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# FTM Chest Reconstruction Surgeries

DISCLAIMER
The information contained herein is to be used for educational purposes only. The author is not a medical professional, and this information should not be considered medical advice. This information should NOT be used to replace consultation with or treatment by a trained medical professional. The listing of a medication herein does not imply endorsement by the author.

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Introduction

Chest Reconstruction Surgery

> Double Incision/Bilateral Mastectomy

> Keyhole/Peri-areolar

Costs for chest reconstruction

Pre-surgical advice

Scarring

Resources

Introduction
Most (but not all) trans men will have at least one surgical procedure in his lifetime related to gender transition, if not several of them. However, it is important to note that many trans men do not avail themselves of the surgeries listed below due to cost considerations, health reasons, or personal reasons. Currently, most surgeries related to gender transition are not covered by insurance companies, so costs can be prohibitive for many trans men of lower or fixed incomes.

FTM surgery is generally divided into three main groups:
1. Chest reconstruction surgeries (also referred to as "top" surgery or male chest contouring);
2. Hysterectomy and oophorectomy (removal of the uterus and ovaries, respectively); and
3. Genital reconstruction surgeries (also referred to as "lower" or "bottom" surgery or GRS).
Within these three main groupings are different types of procedures and surgical methods that will be further described herein.

This particular section describes the main types of surgical chest reconstruction procedures that are currently available to trans men. Hysterectomy/oophorectomy and genital reconstruction surgeries (GRS) are detailed in their own separate sections.

The descriptions of the FTM surgeries listed below are generalized. It is important to note that each individual surgeon may use a different technique for any given procedure. If you are considering any of these procedures, it is important to research your options thoroughly and speak candidly with the surgeons you are considering. That way you can choose the procedure and surgeon that best suits your body type, needs, and expectations.

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Chest reconstruction surgery
Chest surgery is the most common surgical procedure sought by trans men. The goal of chest surgery is to create a contoured, male-looking chest. There are two basic procedures that are typically performed to accomplish this goal:
1. Double incision/Bilateral mastectomy
2. Keyhole/Peri-areolar incision

There are a few other surgical variations used for chest reconstruction, including the "inverted T" incision, the "pie wedge" method, and other combinations of incisions that a surgeon may see as the best approach for the patient. These methods are not covered in great detail here, as they are not nearly as common as the above two approaches, and because they are similar to the other approaches except for the resultant scarring. For example, the inverted T approach is quite similar to the double incision method except that the incisions run vertically down from the nipple to the bottom of the pectoral area, and the resulting scar ends up looking like an anchor or an upside-down letter "T." The pie wedge method is also similar to the double incision, but uses a curved incision from the bottom of the nipple toward the underarm.

The surgical method chosen will depend on the body type of the patient and the skills/preferences of the surgeon. In general, guys with larger chests (cup size C or larger) will benefit most from the double incision method, while guys with smaller chests (preferably A, sometimes B) can opt for the keyhole/peri-areolar procedure. The inverted T or pie wedge procedures can be used on guys with medium sized chests (B or C); however, these procedures tend to be used less frequently than the other two approaches because the scarring is not always preferred (as compared to the double incision method).

It is best to discuss the options with the surgeon(s) you are considering. Whenever possible, ask to see photographic samples of the surgeon's work. If you can see an example of their work that shows a patient with a similar body type to yours, so much the better. There is a web site (www.transbucket.com) that serves as a repository for FTM surgery photos and information. The site can be searched by procedure type and by surgeon. Another good resource for FTM surgical information and advice can be found on the FTM Surgery Info Group on Yahoo (groups.yahoo.com/group/ftmsurgeryinfo). These can be invaluable resources when considering which surgeons and procedures may be right for you. See also the resources list below for further information.

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Double incision/Bilateral mastectomy
The double incision technique is effective for individuals with a medium to large amount of breast tissue (cup size C and above, often also recommended for cup size B). In this method, large incisions are made horizontally across each breast, usually below the nipple. The skin is then peeled back so that the mammary glands and fatty tissue can be removed with a scalpel. The muscles of the chest are not touched. Certain areas of harder-to-reach fatty tissue may also be removed via liposuction (such as areas near the armpits). Once the breast tissue has been removed, the excess chest skin is trimmed and the incisions closed, leaving two seams/scars just below the line of the pectoral muscles.

The techniques for treatment and placement of the nipples with the double incision method vary among different surgeons. Usually, the original nipples are completely removed, trimmed to a smaller size, and are then grafted onto the chest in a higher, more aesthetically-male location. Some surgeons use a "pedicle" technique, wherein the nipples are left partially attached to the body via a stalk of tissue. They are then repositioned in a more aesthetically-male location, while their connection to the body via the pedicle stalk remains intact. They may or may not be trimmed to a smaller size. The pedicle option is sometimes chosen in an attempt to maintain sensation in the nipples.

Occasionally, some surgeons may choose not to preserve or graft the nipples in any way, but this is a far less common option. If, for some reason, the nipples cannot be retained during the procedure, or if the nipple grafts are lost because of tissue death, there is an option of tattooing "nipples" onto the chest at a later date, which can have an aesthetically satisfactory outcome. Be sure to discuss clearly with your surgeon the methods they will be using for nipple placement/grafting.

Before the incisions are sealed, two "drains" consisting of long, thin tubing are placed along the length of each incision. The drain tubing exits the body through a small incision hole under each armpit, and is attached to a small plastic bulb on either side. The tubing/bulbs are to help drain off and collect excess blood/fluid so that it will not build up under the skin. They are left in place for several days to a week, depending on how much fluid continues to drain. Drains need to be periodically emptied of fluid by the patient (you may need a friend to help with this).

The surgery itself takes about 3 to 4 hours, 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.

Each surgeon will provide specific instructions about follow-up care and healing time. In general, if you have a desk job, you'll probably need at least a couple of weeks off from work to allow for the body to heal. If your job requires moderate or heavy lifting, or frequent raising of the arms above the head, you'll probably need at least a month or two away from those heavy-lifting tasks. Speak to your surgeon about specific tasks and concerns. Do not try to go back to tasks before your body has had a chance to heal properly; the risk of scarring and complications is greatly increased if adequate healing time is not allowed.

The final result of the surgery usually provides for a well-contoured male chest, but it leaves two significant horizontal or U-shaped scars below the pectoral area. Examples of double incision surgery can be viewed at www.transbucket.com.

Potential pros for the double incision method:

- For guys with big chests, this is the method that provides the best results for a male-contoured chest.
- Scars, while large, are placed under the lower border of the pectoral muscles, so that muscle development in that area can make them slightly less noticeable. Chest hair growth with testosterone therapy may also cover the appearance of scars.
- This method provides for easier access to and removal of all mammary tissue, as compared to the keyhole procedure.
- Proper repositioning and resizing of nipples makes for a more male-looking chest.

Potential cons for the double incision method:

- Prominent scars on the chest (some may also experience raised or reddened scars)
- Partial or complete loss of nipple sensation
- Potential loss of nipple grafts due to tissue death
- Nipple placement may be uneven or not aesthetically pleasing
- Nipple size/appearance might not be pleasing
- The appearance of "dog ears" under the armpits (excess, protruding skin at the end of the incision)
- Appearance of puckering along the scars
- Areas of numbness in the armpits due to liposuction in that area
- May require revision
- The usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).

Keep in mind that many surgeons will 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. Be 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 the patient may still need to pay at least some money for revisions.

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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 is ideal; sometimes recommended by certain surgeons for cup size B). They are both done via incisions around the areola (the area of darker skin around the nipple), though the techniques differ slightly, as described below.

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. Once the breast tissue has been removed, the incision is closed. The nipple is usually not resized or repositioned.

In 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 may also be trimmed away 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-- much like pulling a drawstring bag closed. Thus, this 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.

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. Drains need to be periodically emptied of fluid by the patient (you may need a friend to help with this).

The surgery itself 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.

Each surgeon will provide specific instructions about follow-up care and healing time. In general, if you have a desk job, you'll probably need at least a couple of weeks off from work to allow for the body to heal. If your job requires moderate or heavy lifting, or frequent raising of the arms above the head, you'll probably need at least a month or two away from those heavy-lifting tasks. Speak to your surgeon about specific tasks and concerns. Do not try to go back to tasks before your body has had a chance to heal properly; the risk of scarring and complications is greatly increased if adequate healing time is not allowed.

The final result of the surgery does not leave significant visible scarring. Examples of keyhole and peri-areolar surgery can be viewed at www.transbucket.com. Revision with this type of surgery is not uncommon.

Potential pros of keyhole/peri-areolar:

- Minimal scarring
- Retention of sensation in the nipples

Potential cons of keyhole/peri-areolar:

- Nipple placement may not be ideal
- Chest may not appear completely flat (i.e., may appear to be a breast reduction rather than a flat, male chest), depending on skin retraction and/or leftover/uneven fatty tissue
- Risk of nipple loss due to liposuction trauma of surrounding tissue
- Numbness from liposuction
- Insufficient retraction of remaining skin, leaving sagging or puckering areas
- Puckering around the scar in peri-areolar technique
- May require revision
- The usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).

Keep in mind that many surgeons will include future revisions with the cost of their fee, so that imperfections such as nipple problems, uneven tissue, or puckering can be addressed. Be 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 the patient may still need to pay at least some money for revisions.

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Costs for chest reconstruction
In the United States, one can expect to pay between $1,500 and $8,500 for chest surgery, depending on the surgeon's fee, cost of the surgical facility, the cost of the anesthesiologist, and other miscellaneous expenses (tissue pathology tests, aftercare visits, travel and hotel stay, etc.). As mentioned in the introduction, gender reconstruction-related surgeries are typically not covered by insurance companies in the U.S., so these costs must often be paid out of pocket by the patient.

Some patients may be able to seek out lower surgical fees by traveling abroad for surgery (though the cost of travel and lodging must also be factored in to the final figure). There are skilled surgeons in a number of countries, and by using resources such as www.transbucket.com, you can view examples of FTM surgical work from all over the world. No matter the surgeon you are considering, research your options carefully, and remember that while cost is obviously very important, it may not be the only factor when making your final decision.

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Pre-surgical advice
One of the main keys to an optimal surgical outcome is the overall health and fitness of the patient going into surgery. Two factors that are often considered important before a chest surgery procedure (besides overall good health) are smoking and excess body weight.

Smoking slows the ability of the body to heal itself after surgery; thus, it is usually recommended that patients who smoke avoid smoking for at least two weeks prior to surgery, if at all possible. It is not necessary, but highly recommended.

As for the issue of excess body weight: while there is no reason why an individual who is overweight cannot undergo surgery if he is otherwise healthy, the aesthetic result of chest reconstruction is dramatically improved if the patient is near optimal body weight at the time of the procedure. This allows the surgeon to accurately contour the chest in a manner proportionally correct for that individual, lessening the chance of "dog ears" under the armpits, and improving the chance for overall symmetry.

However, if a patient cannot foresee losing weight before the procedure, or simply chooses not to lose weight, he should be able to proceed if he is in otherwise good health. Some surgeons are more willing to work with patients with larger chests and excess body weight than others. Speak to the surgeons you are considering if you have weight concerns.

Other, specific pre-surgical advice will be provided to you by your surgeon. Typically, you will be asked to discontinue use of aspirin, ibuprofen, and other blood-thinning medications during the 10 days prior and up to the surgical date. You may also be asked to discontinue use of other medications; be sure to discuss any medications you are taking-- including supplements-- with your surgeon.

There are certain vitamins and supplements that are said to help benefit in the healing process. You may wish to research this topic and outline a nutritional regimen for both before and after surgery to aid your body's natural healing process. However, taking supplements or vitamins is not necessary for a positive surgical outcome.

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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.

The body makes scar tissue in the natural process of healing itself from a wound. During the first several weeks after surgery, collagen accumulates at the scar site. This process tends to create temporarily raised and sometimes darkened scars. After this initial healing period, the scars begin to mature and become less prominent over time, usually flattening and fading in color over a period of months and years.

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). Speak directly with your surgeon about ways to minimize scarring.

If hypertrophic scarring occurs, there are post-operative scar treatments available to address the problem. These products include topical Vitamin E oils or lotions, topical products such as Mederma, Scar Fade, and ScarEase, silicone gel creams, or re-usable silicone sheeting. These scar remedies may work for some patients and not others.

Keep in mind that scars will look their worst at about six weeks post-operative, and will fade and become less noticeable in the upcoming months and years. If you have an area of particularly bad scarring, you may wish to consult with your surgeon about possible revisions.

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Resources

Transbucket
www.transbucket.com
Transbucket is a repository for images of FTM gender reassignment surgery results. Trans men can upload pictures of their own surgical results, as well as search and sort through images other trans men have submitted.

FTM Surgery Info Group on Yahoo
groups.yahoo.com/group/ftmsurgeryinfo
An extensive resource for information, photos, links, and research materials pertaining to surgery options for Female-to-Male transgender persons. You must apply for membership to access this group. Includes information about the following FTM-related procedures: metaoidoioplasty (metoidioplasty), phalloplasty, Centurion, hysterectomy, vaginectomy, salpingo-oophectomy, scrotoplasty, urethroplasty, testicular prostheses, and chest surgeries including double incision, liposuction, periareolar, keyhole, non-surgical enhancement alternatives such as pumping, stretching, piercing, and more. Interested persons are required to answer a short questionnaire before membership is granted.

The Transitional Male
www.thetransitionalmale.com
Check out both the Surgery Information Index and the Surgical Photo Galleries on this site.

Trans Care Project of Vancouver, British Colombia
www.vch.ca/transhealth/resources/tcp.html
Completed in January of 2006, the Trans Care Project created a series of training materials and practice guidelines for clinicians treating trans patients, as well as consumer information about trans health for trans people, FTM and MTF. Their materials are downloadable in PDF, and cover numerous topics of concern to trans people and their care providers. Check the Project's Online Library to view the pamphlet "Surgery: A Guide for FTMs."

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