• Reference Number: HEY434-2023
• Departments: Acute Medicine Unit, Breast Services
• Last Updated: 1 December 2023

Introduction

You will have been referred to the Breast Service following an appropriate referral from the Gender Identity Service, supported by a specialist confirming your diagnosis. The referral confirms that funding is now in place for your surgery.

This leaflet has been produced to reinforce the information that has been given to you about your surgery. Most of your questions should have been answered by this leaflet. It is not intended to replace the discussion between you and your doctor, but if, after reading it you have any concerns or require any further explanation, please discuss this with a member of the healthcare team caring for you. The surgical team comprises a group of surgeons who all work together to provide the best surgical care for you.

It is important that if you decide to have your surgery with us, you are aware of the appointments schedule. You will need to attend all appointments both before (pre) and after (post) surgery. Below is a list of the appointment schedule you are expected to attend if you wish to have surgery with us:

• Pre-surgery: initial consultation with surgeon.
• Pre-surgery: pre-operative assessment prior to the surgery.
• Post-surgery: follow up at around 10 days, for drain removal and nipple/wound check.
• Post-surgery: follow up at 6 months to assess how the surgery has gone and to discuss if any further surgery is necessary.

You will need to agree to attend all of these visits before we can consider you for surgery.

What is this type of breast surgery?

This surgery is an operation to remove most of the breast tissue in order to help create a flatter chest shape.

The operation is performed under general anaesthesia and involves the removal of most of the breast tissue with the preservation of the nipple and areola (coloured area), if possible. The particular surgical technique used is dependent on the breast size of the individual patient and initial assessment:

Liposuction may be used to remove breast tissue via small incisions.

An inframammary fold mastectomy and free nipple areolar grafts (removal of the breast from the fold underneath the breast) results in a scar along the crease of the skin directly under the breast. The nipples may be completely removed and repositioned. If the nipples are not preserved, both nipple and areola tattoos can be done at a later date.

A periareolar reduction may be used by making a circular cut around the outer edge of the areola, leaving the nipple partially attached. Breast tissue is removed and the excess skin is trimmed. The nipple is then repositioned and a ‘purse-string’ (type of stitch) technique is used to pull the skin around the areola tighter together to close the reduced area.

All of these surgical options will be discussed fully as to which will be the most appropriate for you.

Your initial consultation

You will be seen by the consultant surgeon and asked various questions about your general health, as well as being given a physical examination, which will include several measurements of the breast being taken and recorded.  Consent will be required for clinical photography, involving before and after surgery pictures, to complete an accurate visual record.  Each option of surgery will be discussed with you including the risks, advantages and disadvantages of each, as relevant to you.

This consultation provides an opportunity to see pictures of previous pre and postoperative surgery results. You are encouraged to ask questions and discuss any concerns fully with your consultant to understand the potential issues of your surgery. It is important that you have realistic expectations of the final appearance of your chest.

Can there be any complications or risks?

As with all surgery, there can be complications or risks. Your consultant will go through these in detail with you as part of your consultation; however, we have listed some of these below for your reference.  If you have additional concerns regarding risks or complications, please do not hesitate to discuss these with your consultant.

General complications and risks could include:

General surgery risks – bleeding, infection, bruising and scars. Steps are taken to reduce risks, such as injections to help prevent adverse blood clotting; use of compression stockings to help prevent deep vein thrombosis.

Haematoma – a collection of partially clotted blood under the skin at the site of the surgery. This may result in a return to theatre to drain depending on the severity of the haematoma.

Asymmetry – this is when both sides are uneven post-surgery. It may be possible to correct this with further surgery at a later date.

Synmastia – this is when the two scar lines meet at the central point and results in one long scar. This may be unavoidable, but may possibly be corrected by surgery at a later date

Loss of nipple graft – there is a small possibility that the nipple graft may not take and you may lose your nipple graft. It may be possible to have a nipple reconstruction at a later date.

Bruising – is highly likely, this may cause the breast area to become a little discoloured and may spread down towards the abdomen. Your body will absorb this bruising and rarely needs any intervention but if worried, contact the Breast Care Unit.

Seroma – this is a build-up of serous fluid (produced by the body to aid healing) between the tissues and the skin. This fluid is usually absorbed by the body, but if it is present in large amounts, it can be uncomfortable. The fluid can be removed by inserting a fine needle and removing the fluid.  This is quite a common procedure undertaken in the breast clinic outpatient department.

Skin necrosis – occasionally the blood supply to the flaps of skin on either side of the surgical incision is inadequate.  This is significantly more common in people who smoke. The skin involved dies (necrosis) and gradually heals by scarring. If this area is quite extensive, surgical removal may be required, although this is not common.

Nipple necrosis – if the nipple is retained, there is a small possibility that the nipple may lose its blood supply and become necrotic. This means that a poor blood supply to this area may result in the loss of some colour and the nipple may not survive. If this happens, it is possible to have a nipple reconstruction at a later date.

Infection – this may occur despite the routine administration of antibiotics. Any signs of redness, heat, discharge or raised temperature needs to be reported to your health care team. An earlier follow-up appointment can then be made to attend the breast clinic outpatient department.

Fat necrosis – this is a condition that can occur under the skin post-operatively. It results in hard lumps forming within the breast area which can be a concern for the patient. The condition is benign (harmless) and does not carry any risk of cancer. However, all lumps should be investigated appropriately.

Scarring – gradually fades, varying with each individual. If you do suffer from an infection, this can affect scarring; the scar can become thicker than expected and take longer to fade. Even without any infection, some scarring can become thicker and overgrown due to a condition called Keloid (excessive tissue growth in the wound area).

Nipple sensation – this may be lost completely or there may be some small loss or even increased feeling in the cases of surgery retaining the nipple area. There can be no guarantee regarding this.

Skin sensation – it is quite normal for the skin sensation to change with areas of numbness, tingling, small sharp feelings after surgery due to the normal healing process. Again, this can vary greatly from one individual to another.

What will happen after your initial consultation?

After your initial consultation, you will be placed onto a waiting list. When a suitable date becomes available for your surgery, you will receive a letter with appropriate details including:

• A date for your pre-assessment appointment.
• A date for your surgery, times and where to attend.

Pre-operative assessment

You will be sent an appointment approximately 2 weeks before your surgery to attend a pre-operative assessment. The pre-operative assessment will be performed by the nursing staff on the breast care unit and will prepare you for your surgery. It will involve recording your Blood Pressure, pulse and temperature along with height and weight and BMI.  You will be swabbed for MRSA (routine for all surgical procedures) and blood samples will be taken. You do not need to fast for this appointment, but you must be well hydrated (ideally drink water) for us to be able to sample your blood. You may be contacted after this appointment if there are any results which fall outside of normal levels. The blood samples must be performed prior to your surgery and cannot be performed at your local hospital. At this appointment you will receive all the information about your surgery and recovery, so it is important that you attend. We will answer any questions you may have.

Your operation

You will need to contact Ward 16 or the Day Surgery Centre directly if you require someone to accompany you. Otherwise, you will need to attend the ward alone at 07:30. Arrival at 07.30 allows time for your surgeon to talk to you, explain the procedure and any risks or complications which may be involved. If you are still happy to go ahead, the surgeon will ask you to sign a consent form and will mark your body on the area for surgery, using a skin marking pen. The anaesthetist will also review you and ensure that you are fit enough for surgery. The ward will have a rough estimation of the time of your surgery, you may wish to update your family or friends of this estimated time.

There is no room for family/friends to stay at the hospital during your surgery so they will need to book into local accommodation.

It may be a number of hours before your surgery, we suggest bringing something to occupy you. When your surgery time nears, the ward staff will ask you to put on a surgical gown, this is backless so you will need a dressing gown to put on over it and a pair of soft shoes/slippers as you will walk to theatre. You will also be fitted with a pair of white anti embolic socks which help to prevent blood clots post-surgery. We advise that you continue to wear these for two weeks post-surgery.

Post-operatively

Following surgery, you will wake up in  he recovery suite. This is a high observation area where you will be monitored until you are considered well enough to return to the ward. The staff will perform blood pressure and pulse checks and you may have an oxygen mask on. This will be removed once you have fully recovered from the anaesthetic.

You may have been fitted with a pair of “Flowtron boots” during your surgery. These are self-inflating devices which wrap around the lower leg. These inflate and help to improve blood flow back up the leg to reduce the risk of blood clots. These will be removed once you have recovered. You will need to leave the white anti embolic socks on.

The nursing staff will try to ensure that you have appropriate pain relief, but it is normal for patients to experience some level of discomfort. Please purchase appropriate pain relief in preparation for hospital discharge (e.g. paracetamol and ibuprofen).

You will be fitted with a binder in theatre following your surgery, this will be padded with cotton wool. The binder is used to reduce scarring, the pressure from the garment helps to flatten scars. You will need to wear the binder for 6 weeks post-surgery, but you are able remove to wash.

You will have 2 drains following your surgery, these help to prevent any fluid build-up between the tissue and the skin. You will be discharged home with the drains, the nursing staff will show you how to empty and re-vacuum them. You should be provided with bags to carry the drains in from the ward before discharge.

The normal length of stay for this type of surgery is 2 nights. You will be reviewed by your surgeon the day following your surgery and if you have experienced no complications, you may be discharged at this point. For the 24 hours immediately following discharge, you will need to have accommodation within a 30-minute travelling time. If you attend the hospital alone, you will need to be admitted for 2 nights post-surgery. If you are travelling by car, it is advisable to put a cushion or soft pillow under your seat belt for comfort and protection post-surgery. For legal reasons, you will still need to wear a seat belt. If you are travelling by public transport, we strongly advise against carrying heavy bags. Before discharge home, the nurse will advise you of activities to avoid and exercises to perform.

You will receive an appointment to attend the dressing’s clinic approximately 10 days post-surgery. It is important that you attend this appointment as we will check to ensure that your suture line is healing, check your nipple grafts have taken and give you important advice and instructions.  At this appointment we will remove the drains and all dressings.  We will redress both your surgical suture line and nipple grafts. You will need to buy surgical tape (micropore tape) to cover the suture line whilst you have your binder on. The micropore tape is an important part of your wound care routine and is discussed in more detail below. The nurse will show you how and where to apply the micropore tape. You will need to keep your nipples grafts covered whilst you are wearing your binder. We will advise on wound care dressings and how to care for your nipple grafts at the dressing clinic appointment too. You will need to continue to wear the binder for 6 weeks post-surgery. You are not able to drive whilst you have your drains in, as a result, you will need to make arrangements for someone to bring you to this appointment (see attached ‘Day 10 Post Surgery Wound Care instructions guide’)

The recuperation period post-surgery normally takes 4-6 weeks. It is normal to have some bruising and swelling, but this will settle with time. You are able to go out of the house and perform normal activates, but are strongly advised against any heavy lifting or carrying. It is advisable to avoid any activities which involve the over use of your arms or raising your arms over your head for the first 4-6 weeks. We do advise that you take some time off work, the length depends on the type of job you do. If you have a heavy manual job, you should take the full 6 weeks, other jobs may only need 4 weeks. Upon request, the ward can provide a sick note to cover this period. It is not advisable to drive a car for the first 2-3 weeks, as you will need to have a full range of upper body movement and be able to perform an emergency stop. You may find you are not insured if you drive too early post-surgery.

After 6 weeks you can remove your binder and start scar moisturise and massage (see below section). You will need to continue to use the surgical tape for 3 months post-surgery.

At 6 weeks if everything is healed and healthy you can gradually start upper body exercises. By this time you should be able to go back to work and perform all your usual activities. Swimming and vigorous upper body exercise can be resumed 3 months post-surgery.

How to care for your wounds

As mentioned above, please refer to the ‘Day 10 Post Surgery Wound Care instruction guide’ below.

Following your wound review/drain removal at the dressing clinic it is important to continue with the micropore tape to your healing wounds/scar lines for 3 months. The micropore tape will give support and protection to the healing wounds and reduced friction on the scars. Without the micropore tape wounds may become open, scars are likely to be wider and more prominent once fully healed.

You may shower with the micropore tape in place, pat the tape dry after showering and leave in place. Remove and re-apply the tape twice weekly.

How to care for your scars – moisturise and massage

Any surgery to the skin will leave a scar. Scars can take 12-18 months to fully heal and mature, whilst going through a process of stages. Initially, scars may be red, hard, itchy, raised and lumpy. With time, patience and scar care, scars may become lighter in colour and softer to touch. Avoid scratching or picking your scars.

Three months following your surgery start scar moisturising and massage using Bio Oil or a non-scented emollient is recommended (only to fully healed wounds). Scar massage can help to improve the overall appearance of your scars. To massage the scars use short circular finger movements to apply the Bio Oil or emollient twice daily on the scar lines and surrounding skin, for up to 10 minutes.  Start the massage with a gentle, light pressure. Aim to increase the pressure to a deeper, firmer massage after the first week. This massage technique should not be painful and should be used on all scars – including the nipple area. Please read the manufacturers product information prior to use.

Some people produce excess scar tissue during the healing process, these scars may start to become hypertrophic. Hypertrophic scars are usually raised, firm and uncomfortable. Specialist silicone-based scar tape products are available, which may help with hypertrophic scars. Your surgeon does not recommend routine use of silicone based scar products, these products should only be used if your scar is hypertrophic 6 months post-surgery. Please ensure you read the manufacturers guidance carefully, should you choose to use a silicone scar product.

Further scar care – sun protection

Scars are sensitive, exposure to sunlight and tanning bed UV radiation can cause scars to burn easily. It is recommended to avoid exposing your scar to the sun and tanning beds for the initial 12-18 months following surgery, whilst scars mature.

After this time use a high sun protection factor (SPF 30 or higher including UVA/UVB protection). Apply the SPF cream to your scars before exposing them to sunlight. Re-apply SPF cream frequently and generously at least every 2-4 hours or sooner after swimming or sweating. Follow the manufacturer’s guidance on the SPF products you choose to use.

Avoid scar exposure when the sun’s rays are strongest (in the UK this is late spring, through the summer until early autumn). There is no SPF cream which provides a total sun block, please be cautious when exposing scars to sun light or UV sun beds. Sun burn and skin tanning will cause scars to become more visible (darker/hyper pigmented).

Follow up and further treatments

You will be reviewed at 6 months post-surgery which will allow your surgeon to access how well you have healed and whether any further surgery is necessary. Photographs will be recorded for audit purposes to ensure an accurate record.

The surgeries that may be considered are:

Liposuction – this involves the removal of extra fatty/glandular tissue from the breast/armpit area to help create a flatter contour. This procedure may sometimes be undertaken at the same time as the mastectomy (removal of the breast) or at a later date, when post-operative swelling has subsided, allowing particular areas of concern to be identified and discussed.

Dog-ear correction – this refers to the possible, puckered appearance of the skin at the end of the scar line, looking like a little flap. This can be removed by a minor operation at a later date.

Nipple reconstruction – a procedure can be undertaken to replace the lost nipple, if not retained, by creating a small lump projecting from the skin on the breast. This could be done at a later date, once the original wound area has healed properly.

Nipple/areola tattoo – the area around the nipple can be tattooed with colour onto the skin, either around an existing nipple or colour shading applied to provide definition of nipple and areola. This procedure can produce extremely realistic results.

Gender Affirmation Post-Surgery Wound Care instruction guide

This information is relevant once your post-surgery drains have been removed at day 10

• Binder to be worn for a total of 6 weeks from day of surgery, can be removed to wash binder and bathe
• Can use deodorant under arms
• Drain dressings can be removed after 72 hours (3 days)
• For first 7 days post drain removal shower only on back or shallow bath and wash  hair over sink
• After 7 days can wash and shower as normal

Bilateral Mastectomy and Free Nipple Grafts

Peri-Areolar Mastectomy

Leave nipples covered with dressing for first 7 days after change of dressing in dressing clinic Replace dressing  on nipples as required with large non adherent waterproof plaster for 6 weeks until binder removed Micropore tape to suture line for 3 months after drains removed, can shower with  it on and replace as required (twice weekly is recommended) Can use Bio Oil or a non-scented emollient from 3 months

Micropore tape to suture line (nipple edges)  for 3 months post-surgery, can shower with  it on and replace as required (twice weekly is recommended) Can use Bio Oil or a non-scented moisturiser on scar lines from 6 weeks

• If you develop any new redness , swelling, discharge, pain or the area is  hot to touch contact own GP to rule out any infection
• Avoid any heavy exercise for the first 6 weeks such as heavy housework, going to the gym, weight training, and carrying heavy objects. You can then gradually increase your exercises and start to work out. You should wait 3 months to start swimming and vigorous upper body workouts.
• You will need 4-6 weeks off work post-surgery depending on your job. The ward should have provided you with a sick note. Your GP can provide additional sick notes as needed.

Any other concerns or questions, please, do not hesitate to contact the Breast Care Unit on 01482622679 (leave a clear voice message, with your name/HEY number and phone number) or our email address is hyp-tr.breastcareunit.nurses@nhs.net.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.