Preparing for surgery
For any kind of surgery you need to be both physically and psychologically ready.
Physical readiness involves being in a reasonable state of general health and completing any pre-surgical requirements as advised by your surgeon, such as quitting smoking or slimming down to an optimal body weight.
It is also important to have a post-surgical plan in place to ensure that you have a safe place in which to recover and friends, family, or other caregiver to assist you in the first few days of recovery.
If you regularly wear binding to minimise the appearance of your chest then you should mention this to your surgeon as it can sometimes affect the health and suitability of chest tissue for certain FTM surgical options.
You may be advised to reduce the amount of binding prior to surgery to allow your skin to breathe.
Achieving A Healthy Weight Prior To Surgery
Transmen with excess body weight may not be ideal candidates for FTM surgery and some surgeons may choose not to perform chest reconstruction unless you can achieve an optimal weight.
Although there are increased risks to do with surgery in general (such as anaesthetic and respiratory complications) a major reason that surgeons prefer to operate on someone at their near optimal weight is because this can dramatically improve the aesthetic result.
The surgeon can more closely contour your chest in proportion to your body and reduce the risk of leaving dog ears under the armpits.
Symmetry is also better achieved in patients who are not carrying excess weight.
Physical readiness is not the only consideration with chest reconstruction surgery however, as mental preparation is also very important.
Ensuring that you understand the profound effect that your surgery can have on your sense of identity and self is vital as expectations need to be realistic to avoid disappointment after any initial post-surgery euphoria abates.
Take time to discuss your priorities with your surgeon and remember that non-trans men do not all have identical chests so there is no standard model for FTMs to aspire to.
Discussing Your Options
Looking at pictures of previous patients can give you a realistic view of the outcome of different procedures.
It may help to concentrate on those with a similar body size and shape to yourself in order to see how their surgery has affected them.
Some transmen are more concerned about retaining touch sensation and others with achieving as natural a look as possible making different procedures more likely in each case.
Removal and transplantation of the nipple (a nipple graft) is not a reversible process and requires careful consideration.
The more the nipple is moved and resized the more likely nerve damage and loss of sensation.
Going Into Hospital
If you are undergoing chest reconstruction alone (without any FTM genital surgery), you will be admitted to the clinic on the same day as your surgery.
Patients will require pre operative tests prior to their admission. We try and combine this with your initial consultation before surgery, especially if you do not live locally.
As the procedure is performed under general anaesthetic you will usually be told not to eat or drink anything after midnight the night before your operation.
You will also be given guidance on when to cease any medications or hormone therapy with blood-thinning medications such as aspirin usually stopped for ten days or so prior to the procedure.
It is important that your surgeon knows all of the medications, whether prescribed or otherwise so as to minimise risks of complication.
Some herbal and nutritional supplements may interact with anaesthetic or cause poor blood-clotting, for example.
Chest Reconstruction Risk & Complications
The risks of chest reconstruction vary according to the procedure performed.
The risks should be considered along with the usual risks of anykind of surgery such as thrombophlebitis (blood clot formation), problems with anaesthesia, blood loss, infection, and death.
The risk of these occurring is minimal and efforts are taken to reduce their likelihood such as getting you moving as soon as possible after FTM surgery, staying hydrated, monitoring your respiratory and cardiac function, and administering antibiotics as necessary.
To help reduce the risks further it is important to follow your pre and post-surgery guidance as instructed by your physician.
Risks Specific To The Double Incision Technique
The double incision technique is often performed on transmen with a larger body mass and comes with the risk of the appearance of "dog ears" under the armpits after chest reconstruction.
This is where excess skin protrudes at the end of the incision and may require further surgery to remove the skin.
Puckering may occur along the scars and require surgery to minimise its appearance.
Numbness under the armpits can be a complication of liposuction used during tissue removal which may resolve as traumatized nerves heal or could be a permanent result of nerve damage.
Additionally, nipple grafts may be lost due to tissue death and require further surgery to remove the tissue followed by additional FTM surgery to tattoo a replacement "nipple" if desired.
You may find that you are unhappy with the placement of the nipples or that they are asymmetrical.
It is important to remember that your chest will be swollen and tender immediately after surgery and that it takes time for your new appearance to settle down.
If, after sufficient healing time, you are dissatisfied with the size or appearance of your nipples then you may be able to have further reconstructive FTM surgery to reposition or trim them.
Many transmen have one or more chest reconstruction surgeries as part of their FTM journey.
Imperfections such as "dog ears" or areas of bad scarring can be addressed along with nipple problems and surgeons usually wait eight to twelve weeks before assessing the desirability of further surgery.
Surgical revisions may be included in the cost of your initial chest reconstruction surgery, although you are likely to have to pay additional costs for the surgical facilities and anaesthesia. It is, therefore, important to understand what is included in any costs quoted.
Risks Specific To The Keyhole/Peri-Areolar Technique
Those undergoing a keyhole or peri-areolar procedure may find that their chest does not look completely flat and that uneven fatty tissue and skin can give the appearance of a breast reduction rather than a chest reconstruction.
This may be an initial effect of the swelling and bruising common immediately after chest reconstruction and you should wait for the inflammation to subside before considering further surgery.
In some cases, there may have been insufficient retraction or trimming of the remaining skin leaving areas of sagging or puckering.
Where the peri-areolar technique has been used the drawstring procedure may give an effect of puckering around the areola requiring revision.
As the nipple is not removed and grafted during the keyhole and areola procedures it may be that final nipple placement is not ideal and that you would like further surgery to move the nipple to a more aesthetically "male" position.
It is also possible that numbness or alterations in sensation of the nipple may occur due to trauma from liposuction.
You may find that you feel exhilarated and liberated after your chest reconstruction but it is common for an initial wave of euphoria to be followed by general ups and downs in mood.
It is normal to experience some difficulty in adjusting to changes in your body's feel and look, especially when also experiencing post-surgical pain and possible complications.
The reaction of other people to your FTM surgery can also present problems as it may be that family and friends realise for the first time that your issues with gender are not superficial or temporary and are unable to provide the support they offered previously.
Taking care to have a support network available to you in your recovery period is very important and you may feel that delaying surgery is preferable until a time where you have sufficient emotional resilience to face the psychological challenges gender confirmation surgery involves.
Chest Reconstruction Keyhole/Peri-Areolar Technique
Keyhole and peri-areolar techniques are effective methods of chest reconstruction if you have small amounts of breast tissue.
Most FTM surgeons offer these techniques if you fit an A cup or small B cup, although some surgeons will offer the peri-areolar technique up to a AA cup or 120grams of tissue.
The two procedures are similar in that they are performed by removing breast tissue through an incision around the areola (the area of darker skin around the nipple), but they do differ slightly in other ways.
Retention of nipple sensation is a major advantage to these types of surgery as is the minimal, and mostly hidden, scarring disguised by the darker areola.
Chest reconstruction will usually be performed as a morning operation and lasts for around three to four hours.
You will then be taken to recovery and monitored as you come round from the general anaesthetic.
Most patients are discharged that afternoon although others require an overnight stay.
The surgeon will make a small incision along the bottom of your areola and remove breast tissue using a liposuction needle inserted into the incision.
Your nipple will be left attached to the body via a pedicle (stalk of tissue) making it advantageous over the double incision technique.
After sufficient tissue has been removed the incision will be closed up without the need, in most cases, for the nipple to be resized or repositioned.
If, after your surgery, you are dissatisfied with the position of the nipple you may be able to have revision FTM surgery to move it higher or correct any asymmetry occurring as a result of surgery.
This technique involves your surgeon making an incision in a circle around the edge of the areola.
Breast tissue is then removed used a scalpel and liposuction to reduce the volume of the breast, taking care to leave the nipple attached to the body via a stalk of tissue (pedicle) to preserve nerve function.
A wider ring of skin may be removed in a circle around the areola and the skin is pulled toward the center of the opening and stitched to the edge of the areola.
This "drawstring" effect can allow for some slight repositioning of the nipple to achieve a more natural look whilst preserving sensation.
The areola may be trimmed to reduce its size in proportion to your new chest and excess skin on the chest may also be trimmed to keep the chest appearance taut.
Mr Yelland does not use surgical drains.
Chest Reconstruction Double Incision Procedure
The double incision technique is often used for transmen with larger amounts of breast tissue or inelastic chest skin.
The Usual Candidate
Transmen with a C cup size of above are usually candidates for this type of chest reconstruction FTM surgery. Horizontal incisions are placed under the line of the pectoral muscles to reduce visibility.
This surgery usually involves the removal and repositioning of the nipple which results in a loss of nipple sensation.
Letting your surgeon know your priorities for the outcome of your surgery, including retention of touch sensation, natural appearance, and so on, prior to chest reconstruction ensures that they tailor your procedure to best achieve your desired result.
Surgery usually takes around one to two hours and is done using general anaesthetic.
The procedure includes an overnight stay in the hospital. You will be reviewed by Mr Yelland on the morning after your surgery and be discharged in the late morning.
The Incisions & Tissue Removal
Large incisions are made in a horizontal curve following the line of your pectoral muscle.
The skin is then peeled back to expose the mammary glands and fatty tissue which is removed using a scalpel or liposuction in harder areas such as near the armpits.
The muscles of the chest are not impacted by the procedure.
A degree of skin is also removed to keep the chest taut and the incisions are sutures to leave two seams just below the pectoral muscles.
The double incision technique usually requires the nipple to be removed, cut to size, and grafted onto the newly sculpted chest in the approximate position of the male nipple.
Surgeons often use different approaches to nipple repositioning and it is important to establish which procedure your chest reconstruction surgeon will be using.
It may be possible for your surgeon to leave a pedicle (stalk of tissue) attaching the nipple to the body before moving it into a higher position more commensurate with a male chest.
Some areola trimming is usual, however, to maintain proportionality of the nipple to the chest. The use of the pedicle technique can retain nipple sensation in some cases but is not always possible.
On rare occasions it may not be possible for a surgeon to preserve or graft the nipples into their new position.
This is an uncommon occurrence but may occur due to tissue death.
If this happens then a further procedure to tattoo nipples onto the chest is an option after your newly reconstructed chest has healed from the first operation.
This may be covered in the cost of your initial procedure and should be checked with your surgeon along with the methods he/she is intending to use for nipple repositioning.SURGICAL DRAINS
Mr Yelland does not use surgical drains.
Advantages of the Double Incision Technique
If you are of a larger build with a bigger chest, then the double incision technique usually offers better results for a more contoured male chest.
The scars from the procedure are somewhat disguised by the natural line of the pectoral muscle and some transmen find that they become even less visible as their muscles build from working out.
If you are having testosterone therapy, then chest hair-growth may also help to cover the scarring.
The proper repositioning and resizing of the nipples during this procedure can give you a more natural looking appearance.
The double incision method also allows your surgeon easier access to remove a substantial amount of mammary tissue in comparison to the keyhole technique.
Reconstruction Surgery Recovery
After you come round from the anaesthetic you will stay in hospital overnight.
Post- Surgical Care
You will return to your room with intravenous fluids, a tight binder across your chest (this is to minimise any swelling or formation of haematoma).
The nurses will monitor you closely. They will check your pressure dressings which are over your nipples and suture lines.
You will be able to eat and drink on return to the ward.
You will be seen post-surgery by Mr Yelland.
The following morning after your surgery Mr Yelland will examine you to ensure you are fit for discharge. You will be seen by a physiotherapist and you will be given exercises to follow in your recovery period.
You will be advised to wear a binder post-operatively which is of Neoprene construction. These are quite sweaty and do contain some latex. It is wise to wear a T-shirt between this and your skin.
The nurses will give you dressings to take home. Will discuss your post-operative care, give you contact numbers for night and day.
A sick certificate will be issued should you require one for two weeks. If you require longer Mr Yelland will assess you in your post-operative consultation.
You will be given an appointment on the day of discharge for your post-operative appointment, this is usually 5-10 days.
At you post-operative appointment your dressings will be removed by Mr Yelland or Specially Trained Nurse.
If you have clips around your areolar these will be removed, sutures will be removed and a further dressing will be applied for 24 hours. This can then be removed.
Possible Post Operative Complications
DVT (Deep Vein Thrombosis), pulmonary embolism. It is important for you to mobilise post surgery. Drink plenty of water. DO NOT SMOKE, this can reduce the blood supply to your nipples and contribute to nipple necrosis.
Binders & Dressings
Your incisions will usually be covered with gauze dressings and a pressure dressing over your chest to provide both support and protection.
A binder (compression vest) is usually worn to aid healing for up to four weeks after chest reconstruction surgery and this can encourage the skin of the chest to tauten and prevent fluid build-up.
If you had nipple grafts, then these will be covered with special cushioning and gauze dressings that stay in place for around 7-10 days after FTM surgery until removed by the surgeon to check healing.
Checking For Infection
Following removal of your dressings. It is important to observe any changes in your incisions (you may need to use a mirror or get a friend to check for you).
If you can see any redness that extends more than an inch from the incision site this may be a sign of infection and should be investigated. Some redness and tenderness at the incision is perfectly normal but any fluid seepage or changes in inflammation, particularly if you have a headache or fever, should be reported immediately.
Swelling, Tenderness, & Numbness
Swelling and tenderness is common for at least a month after surgery and initial bruising is usually no cause for concern.
If, however, you observe any increased bruising and develop a pooling of blood under the skin causing a visible lump then seek immediate medical attention as this can indicate a haematoma.
Burning pain, sharp shooting pains and general discomfort can be common, and this will usually dissipate over the first few days after surgery.
Numbness may occur across the chest and in the nipple, this will usually subside (sometimes taking up to a year) as the nerves in the chest heal but may be a permanent feature if severe nerve damage occurs.
Returning to work
Your surgeon will give you specific instructions regarding post-surgical care and recovery from chest reconstruction.
If you have a fairly sedentary occupation, then you may be able to return to work after a couple of weeks once normal movements are no longer painful.
Any profession which requires heavy lifting, frequent raising of the arms above the head, or strenuous activity is likely to necessitate a longer hiatus from work such as a month or two.
You may be able to alter your responsibilities at work for a few weeks such as switching to a desk job temporarily and you should discuss this with your employer where possible.
Your surgeon will offer guidance on post-operative care to minimise potential scarring.
Your GP or nurse should be able to address any rupture of a small number of stitches but you will most likely require attention from your surgeon if your wound begins to open up or if fluid builds up in your chest.
If adequate healing time is not allowed, then increased visibility of scarring is more likely.
You should not attempt any weight-lifting exercises until cleared by your surgeon as any increase in pectoral muscle size during the healing period may tear the stitches, cause substantial pain, and/or lead to a necessity for further surgery.
Some degree of scarring is the natural response of the body to help heal itself following trauma.
This occurs due to the deposition of fibrous collagen and can create temporarily raised and darkened scars.
These usually fade over the next few months but can occasionally remain thickened and red if you develop hypertrophic scarring.
This type of scarring may be connected to genetic factors but is also a feature of overstretched scars which have not been given adequate healing time prior to the resumption of activities.
Treatments to reduce the visibility of hypertrophic scarring are available although their success is variable. Most scars will look their worst at six weeks or so after FTM surgery and will start to fade after that time.