Gender Affirmation Surgery: A Discussion About MTF, FTM and N Top Surgery Techniques

As a follow-up to our interview with Dr. Melina Wald about the Gender Identity Program, we spoke to Christine Rohde, MD, Chief of the Division of Plastic Surgery about top surgery, the most common surgical component of gender affirmation care.

Top surgery is a very individualized procedure whether having Male to Female (MTF), Female to Male (FTM), or a Non-Binary (N) procedure. It’s about ensuring one feels wholly themselves, both mentally and physically. And just as transitioning is unique to each individual, so are the surgical methods. Surgery should fit your personal goals, never the other way around.

Let’s start with what Columbia offers for those seeking gender-affirming surgical procedures. Do we offer both top and bottom surgery?

Not yet. We do top surgery and facial procedures, like facial feminization and masculinization, but we don’t do bottom surgery—at least not yet.

Is that something you plan to provide in the future?

Yes. What I'd like to do is hire someone who specializes in gender affirmation surgery. But part of it is that in order to do bottom surgery well, you need an integrated team with urologists, gynecologists, etc. So, it's not just as simple as just hiring a plastic surgeon. It’s having that integrated team to be able to do it really well.

And part of the reason that our current group doesn’t do bottom surgery is that the results are really variable. There are a lot of different techniques. There's definitely no consensus on what the best way is to do anything. And so, the bottom line is it's not something that I can confidently say, oh, people always do great from that kind of surgery.

And it can certainly affect function much more so than top surgery. So to me, I feel like people who do it should be experts at it. And that's why I want to hire an expert here, as well as a whole team. And that includes social work and all that, too.

Part of the good thing here is working with Dr. Wald and Dr. Bockting and their Gender Identity group. Gender affirmation care is what they do—taking care of patients, providing supporting documentation, and all the mental health things involved in taking care of the whole person.

So, when does the plastic surgeon enter the picture? How early in the care process do you start to see patients?

It's pretty much when they've decided or are close to deciding that they want to have surgery. They're usually followed along by a psychiatrist and/or psychologist, and they may or may not have been taking hormones. And they're at some point in the transition process, beginning or further along.

If they're transitioning from male to female, or female to male, or if they're non-binary, then they're going through the care process. And that's a good time to meet with our patients because we need supporting documentation before we are able to submit to insurance.

Will you explain what is included in the documentation that insurers need?

So, every insurer is a little bit different, but in general, it's a statement that this person is undergoing a transition or is gender non-binary and that it would be most appropriate for this person to undergo surgery to match who they are. Usually, there needs to be some time period where they're followed by psychiatry and that they don't have any other underlying issues that would preclude them from having surgery. That they're not being coerced in any way.

And although it's not a requirement per se for me, I definitely want patients on hormones for certain procedures. For example, if someone is having female to male top surgery, I want them to be on testosterone for a period of time because there are changes that can happen in the breasts and the body overall that we want to be fairly stable. And it can maximize the aesthetic results from top surgery.

Are you more frequently doing FTM top surgery on patients who are already on hormones because of what you just mentioned?

It's not infrequent that patients are not taking hormones. It’s a personal choice. They may or may not want to be on hormones. It's not a requirement.

In general, though, more patients who are transitioning will have been on testosterone for a period of time. And as I said, for female to male top surgery I think that's better, aesthetically. Or for male to female, which interestingly, we just don't see as often. But it's a mix of whether someone's going to have been on hormones or not.

And then, we will see patients who are gender non-binary, who don't necessarily want a male chest, but they don't want a female chest either. So, there are subtle differences that we'll talk about. And it's always a discussion in order to find out exactly what somebody's goals are from surgery. How they will feel good and whole in their body.

Walk us through the surgical consult conversation. Is it about what someone is looking for aesthetically and how to best achieve it?

Yeah, it really is. The conversation visit is talking about their individual goals. Based on that, we may discuss a variety of surgical techniques and then find out what would best match them.

And there is always a trade-off when you're doing this type of surgery—where you're trading scars for a contour of your body that is more congruent with your gender. So, there's always a discussion about that trade-off.

Different types of procedures will result in more or less scarring. It depends on what someone's chest looks like at the beginning. And I would say that we probably see way more patients who only want top surgery and not bottom surgery. And I think that's partly just because of what I was saying about the potential that surgery can impact function.

Are there different techniques for top surgery, does surgical approach vary depending on the surgeon?

There are different techniques. So, let’s take female to male top surgery—It’s looking at the size of their breasts and the position of their nipple-areola complex. Things that can impact how I do surgery. So, unless someone's extremely small, the two main ways to do it are a double incision, which is a keyhole underneath the breast with a free nipple graft. And that's probably the most common way that I do things.

And I think for most people who do a lot of top surgery, that's their most common way as well. There is another way that preserves the nipple sensation. But that does leave behind some breast tissue and can end up making them not as flat-chested. It all depends on your goals for the surgery.

Will you explain the keyhole procedure?

So, essentially we do what's similar to a subcutaneous mastectomy where we leave the skin, but remove all the breast tissue underneath the skin. And we remove the nipple and areola complex, and then we remove extra skin as it's pulled down.

And then we do a scar across the bottom of the breast. And position the nipple-areola complex as a free nipple graft, meaning we put it on as a skin graft at a more male appearing position on the chest. And we do that with the patient sitting up in the operating room to determine where we want to put it and tweak it a little bit.

We also make the nipple-areola complex smaller, again, to fit the male chest. We use the pectoralis muscle as a landmark when we're doing these types of things. And oftentimes, if someone's been on testosterone, they may have a more well-developed pec, which actually helps with the appearance.

Is that specifically why you often recommend patients start testosterone before the procedure?

Yes, but not only that. It actually atrophies the breast tissue a little bit. And in general, it helps the aesthetic appearance to be able to do it after they've been on testosterone.

Generally, how long do you recommend someone be on testosterone before having FTM surgery?

Usually, at least three months. Enough time to see changes that are stabilizing.

And again, it's not required. But it's just something I talk to patients about. I think that it's a better idea to be on it first if they're going to be on testosterone.

Is the consult and surgery process the same for adults and patients younger than 18?

Yes, but I see quite a few patients who are under 18, and the hard part is there are many insurers who won't cover surgery for somebody under 18. So, they require some additional documentation, some additional discussion with the insurance company to be able to get it approved.

So, even in those cases, you are able to get approval from the insurance company? What additional documentation is needed?

Yes, with added documentation, we can. And that’s usually from the psychiatrist or the psychologist explaining that somebody is ready for surgery at that age and that waiting until they're 18 is unnecessary and potentially medically harmful.

But every insurance company is different, so people should definitely look at what their benefits include. Beyond it being harder to get approved for people under 18, it also varies state by state, what may be approved by insurance or not.

What should folks know about preparing for FTM or N surgery? What should they expect?

Recovery is generally about two to four weeks after surgery. And with the free nipple grafts, because they really need to heal, I wouldn't have them shower for two weeks afterward.

There are restrictions on activities, but these are all normal things after any surgery. And I think the biggest thing to realize again is there's a tradeoff of scars for a more congruent contour to the body, and that the scars are permanent. And it depends on how somebody heals, what the scar appearance would be.

Talk us through the process of male to female (MTF) top surgery, from consult to procedure.

We generally start with a conversation about size, and that’s obviously with implants. In some ways, it's similar to someone coming in for breast augmentation, where we discuss types of implants, the size that they want to be. We actually spend quite a bit of time discussing size, and I do measurements where there may be limits to what the size can be just based on their anatomy and how wide their chest is, those kinds of things.

And then we have a discussion about how we would do the surgery. Usually, we have to lower the inframammary fold, the boundary between the breast and the chest, as we just have to expand the space that the implant will be in. And also, recognizing that the way that we put implants in, over time, they may fall, which is what we want. So sometimes they may start off a little higher appearing and then over time, they may fall.

And it depends on what their chest looks like whether we put it above the muscle or partially below the muscle. Although in general, I prefer to put it partially below the muscle. But the most important thing is—because we're putting in an implant in this space where someone really doesn't have a lot of breast tissue—that we lower the inframammary fold and we create space enough for the implant, which we create with our dissection.

Why do you prefer to do implants partially below the muscle?

You know, it depends on how big somebody’s muscles are and things like that. But if someone is going to have a pretty significant implant, if that’s my patient’s goal, the slope of the breast is more natural-appearing if it's underneath the muscle because the muscle shades the implant.

Whereas, if you put it above the muscle, it's right under the skin. So, it's more obvious that someone has an implant. And some people may want to have that really augmented look, so we would have a conversation about that. Whereas, other people may want to have it look more natural.

Are there components to after-care or implant longevity that folks should know?

It's very similar to augmentations where we talk about implants not lasting forever, and that implants change with time. They may need revisions because implants stretch the skin, and you can even get stretch marks in your skin from the implants. And so, once you start putting implants in someone, it may be that they need implants again several times in the future. Generally, implants last about ten to 15 years.

Any closing thoughts, or takeaways we have not yet discussed?

I just want to reiterate that this is about multidisciplinary care of the whole patient. We as surgeons are just one piece of it, and it's still a field that we're refining. And it's growing as demand increases; our techniques are also improving. What I do is top surgery, but our craniofacial surgeons can do facial feminization or masculinization. And we can help you find the right surgeon for what you need. We’re here to help you achieve your goals and will do everything we can to get you there.

Read Part 1 of this interview on Gender Identity Care with Dr. Melina Wald here.

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