Masculinising Chest Surgery

Overview:

Masculinising chest surgery is indicated for patients with a persistent and well documented gender dysphoria who are assessed to benefit from mastectomy as part of a masculinising chest process. This process is likely to include male hormone supplementation and surgical breast removal with resitting of the nipples in a masculine position.

The chest and reconstructed nipple do not have the same sensitivity as the preoperative chest and natural nipple and nipples will not react in the same way to touch or temperature but are designed to give a more natural male appearance to the chest. The new nipple may be designed flat or have more projection and your preferences should be discussed with Mr Rubin.

Principle types of operations:

Double Incision Technique:

This technique is used most often. It is particularly indicated where there is significant excess skin and a degree of droop to the breast as these are more difficult to correct satisfactorily with other techniques.

Circumareolar:

This technique which leaves a scar around the nipple rather than across the chest is most suited to patients with small or minimal breasts. Nipple-areolar complex is not removed as a graft but kept attached. The main downsides with this technique are that the scar around the nipple is prone to be irregular as excess skin is gathered up around the nipple.

There is also a higher incidence of bleeding after surgery. One reason for this is the visualised operative field during surgery is reduced making it harder to see small bleeding vessels.

Circumareolar with medial and lateral extensions:

This has some of the advantages of a circumareolar technique but with a more predictable outcome. A proportion of the excess skin is taken out with the medial and lateral extensions which also has the advantage of allowing improved visibility of the operative field. There is a higher incidence of bleeding after surgery than with the double incision technique but lower than with the circumareolar technique alone.

Supero-medial pedicle technique (2 stage):

This is a technique that is very rarely used as 2 stages of surgery are necessary for most patients. In this technique (as with the Circumareolar) nipples are not removed and replaced as a graft but instead is retained with its blood supply. Keeping the nipple alive on its pedicle means that there is excess breast tissue on the inside of the chest which usually requires removal some months later.

Nipple Graft:

This is commonly performed during the double incision technique and the aim is to create the new nipples in a position that is considered masculine and as symmetrical as possible to the nipple on the opposite breast. Variables include nipple size and the degree of projection and if you have specific preferences please discuss these with Mr Rubin before surgery.

Risks and Complications & After Care

Risks and Complications:

It should be remembered that no matter how straight forward and routine a surgical procedure may be they all have their risks of complications and limitations

  • Infection - requiring antibiotics or further surgery, rarely can cause lead to loss of the nipple graft
  • Bleeding – sometimes requiring an emergency return to theatre to deal with the bleeding (approximately 1-3% in the double incision technique and considerably higher in the circumareolar), bleeding under the nipple or nipple graft can result in loss of the nipple, fortunately this is unusual.
  • Seroma which is fluid that is released by raw surfaces and can therefore collect within the chest. We try to minimise this by employing drains for the first one or two nights after surgery, and advise the wearing of a chest wrap (which we supply) for the first 4-6 weeks.
  • Reduced chest and nipple sensation. This occurs within the chest wall because nerves that supply sensation might pass close to or through the tissue being removed. For similar reasons some discomfort can be felt at 2-3 months as the nerves wake up. However this almost always settles down. But Some of the tactile sensation within the nipple graft usually does return but can take several years.
  • Stretched lumpy or red scars that can take 12 months or so to soften flatten and fade and occasionally require further treatment. We recommend early scar intervention to minimise the duration and intensity of this process.
  • Delayed wound healing - may require dressings.
  • Loss of the nipple graft (around 1% chance). Loss of the nipple can also occur in the circumareolar technique and in the 2 stage supero-medial pedicle technique due to a failure in the blood supply
  • Patients with higher BMI are at increased risk of wound healing difficulties including fat necrosis and delayed healing.
  • Asymmetry: the chest and nipple of one side will never be a perfect match for the chest and nipple of the other side and there may be some asymmetry seen post operatively, but every effort is made to recreate a symmetrical appearance.
  • Over time the nipple graft may flatten out.

Aftercare:

  • A drain is inserted to each chest during surgery which is usually removed on the following day prior to discharge, most patients will only require 1 night as an inpatient postoperatively and can be discharged on the following day.
  • Your initial dressings are splash proof and you may shower with care. They should be kept on for the first week post-operatively until the first graft check (between 5 and 7 days after surgery). Dressings are refreshed at point but may be completely removed by 12 days following surgery.
  • You are provided with a chest wrap and are advised to wear it continuously as far as possible for the first 4-6 weeks which will help secure a favourable outcome with reduced likelihood of seroma.
  • Scar care: We recommend a gentle scar care regime from 3-4 weeks following surgery and continued until the all colour has faded from the scar. Which could take over 9 months. Regimes can include the use of simple moisturiser, bio oil or silicone gel. Alternatively micropore tape or silicone scar tape.
  • After masculinising chest surgery, you should be able to resume light activity within 2 weeks and normal daily activity by 4-6 weeks. Please discuss more specific sports oriented activity with Mr Rubin.
  • Breast Cancer: During surgery of this type it is not possible to remove 100% of breast tissue. This means that although highly unlikely it remains theoretically possible for breast cancer to develop. Usual breast screening (mammography) is not possible and so patients are advised to maintain awareness of any changes within their chest and to seek medical advice if necessary.
  • The way people understand and experience their gender identity can change over time. It is possible that you could experience such a change in the future, meaning you become unhappy with the outcome of masculinising chest surgery, because it is no longer in keeping with your identity. Although post-treatment regret of this kind appears rare, it can happen any time, even many years, after surgery.Because there may be changes to how you feel about my body after surgery it is important to discuss any such changes with the clinicians involved in your care. For this reason, you are been advised to seek follow up care with your gender clinician in the 6 months after your surgery
  • Follow up with Mr Rubin usually takes place between 8-12 weeks after surgery and then at approximately 1 year.

Additional information

If you have any concerns or questions, please feel free to contact us @:

hello@londontopsurgery.com

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LondonTopSurgery is a bespoke ‘top surgery’ service run by Philip Rubin, based in a beautiful part of North London situated close to Kenwood and the Hamstead Heath extension.

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