Chest Wall Surgery for Gender Dysphoria

Who is this treatment suitable for?

Chest wall masculinisation surgery may be suitable for patients who have been assessed as appropriate for consideration of surgery by Consultant Psychiatrists through a recognised Gender Identity Clinic (GIC). For patients transitioning from female to male, the presence of breasts can be a significant personal and social stigma and many seek surgery to masculinise the chest.

What does the treatment involve?

Chest wall surgery is tailored to the individual patient. You will be assessed by your consultant reconstructive surgeon who will advise on the most appropriate surgery for your breast size and body shape.

Surgery involves achieving two main objectives:

1. Removal of all or most of the breast gandular tissue

Techniques used depend on the size of the breast and patient preference.

No or little excess skin:

For small breasts, liposuction of the breast alone may be sufficient. However, in the majority of cases, excision of the residual breast ‘disc’ is performed via a hemi-areolar incision. This leaves minimal scarring (a semi-circular scar underneath the areola and usually one to two 5mm scars from the liposuction cannula). The final result relies on both the surgery and the natural elasticity of the patients’ skin to shrink back to the chest wall. This skin shrinkage takes time and hence, though the chest will be flatter immediately following surgery, the final result may not be achieved for several months.

If excess skin needs to be removed, there are two options:

i. Peri-areolar technique:

For small breasts with good skin elasticity, excess skin is removed from around the existing areola to tighten the chest wall skin and the areola is usually reduced in size.

ii. Bilateral Inframammary Fold Mastectomies and Free Nipple Grafting

This technique (also termed “double incision”) is used for moderate to large breasts. It involves an incision in the inframammary fold of the breast, following the lower border of the pectoralis major muscle. The breast gland and excess skin are removed. The wound is closed, aiming to produce as straight-line scar as possible, and the nipple-areola complex is re-sized and re-positioned as a free graft.

2. Resizing and repositioning of the nipple-areolar complex

The nipple-areolar complex is reduced in size to the diameter of a one to two-pound coin (around 2 to 2.5cm in diameter).

This is achieved in one of three ways:

i. As part of the peri-areolar technique. The nipple blood supply is maintained.

ii. Excising the nipple-areolar complex and replacing in the appropriate position back on the chest wall as a free graft. This is by far the commonest way of repositioning the nipple-areolar complex as part of the double incision technique. If the nipple is large, it is not uncommon for the upper portion of the nipple to necrose (die off), leaving a raw area at the tip of the nipple which heals itself over the course of a few weeks. The nipple once healed is numb.

iii. Maintaining the nipple areola complex on a dermal bridge, or “pedicle”. This maintains the blood supply to the nipple but not usually sensation. This may increase the chance of the nipple surviving at the original operation, but can leave additional bulk on the chest which patients may not like and may require de-bulking of this tissue at a second surgery. For this reason, it is not commonly performed.

The latter two techniques can reduce the diameter of the areola, but not the size of the nipple itself. If the nipple is large enough to require reduction, it is safer to do this in a small separate operation under local anaesthetic. However, the nipple height is usually flattened out as part of the grafting procedure, so nipple reduction is rarely necessary.

How should I prepare for the surgery?

Surgery is performed under general anaesthetic and your surgeon will assess your fitness with regard to this.

You can prepare for surgery by:

• maintaining a good level of fitness (regular walking or other exercise)
• avoiding smoking nicotine products a minimum of 4 weeks prior to surgery.

If you are taking any medications that thin the blood (such as aspirin) you may be asked to stop this prior to surgery. In addition, if you regularly take any health supplements or herbal medications, it is important to disclose this to your surgeon, since some supplements can interact with medications or increase the risk of bleeding.

How long is the recovery process?

You should bring a binder with you so that it can be placed on the chest to give compression immediately after surgery. Most patients will spend one night in hospital, though sometimes day-case surgery may be appropriate depending on patient and surgeon preference.

On discharge, you will need to be accompanied by a relative or friend. Patients who live far away often choose to stay locally to Brighton for a night or two before travelling home. You will not be able to drive after surgery. Most of the time, patients are comfortable enough to drive approximately two weeks following surgery, but you must feel safe to do so and be fully in control of the vehicle.

You will receive instructions for dressings, showering, length of binder application etc... from your surgeon. Return to work depends on type of employment and varies from 2 – 6 weeks.

Patients are seen for a post-operative check usually between 10 to 14 days. Wounds are generally healed at this stage and you are encouraged to gently return to normal activities.

Important points to be aware of

The skin of the chest will feel different. It often feels numb in the lower part, especially around the scar, though not in all cases. This often depends on the size of the breast and amount of dissection required. Occasionally, the skin can feel hypersensitive, especially when in contact with clothes. This generally resolves with time.

Scars can remain pink for many months after surgery and will reach maximum maturity at 18 months. In order to protect the scar while healing, taping the scar with micropore tape for several weeks can be helpful. After this time, moisturising and massaging the scar twice daily will help to soften the area and break down scar tissue.

The nipple-areola complex: though the same shape is designed at the time of surgery, shape can change over time such that they do not exactly match. This is entirely normal – most nipple-areolar complexes have normal asymmetries. The colour can also change, becoming either darker or lighter.

Risks and complications of this treatment

The majority of patients will recover from surgery without complication, but all surgery carries potential risk including Chest infection, heart complications, stoke and DVT. Should you experience any complications, your surgeon will ensure you receive any necessary treatment.

During your consultation your surgeon will discuss with you any risks that are specific to your surgery.