture):

  • The “anchor” scar is the more traditional pattern and is best used for very large breast reductions or for women who are more likely to experience problems with wound healing, due to heavy smoking or problems with their general health.
  • The “vertical” scar is a more recent development designed to result in less overall scarring. A second benefit is that the breast shape is usually more pert and longer lasting. This scar pattern seems to be best for fit, healthy non-smoking women undergoing a more modest breast reduction

For really massive breasts it may be better to completely remove the nipple altogether, undertake a breast reduction using the anchor scar and then graft the nipple back on at the end of the procedure.

How long is the operation?

Breast reduction surgery usually takes about 3 hours

How many days in hospital?

Most women undergoing a breast reduction stay in hospital overnight and go home on the day after surgery. Occasionally the drain bottles may be quite full the next day and may need to stay in for a further day or two, delaying discharge from hospital.

Postoperative period in hospital

When you wake up you will have surgical tapes over your breasts. The operation causes a moderate amount of discomfort and you will receive regular painkillers which should keep you comfortable. You should limit your arm movements and wear your sports bra before being discharged from hospital.

Postoperative Follow Up

After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect your wounds, which may or may not have healed at this time. If they have, you will be given advice on wound care, bathing and exercise advice. If they have not quite healed by this one week visit, she will reapply the dressings and arrange to see you again the following week. Once your wounds have healed you will be given an appointment to see me six weeks after your operation. At this appointment I will check on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.

Will a breast reduction operation cause breast cancer?

Breast reduction surgery does not increase your risk of developing a breast cancer. Any tissue that I remove during breast during surgery is routinely sent to the laboratory to be examined to exclude breast cancer. I shall tell you the results of this test at our 6 week review in clinic.

Will a breast reduction operation affect my ability to feel or detect breast cancer?

Breast reduction will not affect your ability to feel or detect a breast cancer. Your breast will, however, feel different after your operation. You should allow six weeks for the breast to properly heal and then you should start to feel your breast so you get to know how it feels. There will be some internal scarring and lumpiness. This is normal. The important thing to do is to learn what is “normal” for your new breast, and with subsequent regular breast self examination you will be looking for any new change from this “normal”.

What are the possible risks?

All surgery carries the potential for complications. The specific complications that may occur with breast reduction are:

  • Infection; infection is not uncommon with breast reduction and can result in swelling, redness and tenderness at any time up to 3 weeks after surgery. This usually responds well to a course of antibiotics. Occasionally however, it can result in some opening of the wounds. This wound breakdown is not a disaster and is usually managed by regular wound dressing and usually heals in four to six weeks.
  • Bleeding: bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid any strenuous exercise over this time. Arm movements should be limited for the first week. Should a bleed occur into the breast, the breast can swell quite dramatically and you may develop visible bruising and tenderness. If this happens you usually need to return to theatre to have the blood removed and the bleeding stopped.
  • Ugly scarring: although most scars settle very nicely to leave a pale flat line, occasionally scars may become red, raised, wide, itchy or ugly. This is fairly uncommon in breast reduction, but any wound breakdown which occurs in the early postoperative period (particularly of the vertical limb of the anchor scar or the vertical scar) may result in a stretched flat scar.
  • Wrinkling: this is seen almost without exception with the vertical scar technique. The skin under the breast is puckered and very wrinkly for the first six weeks after surgery. This is a necessary part of the operation and happens because we are trying to limit the size of the final scar. After six weeks, these wrinkles will have mostly disappeared to leave a fine scar. In about 5% of cases these wrinkles may persist up to 6-9 months after surgery. If they do not settle after this time, they can be simply cut out in a minor procedure under local anaesthetic.
  • Dog ears: dog ears are small folds of skin which occur at either end of the scar, caused by a natural folding of the skin when the wound is closed. Great care is taken during the operation to avoid producing dog ears, but occasionally (5%) they cannot be avoided. Small dog ears seen in the early postoperative period will eventually settle on their own in the first 6-9 months after surgery. If they do not settle after this time, they can be simply cut out in a minor procedure under local anaesthetic.
  • Nipple loss: One of the worst complications of a breast reduction procedure is complete or partial loss of a nipple. As mentioned above, the nipple is moved on a block of tissue which preserves a blood vessel and nerve, but if this blood vessel becomes kinked or damaged, the blood supply to the nipple will fail and the nipple will die. If this happens, the nipple will become darker and darker and eventually blister and disappear. Fortunately this is a very rare occurrence and only happens approximately once in every 2000 breast reductions
  • Altered nipple sensation; in the same way, the nerve that we try to preserve to the nipple may be damaged at the time of the operation and results in a numb nipple. This is a much more common occurrence. If the nerve to the nipple is damaged, the nipple will be numb when you wake up. About 7 in every 10 women will experience a reduction in nipple sensation, but a few will find their nipples become very sensitive and even clothes brushing against them will be unpleasant. About half of all women who do experience altered nipple sensation will eventually regain some sensation.
  • Breast skin numbness: in a similar way, some women will develop numb patches over the skin of part of their breasts. Again, this usually improves with time, but can occasionally be permanent
  • Asymmetry: no two breasts are almost ever the same, and some degree of asymmetry is common both before and after this procedure and cannot be avoided, it is one of the limitations of any given pair of breasts. Great care is taken to ensure that the two breasts are as symmetrical as possible, but occasionally an unacceptable asymmetry results. If this happens you will be advised to wait for 9 months for all scarring and swelling to settle fully before we reassess the final outcome. At this time you may have to return to theatre to have minor asymmetries of breast volume corrected by a small liposuction procedure or minor asymmetries of nipple position corrected by relocating the nipple under local anaesthetic.
  • Blood clots: occasionally a blood clot may form in the deep veins of the legs (deep vein thrombosis). These clots can have the potential to break off and travel inside the veins into the lungs (pulmonary embolism). Any surgery carries a small risk of causing a blood clot in the leg viens. To reduce the risk of this happening, you will be given surgical compression stockings to wear throughout the first 2 weeks after surgery, special inflating compression devices will be applied to your legs in theatre and worn for the first 24 hours in hospital, and you will be given a daily injection to slightly thin your blood.
  • Fat necrosis: in the same way that a nipple may die, if the blood supply to part of the breast tissue within the breast is damaged during the operation, a piece of breast tissue may die. This usually becomes apparent about 2-4 weeks after the operation. The breast may appear to be healing well, but then a firm, tender lump may develop. This lump of dead fat is called fat necrosis and does not usually require any treatment. It usually settles on its own over the following few months; though occasionally may discharge old liquid fat and fluid through a small hole in the scar on the breast and need regular dressing until this heals on its own.
  • Breast feeding: It is usually not possible to breast feed after a breast reduction procedure because the milk ducts under the nipple have to be divided when relocating the nipple to its ideal position.
  • Drooping: your new breasts should be firm and well shaped. However, with time, these tissues may become lax and the breasts may start to droop. This is just a part of the natural aging of your own tissues but may be helped by wearing a bra to support your new breasts.

Postoperative Advice Sheet

Unequal Breasts

What is breast asymmetry?

A woman's breasts are rarely exactly the same shape and size, but most women are not troubled by minor differences in size/shape. Occasionally however, there may be an obvious difference in breast size which causes distress and embarrassment.

When should I have the operation?

Breast asymmetry is usually apparent early on in puberty. If a small difference in size exists the smaller breast may catch up to match the larger breast and so it is wise to wait and see what happens. The breasts are usually fully developed by about the age of 18. However, if a very large difference exists early on it is unlikely the smaller breast will catch up and you should seek a referral from your GP.

What can be done about it?

There are several options to achieve breast symmetry.

  • Smaller Breast Enlargement: A silicone implant can be inserted into the smaller breast to closely match the volume of the larger breast (see breast augmentation).
  • Breasts Enlargement: If both breasts are rather small, a silicone implant can be inserted into each breast. Placing a larger implant into the smaller breast will result in equal sized breasts.
  • Larger Breast Reduction: The larger breast can be made smaller by either a breast reduction operation or by liposuction. Liposuction offers the advantage of less scarring but the amount of reduction is limited and there is less control of the final breast shape.
  • Breasts Reduction: If both breasts are rather large, they can both be reduced. The larger breast can be reduced more than the smaller breast to result in equal sized breasts. See breast reduction
  • Non-Surgical Treatment: If you do not wish to undergo surgery, a small silicone prosthesis can be made for you which you can slip inside your bra to pad out the smaller breast to achieve a balanced look.

What can be done if I am only 13 but have a very large difference in the size of my 2 breasts?

This is a rare situation, but rather than suffer the embarrassment of growing up with markedly dissimilar breasts, an inflatable breast implant can be inserted in the smaller breast. This device can be inflated on an intermittent basis to maintain breast symmetry during growth of the larger breast. The device is inflated by injecting through the skin into a small port which is buried beneath the skin near the armpit. Once breast development is complete, the device can be exchanged for a simple silicone implant.

Is treatment available on the NHS?

Treatment of breast asymmetry is usually available on the NHS, but only if there is a difference of 2 cup sizes between the breasts eg one breast is a B cup and the other is a D cup. You should discuss this with your GP.

What are the limitations of the procedure?

As mentioned above, no two breasts are ever EXACTLY the same size. The aim of this operation is to get an acceptably close match for shape and volume.

Breast Uplift

What is breast uplift?

Breast uplift is an operation whereby breasts are reshaped. It is a very similar operation to a breast reduction, only the skin is tightened and no breast tissue is removed.

Who will the operation help?

Often as a result of weight loss, having children, breast feeding or just with aging, the breast skin stretches and the breasts sag. This sagginess can be corrected by a breast uplift.

What size will my new breasts be?

As no breast tissue is usually removed, your breasts will stay the same size, but will be reshaped to appear firmer and more pert.

It is very difficult to do a mastopexy on a very small breast (eg an A or small B cup) as there needs to be a certain amount of breast tissue left to reshape into a natural breast shape. If the breast is small and saggy, it may be that a breast augmentation is a better choice. Occasionally, I may recommend a combination of breast augmentation and mastopexy combined. This can carry a higher risk of complications and sometimes it is best done as 2 separate operations 6 months apart. This will be discussed at consultation.

Is breast uplift available on the NHS?

Breast uplift is rarely available on the NHS. The only time it may be considered is for women who have undergone massive sustained weight loss (more that 6 stones weight loss sustained for over a year) and whose breasts have shrunk to form empty, saggy folds of skin.

Before and after photos

How is the operation done?

The operation is done under a general anaesthetic (with you asleep). The ideal position for a nipple is level with the crease under the breast. The first stage is to move the nipple upwards to its ideal position. The nipple has to be moved with a block of breast tissue in order to keep a blood vessel (and hopefully a nerve) with it, to keep it alive! Once this has been done, the skin is lifted off the lower half of the breast and the breast tissue is folded onto itself and reshaped. This is the key step in a mastopexy operation and once the breast tissue has been reshaped it is held in shape using buried, permanent stitches. You will then be sat upright on the operating table to ensure your breasts are of equal size and shape. A drain is then usually placed in each breast (which emerges from your skin close to your armpit). At this stage the skin is redraped over the reshaped breast and any excess skin is carefully tailored and cut off. The skin wounds are closed using buried, dissolvable stitches. Your wounds are then dressed and surgical tapes are applied all around your new breasts. The tapes help to support your new wounds and shape your breasts until they have healed a little.

What shape will my scar be?

You will have a scar around your areola and a vertical scar running down from the centre of this areola scar to the crease under your breast (see picture). In the early weeks the skin under each breast will contain many wrinkles which appear unsightly. Do not worry about this, it is normal. Over the next six weeks these wrinkles will disappear.

How long is the operation?

Mastopexy surgery usually takes about 2-3 hours

How many days in hospital?

Most women undergoing a mastopexy stay in hospital overnight and go home on the day after surgery. Occasionally the drain bottles may be quite full the next day and may need to stay in for a further day or two, delaying discharge from hospital.

Postoperative Period in Hospital

When you wake up you will have surgical tapes over your breasts. The operation causes a moderate amount of discomfort but you will receive regular painkillers which should keep you comfortable. You should limit your arm movements and wear your sports bra before being discharged from hospital.

Postoperative Follow Up

After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect your wounds, which may or may not have healed at this time. If they have, you will be given advice on wound care, bathing and exercise advice. If they have not quite healed by this one week visit, she will reapply the dressings and arrange to see you again the following week. Once your wounds have healed you will be given an appointment to see me six weeks after your operation. At this appointment I will check on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.

Will a mastopexy operation cause breast cancer?

Mastopexy surgery does not increase your risk of developing a breast cancer.

Will a mastopexy operation affect my ability to feel or detect breast cancer?

Mastopexy will not affect your ability to feel or detect a breast cancer. Your breast will, however, feel different after your operation. You should allow six weeks for the breast to properly heal and then you should start to feel your breasts so you get to know how they feel. There will be some internal scarring and lumpiness. This is normal. The important thing to do is to learn what is normal for your new breast, and with subsequent regular breast self-examination you will be looking for any new change from this normal.

What are the possible risks?

All surgery carries the potential for complications. The specific complications that may occur with a mastopexy are:

  • Infection: Infection is not uncommon with mastopexy and can result in swelling, redness and tenderness at any time up to 3 weeks after surgery. This usually responds well to a course of antibiotics. Occasionally however, it can result in some opening of the wounds. This wound breakdown is not a disaster and is usually managed by regular wound dressing and usually heals in four to six weeks.
  • Bleeding: Bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid any strenuous exercise over this time. Arm movements should be limited for the first week. Should a bleed occur into the breast, the breast can swell quite dramatically and you may develop visible bruising and tenderness. If this happens you usually need to return to theatre to have the blood removed and the bleeding stopped.
  • Ugly Scarring: Although most scars settle very nicely to leave a pale flat line, occasionally scars may become red, raised, wide, itchy or ugly. This is fairly uncommon in mastopexy, but any wound breakdown which occurs in the early postoperative period (particularly of the vertical limb of the anchor scar or the vertical scar) may result in a stretched flat scar.
  • Wrinkling: This is seen almost without exception; the skin under the breast is puckered and very wrinkly for the first six weeks after surgery. This is a necessary part of the operation and happens because we are trying to limit the size of the final scar. After six weeks, these wrinkles will have mostly disappeared to leave a fine scar. In about 5% of cases these wrinkles may persist up to 6-9 months after surgery. If they do not settle after this time, they can be simply cut out in a minor procedure under local anaesthetic.
  • Dog Ears: Dog ears are small folds of skin which occur at either end of the scar, caused by a natural folding of the skin when the wound is closed. Great care is taken during the operation to avoid producing dog ears, but occasionally (5%) they cannot be avoided. Small dog ears seen in the early postoperative period will eventually settle on their own in the first 6-9 months after surgery. If they do not settle after this time, they can be simply cut out in a minor procedure under local anaesthetic.
  • Nipple Loss: One of the worst complications of this procedure is complete or partial loss of a nipple. As mentioned above, the nipple is moved on a block of tissue which preserves a blood vessel and nerve, but if this blood vessel becomes kinked or damaged, the blood supply to the nipple will fail and the nipple will die. If this happens, the nipple will become darker and darker and eventually blister and disappear. Fortunately, this is a very rare occurrence and only happens approximately once in every 2000 mastopexies.
  • Altered Nipple Sensation: In the same way, the nerve that we try to preserve to the nipple may be damaged at the time of the operation and results in a numb nipple. This is a much more common occurrence. If the nerve to the nipple is damaged, the nipple will be numb when you wake up. About 7 in every 10 women will experience a reduction in nipple sensation, but a few will find their nipples become very sensitive and even clothes brushing against them will be unpleasant. About half of all women who do experience altered nipple sensation will eventually regain some sensation.
  • Breast Skin Numbness: In a similar way, some women will develop numb patches over the skin of part of their breasts. Again, this usually improves with time, but can occasionally be permanent
  • Asymmetry: No two breasts are almost ever the same, and some degree of asymmetry is common both before and after this procedure and cannot be avoided, it is one of the limitations of any given pair of breasts. Great care is taken to ensure that the two breasts are as symmetrical as possible, but occasionally an unacceptable asymmetry results. If this happens you will be advised to wait for 9 months for all scarring and swelling to settle fully before we reassess the final outcome. At this time you may have to return to theatre to have minor asymmetries of breast volume corrected by a small liposuction procedure or minor asymmetries of nipple position corrected by relocating the nipple under local anaesthetic.
  • Blood Clots: Occasionally a blood clot may form in the deep veins of the legs (deep vein thrombosis). These clots can have the potential to break off and travel inside the veins into the lungs (pulmonary embolism). Any surgery carries a small risk of causing a blood clot in the leg viens. To reduce the risk of this happening, you will be given surgical compression stockings to wear throughout the first 2 weeks after surgery, special inflating compression devices will be applied to your legs in theatre and worn for the first 24 hours in hospital, and you will be given a daily injection to slightly thin your blood.
  • Fat Necrosis: In the same way that a nipple may die, if the blood supply to part of the breast tissue within the breast is damaged during the operation, a piece of breast tissue may die. This usually becomes apparent about 2-4 weeks after the operation. The breast may appear to be healing well, but then a firm, tender lump may develop. This lump of dead fat is called fat necrosis and does not usually require any treatment. It usually settles on its own over the following few months; though occasionally may discharge old liquid fat and fluid through a small hole in the scar on the breast and need regular dressing until this heals on its own.
  • Breast Feeding: It is usually not possible to breast feed after a mastopexy procedure because the milk ducts under the nipple have to be divided when relocating the nipple to its ideal position.
  • Recurrence of Drooping: Your breasts drooped before surgery because the skin and tissues became lax. The mastopexy operation tightens up the skin and tissues but there remains a possibility that, with time, these tissues may become lax again and the breasts may start to droop again. This is just a part of the natural aging of your own tissues but may be helped by wearing a well fitting bra to support your new breasts.

Postoperative Advice Sheet

Male Breast Correction

What is gynaecomastia?

Gynaecomastia (female breast) is a condition in which men develop a female breast.

Why does gynaecomastia happen?

When children are born, male and female children both have a nipple and a small pad of tissue underneath the nipple called the breast plate. This breast plate is sensitive to circulating hormones and will enlarge when the hormone oestrogen is present. In females at puberty, oestrogen circulates and a breast develops. In males at puberty, both oestrogen and testosterone circulate and usually no breast develops, but the breast plate often swells a little and may become tender. This slight enlargement lasts for a year or two and then settles. It does not usually require any treatment.

Occasionally, however, either an abnormally high oestrogen level occurs in boys OR the breast plate may be abnormally sensitive to oestrogen and a breast develops in males.

What should I do if I think I have gynaecomastia?

In the first instance you should contact your family doctor who will need to rule out an underlying cause for this condition. There are many possible causes. Once all possible treatable causes have been dealt with, the gynaecomastia may disappear on its own. If there are no identifiable causes, we can then treat the breast itself.

What if I am overweight?

Obese males often develop fat deposits which resemble breasts. Losing weight will usually result in these breasts disappearing. As all surgery is potentially dangerous, it is far better to lose weight by a combination of diet and exercise than undergo an operation to remove fatty breasts from an obese person. However, some people find that despite losing weight, the breasts persist. After careful examination to exclude other causes, these breasts can then be treated as above.

How do you treat gynaecomastia?

There are two main surgical options to reduce the breast.

1. Liposuction: The simplest surgical method to treat the breast is to use liposuction to suck out the breast tissue and fat. The skin will usually retract to take up the slack. This results in the least scarring and probably offers the best cosmetic outcome in most cases.

Very big breasts can be treated with liposuction, but it may take several procedures, six months apart, to allow the skin time to retract between treatments. Occasionally the skin does not retract fully and the excess skin has to be surgically removed. This can result in unsightly scars. Occasionally the breast tissue is so firm that liposuction cannot break it up. If liposuction fails the next treatment option is to try open surgery.

2. Surgery: A small incision is made around the bottom half of the areola (see picture) and through this hole, the entire breast plate is cut out.

Is gynaecomastia treatment available on the NHS?

Gynaecomastia treatment is usually available on the NHS. However, in some areas funding is no longer available. You should discuss this with your GP.

                                                           Before                                      After

How is the operation done?

Surgical excision of gynaecomastia is done under general anaesthetic (with you asleep). The extent of the breast tissue is marked out on your skin with a pen, and then a small incision is made around the bottom half of the areola and through this hole, the entire breast plate is cut out. A small drain is inserted into the resulting space which emerges from the skin close to the armpit. The incision is closed with buried dissolvable stitches and surgical tapes applied. Finally the skin is taped into position to encourage it to shrink up and stick, and to prevent any fluid from accumulating in the spaces where the fat has been removed. A tight elasticated pressure garment is then put on over the surgical tapes to add further compression.

Alternatively the breast fat/tissue can be removed by liposuction via a small (less than 1cm) incision placed on the side of the chest wall. Again, this is done under general anaesthetic. After the procedure the small wound is closed with a buried dissolvable suture and the skin is taped to the chest wall and further supported with a tight elasticated garment.

What are the limitations of the procedure?

Occasionally the breast may be very large and the skin may not fully retract to take up the slack. In this case, this excess skin may have to be surgically removed which may results in unsightly scarring.

How long is the operation?

Surgical excision of a gynaecomastia takes 1 hour.

How many days in hospital?

You would normally stay in hospital overnight, and provided the drain is not producing too much fluid, the drain is removed the following day and you may go home.

Postoperative Follow Up

After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect your wounds, which may or may not have healed at this time. If the wounds have healed you will be given advice on wound care, bathing and exercise advice. If they have not quite healed by this one week visit, she will reapply the dressings and arrange to see you again the following week. Once your wounds have healed you will be given an appointment to see me six weeks after your operation. You should continue to wear your pressure garment until you see me. At this appointment I will check on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.

What are the possible risks?

Any surgery has the potential for complications. Although gynaecomastia is generally a very safe operative procedure, it does carry the following risks:

  • Infection: Infection is a fairly rare complication and can result in swelling, redness and tenderness either spreading out from the stab incision scar or may develop anywhere over the liposuctioned area at any time for up to 3 weeks after surgery. This usually responds well to a course of antibiotics.
  • Bruising: Bruising almost always happens with liposuction and should be considered inevitable. The bruising may range from very minor to black and blue. It usually settles within 2-3 weeks.
  • Bleeding: Bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid any strenuous exercise over this time. For the first week after surgery you should try to limit movements at the liposuction site. Should a bleed occur under the skin, the area may swell quite dramatically, it can be quite painful and tender. If this happens you may need to return to theatre to have the blood removed and the bleeding stopped.
  • Ugly Scarring: The small incisions will initially be red and a little thickened for the first six months or so, but will eventually settle very nicely to leave a thin, pale, flat scar which is well hidden at the edge of the areola. Occasionally however, scars may become red, raised, wide, itchy or ugly. This is fairly uncommon.
  • Numbness: The nerves to the skin can be stretched or even cut during the operation resulting in numbness of the overlying skin. This is quite common and it usually recovers, though there is a small chance that a small area of numbness may be permanent.
  • Seroma: Occasionally fluid can collect in the area beneath the breast skin. This results in a bulge or swelling. It is treated by inserting a needle and sucking the fluid out, though it may recur and can take several months to settle. This seroma may lead to internal scarring and create ugly folds and irregularities in the overlying skin. To reduce the risk of a seroma, you should wear the compression garment for the first 6 weeks after surgery.
  • Irregularity: Great care will be taken to ensure the remaining fat is left smooth to form a natural contour. However, internal scarring, seroma formation, bleeding etc can result in irregularity and unevenness at the operation site. This is difficult to correct, but deep massage over several months may help to smooth it out.

Postoperative Advice

**PIP implants - INFORMATION**
PIP Breast Implants - Information

Firstly I would like to reassure all of my patients that I have never, ever used PIP breast implants. Therefore if I undertook your surgery then you do not need to be concerned about the adverse publicity surrounding these PIP implants.

Secondly, the recent adverse publicity refers ONLY to PIP implants. All other breast implants are safe.

The implants that I have used are all excellent implants with proven safety records. As I discussed with you at our pre-operative consultation, rupture is extremely rare and there are no long-term health risks associated with normal silicone implants.

 

PIP implants: the problem

Poly Implants Prostheses (PIP) implants were made by a French manufacturer. Initially these implants were manufactured to an acceptable level, but it appears that due to economic pressures, the company made a decision to make them to a lower standard. It appears that these changes were made some time in 2001. There appear to have been two significant changes in the manufacturing process:

1. The outer shell initially comprised a multilaminar silicone, but the outer protective layer was omitted, rendering the implants more likely to rupture.

2. At the same time, the gel filler was changed from medical grade silicone to cheaper, industrial grade silicone containing Baysilone (a fuel additive), Silopren and Rhodorsil (both used in the production of rubber tubing).

 

Thus, these implants rupture far more frequently than other silicone implants, and the leaking gel appears to be more irritant than the extremely inert medical-grade silicone.

As long as 5 years ago, reports started to appear in the Plastic Surgical Journals that these PIP implants had an increased risk of rupture and most plastic surgeons avoided them.

These implants were finally withdrawn from use on 31st March 2010.

What happens when an implant ruptures?

When a breast implant is inserted into the body, the body creates a thin wall of scar tissue all around the implant. This wall of scar tissue is known as a capsule and cannot usually be felt. Rupture of an implant usually causes the capsule to thicken and shrink down on the implant; known as a capsular contracture. This capsular contracture changes the shape of the implant and makes it feel harder. With time the breast may distort in shape and become painful. Pain is often limited to the breast itself, but the pain may be poorly localised and may even radiate to the chest wall and down the arm.

If the silicone leaks out of the implant and the surrounding capsule, the body usually identifies the free silicone rapidly and forms a wall of scar tissue around it so that it forms a lump of scar tissue and silicone; a silicone granuloma. This usually presents as lumpiness around the hardened implant. These lumps may or may not be tender.

Some silicone may be absorbed into the lymphatics around the implant capsule and these lymphatics carry the free silicone to the armpit, where the silicone collects in the glands (lymph nodes). These glands swell up and if the silicone is irritant, then this may cause pain, which may radiate down the arm.

The following case demonstrates a ruptured PIP implant in which silicone has migrated to the armpit glands (lymph nodes):

 

Figure 1. A PIP implant which has been removed from the right breast via the original scar. The implant that has been removed is shown contained within the ?capsule? of scar tissue, which the body has formed around the implant. Note, the right breast is smaller, but of a normal shape ? it is acceptable to leave the implant out and close the incision at this stage if the patient is happy to lose her implants. Alternatively, a new implant can safely be inserted into the pocket in the breast at this stage.

 

 Figure 2 . The capsule has been removed, revealing a large tear in the shell of the implant. Some of the silicone filling is missing.

 

Figure 3. The right armpit glands (lymph nodes) are enlarged with silicone. As they were painful, they have been removed via a separate incision in the armpit. Note that a new implant has been inserted into the right breast and the wound closed and dressed.

 

What should I do if I have PIP implants?

1. Firstly, do not panic. There is no urgent need to have these implants removed immediately ? they do not pose an immediate health concern.

2. Secondly, you should confirm whether you have PIP implants or not. Contact the surgeon or clinic who did your operation and they will provide you with this information.

3. Thirdly, if you do have PIP implants, and they are currently causing you problems (ie hardening, distortion of the breast, pain or evidence that they are leaking) then you should arrange to see a surgeon promptly to discuss removal of the implants.

4. Fourthly, if you have PIP implants but they are not causing any problems then there is mixed advice:

4.1. The current UK government position on PIP implants is that there is no need for removal of these PIP implants, unless they are causing problems.

4.2. The French government position on PIP implants is that, regardless of symptoms, these implants are substandard and should be removed.

4.3. My personal opinion is that these implants should be removed. The reasons for this are: they are substandard; they have a high risk of rupture (the consequences of which can be significant); and they contain non-medical grade silicone which, although is probably inert is not specifically manufactured for use in the human body and so should be removed.

 

How can these implants be removed?

Simple removal of PIP breast implants is a relatively safe, straightforward procedure. The old scar is opened and the implant and ?capsule? are removed together. It is a personal decision upon whether you wish to receive a new, safer implant, or would prefer to avoid implants altogether. This could also be considered an opportunity to change the size of your implants if you wish.

If you have painful silicone granulomas or lymph-node enlargement, then the operation may be a little more involved. I will discuss this with you in more detail if necessary at the time of your consultation.

Who should pay for implant removal?

There is much debate at the current time about who is responsible for paying for corrective surgery. The PIP company has gone into liquidation. Over 300 patients are being represented by a lawfirm and are attempting to recover costs. The clinics which inserted the implants are denying responsibility because they bought the implants in good faith from the manufacturer. I would recommend that in the first instance you appeal to the clinic where you received your implants in the hope that they will be prepared to undertake corrective surgery free of charge. If this fails, then you have 2 options:

If your implants are causing problems, then you are eligible for NHS surgery to remove the implants and thus alleviate your pain or discomfort. However, the NHS will not replace the implants for you ? so you will return to your pre-enlargement state.

If you do not have implant-related problems but are (understandably) keen to have the implants removed and exchanged for good quality implants then, at the current time, you will need to fund this operation for yourself in the private sector. I would urge you to visit an expert plastic surgeon to discuss this procedure. If you wish to arrange a consultation with me then you can contact Jude on 0121 361 8008. If you would prefer to find a suitably qualified surgeons in your own area then I would advise you to visit either SaferCosmeticSurgery (SCS) or the British Association of Aesthetic Plastic Surgeons (BAAPS) websites.

Breast Enlargements

What is breast enlargement?
Breast enlargement is an operation whereby breasts are made larger by inserting an implant into them.

Who will the operation help?

Breast enlargement is a good operation for women who:

  • have never really had any breast tissue
  • have had larger breasts at one time, but due to weight loss or childbirth have been left with small saggy breasts;
  • are not happy with the shape of their breasts;
  • simply would like bigger breasts.

What are implants made of?

There are two main types of breast implant:

1. Silicone Implants: consist of a silicone shell (outer wall) filled with silicone gel. The gel in modern silicone implants is thick, so that if the implant is cut or ruptured the gel stays together and does not run or leak everywhere. Silicone implants can be either round or teardrop shaped (see picture): 1. Round implants are a good choice if you already have enough breast tissue to give you a good breast shape. 2. Teardrop shaped implants are a good choice if you have very little breast tissue and you need the implant to shape your breast.

For more information on silicone implants click here.

2. Saline Implants: consist of a silicone shell filled with saline (salt water). These gained popularity during the early 1990's when there was a lot of misinformation regarding the safety of silicone implants (see below). However, they do not feel as realistic as silicone implants and have a tendency to leak slowly which results in a wrinkling of the silicone shell and visible ripples in the breast.

What size implants should I have?

The size of implants you receive is a very personal decision, but there are certain limitations that apply. As a general rule with breast augmentation, the bigger you go the more un-natural the appearance of the breast becomes. Some women opt for small, natural looking breasts whilst others prefer larger ones which may appear enhanced.

If you have never had much breast tissue, the skin of the breast is usually a limiting factor and will only stretch to accommodate a modest sized implant before starting to look enhanced, whilst if you have lost a lot of breast tissue (after breast feeding or weight loss for example) you may need quite a large implant to restore shape and take up the slack. Alternatively you may prefer to have a modest sized implant and combine this procedure with a surgical tightening of the skin (breast uplift).

We will decide upon the ideal implant for you together at the time of the first or second (free) consultation. You should bring with you a sports bra of the size that you aspire to fill. You will also need this sports bra after the operation to support your new breasts for comfort for the first few weeks after surgery. I would recommend that you buy either a Marks and Spencer's sports bra (Impact factor 3) or a Berlei Shock Absorber (Impact factor 3). The chest girth will need to be the same as the bra that you usually wear, but the cup size will vary according to what you would like to be. For example if you currently wear a 34A bra but wish to become a C Cup, you should bring a 34C sports bra with you to your initial consultation. I will then undertake measurements of your actual and ideal dimensions. You will then put on the sports bra and we will insert a range of implants of varying size until you find one that best gives you the figure you want. You can try to do this yourself at home by filling a freezer bag with dried rice until you get the shape and size you desire. The volume of rice in the bag can then be measured using a kitchen measuring jug.

How is the operation done?

Under general anaesthetic a small incision about 4cm long is made in the crease underneath the breast. A pocket is created either immediately behind the breast tissue, or underneath the muscle behind the breast. This pocket is made using an electric scalpel which results in very little or no bleeding and minimises pain as the tissues are not unduly stretched or torn. The implant that has been chosen and agreed upon before the operation is then inserted into the pocket and the operating table adjusted so that you are sitting upright. This allows me to accurately determine the correct position of the implants and ensures the best shape and symmetry. I do not usually use drains but if there has been any bleeding or oozing from your breast tissue during the operation I will place a single drain which will emerge from your skin close to your armpit. The incision is then closed, using three layers of buried dissolvable stitches. The wound is then dressed and surgical tape is applied to accurately define the crease underneath your breast and to gently hold the implant downwards and towards the mid-line (as there is a natural tendency for the implant to move upwards and outwards until it has stuck to the overlying breast tissue).

Which incision is best?

A number of different scar positions have been proposed (see picture):

  • Armpit: The incision can be made in the armpit, but this often results in an implant which sits to high, and there can be troublesome bleeding at the lowermost, innermost part of the breast, which is very difficult to see and control via an armpit incision.
  • Around the Areola: The incision can also be made around the areola (dark circle around the nipple). The problem with this approach is that nipple sensation may be affected and also, there are certain bacteria in and around the nipple which may cause capsular contracture around the implant.
  • Belly Button: Implants can be inserted via a small incision around the belly button, however, only saline implants can be inserted with this method and again any troublesome bleeding is very difficult to control.
  • Under the Breast: For these reasons the incision in the crease beneath the breast is my preferred approach.

Which pocket position should I choose?

 Sub-Glandular                                                                             Sub-Muscular

  • Sub-Glandular: Generally speaking a pocket beneath the breast puts the implant where the breast tissue usually is and results in a more natural appearance. However, if you have very little breast tissue over the implant the edge of the implant can be seen (especially in the upper cleavage area).
  • Sub-Muscular: If you have very little breast tissue and do not want to see the edge of the implant it is best to put the implant under the pectoralis muscle. However, this approach is more painful as the muscle is stretched and the breast shape is a little less natural. Furthermore, the main disadvantage of sub-muscular pockets is that when the "pec" muscle contracts the implants may move or distort the breast shape as shown in these videos:

This video shows a small amount of movement with sub-muscular implants

This video shows quite a lot of movement with sub-muscular implants

This video shows a patient with submuscular implants demonstrating a wide cleavage, and abnormal movement which also induces a double bubble deformity beneath the right breast

This is the same patient as above, but now larger implants have been inserted into a sub-glandular pocket eradicating the wide cleavage, double-bubble deformity and abnormal movement

Before and After Photographs

Sub-Glandular Pockets:

Sub-Muscular Pockets:

How long does the operation take?

Breast enlargement usually takes about 60-90 minutes

How many days in hospital?

Breast enlargement is usually done as a day case procedure i.e. you come to the hospital on the morning of surgery, undergo surgery and go home on the same day. However, some women prefer to stay in hospital overnight and go home on the day after surgery. Furthermore, if a drain is required this will stay in place overnight and provided it has not produced too much fluid, the drain is removed the following morning and you may then go home.

Postoperative Period In Hospital

When you wake up you will have surgical tapes over your breasts. The operation causes a moderate amount of pain and discomfort and you will receive regular painkillers which should keep you comfortable. You should wear your sports bra before being discharged from hospital.

Postoperative Follow Up

After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect the wound, which should have healed nicely. You will be given advice on wound care, bathing and exercise advice.

You will be given an appointment to see me six weeks after your operation. At this appointment I will be checking on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.

What are the possible risks?

All surgery carries the potential for complications. The specific complications that may occur with breast augmentation are:

  • Capsular Contracture: When the implant is first placed into your breast, your body will recognise it as foreign and form a flimsy wall of scar around it to seal it off. Once it has done this your body will forget about it. You will not be able to feel this flimsy wall of scar and it will not cause you any problems. Occasionally however, something will irritate this wall of scar and it will thicken and start to squeeze down on the implant. This will cause the implant to feel much firmer and to change shape and become round, like a tennis ball. As a result, your breast will become firm or even hard, change shape and may become uncomfortable. This is known as a capsule. Capsules happen in about one in twenty breast enlargements. They may occur as early as a few months after surgery or may develop many, many years after surgery. We do not know why capsules develop. They are treated by a further operation, to remove the implant and thick wall of scar and replace it with another implant. Once you have had one capsule there is a slightly higher risk of developing another capsule around this new implant.
  • Nipple Sensation: The breast enlargement procedure can stretch the nerves to the nipple and this can affect nipple sensation. Sixty percent of women experience some alteration in nipple sensation initially. Most of these will experience a reduction in nipple sensation, but a few will find their nipples become very sensitive and even clothes brushing against them will be unpleasant. This altered sensation mostly recovers to normal within six weeks, but about 8% will still have some altered nipple sensation at six months and for some women this may be permanent.
  • Breast Skin Numbness: In a similar way, some women will develop numb patches over the skin of part of their breasts. Again, this usually improves with time, but can occasionally be permanent. As the nerves begin to regain function you may notice occasional sharp shooting pains which could be described as being like a small electric shock. This is a good sign indicating nerve recovery and can continue for up to 18 months after surgery.
  • Infection: Fortunately infection is rare with breast enlargement, but can cause swelling, redness and tenderness up to 3 weeks after surgery. This usually responds well to a course of antibiotics but very infrequently the infection can spread around the implant. If this happens, the implant may have to be removed completely and left out for several months until the infection is entirely eradicated before a new implant can then be inserted.

Once you have had breast enlargement it is a wise precaution to ask your dentist to give you  antibiotics
before any proposed dental treatment

  •  Bleeding: Bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid any strenuous exercise over this time. Arm movements should be limited for the first week. Should a bleed occur into the breast, the breast can swell quite dramatically and you may develop visible bruising and tenderness. If this happens you usually need to return to theatre to have the blood removed and the bleeding stopped.
  • Asymmetry: No two breasts are almost ever the same, and some degree of asymmetry is common both before and after this procedure and cannot be avoided, it is one of the limitations of any given pair of breasts. Great care is taken to ensure that the two breasts are as symmetrical as possible, but occasionally one or other implant may move slightly and create an unacceptable asymmetry. If this happens you will be advised on massage exercises to try and correct it, but ultimately you may have to return to theatre to have the implant relocated.
  • Ugly Scarring: Although most scars settle very nicely to leave a pale flat line, occasionally scars may become red, raised, wide, itchy or ugly. This is very uncommon in breast enlargement, and is determined more by a persons body tissue than by the surgery itself.
  • Breast Feeding: The ability to breast feed is not affected by having breast implants.
  • Visible Implant: In very thin patients, despite placing the implant beneath the muscle behind the breast, the edge of the implant may still be noticeable beneath the skin.
  • Visible Rippling: The shell of the implant may occasionally form rippling or folds. In the majority of women this will not be noticeable, but in thinner ladies this rippling may be felt or even seen.
  • Implant Rupture: The implants used are extremely durable and rupture due to direct pressure is extremely unlikely. There is a popular myth that ladies with breast implants cannot fly in aeroplanes because their implants may rupture. THIS IS NOT TRUE, it is perfectly safe to fly with your implants, though it is a wise precaution to avoid long-haul flights for about 3 months after surgery due to the slightly elevated risk of economy class syndrome (also known as deep vein thrombosis) in the early postoperative period.

Is breast enlargement available on the NHS?

Generally speaking breast enlargement is not, and should not be, available on the NHS. However, for a small number of women who have never developed any breast tissue; or who have one breast significantly smaller than the other; or who have severely mis-shapen breasts, it is possible to have breast implants inserted on the NHS.

Postoperative Advice after breast augmentation

Inverted nipples

What is a inverted nipple?

Inverted nipples is when one or both nipples are pulled into the breast so they create a dimple or crease. This is usually caused by a short milk duct which prevents the nipple from jutting out as it normally would. Mostly, inverted nipples are simply a cosmetic issue, but occasionally they can become sore or infected.

Correcting an inverted nipple

An inverted nipple can be corrected by a simple operation which divides the shortened milk duct and allows the nipple to jut out fully. If all of the milk ducts need to be divided, this may impair your ability to breast feed. This simple procedure can be done under either a local or general anaesthetic depending upon your own preference.

A word of caution: If a nipple becomes inverted over a short period of time (weeks or months), this needs to be taken seriously as it can occasionally be caused by a breast cancer. In this event, you should visit your family doctor and discuss it with them.

Gender Reassignment Chest Surgery

What is gender reassignment surgery?

Chest surgery is the commonest surgical procedure sought by transitioning men. The aim is to remove the breasts, recontour the chest to a male shape and reduce and reposition the nipples. There are a number of surgical options for achieving these goals. The final choice of scar pattern needs to be decided on an individual basis, and I will discuss the pros and cons of these at consultation.

The main choices for scar pattern are:

  • Double Incision: This is the best choice for moderate or larger breasts and results in a scar in the crease line under the breast and another scar around the nipple. Variations in the exact position of the larger scar can be discussed and decided upon at preoperative consultation.
  • Peri-Areolar Incision: Generally speaking, this is the best choice for small breasts, where not much breast skin has to be removed. This results in the smallest scars, but these scars are at greatest risk of becoming stretched or becoming thick, red and itchy.

This is the video diary of one of my patients who has put together a fascinating contemporaneous account of his journey through transition with hormones and chest surgery.

Further information is available at:

http://groups.yahoo.com/group/FTM-UK/

http://www.ftmguide.org/chest.html

http://www.transbucket.com/