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Dr. Megan has been a dedicated ally to the LGBTQIA+ community of Seattle and beyond for the last 5 years. She is passionate about providing compassionate, respectful and diligent care to her patients through this life-changing portion of their journey.
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TOP SURGERY
OVERVIEW
Top surgery can be life-changing, whether it comes at the beginning, middle or at the end of a patient’s journey. The surgery can be performed in isolation or with a number of other steps such as hormone therapy and other gender-affirming surgeries. Top surgery is not, however, a one-size fits-all procedure. While masculinization of the chest is often the result patients seek, it is not the only goal or option pursued. Having a thorough discussion with a patient during the initial consultation will help Dr. Megan and the patient better identify their surgical goals and how best to achieve them.
Patients seeking FTM Top Surgery generally fall into one of two categories. Patients with a significant amount of native breast tissue, excess skin, and widened and low areolas are candidates for a Double Incision Mastectomy with or without full thickness nipple grafting. Patients with no excess skin, minimal glandular breast tissue, and smaller areolas positioned near the lateral border of the pectoralis major muscle are good candidates for a Periareolar or Keyhole Mastectomy. Some patients find it imperative to preserve nipple sensation. For these patients, a more traditional Breast Reduction can be an option. Ultimately, patients must remember that anatomy is the driving factor in choosing which procedure will give the best aesthetic outcome for the patient.
Masculine Features of the Chest:
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Prominent Pectoralis Major Muscle
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Removal of feminine features such as the axillary fat pad
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Smaller areolas (approximately 2cm in diameter)
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Placement of areolas in a more lateral position
DOUBLE INCISION:
Double Incision or a Double Mastectomy is the most common procedure performed for top surgery. The goal of this procedure is to remove the extra skin and most (but not all) of the underlying breast tissue. Some tissue is left on the chest to create a contour which is proportional to the rest of the body. Removal of the breasts will leave lengthy scars on either side of the chest wall. To make anatomic sense and to improve aesthetics, the scars are generally placed along the lower and lateral border of the Pectoralis Major muscle, starting in the midline fairly flat and straight and then curving upwards towards the armpit. However, incisions can vary in their appearance based on patient anatomy and patient goals. Patients with a significant amount of extra skin on the sides of the chest may have their incisions connected in the midline, extend onto the sides of the chest beyond the muscle boundaries, and/or have a more linear, horizontal scar shape.
Once the excess breast tissue and skin have been removed, liposuction is used to help sculpt the chest, remove the feminine axillary fat pad, better highlight the Pectoralis Major muscle, and improve the overall aesthetics. Should a patient desire to maintain their Nipple Areolar Complexes, these are removed as a full thickness skin graft and placed back on the chest wall at the end of the procedure. When masculinizing the chest, the areolas are reduced in size (approximately 2cm in diameter) and placed in a more lateral (out to the side) position. Penrose drains will be placed to facilitate fluid drainage and bolster dressings will be sewn directly over the nipple grafts for the first week to help keep them in position while they are healing.
While individual patient anatomy will ultimately help to dictate the final appearance of the chest, there are elements of a Double Incision procedure for which we have a good degree of control over:
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Amount of tissue left on the chest wall (i.e how flat the chest is after surgery)
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Shape of the scars (to some extent)
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Size of the areola
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Final position of the Nipple Areolar Complexes.
KEYHOLE:
A Keyhole Mastectomy (Periareolar Mastectomy) involves making an incision around the areola through which most of the breast tissue is removed. Liposuction is also performed as part of this procedure to remove the feminine axillary fat pad and to sculpt the overall chest. A Keyhole procedure is reserved for patients who have specific anatomical characteristics: minimal glandular breast tissue, no significant skin excess, and those who have smaller areolas which reside naturally close to the lateral border of the Pectoralis Major muscle. While a Keyhole Mastectomy always remains an attractive surgical option for patients due to its minimal scarring, it must be reserved for the right patient. It is important to consider what a Keyhole Mastectomy does and does not address on the chest wall in order to determine who is an ideal candidate. A Keyhole Mastectomy does reduce the size of the gland, and liposuction will be performed simultaneously to sculpt the chest. A Keyhole will not, however, remove excess skin, relocate the areolas or resize the areolas. How the skin retracts after gland removal can be difficult to predict. Patient selection is critical in a Keyhole to avoid high revision rates and to ensure a successful aesthetically pleasing outcome.
BREAST REDUCTION:
For some patients, preservation of nipple sensation is imperative for their post-surgical goals, whether for sexual function or to maintain the potential to breast-feed. These patients will often seek a more traditional Breast Reduction technique to achieve this. Much like a Double Incision Mastectomy, a Breast Reduction will remove glandular breast tissue, excess skin, and can resize and reposition the areolas. Incisions in a Breast Reduction resemble an upside down ‘T’ or an ‘anchor’ shape. Unlike a Double Mastectomy, however, the nipple and areola is not removed as a skin graft in a Breast Reduction. The nipple areolar complex maintains its blood supply during these procedures through what is called a surgical ‘pedicle.’ A ‘pedicle’ is the tissue surrounding the blood vessels and nerves that run from the underlying chest wall to the nipple and areola. This tissue must be carefully preserved during the procedure in order to maintain sensation and function. Consequently, a Breast Reduction cannot create a flat chest. It is also important to remember that sensation and function preservation cannot be guaranteed in this type of procedure.
DOUBLE INCISION
AM I A GOOD CANDIDATE?
A good candidate for Top Surgery is in good overall health and, if a smoker, is willing to refrain from smoking at least 4 weeks prior to and 4 weeks after the surgical procedure. At least one letter of support from a mental health provider will be required. It is imperative that a patient have a good support system during this time not only to assist with help during the immediate postoperative period but also to help provide emotional support during this important transition.
THE PROCEDURE:
Prior to surgery, photographs will be taken and the patient will be marked in a standing position. The patient will be put completely asleep during the procedure using a general anesthetic. The surgery itself takes approximatly 1.5 to 2 hours to complete. Once in the operating room and asleep, a tumescent solution is first infiltrated throughout the chest wall. The purpose of the solution is to help with bleeding, postoperative pain control, and the surgical dissection. Pre-sized markers are then used for resizing the areolas and the grafts are harvested. For patients desiring masculinization of the chest, 2 centimeters in diameter is standard. The graphs are then thinned out-- a step which is necessary for their survival but may decrease the final projection of the nipple itself. The breast tissue and extra skin are then removed. The muscle is not disturbed during this dissection. Liposuction is then performed to help sculpt the chest, remove the feminine axillary fat pad, and to better define the Pectoralis Major muscle. Once optimal contour and symmetry is achieved, the skin edges are closed with three layers of sutures placed beneath the skin. Prior to placing the final row of sutures, a Penrose drain is placed to facilitate drainage of fluid within the pocket. Drainage will be collected in the absorbent pads placed outside the chest to be changed daily. Lastly, the new position of the nipple areolar graft is determined, and the grafts are sewn into position. A gauze dressing is sutured directly on top of the grafts to ensure they do not move during the first week after surgery. Surgical tape will be placed over the incisions and the chest is dressed with an absorbable pad and a compression binder. Patients are discharged home to recover.
AFTER SURGERY:
The patient will be dressed in an absorbable pad and compression binder. The compression binder should be snug but should not restrict breathing or sleeping. The pads should be changed two times per day for the first couple of days, transitioning to once per day as the drainage decreases. Initially, patients and caregivers should expect lots of drainage mostly from the fluid that was placed in the tissue to perform the surgery itself. Drain output does not need to be measured with Penrose drains.
At the first postoperative visit, the Penrose drains will be removed. The patient may begin showering after this visit but must keep the bolster dressings over the grafts dry. The patient will return one week after surgery for an additional visit to remove the bolster dressings over the grafts. After this visit, the binder will be discontinued and the patient may begin daily dressing changes to the grafts of Aquaphor and non-adherent gauze.
Restrictions after surgery include no heavy lifting greater than 10 pounds per side and no arms above the head for a total of four weeks. Patients are encouraged to be up and walking the day of surgery to prevent the development of blood clots in the legs. Most patients only require a short course of stronger pain medication followed by a transition to Tylenol and Ibuprofen. Patients typically take 10 to 14 days off work depending on the nature of the patient's work.
WHEN WILL I SEE MY RESULTS?
Final results for contouring of the chest are generally not seen until 3 to 6 months post surgery. Liposuction creates lots of swelling and we must be patient to wait for all the swelling to resolve before determining the final outcome. The surgical scars and nipple grafts will heal quickly in the first couple of weeks but will not reach their final appearance until one year after surgery. Diligent scar care initiated at three weeks postoperatively will help improve the appearance of scars.
KEYHOLE MASTECTOMY
Surgical markings are placed and preoperative photographs are taken prior to heading to the operating room. The patient will be placed completely asleep to perform the surgery. On average, the surgery will take approximatly 1.5 to 2 hours to complete. Once asleep in the operating room, an incision is made along the lower areolar border to access the underlying breast tissue. The tissue is dissected free from its anterior and posterior attachments, and all glandular tissue below the level of the nipple is removed en bloc (as a single unit). The underlying pectoralis muscle is not removed in this procedure. The glandular tissue above the level of the nipple is then shaved down and sculpted in a stepwise fashion to create the contour of a proportional pectoralis major muscle and to avoid a concave appearance. Lastly, fine liposuction is used to create contour and remove the feminine axillary fat pad. Once the desired contour and symmetry is achieved, internal sutures are placed to close off any dead space and a Jackson Pratt drain is placed exiting the side of the chest. The incision is closed in 3 layers of internal, dissolvable sutures. Tape is applied to the external incision and the patient is dressed in a compression binder. Patients are discharged home to recover.
AFTER SURGERY:
After surgery, the patient is discharged home to recover. Patients are encouraged to be up and walking the day of surgery to prevent blood clot development in the legs. Drain care in a Keyhole Mastectomy is much more involved than in a Double Incision. Jackson Pratt drains (JP drains) are closed-suction drains which constantly draw fluid out of the surgical pocket. The fluid output must be measured and tracked in order to help us determine when the most appropriate time to remove the drains will be. If removed too soon, fluid may build up in the pocket that will require in-office drainage. The patient will be seen for their first postoperative appointment 3-4 days after the procedure. Drains are usually not ready to be removed at the initial visit and will require a second appointment specifically for this. The compression binder will be worn for a total of seven days after surgery.
Patients generally require 7-10 days off work depending on the nature of work. Restrictions include no heavy lifting greater than 10lbs per side for a total of four weeks after surgery. Most patients only require a short course of stronger pain medication, followed by transition to Tylenol and Ibuprofen for pain control.
WHEN WILL I SEE MY RESULTS?
Final results for contouring of the chest are generally not seen until 3 to 6 months post surgery. Liposuction and surgical dissection create lots of swelling and we must be patient to wait for all the swelling to resolve before determining the final outcome. A compression garment may be worn longer than the initial week to help resolve swelling quicker should the patient desire.
BREAST REDUCTION
AM I A GOOD CANDIDATE?
The ideal candidate for a Breast Reduction for Chest Reconstruction is in good overall health and is a non-smoker for at least 4 weeks before and 4 weeks after surgery. When a patient is seeking a Breast Reduction for Gender Dysphoria, it is imperative that a patient understands the benefits and also trade-offs of a Breast Reductionfor this indication. In order to reliably maintain sensation and blood supply to the nipple and areola, some amount of breast tissue must be left on the chest. The amount of tissue left on the chest is directly proportional to the distance from the nipple to the underlying muscle. Thus, the larger of the breasts, the more tissue must be left on the chest. Obtaining the flat chest we achieve with a Double Incision is not possible with a Breast Reduction. The ideal candidate for this procedure understands and is willing to accept this trade off in order to preserve nipple sensation.
THE PROCEDURE:
A Breast Reduction can be safely performed in an outpatient setting. The patient will go completely to sleep during the procedure using a general anesthetic. The average surgery time is approximately 2.5 hours. A patient is first marked in the preoperative area and photographs are taken. Once in the operating room and a sleep, the first step of a Breast Reduction is to resize the areola and define the pedicle. The ‘pedicle’ is the tissue containing the nerves and blood vessels that run from the chest wall to the nipple and the areola. This tissue must be left intact in order to preserve sensation and blood supply to the nipple and the areola. Once this tissue is isolated, any excess skin and glandular tissue can be directly removed. The skin edges are then closed with multiple layers of sutures. Drains are usually not used in this procedure. The scar pattern a patient should expect resembles an upside down ‘T’ or an anchor. If liposuction is planned, it will be performed after the skin edges have been closed. Once completed, tape will be placed over the incisions and the patient will be placed in a light compressive dressing. The patient will go home to recover once they are ready for discharge.
AFTER SURGERY:
After surgery the patient is discharged home to recover. Patients are encouraged to be up and walking the day of surgery to prevent blood clots in the legs. Pain medication will be prescribed and generally taken for a short time before transitioning to Tylenol and Ibuprofen. Patients generally require 7-10 days off work depending on the nature of work. Restrictions include no heavy lifting greater than 10lbs per side for a total of four weeks after surgery.
FAQ
(1) WILL MY INSURANCE COVER THE PROCEDURE?
While many more insurance companies are covering Top Surgery for patients, the easiest way to answer this question is by contacting your insurance company directly. How much of the procedure is covered by insurance can also vary depending on a patient’s plan, deductible, etc. Insurance companies will often require 2 letters of support in order to approve the surgery-- one from a mental health provider and one from a primary care physician. Some insurance companies will require hormone therapy for a particular duration prior to approval.
(2) HOW LONG AFTER SURGERY SHOULD I WEAR MY COMPRESSION BINDER?
Due to the extent of Liposuction performed during Top Surgery, quite a lot of swelling is created with this procedure. It is not until all the swelling has resided that the final outcome reveals itself. However, with Top Surgery in particular, patients often bind prior to surgery and may even have dysphoria associated with the binder and binding. Hence, the minimal requirement for compression after surgery is only one week. A patient may continue compression for a longer duration if they choose.
(3) WILL MY DOUBLE INCISION INCISIONS CROSS THE MIDLINE?
How long the incisions will be and if they connect in the midline are completely dependent on each individual’s anatomy. The more extra skin there is to remove, the longer the incision will be. If the breasts naturally sit very close to one another, there is a much higher probability of them touching in the middle. Rest assured, however, that Dr. Megan will use all the “tools in her toolbox” to try to avoid this scenario.
(4) WILL I HAVE DOG EARS
Dog ears represent extra skin or tissue at the end of an incision. They can begin to appear as the healing process takes place or they can be present if an area of excess skin could not be addressed specifically during surgery. These areas, if present, are usually small and can easily be excised with the use of an injection of local anesthetic in the clinic. In some patients with larger chests and a significant amount of extra tissue on the sides of the chest, there will inevitably be dog ears present on the back because the loose, extra skin extends beyond the surgical field and onto the patient's back. Removal of this tissue is considered a separate procedure.
(5)HOW SHOULD I CARE FOR MY SCARS?
The hallmark of all scar care is moisture and the avoidance of tension. For direct scar care, patients may opt for a simple everyday moisturizer, for the addition of scar specific creams such as Bio Oil or Mederma, or for the application of scar tapes and silicone gel sheets. Silicone gel sheets show the best evidence of helping scars to heal with the best cosmetic appearance. They work by trapping moisture in the scars instead of relying on the patient applying a moisturizing agent. Regardless of what scar care is decided by the patient, consistency is key. It is important to remember that the healing and remodeling process for scars takes place over an entire year.
(6) WHAT IS A LATERAL ROLL?
A lateral roll is the extra tissue that extends beyond the sides of the breasts, onto the sides of the chest wall, and possibly even onto the patient’s back. While it is important to address this tissue with both liposuction and direct excision during the initial procedure to achieve the best cosmetic result, it adds significant time and effort to do so. As a result, it is considered an additional part of the procedure. Excision of this tissue will create a much longer scar, and often the scar will be situated in a more horizontal position (as opposed to swooping up into the armpit to follow the Pectoralis Muscle). In some cases, the extra skin extends beyond the sides of the chest and surgical field onto the back. In these cases, the patient must accept that all of the extra tissue will not be excised as part of the Double Incision.