Surgery

A Guide For F.T.M.s

Sourced from Vancouver Coastal Health, Transgender Health Program

(The Gender Centre advise that this article may not be current and as such certain content, including but not limited to persons, contact details and dates may not apply. Where legal authority or medical related matters are cited, responsibility lies with the reader to obtain the most current relevant legal authority and/or medical publication.)

Sex reassignment surgery (S.R.S.) refers to surgical techniques used to change trans people's bodies. S.R.S. is sometimes called "gender reassignment surgery" (G.R.S.) or "gender confirming surgery."

Not all trans people have S.R.S. Among those who do, there are various reasons for having S.R.S. Some people have it to reduce physical dysphoria - strong discomfort with the mismatch between identity and body. Others feel O.K. about their bodies, but are very uncomfortable with how other people perceive them (social dysphoria), and want to change their physical appearance to be able to live in a way that better matches their identity.

For any kind of health issue, choosing surgery is a big decision, and S.R.S. is no exception. This booklet aims to:

• describe options for F.T.M. S.R.S.;
• explain possible risks and complications of F.T.M. S.R.S.;
• describe what to expect before and after F.T.M. S.R.S.; and
• explore issues to consider in making the decision to have S.R.S.

Surgical Options for F.T.M.

For s, the goals of S.R.S. are to reduce "female" characteristics and make the body more "masculine" or androgynous (depending on how you identify. F.T.M. S.R.S. can include some or all of the surgeries listed later.

Each of these surgeries has risks, but they are also proven to help F.T.M.s with physical and/or social dysphoria to live more comfortably. The details of top surgery and lower surgery are discussed on the following pages.

Options for F.T.M. Sex Reassignment Surgery

Top Surgery Options

• Reduction Mammmaplasty - removing some breast tissue to make the chest smaller.
• Chest Reconstruction - removing breast tissue and excess skin and altering the nipple and dark area around it (areola)

Lower Surgery Options

• Hysterectomy - removing the uterus
• Salpingo-Oopherectomy - removing the fallopian tubes and ovaries
• Colpecto, or Vaginectomy - removing the vagina
• Colpocleisis -closing the vagina
• Metaidoioplasty (also spelled "Mataidioplasty" or "Metoidioplasty") - making the clitoris appear larger to form a small penis
• Phalloplasty - making a penis using tissue from another part of the body
• Urethroplasty - lengthening the tube that carries urine from the bladder to exit
• Scrotoplasty - creating a scrotum, "balls"

Other Surgery Options

• Liposuction - removing fat from the hip, thighs and buttocks
• Implants - inserting material into the calf, jaw, chin or chest to make these areas more muscular

F.T.M. Chest Surgery

Testosterone tends to bulk up muscles and reduce fat, and this can slightly change the shape of your chest, but testosterone doesn't make breast tissue go away. Only surgery can remove breast tissue.

What about binding?

Binding refers to the process of flattening your breast tissue to create a smaller and less noticeable chest. Some F.T.M.s bind all the time; others only do it when they go out in public or in specific circumstances. For some F.T.M.s binding is a viable alternative to chest surgery. For others it's only partially successful and is a short-term, stop-gap measure until surgery. The type of materials used depends on the size of your chest, your overall build, and what you can afford. Visit these websites for further details: Hudson's F.T.M. Resource Guide and The Transitional Male

Binding can have health consequences. Many of the synthetic materials used for binding don't allow your skin to breathe (promoting rashes and fungal infections), and when binding is done too tightly it can cause pain and restrict your breathing. Tight binding is especially dangerous for young F.T.M.s whose bodies are still growing, as it can affect rib and lung development. To reduce the potential risks of binding:

• Loosen your binder if it hurts, cuts your skin, makes it difficult to move, or makes it difficult to take a deep breath;
• Give your skin a chance to breathe. Take breaks from binding; and
• Wear a thin undershirt under your binder to help absorb sweat and prevent skin irritation.

Binding over a long period of time makes your skin less elastic, which can affect your surgical options and results. If you are planning to have chest surgery, talk with your surgeon about their recommendations for binding.

Types of F.T.M. chest surgery

Breast reduction (Reduction mammaplasty)

If you want a smaller chest but not a "male" looking chest, you might want to consider reduction instead of reconstruction. Getting a reduction affects your options for reconstruction, so it is not recommended that you have a reduction first if you are planning on getting reconstruction later.

The techniques used for reduction in F.T.M.s are the same as reduction for women. For a detailed explanation of the breast reduction procedure, see the Canadian Society of Plastic Surgeons website.

Chest reconstruction

In F.T.M. chest reconstruction, the goal is to create a "male" looking chest. This can include:

• removing most of the breast tissue;
• removing excess skin;
• removal of the crease where the breast meets the chest wall (inframammary fold); and
• resizing and repositioning the nipple and the dark area around it (areola)

F.T.M. chest reconstruction also includes preserving as much sensation as possible and trying to minimize scarring.

There are three possible techniques that can be used, depending on the size of your chest, the elasticity of your skin, and your preferences:

Keyhole

• Used for Small breasts (A or small B cup) with good skin elasticity.
• Incision/scar along bottom edge of areola.
• Breast tissue is removed via a small incision under or across the areola.
• Nipples are not resized or repositioned.

Drawstring/Purstring

• Used for moderate sized breasts (B or C cup) with good skin elasticity.
• Incision/scar - circle around the edge of the areola.
• Breast tissue is removed via an incision around the edge of the areola. A ring of skin is then removed in a wider circle around the areolar incision and the skin is pulled toward the centre of the opening and stitched to the edge of the areola. This creates an effect similar to pulling a drawstring bag closed
• Areola may be trimmed to reduce its size. It may be possible to reposition the nipple.

Mastectomy with free nipple grafts (double incision)

• Used for large or saggy breasts or inelastic skin.
• Incision/scar - horizontal or U-shaped cuts across each breast, the nipple. The aim is to place the incisions just under the line of the pectoral muscles so it is not highly visible.
• The skin is peeled back and the breast tissue and excess fatty tissue are removed. The excess chest skin is then trimmed and the incisions closed.
• Nipples are removed, trimmed to smaller sizes and grafted onto the chest to approximate positioning of the "male" nipple. Some surgeons leave the nipple attached via a stalk (pedicle) of tissue and move the entire stalk to preserve sensation.

As part of considering which technique to have, it's important to consider your goals in terms of balance between nipple appearance and sensation. The more the size and position of the nipple is changed, the less sensation you'll have. If nipple sensation is not important to you but nipple appearance is, a nipple graft may be your best bet. If nipple sensation is very important to you, talk with the surgeon about techniques to reposition the nipple without removing it.

What will my chest look like afterwards?

Looking at pictures of F.T.M.s who have had chest surgery can help you get a sense of what to expect. The Transster website includes pictures of F.T.M. surgery results by various surgeons. You can also ask surgeons to see before/after photos of their patients.

If you look at a number of photos you'll see that the results vary greatly. Some F.T.M.s have chests that look exactly like non-trans men's chests, but for most F.T.M.s, getting to that point takes at least one (and sometimes more than one) revision surgery. The final results depend on what your chest was like to start with (chest size, quality of skin, etc.). It is important to remember that, like non-trans men, not all F.T.M.s have identical chests. Many surgeons' websites have photos of F.T.M.s who are young and relatively thin. But most non-trans men do not have buff, rippling torsos with perky nipples, and it's unrealistic to expect this for yourself if this doesn't match your body. In looking at surgical pictures, look at F.T.M.s who are close to your build and age to get a sense of what a realistic result might be for your body.

Because F.T.M.s have had less exposure to testosterone than non-trans men, F.T.M.s tend to have less developed muscles. A balanced exercise program that includes weight training to build the pectoral muscles (front chest wall) before and after chest surgery can help give a more "masculine" contour.

Timing of F.T.M. chest surgery

Chest surgery can be done at any stage - as a first (or only) step, or after you've already gone through other body changes (e.g., testosterone). F.T.M. chest surgery is usually done as a single surgery, but in S.R.S. programs where there is a team of surgeons working together, it can be done at the same time as hysterectomy/oophorectomy to reduce the number of times you have to go through general anesthetic.

What to expect before and after F.T.M. chest surgery

At the hospital

You will most likely be admitted to hospital the same day as your surgery. You may be asked to come to the hospital the day before surgery to go over information about the surgery and to have a last-minute physical checkup. You will be told not to eat or drink after midnight the night before you have surgery.

After your surgery, you will be monitored by hospital staff as you come out of the anesthetic. Chest surgery is a relatively simple procedure and you will probably be sent home the same day as surgery, with medication to help control pain and antibiotics to help reduce the risk of infection as your wounds are healing. F.T.M.s who are having mastectomy may be kept in hospital overnight.

You will need to have someone drive you from hospital or take a taxi, as it's not safe to drive after chest surgery.

After chest surgery

Gauze dressings will be placed over the incisions, with a tensor bandage wrapped around your chest for protection and support. After reduction, a special surgical bra is worn until the swelling and bruising have gone down. After reconstruction, a compression vest is often recommended for one month to prevent fluid buildup and to help the skin tighten. Depending on the amount of tissue removed, you may have drainage tubes in the incisions or drains in the side of your chest to help drain excess fluid.

For the first three days after surgery, a home care nurse will visit you once a day to check your dressings and monitor and empty your drains. Three days after surgery, the gauze pads over your incisions will be taken off and you will be able to take a shower. There will be adhesive tapes ("steri-strips") along the incision line; leave these on, and be careful not to soak them in the shower (it's O.K. if they get splashed with a bit of water, but don't run water directly over them). After showering, gently pat the steri-strips dry. They will fall off on their own in 7–10 days. You can use fresh gauze pads as needed to protect the incisions. If you have drains, they will be removed by the surgeon or another doctor 3–7 days after surgery (your surgeon will give you instructions). Antibiotics continue until the drains are removed.

It is normal for the incisions to be red, but the redness shouldn't go beyond the incision for more than 1 - 2 centimetres (if this happens, see a doctor right away, as it can be a sign of infection). It is also normal to see or feel the knot in the stitches at the end of the incision. The stitch knot is not a problem; it will either dissolve on its own or come to the surface of your skin, in which case a doctor or nurse can clip it free. If you had nipple grafts, your nipples will be covered with a special cushion and gauze. These will be taken off by the surgeon 5 days after surgery to check healing.

A medium level of bruising and swelling is normal. Your chest will probably feel sore and swollen for at least a month after surgery; if you have a large amount of swelling, see a doctor. Feelings of sharp shooting pain, burning pain, or general discomfort are common as part of the healing process and will eventually go away. Usually serious discomfort passes 1 - 2 days after the surgery. Your chest skin and nipples may be partially or totally numb at first; sensation usually partially returns within a year of surgery, but may not fully return.

You can go back to your usual routine when you feel well enough to do so (i.e., normal movements don't cause pain). This is typically 1 - 2 weeks but can take longer in some cases. You should avoid any activity that is vigorous enough to raise your heart rate for 3 - 4 weeks, and should not do anything that involves lifting, pulling, or pushing for at least 6 weeks to help the scars heal.

Risks and possible complications of F.T.M. chest surgery

All surgeries (not just S.R.S.) involve possible risk of infection, bleeding, pain, and scarring. Antibiotics are usually given at the hospital to reduce the risk of infection, and the home care nurse who will check your dressings in the first couple days after surgery will also be looking for infection. It is normal for your chest to be sore after the surgery, and for the incision line to be red. If the redness goes more than 1 - 2 centimetres beyond the end of the incision, the skin is very tender or warm, and you don't feel well, see a doctor to check whether you have an infection.

All surgery that involves general anesthetic is a serious medical procedure. With any surgery there is a risk of blood clots (which can be fatal) or a negative reaction to the anesthetic. Surgeons, anesthetists, and surgical nurses are experienced in preventing problems and responding to any emergencies that happen during surgery. After you're discharged from the hospital, to prevent blood clots move around as much as feels comfortable, and drink plenty of water. Get emergency medical help (call 000) if you have sudden shortness of breath, chest pain, dizziness, or tender, warm, and swollen legs - these can be signs of a blood clot and you may need emergency help.

Your G.P. or nurse can handle minor infection or rupture of a small number of stitches after you've been discharged from the hospital. You will be referred back to your surgeon if you rupture so many stitches that the wound keeps opening more and more, or if fluid/blood builds up in your chest. If your notice an increasing amount of blood in your drains, contact the surgeon immediately.

Possible complications specific to F.T.M. chest surgery include:

• problems with the contouring/skin: puckering, chest sunken or puffy in places, lopsided (one side looks different than the other), "dog ears" (excess skin at the end of the incisions), sagging skin that fails to tighten up after surgery;
• lopsided repositioning or resizing of the nipple (one side looks higher/larger than the other)
• change in sensation to nipples/breast skin: less sensation or more intense sensation
• nipple grafts may die and need to be removed
• thick, red, rope-like scars.

You will likely have to have further surgery if:

• you have contour problems or your nipples are lopsided: the surgeon will wait 8 - 12 weeks after surgery to see what your chest looks like after the post-surgical swelling fades
• your nipple grafts die: another graft, nipple reconstruction, or tattooing can be done at a later time
• you have severe scarring

Can I still get breast cancer after chest surgery?

Studies of non-trans women who had breast reduction found reduced risk of breast cancer. Removing your breast tissue decreases the number of cells that can become cancerous. But even a complete mastectomy can't remove all breast tissue cells (there will still be microscopic amounts). This means you will still have a risk of breast cancer. Cases of breast cancer in F.T.M.s after chest surgery have been reported.

Breast cancer is believed to be heavily influenced by exposure to the hormones estrogen and progestin. There is no clear evidence that F.T.M.s who take testosterone are at increased or decreased breast cancer risk.

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