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Your Guide to Transgender Surgeries

Top Surgery Guide for FTMs:



What is Top Surgery?:


 Chest reconstructive surgery, or "top surgery" is the removal of the breasts for FTM (female to male) individuals.  The technical name for this procedure is a bilateral masectomy. Top surgery is the most common surgical procedure for trans men. The goal of chest surgery is to remove the breasts (man boobs), and create a more contoured, male typical chest.


What Different Types of Top Surgery Are There?:


There are two main surgical techniques for FTMs:

1: Double Incision / Bilateral Masectomy
2: Keyhole / Peri-areolar Incision

 There are a few less common types that are mostly just a variation of these two techniques. Some examples are the "pie wedge" and "inverted T" variations. The inverted T technique is basically the double incision method, except that the incision runs vertically down from the nipple to the bottom of the pectoral area, which leaves a scar that looks like an upside down letter T. The pie wedge method is also similar, but with a curved incision that goes towards the underarm.

 The surgical method chosen will depend on the particular surgeon's skills and training, as well as your particular body type. Usually trans men with a C cup size or larger chest size will get the most benefit from the double incision method, while guys with smaller chests can get the keyhole procedure. The pie wedge and inverted T techniques are usually used on trans men with B or C size chests. They are used less frequently though because the scarring usually isn't as cosmetically pleasant with scar tissue verses the double incision method.


Double Incision Method:


 The double incision method is effective for individuals with a medium to large chest size. This method uses large horizontal incisions below the nipple, across both sides of your chest. The skin is peeled back to allow the mammary glands and fatty tissue to be removed with a scalpel. Normally, your chest muscles aren't touched. If some of the fat is hard to reach or remove, than some minor liposuction might be used as well. After this tissue is removed, the excess skin is trimmed and the incisions are stitched closed. This leaves two scars below the pectoral muscles.

 The techniques to resize and replace the nipples can vary between patients and surgeons. Most of the time your nipples are removed, resized and then grafted back onto the chest. Some surgeons use the "pedicle" technique, which leaves the nipples partially attached to the body with a stalk of tissue, in hopes of preserving more nerve function and feeling.

 Sometimes the nipple isn't or can't be kept. In those situations there are nipple tattoos that an help the cosmetic appearance some. Make sure to check what your surgeon's technique is.

 Two drains consisting of long, thin tubing are placed along the incision before it is sealed shut. It drains out of a small hole under each armpit, and is attached to a small bulb on each side. The drains help to release the excess blood and fluid so that it won't gather beneath the skin. These tubes are left in place for a few days to a weeks, depending on how much fluid is building up. You will need to empty the fluid from the bulbs occasionally as needed.

 A bilateral masectomy is about a 3 to 4 hour surgery that is done under general anesthesia. It is usually an outpatient procedure. Some surgeons might require an overnight stay to see if any blood or fluid builds up and needs to be released or stopped. There is at least one follow up visit to remove the drains and stitches. Another visit might be needed to check your healing progress. A binder is usually worn for 1 to 3 weeks to prevent swelling and fluid buildup.

 Your surgeon will provide specific instructions for aftercare to follow. Generally though, you will probably need to plan on a couple of weeks off of work to heal. If your job is very labor intensive, you might even need a month or two off of work or away from heavy lifting. You need to be careful not to do too much too soon, you can cause complications, slow healing and increase scarring.

You can expect a very male looking chest, however in most cases there will be scarring.


Double Incision Pros:


1: Best results for larger chest sizes
2: The large scars can be slightly hidden beneath chest muscles
3: Testosterone fueled chest hair can reduce the scars appearance
4: Easier access and removal of mammary tissue
5: Repositioning and resizing makes for a male appearance


Double Incision Cons:


1: Large, prominent scars on the chest
2: Partial or complete loss of nipple sensation
3: Nipple placement might be uneven or not cosmetically pleasing
4: Nipple size might not be aesthetically pleasing
5: Appearance of excess skin at the end of incision "dog ears"
6: Appearance of puckering along the scars
7: Numbness in armpits from liposuction
8: Might require revision
9: Typical surgery risks, bleeding, infection, anesthesia complications, blood           clots, nerve damage or even very rare chance of death.

 Most surgeons include future revisions with the cost of their fee, so that imperfections such as dog ears, areas of bad scarring, or nipple problems can be addressed. Please make sure to ask any surgeon if revisions are included in his or her fee. Additional costs of the surgical facilities and/or anesthesia, however, is usually not covered for revisions, so you still will need to pay for that if needed.


Keyhole/Peri-areolar Incision:

 The keyhole and peri-areolar techniques are effective for individuals with small amounts of breast tissue (cup size A or smaller, sometimes cup size B). They are both done via incisions around the areola (the area of darker skin around the nipple), though the techniques are slightly different.

 In the keyhole method, a small incision is made along the border of the areola (usually along the bottom), and the breast tissue is removed via a liposuction needle through the incision. The nipple is left attached to the body via a pedicle (a stalk of tissue) in order to maintain sensation. After the breast tissue has been removed, the incision is closed. The nipple is usually not resized or repositioned.

 For the peri-areolar method, an incision is made along the entire circumference of the areola. The nipple is usually left attached to the body via a pedicle in order to maintain sensation. Breast tissue is then "scooped out" by scalpel, or with a combination of scalpel and liposuction. The areola may be trimmed somewhat to reduce its size. Excess skin on the chest might also be trimmed along the circumference of the incision.

 The skin is then pulled taut toward the center of the opening and the nipple is reattached to cover the opening, simular to pulling a drawstring bag closed. This is why the procedure is also sometimes referred to as the drawstring or "purse string" technique. The nipple/areola may be repositioned slightly, depending on original chest size and the available skin.


 Just like in the double incision method, "drains" consisting of long, thin tubing may be placed in the chest to help drain off and collect excess blood/fluid so that it will not build up under the skin. Because there are no long incision lines to follow, the individual drain tubes are inserted through the original incision, and curved along the pectoral area, exiting the body through two small incision holes under the armpits. The tubing is attached to a small plastic bulb on either side. They are left in place for several days to a week, depending on how much fluid continues to drain. You will need to occasionally drain the fluid yourself.

 The surgery takes about 3 to 4 hours (perhaps longer if there is a large amount of chest tissue), and is done under general anesthesia. It is most often done on an outpatient basis, where the surgery is performed in the morning and the patient is sent home by mid-afternoon. Some surgeons may require an overnight stay. There are usually at least two post-surgical follow-up visits to remove drains and sutures (usually within the first week or so), and to check the overall healing progress of the chest. If there are complications, more follow-up visits may be necessary. A binder is usually worn for one to three weeks to aid in healing.

The final result of the surgery does not leave significant visible scarring.


Keyhole/Peri-areolar Pros:

1: Minimal Scarring

2: Retention of sensation in the nipples


Keyhole/Peri-areolar Cons:

1: Nipple placement might not be ideal
2: Chest may not appear completely flat (may appear to be a breast reduction       rather than a flat, male chest)
3: Risk of nipple loss due to liposuction trauma of surrounding tissue
4: Numbness from liposuction
5: Insufficient retraction of remaining skin, leaving sagging or puckering areas
6: Puckering around the scar in peri-areolar technique
7: May require revision
8: Typical surgery risks, bleeding, infection, anesthesia complications, blood           clots, nerve damage or even very rare chance of death.


How Much Does Top Surgery Cost?:

 Top surgery usually costs between $2,000 to $11,000, depending on the surgeon and location. Insurance usually doesn't cover this in the United States. You can check the United States and Canada directory or the Worldwide Directory to find surgeons and prices when available.


Scarring:

 Scarring is a risk with any surgery. The degree of scarring will vary depending on the type of procedure and techniques of the surgeon, the amount of tension on the incisions as they heal, and the genetic makeup of the patient.

 Sometimes, scars remain thickened and quite red. This is called hypertrophic scarring, and it occurs in some patients. It may simply be due to heredity, or from incisions that have been unduly stretched during the healing process (if, for example, a patient reaches frequently above his head during the healing process, this may pull at the scar tissue).

 There are some products that can reduce scarring. These include topical Vitamin E oils or lotions, topical products such as Mederma, Scar Fade, silicone gel creams, or silicone sheets.


Complications:

 Top surgery may lead to problematic complications after surgery. The National Institutes of Health report that wounds on the chest wall may persist long-term, leading to skin loss or infection. A buildup of blood at the surgical site (called a hematoma), formation of hard scar tissue at the surgical site, and bleeding into the area where the breast used to be may also occur. In some cases, another operation is necessary to stop the bleeding. There is also a high chance of scarring, especially using the double incision method.

 According to the Mayo Clinic, 20 to 60 percent of patients will experience chronic pain after a mastectomy. It is a condition known as Post-Mastectomy Pain Syndrome (PMPS). Symptoms of this condition include pain in the chest wall, pain or itching in the shoulder or armpit, pain around the surgical scar and tingling down the arm.

 A study published in the August 2008 issue of the "British Journal of Cancer" finds that patients who have had previous breast surgery,  and younger patients are at increased risk of developing post-mastectomy pain syndrome. The authors note that PMPS may develop immediately following surgery or not until several months afterward. For some, the pain may persist for years. The cause of PMPS is not entirely clear, although it may be the result of nerve damage in the chest wall or in the armpit region.


Top Surgery Requirements:

 Each surgeon has different requirements before they will perform this surgery on a trans man. Most require one letter from a gender therapist and for you to be at least 18 years of age, or have parental consent. Some also require for you to have taken testosterone therapy. You can find surgeons and what they require in the United States and Canada directory, or the Worldwide directory.


Surgeons that Perform Top Surgery:

Dr. Meltzer (Arizona) Full Guide
Dr. Gary Alter (California) Directory Only
Dr. Joel Beck (California) Directory Only
Dr. Curtis Crane (Brownstein's replacement) (California) Full Guide
Dr. Peter Davis (California) Directory Only
Dr. Rex Moulton-Barrett (California) Directory Only
Dr. Charles Garramone (Florida) Full Guide
Dr. Harold Reed (Florida) Full Guide
Dr. Daniel Medalie (Ohio) Full Guide
Dr. Steven Robinson (Ohio) Directory Only
Dr. Sherman Leis (Pennsylvania) Full Guide
Dr. Christine McGinn (Pennsylvania) Full Guide
Dr. Kathy Rumer (Pennsylvania) Directory Only
Dr. Peter Raphael (Texas) Directory Only
Dr. Philip Yosowitz (Texas) Directory Only

Dr. Cameron Bowman (British Columbia, Canada) Directory Only
Dr. Pierre Brassard (Québec, Canada) Full Guide
Dr. Hugh McLean (Ontario, Canada) Directory Only

Dr. Chettawut Tulayapanich (Thailand) Full Guide
Dr. Preecha Tiewtranon (Thailand) Full Guide

Dr. Joris Hage (Netherland) Directory Only
Dr. J. W. Mulder (Netherland) Directory Only


Pictures and Videos of Results:

Double Inscision, Video
Peri-areolar Before, After, Video