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Female to Male Breast Reconstruction

The great challenge in reconstructing a male- appearing chest from a female breast is the management of the overlying breast skin. There is always a “skin excess” when the underlying glandular and fatty breast tissue is surgically removed. One goal in gender reassignment surgery is to manage this skin excess with a minimal amount of scarring. Excess skin can easily be cut away but every incision in surgery leaves a scar — the challenge for the surgeon is to remove this excees skin and to “hide” the incisions in natural folds, previous scars, or in the pigmented skin of the nipple-areolar complex.

The most critical factor in determining the appropriate procedure for each patient is the breast size. A very large breast (C-cup or larger) always requires a more extensive incision or series of incisions. Obviously, the larger the breast size, the more overlying skin there will be left to manage after the underlying breast tissue is removed. My preference for the large breast is to place an incision in a horizontal direction with a gentle curve that follows the curve and lower border of the pectoralis muscle. This scar, although it is long, can heal very nicely and can be “hidden” in the fold that is created by the well-developed pectoralis muscle. With a long incision, there is no problem removing the skin that is in excess after the breast tissue is removed and this procedure can be performed in one stage with only a small percentage of patients requiring any surgical revisions. Chest hair growth is also very beneficial in helping to conceal the scarring. With this procedure, I often will completely remove the nipple areolar complex, decrease it to the appropriate size, and replace the nipples in their new elevated and more lateral position as skin grafts. Liposuction also is an integral part of any breast reconstruction surgery to help create a smooth contour and transition from the breast to the surrounding chest wall.

The B-cup breast size has always created controversy for the plastic surgeon. A patient could be evaluated by 10 different surgeons and receive 10 different opinions on how the procedure should be performed and where the incisions should be placed. Common incisions used are: 1) the inverted “T”, 2) a horizontal incision on either side of the nipple, 3) a vertical incision under the nipple which curves outward near the fold of the pre-existing breast, and 4) the peri-areolar incision.

My preferred incision for the B-cup breast and smaller is the periareolar incision. The average male nipple-areolar complex (NAC) size is about the size of a dime or slightly larger. The average female NAC size is about the size of a half dollar, but it will be much larger in larger breasts. An incision is always made around the entire border of the NAC to reduce the size. This incision is called a periareolar incision. Because this incision is placed at the junction where the normal skin joins the pigmented or colored skin of the NAC, this incision can “hide” nicely and can appear to be the border of the pigmented skin. The excess skin is removed in a circular fashion around the NAC. The challenge is then to close the large skin circle to the dime-sized new NAC. The discrepancy in size of the outer skin circle to the inner circle (NAC) creates a very pleated skin closure — much like a drawstring purse. With normal healing, all skin will contract and tighten. We are relying on the skin contraction properties (which are different in each patient) to tighten the skin and to reduce the appearance of the pleating. Almost every patient will require a minor surgical revision to manage persistent pleating after the first stage procedure. If bothersome pleating exists after the revision, then the patient and surgeon must decide on creating another scar and in which direction. Often this additional scar or scars will be short and well-accepted by the patient because residual pleating rarely extends for more than an inch from the border of the NAC. Obviously, if the scar can be limited to the periareolar incision, this is the most desirable situation as there would be no obvious scarring that the patient might have to “explain” to someone when the chest was exposed.

In summary, the goals of female to male breast reconstruction surgery are to remove the glandular and fatty breast tissue with a smooth transition to the surrounding chest wall, to decrease the NAC size, and to perform the surgery with acceptable and minimal scarring.

Originally published in 1998 True Spirit Conference book.

Gender Reassignment Surgery: Female to Male Breast Reconstruction

By Beverly A. Fischer, M.D, 2002, amboyz.org

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Female to Male: Sex Reassignment Surgery

This is one of the more controversial aspects of the transgender (TG) experience. There are many transgender folk who choose not to have any surgery, some who pick and choose which surgeries they want, and some who feel they have no choice but to go through all of them. There are also the moral pressures to consider from internal and external sources. Average cost ranges are as follows:

Chest…………………..$2100 – $7500

Hysterectomy………….$10,500 – $18,000

Metoidioplasty…………$8,000v- $15,000

Phalloplasty……………$15,000 – 150,000

Please keep in mind that these costs vary from doctor-to-doctor as well as from country-to country.

Most of the surgeries listed above can only be acquired by paying the surgeon cash up front. The cost is one of the weightiest factors as to whether a person decides to have the surgery or not. Many FTMs are under-employed, if not unemployed. Those who do seek surgical alteration often work 2 and 3 jobs to save the money needed. Some of the younger FTMs work the streets just for survival money, although a few have used this as a means to supplement other earnings for surgeries. A few FTMs have been able to acquire some or all of their surgeries through insurance. This is very rare since most insurance companies explicitly exclude transsexual treatments from their covered procedures.

When to have any of the surgeries is also an issue for many FTMs. The Harry Benjamin Standards of Care (SOC) clearly delineates when a transsexual can do certain things pertinent to their transition. Many transsexuals who only choose to do one or two of the surgeries circumvent the SOC. However, this can mean seeking doctors through the black market. The other concern for many FTMs is the condition of the body before and after taking hormones. There have been several FTMs who have sought and received different surgeries before taking hormones. Reasons for this will be disclosed in the following paragraphs.

The double mastectomy and/or mastopexy is the procedure most commonly sought by FTMs. The biggest reasons for this are image/presentation and comfort. Transsexuals are asked to dress and live in the world as a person of the gender they are trying to achieve for a set amount of time&emdash;usually six months to one year before they are allowed to pursue hormone therapy or any of the surgeries. The biggest obstacle for an female to male is usually hiding the breasts. However, this is absolutely necessary. Far too many FTMs have been humiliated, harassed, and even beaten up for walking into the men’s room because their chests gave them away. This harassment is not exclusive to the bathroom situation. Mainstream society is notorious for its violence toward anyone presenting a conflicting image, period. Many FTMs choose to have this surgery before they pursue hormones for several reasons. With testosterone comes body hair. The chest hair that grows in around the sutures and incisions can, at the very least, be incredibly annoying, and in the extreme can become ingrown and even cause infection. Many FTMs also look to the advantage of estrogen keeping the skin more pliant as a bonus. Several individuals have gone through the mastopexy, waited 6 to 9 months to heal, and then begun testosterone therapy. It seems that most of these individuals have less visible scarring or less extensive scarring. The muscle growth into the chest with the testosterone seems to them more natural as well.

A couple of advantages to testosterone are that the healing rate (from surgery) appears to be quicker, and with the advanced muscle development, there is less chance of severed or damaged muscle.

Some of the older FTMs have had the advantage of having an hysterectomy before they’ve sought hormone therapy. Many FTMs feel there is an advantage to this as there will be less of a strain on the liver once testosterone therapy is initiated. Some symptoms of chemical/hormonal imbalance (such as migraines) often disappear after the FTM has his hysterectomy. One advantage of hysterectomy is the possibility of either reducing the dosage of testosterone or extending the time period between injections, thus possibly reducing the strain on the liver. Those who do undergo this surgery are sometimes advised to then take small doses of estrogen. Many refuse because of the implications of femaleness. Many people do not understand that estrogen is present in the male body as well. Testosterone is also used to alleviate osteoporosis, though, and estrogen may not be necessary. People should also be aware that excess testosterone in the system is naturally converted into estrogen.

There are many who choose not to undergo an hysterectomy and suffer no ill-effects, although there does seem to be a greater degree of difficulty dealing with the last few days before the next injection, known as the trough. In the 3 to 4 days before the next injection, many FTMs (with female reproductive organs still functioning) report irritability, shortness of attention span, headaches, fatigue, lack of sex drive, and sometimes cramping similar to menstrual cramping. Some FTMs who experience extremes of these symptoms then pursue hysterectomy, or opt for an oophorectomy.

In recent years, more and more FTMs are choosing the metaoidioplasty (also inaccurately referred to as genitoplasty, and often contracted to metoidioplasty). One reason is money. It is less expensive, and therefore easier to set one’s sights on as an attainable goal. Metaoidioplasty is the freeing of the enlarged clitoris (micro penis) and construction of a scrotal sack with testicular implants. The patient can opt for several choices. A urethral extension can be constructed so that the FTM can pee from his freed penis. This choice carries the risk of infections, fistulas, and corrective surgeries for complications. A hysterectomy and / or vaginectomy can be performed simultaneously. If the vaginal canal is left intact, this gives the FTM better options if he chooses to pursue a phalloplasty in the future.

The phalloplasty is usually a series of surgeries, not just one. The surgeries are still brutal and leave extensive scars on several places of the body&emdash;usually the inside of one forearm, the lower side of the torso, and the side of one thigh. Although these surgeries have been improved upon in the past ten years, there are still major drawbacks that deter many FTMs. The amount of time spent in recovery from the surgeries is extensive. Some FTMs have spent nearly one year in recovery stages from the surgeries, dealing with infections, getting corrective surgeries, and sometimes having to deal with their body’s out-and-out rejection of the graft. The emotional toll of this surgery can be incredibly high. The surgically constructed penis is also non-functional sexually. It does not get erect or flaccid on its own. Most constructions utilize Teflon inserts to achieve erections. A few surgeons use pumps similar to those used for penile reconstruction in genetic males suffering from cancer or erectile dysfunction. There is a chance of rejection with this option. The constructed penis frequently does not look like a penis. In recent years, some doctors have been fine-tuning their surgical techniques and have also teamed up with tattoo artists for better aesthetic results.

Notes on Gender Transition

Revised September, 1997

FTM 101 — The Invisible Transsexuals

By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor

Posted on by Queer News

Female to Male Transgender: General Health Care

There are many reasons why FTMs will be reluctant to seek out medical attention or even preventative health care. Many older FTMs have assimilated even without hormones or surgery. Their greatest fear is discovery. Sometimes even their own partners and families don’t have a clue about their situation, and if they do, they are just as frightened of discovery. Mainstream society has not been very kind to anyone who is perceived as different. An even greater deterrent for many FTMs is the very treatment they receive once in a doctor’s office or in hospital. Far too many of us have stories of being treated like the latest circus attraction, or of being outed to the entire waiting room. Perhaps the greatest fear for many of us is being involved in an accident and being “discovered” on the scene or in the emergency room. The person fears being unconscious or so severely injured that he cannot defend himself while outrageous remarks are tossed about, jokes are cracked, epithets are shouted, treatment is interrupted or stopped. All of these things have happened and continue to happen to transsexuals every day. If it hasn’t already happened to us, it has happened to a friend, and we know that it could happen to us.

Since most insurance companies have explicitly written us out of their policies, most of us find it difficult to seek health care through those avenues, even if they are available to us. There have been many transsexuals who have been denied even simple health care because doctors and insurers can claim that the condition would not exist if we were not pursuing transition. Unless we can find sympathetic health care workers, we are often at the mercy of the big money machine insurance companies.

For the FTM specifically, dealing with the female reproductive organs can be a nightmare. Most of us do not have regular pap smears. The procedure is invasive. And again, finding a gynecologist who is sympathetic is difficult. Most FTMs will not seek out a gynecologist unless they are already experiencing symptoms of a problem. Most gynecologists, when it comes to female reproductive organs, have one goal–that of the continuation of the human race. When a male person with female reproductive organs comes into the office, most gynecologists see the organs and their possibilities, not the person. There are FTMs who have been dealing with severe symptoms of endometriosis or other health problems, and their gynecologists will not remove the organs at the patients request because the gynecologist sees the possibility of saving the organs. The FTM could be in severe, constant pain, not want the organs in the first place, have no intention of ever having children, even be past childbearing years, and the physician will override the patient’s wishes just to save the reproductive organs. Never mind the physical, mental, and psychological strain this puts on the patient. Never mind that it is the patient’s body.

Although many FTMs perform their own breast exams, most do not. They will rarely go to a physician if they find anything unless they already have a doctor who is aware of their situation. If surgery is recommended, many will not follow through because of probable exposure in the operating room. This is often true of hysterectomies as well. FTMs who choose to have one of the lower surgeries can get the hysterectomy at that time. If the FTM has opted to not undergo alteration surgery, chances are he is not getting any kind of medical attention for any health concerns.

Diet is an on-going concern. Many of the FTMs who are seeking some or all of the surgeries are working several jobs just to earn the needed money. There is little time for proper eating and sleeping. Those on the streets have an even greater difficulty meeting even the minimum dietary needs. Usually their main focus is on taking the steps they deem necessary for their transition. It is very important to point out to them that their health is one of the steps of their transition. If they do not have their basic health, they will not be able to maintain the work schedule they’ve set for themselves, they will not heal well from surgery or may even compromise their health to the point that they won’t be able to have surgery, and that they may achieve the goals they’ve set for themselves and then not have the health to enjoy their new life to the fullest.

Notes on Gender Transition

Revised September, 1997

FTM 101 — The Invisible Transsexuals

By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor

Posted on by Queer News

Female to Male Transgender: Mental Health

Mental health is tightly intertwined with general health. Most FTMs tend to isolate. Not only do they deny themselves contact with society at large, they tend to isolate from each other. Even though this has slowly been changing in urban areas within the past five years, it tends to be the rule of thumb. Many FTMs who meet at meetings are happy to share the physical changes they experience. They are very private about emotional and psychological changes. The struggle against gender stereotypes is more pronounced for FTMs; or the majority of FTMs are simply more aware of gender stereotypes. This often creates a barrier between FTMs and MTFs, creating an even greater sense of isolation&emdash;an isolation from those who might be best equipped to understand or help us.

It is quite often difficult for any transsexual to feel confident about themselves or even feel good about who they are when so many people in their lives (and society as a whole) have regarded them as deceivers, evil, worthless, liars, mentally ill, psychologically unfit, ad nauseum. We are required to seek psychological treatment just for verification of our circumstances. We are told how we are to act, whom we are allowed to love what our sexuality may or may not be, what clothes to wear. Many of us have been taught to lie about who we truly are by the very people who are supposed to be helping us learn to accept who we are. It has only been within the last ten years that some therapists and psychologists have become guides to our process and let us come up with the answers to who we are. Needless to say, the trust level transsexuals have for therapy and mental health professionals is very low. Most sympathetic counselors understand that they will have to do a great deal of coaxing and laying down of a foundation for trust with most transgender folk just to draw them out.

The constant threat of being “outed,” harassed, beaten/ and most profoundly, the threat of being killed is an everyday concern that wears on transgender people. People in the mainstream feel that Brandon Teena “got what he deserved, because he deceived” the people in the town where he was murdered. Sean O’Neil received the same general response from his neighbors: people felt he deserved to face the charges brought against him for deceiving those around him. Some of those charges were valid. However, the majority of them were not. (Ask us for more information about these people’s cases, if you are interested.)

If the person is “out” about their transition, or has even transitioned on the job or in a small town, the risks are even greater. The emotional and psychological toll of these threats is tremendous. There is the added threat in many areas of being locked up and committed to any number of treatments, including shock treatment. These kind of mental pressures make every transgender person susceptible to mental illness of one form or another at any given point in their lives. This does not mean that we are mentally ill or incapable all of our lives. Because this is usually the perception that we encounter, our frustration level is only compounded. The suicide rate for transgender folk is very high. Substance abuse, eating and sleeping disorders, abuse as children, and domestic violence have only recently been being viewed as symptoms of the social pressures that transgender people are under as opposed to being a part of our so-called illness. Not only do we need more help around these issues, we need more education and compassion.

As more and more transgendered people come together and share their experiences with each other as well as the rest of the world, the primary emotion that arises is anger. It is usually the first barrier that must be dealt with by mental health professionals. Because of that anger, transsexuals can be marked as socially unfit. Western medicine’s approach to classifying the symptom and not dealing with the root problem(s) is constantly used as a weapon against transgender folk. Until transgendered people are given space to feel safe, that will continue to be true. It is not just the transgendered folk who need help or have a problem; it is society as a whole.

Notes on Gender Transition

Revised September, 1997

FTM 101 — The Invisible Transsexuals

By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor