Breasts are a prominent feature that differentiates a woman from a man. Mastectomy is typically the first surgery performed for sex reassignment.
It involves the surgical removal of the breasts, partially or fully. FTM top surgery for gender affirmation includes subcutaneous mastectomy to create a masculine chest. This procedure involves male chest contouring and may also include nipple grafting or nipple repositioning and resizing by eliminating the glandular tissue.
How to prepare before surgery
- Quit alcohol and smoking at least three weeks before the surgery
- Discuss the medication with your surgeon
- Mentally prepare for the 1 – 4 hours surgery
Types of mastectomy surgeries
- Double incision: If you have naturally large breasts, a double incision approach is suitable for you. An incision is made horizontally or in a U-shape below your breast. The next step involves removing your breast and fatty tissue. Another incision is made to remove your nipples which are resized as per requirement and replaced with a more masculine looking nipple.This procedure often leads to a slight decrease in nipple sensation. The operation will take between three to four hours which is convenient for an outpatient setting.
- Inverted-T or T-Anchor: The inverted-T or T-Anchor procedure is also suitable for patients with large breasts, and the nipple is kept attached to the body tissue. However, the sensation of your nipple may be diminished to some extent. An advantage to this approach is you will avoid nipple grafting which will keep you away from the risk of losing your nipple. On the downside, achieving flatness of the chest for a masculine appearance will be less satisfactory compared to a double incision surgery.
- Keyhole: If you have small breasts your surgeon will suggest the keyhole incision. A small incision will be made under the lower part of the areola. This technique will remove the underlying tissue, without removing any excess skin which may not be necessary.
- Periareolar: Periareolar or circumareolar is usually done on patients having moderate breast size and skin with good elasticity. Here, an incision is made in a circular motion reaching the edge of the areola, removing the breast tissue. Another larger circular incision is made to remove the excess skin. And if necessary a third incision will be made vertically below the areola in case, there is more excess skin to remove.
- Liposuction: This procedure usually is not performed as a standalone surgery. It is commonly combined with other operations to remove the excess skin. For this approach, a relatively small incision of about 4mm is required to eliminate the underlying tissue.
- Fishmouth: In this method, incisions are made at the upper part of the chest requiring consistency with the edges of the chest muscle. The final position of the areola should be in line with the scar. This approach is rarely used except for non-binary trans-masculine patients.
- Lollipop: This is the least common approach for mastectomy surgery. The procedure mimics the periareolar incision, except the incision is vertical.
- Buttonhole: This procedure is similar to the inverted-T method, except that less skin is required to remove. This approach is suitable for those who have less breast tissue. There is less skin to remove which avoids the vertical incision.
Complications and Risks
Generally, the after-effects of surgery include nausea, vomiting, blood clotting, and infections on the wound site. Besides these common effects, mastectomy could leave some complications and side effects.
- Decrease in nipple sensation. Losing sensation after a mastectomy is a common effect, especially after a nipple grafting. Additional procedures are required to correct this complication. There are rare cases where patients lose complete sensation of their nipples after a graft.
- Scarring is visible with mastectomy. Depending on the techniques the scars will vary. The double incision technique results in the most prominent scars.
- In any case of asymmetric nipple position or unsatisfactory nipple size, a revision surgery will be required. However, on being called for revision surgery, there will be no charges.
- Older patients may have more inclination towards risks and complications to mastectomy, owing to their medical history.
Upon experiencing these complications, it would be wise to consult your surgeon without delay. Other reasons to take immediate action right away are dizziness, pain in the chest, shortness of breath and swollen legs.
What to expect after surgery
You can expect to go back to normal work after seven days to nine days, however, avoid strenuous activities. After three weeks you can do moderate exercises like running and cycling. Expect to have a full recovery in six weeks, but if you have gone for surgery that made incisions across the chest, you will be required to avoid lifting over your shoulders up to six months.
While there are reports that the sensation of the nipples is diminished, some patients showed results with increased sensitivity.
It will take time to heal and allow your chest and nipples to settle in the right position. You may have to wait for at least a year to see the final results. If there is asymmetry or other anomalies you will be required to go for revision surgeries which will take a longer time to heal.