• What happens at my first consultation?

Your consultation is always with Mr Turton. This is a detailed meeting to assess your current situation, medical history, suitability for breast reduction, and to perform the bio-dimensional assessment. You will have a full breast examination, and comprehensive measurements made of your frame, existing breast size, glandular analysis, tissue characteristics, and anatomical variations in typical dimensions. Mr Turton will also detail the potential complications, any limitations, short and long term breast changes, costs, the need for future surgery, mammography and follow-up.

• How much breast tissue can be removed/what size can my breasts be reduced by?

Usually 500gms to 800gms.

Massive reductions involve 1-2kgs/side.

Small reductions are also commonly performed (100-500gms), with emphasis on tightening the skin, reshapping the breast and raising the nipple up to its normal position. This may be referred to as a mastopexy-reduction.

• What happens on the day of the operation?

You should avoid any medication, herbal preparations, and vitamins except those that Mr Turton has said it is OK to take. For example- No NSAIDS such as Neurofen the week before surgery. You will also be fasting, and cannot take any liquids, any sips of water, or any food (no sweets, or chewing gum even), from the time specified (usually 6-hours prior to surgery). Avoid moisturiser on the breast area please. Arrive in good time, and you will be checked in first by nursing staff. You will be admitted several hours in advance of your operation so that it is completely unhurried. You should relax in your room (bring a book and magazines). Mr Turton will take your pre-op photo and mark-you up. Mr Turton's anaesthetist will evaluate you and confirm that you can proceed (If you are unwell or have developed a chest infection your operation would obviously be cancelled and rescheduled). You will be walked from the ward to the operating theatre reception for your check in, and then your anaesthetist will commence your anaesthetic- you will drift off to sleep in about 5 seconds! Your will be under full anaesthesia for the full duration of the operation. Mr Turton will additionally use local anaesthesia which provides additional comfort on wakening. Every thing is geared around you, your 100% safety, and your well being. You will be woken up in the recovery room, and supervised 1 to 1 with an experienced recovery nurse after the anaesthetist has reviewed you. You will then be taken back to your room where you may start your recovery within the comfortable surroundings provided.

• How long does the operation take?

Your operation will be conducted meticulously and unhurriedly. You are positioned on a padded operating table. There are additional gel supports that will be placed under your ankles and for your arms to rest on. Your head is on a pillow. There will be pneumatic anti-thrombotic boots around your lower legs which will gently squeeze your calf muscles throughout the operation (Mr Turton has never had a patient develop a DVT), and there will be a special sterile operative warm air blanket covering your lower body (this is called the "huggy-bear". An operation time 2 - 4 hours is typical. Mr Turton places great emphasis on the suturing and will usually spend an hour on this specific aspect. Mr Turton uses various techniques to reduce operative risks such as haematoma and infection; consequently his re-operation rate is well below average. You are fully monitored throughout the operation and the consultant anaesthetist is solely with you (one-to-one consultant care).

• Is it painful?

Most patients use Paracetamol for a few days only, but an anti-inflammatory is included in addition by Mr Turton.

• When can I drive?

Individual advice varies: From 7-days to 3-weeks. You should have come off any strong painkillers before driving (such as Tramadol, Codeine, Dihydrocodeine or Tylex). You should be comfortable that you could make an emergency stop or be able to swerve sharply if needed before driving.

• When can I return to work?

Usually after 1-week. Some patients return after a longer period, typically 2-weeks. Jobs that involve strenuous lifting should be avoided for 3-weeks, and then discussed with Mr Turton.

• How do I decide on what size I want to be/ What size will my breasts be after surgery

Most patients want to be between a C and D cup. The starting size and the health of the remaining tissue during the operation dictates how much further the gland may be reduced. Mr Turton uses his extensive expertise in balancing the volume of the reduction, the goal of a desired breast size, and the blood supply to the remaining tissue. With massive macromastia, he will not compromise on the safety aspect at any point, and if he needs to curtail the resection just before a particular cup size is reached he would always do so. For example, this may mean a patient is a DD rather than a D afterwards, or a D as opposed to a C. To reiterate, most patients want to be between a C and D cup, and this is achieved.

• How long will I be in hospital?

If you have surgery in the afternoon or evening you will normally stay 2 nights. This is for your comfort and allow your drains to stop any fluid building up pressure under the tissue and hence on the scar line. You will be reviewed by Mr Turton the morning after surgery and only released when ready the next day. This is normally always by mid-day.

• Can sex be resumed immediately after the operation?

For your comfort, Mr Turton advises waiting a few weeks as the breasts will be too tender to touch during this time. After this gentle sexual activity, without pressure on the breasts, can resume as long as no pain is experienced. Generally, it takes 6-weeks before you are able to lie on your front at night, which is a useful guide as to how pressure will affect your comfort. Breast massage must be avoided for a minimum of 6-weeks.

• What forms of sports activity can I do after surgery?

Walking - I encourage all patients on walking- no restrictions, and it is important to mobilise straight away.

Arm exercises - You must avoid raising your arms above shoulder height for 3-weeks (either to the side or infront). eg No reaching for top cupboards! Get help with hair washing. Avoid using your arms to lift yourself up or push yourself along on a mattress.

Cycling - from 6-weeks

Paddling in a pool, Sauna/Steam room use- from 6-weeks

Jogging - from 6-weeks; Weight lifting - from 3-months

Cross trainers, Gym, Yoga, Pilates - from 6-weeks

Gentle swimming- from 6-weeks

Pole dancing, Belly dancing - from 6-weeks

Aerobics- gentle reintroduction from 6-8 weeks

Golf- from 3-months (except chip-and-putt); Scuba diving -from 3-months

Tennis/Squash/Badminton - from 3-months

Athletic swimming - from 3-months

• If I lose/gain weight will my breast size reduce/enlarge?

In general, "Yes". Breast tissue is composed of thick glandular tissue and soft fatty tissue. Just as when you put on weight you find that it goes onto the bottom/hip area, you will also often find some of it goes onto the breast area. Big shifts in weight are therefore not desirable. Most people have minor weight fluctuation of 2-4 lbs, which has negligible consequences.

• Is it better to lose weight before reduction surgery?

Yes. The breast shape will be better controlled if you have lost weight and assumed a normal body mass index prior to surgery. At the very least you should bring your body mass index (BMI) to less than 30 through a diet. Some patients struggle with weight loss when they have very large macromastia as is difficult to exercise. Mr Turton would be happy to offer his professional advice in this situation. He has access to a very helpful professional dietician, and physiotherapy services. Occasionaly patients with a BMI over 40 who are unable to achieve weight loss, will need to consider seeing a bariartic surgeon for a bypass or gastric restriction operation. Your General Practitioner can give you further advice, otherwise there are services available relating to this at both Roundhay Hall Leeds and the Leeds Nuffield.

• How can I prevent sagging in future years?

You can't. However careful weight control can modify your risk. Your breasts will always change as you get older, and this is irrespective of whether you have breast reduction and mastopexy or not. This is because of biological changes that occur with ageing: loss of elastin, stretching of collagen, atrophy of breast tissue, loss of skin elasticity, sun damage to skin, smoking related damage, effects of weight change on skin and breast tissue, effects of pregnancies and breast feeding on skin and breast tissue, hormonal changes, weight of breast tissue and quality of supporting tissues.

Wearing a well-fitting bra after your recovery is important (usually from 6-weeks). An underwire bra is safe and recommended. Wearing a comfortable sports bra at night is also very useful. A shock-absorber type bra should be worn during sport. Keeping the skin over the breasts moisturised helps to maintain the elasticity (bio oil is possibly advantageous here). Avoid the use of sunbeds and do not smoke at all (both have a very detrimental effect on skin elasticity and quality, as well as micro-vessel blood flow). Maintain your weight in the healthy range for your body mass index.

• Is the surgery guaranteed for any length of time?

You are covered by the fixed price package for the management of surgery related complications. As these would mannifest early, and usually in the first 2-weeks, the cover is typically for the first 3-months for peace of mind (check specific details at each hospital please). Breast problems that are unrelated to the surgery can occur subsequently in any patient (whether you have surgery or not) and are of course not covered. As a Specialist Breast Surgeon, Mr Turton would normally always be happy to see you for a consultation about any breast related problem during your life. He has extensive experience of different breast related pathologies, investigation, and management.

• In the unlikely event that something did go wrong during/after the operation is further surgery included in the fixed price guarantee and will problems be resolved where possible within cost?

Complications from breast reduction surgery under Mr Turton are very rare, and although he is unable to give each individual patient a categorical guarantee that they won't occur, he can attend to any surgery related complication under the terms of the fixed price guarantee.

The sort of problems that can occasionally occur are haematoma (collection of blood under the skin) in the first 24-hours needing evacuation; this will occur in under 5% of operations and there are techiques that are used to minimise the risk. Infection or slow wound healing can occur at the T-junction. Mr Turton has never had a major wound related infection after breast reduction, and has never had a patient develop MRSA. If such a complication was to occur then you will not only have the technical expertise at hand to deal with it, but also the peace of mind that it is covered by the fixed price package for further surgery, or for further outpatient treatment, should it be needed.

Fixed price packages tend to cover you for complications during the first 3-months after the operation, as this is the time that surgery related complications occur. They do not cover the more long term changes that can occur in breasts in most women. Such as developing a breast lump, or changes in sensation, and future breast sag, They also do not cover dissatisfaction with the size, or shape, unless it is related to a surgical problem. Mr Turton's post-operative pictures are the typical results achieved and not carefully selected photos simply to impress patients. These are the results he will expect to achieve with you, unless there are other limiations.

Mr Turton will always strive to meet your expectations but if there are limitations as to what can be achieved (this may be related to your starting point) then these will be discussed. It is important to be realistic.

• Are follow up consultations chargeable - even at the request of the consultant?

Your first post-operative follow-up is included in your surgical fees. Subsequent follow-ups will always incur a standard follow-up fee (cost approximately £100; please check with Mr Turton's secretary). You will generally require one further follow-up and then can take up the offer of annual or 2-3 yearly review depending on your circumstances. Mammography and USS (cost approximately £160 each) can be arranged depending on your age during the follow up period, if required. Costs reflect Mr Turton's time, and the charges for his rooms, administration and running costs. You are not charged if you attend for review by an out-patient breast nurse. At your follow-up with Mr Turton, you will always see Mr Turton- any follow-up is not delegated to someone else.

• Will breast reduction change my life?

Breast reduction may make you feel more confident within yourself but will not change things if you are dissatisfied with your lifestyle. Surgery in itself will not change a life situation, but the confidence and self-assurance which result from it can indeed empower you to make the required changes, allowing you to live and enjoy your life, to the full. Some patients can rarely have a general problem with body image, and remain dissatisfied with their appearance even when the result has been within the expected and described range. This may be because of something called "dysmorphic body image syndrome". Patients who have a general body image problem are unlikely to gain benefit from cosmetic breast surgery or any cosmetic surgery and should avoid it. Mr Turton would also want to avoid operating on someone who he suspected of having such a problem.

• Will I still have to wear the same style of underwear?

Due to possible changes in shape it should be possible to wear more feminine underwear.

• Do I need to wear some form of support at all times or can I go without a bra?

Once you have recovered from surgery there is no reason why you shouldn't go without a bra on occasions. As long as you feel comfortable it will not have a detrimental effect. In the long term, however, breast tissue will be more susceptible to droop if you do not wear a bra most of the time.

Post Operation Questions

• How will I feel after Breast Reduction Surgery?

The vast majority of Mr Turton's patients feel relaxed and comfortable immediately after surgery. Breast tenderness and a tight feeling, usually become apparent in a gradual manner. At this stage Mr Turton is happy for the nursing staff to dispense Paracetamol and an anti-inflammatory tablet for pain relief. You will only occasionally need to have a stronger pain killer as well, such as Tramadol or Codeine. The anti-inflammatory and Paracetamol combination is very effective and can be continued for a few weeks according to how you feel, but should not be taken on an empty stomach. It is quite common for one breast to be more tender, and to swell slightly more (this is often the right side). Similarly one breast will often recover more quickly and this is quite normal.

Although this would be very rare, the gradual appearance of a great discrepancy in size would not be normal and should be assessed. Similarly if you feel unwell, feverish and develop a temperature you would need assessment. If the skin over the breast swells and becomes reddened and tender you would need assessment. Changes like this would be very unusual indeed, but it is important to know that should they occur, a prompt review is required to assess the cause and treat it.

Occasionally patients feel nauseated as the anaesthetic leaves the system, or sometimes as a result of morphine that may have been given by the anaesthetist during the operation. Both of these are soon out of the system and generally gone by the following morning.

• What happens after the operation?

When the surgery is finished, the anaesthetic will stop and you will gradually wake up over about 5-minutes. At this point you are taken to the recovery area. You are supervised by the anaesthetist and the experienced recovery nurse and then by the recovery nurse alone. The tube that was in your mouth will have been removed and you will feel sleepy. You stay in recovery until fully alert and then you are taken back to your room where you will be made comfortable. The nursing staff will adjust your medication as needed. Your throat may feel slightly sore from the breathing tube but you will be able to sip water straight away.

At this stage there is still a drip in your hand, and this is taken down when you are drinking properly. The Venflon (the name for the plastic needle in the back of the hand) is taken out the following morning, but can come out earlier if you are comfortable and not feeling nauseated.

There will be a drain by your side and this should be kept laid out straight alongside your body so that the tube is not curled up, otherwise it can kink, and stop the suction. This is removed the following day, and is not painful.

Your breast area feels tight and there will be a tubigrip (elasticated support) over your breasts. Often this is in a double layer overnight and then pulled down to a slightly looser single layer the next morning. You will go home wearing the tubigrip day and night, without removing either.

The dressings and the tubigrip must be kept dry. This helps reduce the risk of wound infection. You should therefore have shallow baths (run the water just up to cover your legs) and keep the tubigrip on (but dry) even when you are in the bath. It is good to get help with hair washing. Sponge wash the under arm area and pat dry afterwards.

You will be seen by Mr Turton the following morning after surgery and the nursing staff informed as to when the drains can be removed. You will be given the "take home medication"- painkillers and antibiotics and should have clear instructions and understanding as to when to take them. Please ensure you discuss this with the nursing staff if not sure and if you have any queries after discharge you will be instructed to ring the ward for immediate attention. Mr Turton should be informed of any problems.

• Are there any side effects to the operation?

The commonest one is feeling sleepy for a few hours. Sometimes the anaesthetic or morphine makes you feel sickly, but usually for a short duration only.

You may feel slightly bloated for a few days. This is often due to slight constipation caused by morphine, codeine and tramadol medication. A gentle laxative (lactulose, movicol or senna) will help resolve this.

• What clothes should I bring in to wear leaving hospital after the operation?

A loose button front shirt is ideal. Nothing that needs pulling on over your head.

• Do I need to take time off work after surgery?

Yes. Please check with Mr Turton in relation to what you do. Generally 2-weeks off. 3-weeks or more may be needed if your job involves lifting or heavy manual work. If very sedentary, you can occasionally return after 10-days, but remember that you may still be taking Paracetamol and Voltarol.

• When is it possible to resume household chores?

It is really important not to start household chores straight away. You may be glad to know that husbands/partners/friends will certainly need to help here. I advise against vacuuming and ironing for the first 3-weeks, and then only lightly for the following 3-weeks. The golden rule is "if it feels sore, then don't do it". Listen to your body. You want to avoid repetitive tasks that will slow down tissue healing and resolution of swelling.

• When is it possible to resume Shopping?

You can go shopping the following day. You should not carry heavy shopping bags for 6-weeks. I would also advise against bra shopping for 6-weeks as this is when breast tissue swelling would have generally resolved.

• When is it possible to go out to a Restaurant?

You can go out to a restaurant straight away. You should avoid a very heavy meal and avoid more than a glass of wine or champagne in the first week. Many of Mr Turton's patients go out to a restaurant the very next day after being discharged.

• When is it possible to resume Decorating?

As this can be strenuous you should wait a minimum of 6-weeks.

• I have small children; am I okay to play rough and tumble?

As this can be strenuous as well as painful, especially if you get knocked, you should wait until after 6-weeks.

• Is it okay to sunbathe after the operation?

Yes, after 6-weeks once you have healed. But you should use factor 50 + suntan lotion, or keep scars taped and completely covered by clothes. Remember that you can get sun-burn through thin cotton. If the scar does get sun burn it causes a permanent redness.

• How will my breasts look & feel after the operation?

During the first 3-6 weeks, the breasts tend to feel quite tight and swollen. Full resolution for small reductions occurs in this time. After 3-months the breasts generally feel softer again but this can take 6-months for very large reductions.

• When can I lift my arms above my head?

After 3-weeks usually, unless Mr Turton advises you of specific exercises to perform.

• Is it possible to get further reductions in the future if necessary?

It is important to avoid unnecessary surgery. Further reductions are possible but the technique must be meticulous to avoid the risks of skin necrosis including loss of the nipple and areola. Liposuction is an option too that can be discussed.

• When can I wear an underwired bra?

Usually from 6-weeks. You should avoid trying on multiple bras at this stage. Get professionally fitted and buy from that shop initially. If the underwiring is uncomfortable go back into a sports bra and get refitted in a different shop.

• When can I lay on my stomach?

Usually at 6-weeks; before this it is uncomfortable.

• It says no heavy lifting - what is classed as heavy?

Heavy is anything that is uncomfortable. In general terms lifting shopping bags that are full is what I would term "heavy". Lifting a kettle is OK. Lifting a baby is not.

It is also important to try to avoid using your arms to shuffle yourself up and down the bed, for the first 6-weeks. When you do so, you are pushing hard with your hands onto the mattress and this is forcibly contracting the pectoral muscles.

• Will I be able to breast feed?

No. It is uncommon to be able to breast feed.

• Will a general or local anaesthetic be used?

The operation is carried out under full general anaesthetic and this is regarded as the safest approach. Pure local anaesthesia would be too uncomfortable. "Twilight anaesthesia" carries a level of risk of losing control of the airway if the patient's level of consciousness falls and should be avoided unless there is a very specific reason to use this route. If a request is made for Mr Turton to perform a breast reduction under twilight anaesthesia, he would still insist on a consultant anaesthetist being present to maintain the patient's 100% safety. This should never be an area of compromise simply to reduce the cost of breast reduction.

• How long is the scar tissue healing time?

Skin healing occurs in the first 14 days, but continues to mature over 6-12 months. The scars must be cared for and you should avoid touching or feeling along the scar line for the first 8-weeks. Mr Turton gets his patients to tape the scar for 3-months to keep the scar line like a fine pencil line. Although they look dramatic at 3-weeks after surgery they soon soften and fade. The scars gradually fade over the first 12-months to a pale colour. There are special techniques that reduce scaring & this can be speeded up by using bio oil on the scar after 3-months, or a silicone gel called Dermatix (only available over the counter). The visibility dramatically reduces over 12-months

• Where will the scars be & what will they look like?

Scarring will be around the areola, Vertically: areola to lower crease & Horizontally: in the crease under the breast. In larger reductions, to tighten the skin fold that runs up towards the armpit, it may be necessary or helpful to continue the excision in this area, resulting in a longer curving scar from the under-crease, on the outside of the breast.

• Are there any foods that help heal scarring & skin recovery?

Vitamin C is needed for wound healing; in general most people who have a balanced healthy diet will have normal healing. Please eat sensibly.

• What are the effects of smoking on scarring?

Wound healing is slower, and the risks of wound breakdown and necrosis higher. Scaring is worse. Mr Turton will insist that you stop smoking if he is to perform the surgery and this is a categorical gurantee that you must give. You must also avoid passive smoking. It impairs the microcirculation at a critical time when wound healing is most needed. Smoking when having this type of surgery is a recipee for a disaster. If you do not think you can give up smoking please do not ask for this surgery, or advice Mr Turton prior to surgery so that at the very least he can post-pone the operation.

• What are realistic recovery times?

4-weeks.

• Is breast reduction surgery the correct surgery for me?

It may be that you suffer from many of the typical symptoms of heavy breasts such as upper back pain, neck pain, postural difficulties, bra strap pain, skin sores underneath the breasts. Or it may be that you simply feel that your breasts are out of proportion with your body and that you find it difficult to find clothing that fits. In any of these cases, breast reduction surgery could be right for you. It is essential that you discuss with your surgeon your symptoms, current size and expectations in terms of your post operative size and appearance.

• How long will it take for the swelling to subside entirely

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