Kate Comrie

Good evening. We're just going to wait a few more, about 30 seconds, for everyone to join.

Okay, good evening, everyone. Welcome to our webinar on breast enhancement surgery. My name is Kate, and I'm the Clinical Nurse Specialist in Plastics and Cosmetic Surgery here at Benenden Hospital. Our expert presenter tonight is Consultant Plastic Reconstructive and Aesthetic Surgeon, Mr Simon Mackey, so this presentation will be followed by a question-and-answer session. If you would like to ask a question during or after the presentation, please do so by using the Q&A icon, which is on the bottom of the screen. This can be done with or without giving your name, but please note that this session is being recorded. If you do provide your name, if you would like to look into your consultation, we will provide contact details at the end of the session. I'll now hand it over to Mr Simon Mackey, and you'll hear from me again a bit later on.

Mr Simon Mackey

Alright, well, hello, good evening, so I'm Simon Mackey. I'm a Consultant Plastic Reconstructive Surgeon specializing in cosmetic and reconstructive breast surgery, so I'm just going to run through a few different things this evening, just have a chat about my experience a little bit, and then we'll talk about breast augmentation and some of the options that you might include with a breast augmentation. the surgical process and how we run things at Benenden Hospital, and then a little bit about postsurgical recovery and risks and complications, so there's an awful lot more to go through with any of these procedures, and actually, there is no substitute for a face-to-face consultation and a careful assessment of your needs, and you know your physical attributes to try to plan the ideal procedure for you, so I've been a full-time consultant plastic surgeon since 2012. I've actually been in plastic surgery since 2002 and had quite a wide training in the UK in cosmetic and reconstructive surgery, so people often come in asking for a breast oration or for a boob job.

This is the common sort of phrase people will use, and part of any of these procedures is actually trying to figure out what exactly it is that you want, so whether or not you want to make your breast larger, in which case you may consider breast augmentation, which is a breast enlargement using silicone implants. whether or not your breasts have dropped, possibly after pregnancy or breastfeeding, and actually what you really need is a mastopexy procedure to lift the nipple position, tidy up some of the loose skin, and reposition the breast tissue on the chest. Whether or not you would benefit from a breast uplift but also want to have an enlargement, in which case an implant mastopexy or augmentation mastopexy would be the preferred procedure, some people actually really want to have a breast reduction and that's why it's important to really go through what exactly it is that you're hoping to achieve from surgery because a breast enlargement would clearly be the wrong thing for you then and then many people come to see me having had implants put him years ago with possible complications or long-term consequences of breast implant surgery which can include capsule which is tough scar tissue that form around an implant and that may need to be managed with a capsulectomy and an exchange of implants or you may have discovered you have a ruptured implant in which case it needs to be exchanged or you might have reached a time in your life where you decide that you no longer le need your implants and actually what you really want is to have them removed and then to make the best of you so maybe then you'd combine that with an uplift as well so Breast augmentation surgery using silicone implants is an extremely commonly performed plastic surgical procedure, but over a million of these cases are performed every year worldwide, so ways of enlarging your breasts are the most common by far. these have been around since the 60s have gone through various iterations of implant style and the implants have generally become safer and more predictable to use some people may find that actually they want only a small amount of fat sorry a small amount of enlargement and might be key to avoid an implant in which case you could consider fat transfer but fat transfer slightly less predictable you can't guarantee that all of the fact that is transferred will actually take and I in my practice tend to use it more as a finessing type procedure so if people have got rippling or a contour defect after a previous procedure then you can use fat taken from elsewhere in the body to try to smooth that off so we' have to have a good chat about what it is really that you're after in terms of implants themselves well they're all silicone they have a silicone shell on the outside which can be smooth or textured and they are advanced an ages and disadvantages of each surface the implants can be shaped so teardrop type implants and they really best suited to people who have an oval shaped breast base so if you've either got a tall narrow breast base or a short wide breast  bas, that's when personally I think about considering a shaped implant. If your breast height and width are the same, then you're probably better suited to a round implant because they can't rotate on your chest, which can look slightly peculiar, and the implants that we use at Benenden are all approved by the medicine's healthcare regulatory authority in the UK. We keep a close eye on implant safety.

In planning breast reconstruction surgery, I think you do need to consider that you will have scars that are completely scarless. Surgery is impossible, whatever some websites may claim, but you can normally hide the scars, so typically, the most common scar pattern for breast implant surgery is a 5 cm scar that just sits underneath the breast, just above the fold, and in that position, you hide it away, so if you're wearing a bra or a bikini, people can't see the scar. The other scar patterns mentioned here are really the scar patterns that you'd use if you're planning to lift the breast as well, so a circum areola scar just goes around the areola itself. a lollipop scar can also be used for a breast uplift and then the anchor shaped scars are the commonest type of mastopexy scar pattern but these are only really considered if you if you really need an uplift so in terms of implant position well we've done our access incision to get the implant into the chest the implant can then sit either just beneath the breast tissue itself which might be beneficial if you if you've got a little bit of additional padding but if you're very slender actually you're definitely better off going underneath the pc major muscle and it just gives you an extra layer of cover between the implant and the outside world and it reduces the chance of you're having visible rippling or wrinkling in the cleavage area which can be unsightly problematic, so breast enlargement surgery is useful for people who have experienced aging or postpartum atrophy, which is loss of volume following breastfeeding or pregnancy. We're seeing an increase in the number of people who lose significant amounts of weight using AIC, Semaglutide, and bariatric surgery, and that can also cause disproportionate emptying of the breast, so they may then benefit from breast enlargement surgery. Some people will come in saying that they feel that they're pear-shaped and that their lower half is too large compared to the breasts, in which case breast enlargement surgery can improve your proportions. This means that you wear a size 10 or no size 12 dress top and bottom rather than 10 at the top and 14 at the bottom. Breast implants are also useful for patients or individuals who have significant breast asymmetry, which can be congenital or acquired, either something that you're born with, and it develops with time or something that you may develop over the years. I'm not really going to talk about breast implants for breast reconstruction in this talk, but of course, breast implants are widely used worldwide for breast reconstruction, so in preparing for surgery, you'll see me and Kate.

It's very important that we get a good understanding of your medical background and any medical factors that may come into play. It may mean that we need to modify surgery to tailor things toward you. Smoking is one of the things that you definitely need to stop doing if you're considering any form of mastopexy because there is a significantly greater chance of losing a nipple. Nicotine itself seems to affect wound healing, so in an ideal world for any of these procedures, if you can wean yourself off nicotine before surgery, that's ideal. Certain medicines can thin the blood, which increases the chances of bleeding and an adverse outcome. Some commonly taken supplements, like herbal medicines, star flour oil, for example, garlic supplements, and omega-3 fish oils, can all lead to increased bleeding. In general, I'd suggest that you come off all of these supplements before surgery and for a good couple of weeks because it takes that long for the blood cells to recover really so I always recommend that you delay surgery at least a year following pregnancy so we frequently get asked if we can sneak of a breast or in before a period of maternity leave ends but  I’ve got to say you're definitely better off just delaying things a little bit more and then you'll once  I’ve seen you two times nowadays which enables us to make a full assessment provide you with information sheets on implant safety and other factors that you may need to consider and a quote we would then get you back and I’d spend the second consultation really finalizing the plan choosing the most appropriate type of implants with you and running through limitations risks complications of surgery and your recovery you would also then be booked in for a preassessment check and you'd normally at that point see Kate again who will go through everything with you again before the procedure and we'll also be able to advise you on suitable bras to wear postoperatively so definitely read through the information sheets there's an awful lot of information in there and if you have any questions drop them down I would much rather go through any questions you may have before surgery than afterwards and I think again planning and communication are the key the wrong operation done brilliantly is a disaster whereas the right operation done pretty well is yeah that's what we need so surgery itself you're normally admitted on the day of the procedure the operation takes around an hour and a half or so you have been the operating block for longer than that so friends and relatives need to not worry that you're out of action for most of the morning or most of the afternoon the so having made the incision make a pocket we'll sometimes use some implant sizes at that point just to try and see which of a range of possible implants are going to fit your chest the best and then tend to use huge amount of local anaesthetic to make this as comfortable as possible assuming the pockets are nice and dry then nor don't need to use breast drains for breast implant surgery. Sometimes with a capsulectomy, things are a little bit bloodier, so we might consider a drain, but normally remove that the day after the procedure before you go home, and then I tend to close the wounds up with dissolving stitches, a special glue-type dressing, and then some micropore tape. It's a very straightforward dress. You should normally be okay with paracetamol, ibuprofen, or something similar. Again, you need to avoid an underwire bra for the first 6 weeks. I suggest you take it really nice and easy for the first week or two, and you can go home the same day as the procedure, but equally, because a lot of people travel some distance to get to Benenden Hospital, the package normally just includes your overnight stay, which I think makes it less stressful for you. Actually, postoperatively, there's an emergency phone number you'll be given, which is man-365. We've got nurses and a resident medical officer on site, so most problems can be dealt with fairly easily, but if there's an emergency or something, I need to see you fall a little bit earlier, then they'll get hold of me and I'll come and see you, and then the postop appointments I think it's very important that you come back for what we need from you. If there is any form of issue, I want to be able to spot it earlier rather than later to give you the best chance of a fantastic outcome, and then, really importantly, whether you have your implant procedure done at Benenden or elsewhere, you should make sure that you obtain a card with your implant details on it because in the future, when you come to needing to have your implants changed, it's very important that you know what exactly you've got in. So, in terms of recovery, I think you'll find a shower a couple of days after the procedure.

I think most people including my personal trainers and soldiers are back doing their normal activities at about 6 weeks I think most people can try from around two weeks I think as with any surgery and the eyes of the l the bottom line is that you have to be safely in control of your vehicle and able to perform an emergency stop so you've just got to be honest with yourself and make sure that you can do that it's normal to have a bit of swelling which can be more significant in some people than others and it can take some months or weeks to fully settle down and again everybody's very slightly different so some people bounce back very quickly and others might just take a little bit longer so you've just got to listen to your body and you incrementally increase activities as you feel comfortable so any surgery carries with it potential risks and complications so there are general risks   complications of all procedures, which include infection, bleeding, and blood clots, so you'll be given some horrible stockings.  Postoperatively, try to reduce the chance of deep vein thrombosis in your legs. I tend to give you a low molecular hein to reduce the chance of bleed of a clock forming and then there are some specific risks and complications associated with breast enlargement surgery so some of those are listed here but you can have some numbness which may normally temp but can on occasion have some permanent change you can have temporary nipple sensitivity which can be a bit uncomfortable and unsettling but again that tends to settle off over the subsequent weeks animation is a particular thing so if you flex your p major muscles you can make the breast tissue move over the you along with your back mage muscles but if you've got an implant on top of or under the muscle you can have a little bit more movement so I think that's a limitation of breast implant surgery. Everybody will get a small amount you just need to be aware of it. scars should settle to become soft and flat and pale but they can become red and raised they can be itchy or lumpy or stretched and actually a slightly red ray scar is a normal outcome and it can take about a year for your scars to look as good as they ever will do and depending on again the degree of soft tissue cover that you have over the surface of the implant I think if you if you're very thin or you've got a smaller breast then I think you could expect to be able to feel the implant edge through the skin um when I see you I’ll give you an implant to feel and it just gives you some idea about what that may be like and then I think in the longer term I think all foreign materials placed in the body will eventually form capsule which is scar tissue around them so if you've got a hip replacement that forms capsule well scar tissue wants to shrink so a hip replacement made out of metal or ceramic cannot be deformed as the scar shrinks but breast implants are soft and squidgy so as the as the scar contracts it can narrow the base it can increase projection and it can become a little bit uncomfortable and sometimes painful so a problematic capsule is an absolute indication to have a revision procedure and then there are some very rare complications that do are now known to be linked to breast implants including some very rare tumours that can affect the capsule that forms around the implant shell so for a lady in the united kingdom there is rather sadly a one in8 risk of developing breast cancer in your lifetime breast implants do not change the risk of breast cancer but for depending on the type of implant shell I think the figures that the moment suggest around a one in 30,000 risk of a very rare tumour called al so just things that you do need to consider and then there's a very rare condition known as or reported as breast implant illness so it's a fact that some ladies with breast implants can develop a range of different inflammatory conditions but of course many ladies without breast implants can develop a range of different inflammatory conditions so what exactly breast implant is not sure but it's something that people talk about and I think it's just something to bear in mind and the FDA in America have said that there are definitely a group of ladies for whom removal of implants provides benefit and that can be for a whole host of different reasons but possibly breast implant illness is one of those things and for everybody in my practice who has breast implants put in or removed I contribute to the national breast implant database which is a means of just keeping a close eye on all of the different types of implants and spotting trends and patterns so if it turns out there is a problem with a particular type of implant then we know not to use it in the future so I think the results well the key is good communication you need to have good understanding of what you're hoping to achieve I need to chat to you and make sure that's realistic and let you know what is realistic and then  I think you do need to have a very good understanding of the limitations and potential complications of surgery before proceeding with it. I think results will continues to change throughout your lifetime so if you gain weight or lose weight  further pregnancies the effects of aging and gravity which now that you can't do anything about we'll continue to change the breast so the other reason that people may choose to have further surgery in the future is if the breast tissue droops over the surface of the implant or so it's basically if you change around the implant itself and of course you need to continue to self-examine if you spot a brass lump again the fastest way to manage things is go through your GP go through the one-stop breast clinic when the time comes for you to be invited for breast screening you should definitely go just let the screening team know that you've got breast implants they do slightly different mammogram views called eans views and they have a lower threshold for examining you with ultrasound or MRI and they'll just check that the implants are intact I think bas the British association of plastic reconstructor aesthetic surgeons are going to start suggesting that people routinely come back for an ultrasound scan every five years or so just to check that the implants are still intact and of course if you fall off a bicycle or have trauma to your chest it's definitely a good idea to have a scan and just make sure the implants are intact if you do have a leak or gel bleed which is where some of the silicone can leak through the shell of the implant again the advice is that we should change the implants but medical grade silicone is thought to be safe again it's been around since the 60s and millions of ladies have this worldwide and importantly all implants will eventually need to be changed so I still see people who had implants put in 10 15 20 years ago who at the time were told these will be with you forever and  I’m afraid that's not the case so you do need to literally factor in possible need for implant change or further implant surgery through your lifetime. Okay, and I think I will now hand over to Kate, and then I think we'll take some questions and answers.

Kate Comrie

Brilliant! Thank you very much. What a brilliant presentation. So, at Benenden Hospital, our consultants here are dedicated to providing you with the highest level of care; we are CQC-rated Outstanding. I will see you through your patient journey, and I'm around to answer any questions that you might have, any concerns, or queries. I'm available by phone or email, so there's always someone here if you do have any questions. We've got this beautiful hospital in the middle of the countryside, obviously a clean and calm environment great for rest and recuperation, a high patient satisfaction rate (I mean, it's cosmetic surgery; it's what we want for everybody), and we also have a zero percent recorded rate of MRSA.

So, we would now like to answer some of your questions. So, Mr Mackey, the first question I have for you is: which implants are best to avoid slipping?

Mr Simon Mackey

To avoid slipping, I think you probably meant misposition, so I think there's two things. really there's mal position and mal rotation so partly it's you need to ensure that the pocket that is made is snug for the implant and is just the right shape and size but secondly I think there was a vogue probably less so now but there was a vogue to try to push people towards having anatomical implants which are the tear drop shaped implants and I think though they're really only appropriate if you happen to have an oblong breast based shape so if you've got an oval shape to the breast and you have a shaped implant well it can't rotate think if you're trying to use a shaped implant which has a round base or circular base it can of course rotate and used to see them flipping upside down so I think it's they're very limited people for whom in my practice I think anatomical implants are really appropriate I think depending some people who have had capsulectomy the pocket can be quite large in which case you either need special stitches to be placed inside the pocket to try to shut it down or you can think about using special meds to try and snug the implants and stop it from moving but they're very expensive so I would be thinking really that's almost into the realms of reconstruction so I think it's careful pocket design it's selecting the correct implant to fit your breast footprint and I think the final thing is the implant surface so smooth implants traditionally with the first implants to be inserted or to be used and smooth implants did have a high rate of capsule formation but they also did seem to move around slightly more in the pocket so textured implants came along which do see appear to have a slightly lower rate of capsule formation but they also tend to be gripped by the surrounding tissues a little bit better you get a little bit more ingrowth onto the implant so I think those are the main things I hope that answers.

Kate Comrie

Another question is: would I still have large scars if it is fat that has been transferred?

Mr Simon Mackey

So with fat transfer tend to be smaller scars I think large volume fat transfer is not something that I would necessarily recommend I think there are some theoretical risks with fat transfer of stem cell activation and potential tumour genesis although the data that's coming through seems to suggest that's probably not the case but it can be useful again I in my practice I tend to use it just for smaller defects and for contour irregularities I think for some people with things like tubous breast issue or breast asymmetry which is less than a cup size or so then actually can be very useful and in that situation it's quite nice if you've got ideally want both of the breasts to be made of the same thing and fat is not the same as breast tissue but it's much more similar to breast tissue than breast implant so actually if you've got a breast a symmetry it's quite nice then to be able to increase the smaller breast using fat alone because the breast will then behave more like one another over the years but with fat transfer you would have about centimetre long donor scars so in your love handle area or wherever you've got a bit of spare fat to harvest and then along the breast normally along the inframammary fold itself or from the armpit you again have little puncture incisions but they're quite small they're a few millimetres long but you would you definitely have some donor scars.

Kate Comrie

Lovely, thank you. Does breast surgery cause any problems for breastfeeding?

Mr Simon Mackey

So breast implant surgery shouldn't I think if you're coming underneath the breast and then positioning the show you a picture actually so if you're positioning the implant either underneath just the breast or underneath the muscle where you're not putting anything between the breast tissue and the ducts as they as they come out of the nipple so actually if it's breast implant surgery alone if you are able to breastfeed anyway then you probably should be able to breastfeed so it's about a quarter of ladies actually in some studies can't breastfeed anyway that's even without breast surgery and it may be you're already in that group but breast implants themselves shouldn't stop you from breastfeeding I think some of the mastopexy procedures where you cut around the nipple and you cut might need to cut quite a thin pedicle for the nipple to be able to move it may reduce your chance of being able to successfully breastfeed.

Kate Comrie

Thank you very much. Is there an age limit to having enlargements? This person is in their 50s and worried that their skin won't stretch well.

Mr Simon Mackey

So, there's no specific age limit. I think you're as young as you feel, and I think so long as you're medically fit for a procedure, there should be no specific barrier. I think the oldest lady has done a primary breast or breast augmentation for always 76, so you know and lots of people, there's a whole host of reasons why people might not have surgery performed or might have decided to have surgery performed later in life, so and in terms of skin, I think you probably mean does the loss of elasticity cause a problem? Well, I think sometimes as we get older again, the breast tissue or the volume of the breast reduces, some of the breast tissue melts away a little bit, and you can get some stretching in the scent of the skin, so there may be a slightly higher chance you benefit from an uplift. If you're older, one of the things you could also consider as we get a bit older is just an uplift alone, so sometimes just repositioning the breast tissue on the chest actually gets you enough of a change, and you can actually accept that you have anchor-shaped scars and achieve a very pleasing result without implants at all, so that has benefits, but that's again where a face-to-face consultation just to have a look at the tissues is very valuable indeed.

Kate Comrie

I have previously had breast cysts investigated and removed, but will I still be able to have surgery?

Mr Simon Mackey

It should be absolutely fine. I think if you've got any active breast lumps, then it's always recommended that they be investigated before proceeding with surgery, but that should be fine. Sadly, breast cysts and lumpy breasts are very common, particularly in younger age groups, so it's a frequently encountered concern that people have, but it shouldn't stop you.

Kate Comrie

Great, is the surgery done by cup size?

Mr Simon Mackey

So, rather annoyingly, you can't do it by cup size. It would be nice to be able to give one of the examples I give: if you go into someone like Blue Water and go into six different shops for a measurement, you may end up with two or three different cap sizes, and depending on the style of bra again, it changes, so there are various computer simulations and Irma sizes that can be used. I tend to like to use something called a rice bag test and when I see you I can give you instructions on how to do that but essentially you get some tights tie them so they're very floppy put rice in and then lay it over your entire breast and then put on a stretchy lyro vest or sports vest and you can basically experiment with different amounts of rice until you get the look that you like and it's a really nice way to do it because it's the privacy of your own home you get an idea about the projection about the weight of them as well and then if you weigh the rice we can look through your look at your chest wall measurements and go through the implant catalogues and hopefully come up with an implant that will get you to where you'd like to.

Kate Comrie

How long after breast surgery with implants can I go on a flight? I'm an assistant, so I fly for work.

Mr Simon Mackey

So, we have a lot of issues with what we call cosmetic tourists. Always, it's always in the press. There are people who head off to countries that are slightly cheaper, have cheap surgery done, come back to the UK, and then have a problem. And then, actually, people often incur significant costs because they have to have things sorted out privately or may be able to get emergency care managed within the NHS. So, I think if you're out of the country too early, you essentially become a reverse cosmetic tourist. So, if you're flying too early, if you do have an issue, you might be in a slightly sticky situation. I think if you're flying very long distances as a passenger, well, after a general anaesthetic procedure, there is a slightly greater risk of blood clots in the legs that can migrate to the lungs, and that can be a life-threatening complication of surgery or long-distance travel, so we generally recommend no long-distance travel for 6 weeks following a general anaesthetic procedure. But as an air hostess, I think you're going to be up and up bounds on your feet, so I would be thinking really, if as long as you're safe to drive to the airport, I think if you're feeling comfortable enough to move around and do your job, then probably two weeks would be the absolute earliest, but I think you just have to listen to your body, and if you're not quite ready, you're slightly less comfortable than the next person, then you'd have to take a view. And delay things for a little bit longer. I would have thought two weeks was the earliest.

Kate Comrie

So, we've got somebody who has said that they will need secondary surgery. Their implants are 10 years old and now drooping; they did have a lift, and they have the anchor scar, but one breast is still bigger than the other, and they would have liked it to have been corrected in the first place. Would we be able to make them the same size and lift them?

Mr Simon Mackey

So the breasts are sisters and not twins we want them to be nice close sisters so yeah normally I think at the time of a scheduled implant exchange so it sounds if you probably need a capsulectomy and implant exchange if you want to hang on to your breast implants and then if you're having maxi surgery you can basically lift the smaller breast first and set that as the target and then try to lift and reduce the larger breast to get you more similar in terms of shape and size I think sometimes it's also the opportunity to think about having your implants removed, so I think sometimes our goals change, and if so, you'd have to have a good think about whether or not you go for an implant exchange or just take the implants out, but yes, it should be possible to improve symmetry, which is lovely.

Kate Comrie

Thank you. We apologize if we didn't answer all of your questions. If you provided your name, we would answer it via email. Our private patient team can take your call between 8 a.m. and 6 p.m. Monday through Friday using the number here on the screen. We would be grateful if you could please complete the survey when the session closes, which will help us improve our future events. Our next webinar is on gynaecology, so you can sign up for that via our website if this is of interest to you on behalf of Mr Mackey and our expert team at Benenden Hospital. I'd like to say thank you for joining us today, and we hope to hear from you very soon. Thank you very much.