In my practice, I perform only the top surgery, either female-to-male, or male-to-female. FTM patients are typically quite young, often teenagers or in their early 20s. They have already been psychologically evaluated and started on hormone therapy. They wish to remove unwanted breast tissue. Typically, they spend time every day wrapping the breasts and using binders. They are very self-conscious about this part of their anatomy that is not consistent with their self-image. Fortunately, surgery can correct this problem. Many are comfortable for the first time with their shirt off. Patient satisfaction is very high.
L.E., Age 18
Procedure: Direct breast tissue excision and liposuction of breasts. breast tissue removal in 2 sessions, combining liposuction and direct breast tissue excision.
Before, 3 months after 2nd operation
N.B., Age 20
Procedure: Direct breast tissue excision and breast liposuction.
Before, 4 months
L.J., Age 20
Procedure:Liposuction of chest and subcutaneous mastectomies.
Before, 4 months
D.K., Age 22
Procedure: Direct breast tissue excision and breast liposuction, liposuction of the abdomen and flanks.
Before, 3 months
The procedure is the same as the operation used to treat gynecomastia. Because patients are usually young, skin contractility is usually quite good. This means that usually the breast tissue may be removed without removing skin. The advantage is an inconspicuous scar that follows the lower border of the areola. Even in patients with larger breasts, this is the usual approach. A later procedure can be used to treat any skin excess that remains, keeping any scars to a minimum. The nipple remains attached. Preserving the nipple attachment is important for normal nipple sensation and appearance.
Typically, the excess breast tissue is removed by direct excision (breast tissue is too firm to remove by liposuction alone). In addition, liposuction may be used to remove fatty tissue. An incision is placed in the crease below the breast for access. This small incision also serves as a drainage site for the temporary suction drain. It is important to leave a cushion of breast tissue under the nipple to avoid a saucer-like depression.
Usually the pain is well-controlled with painkillers. If one side hurts much more than the other, this may signal a hematoma, which should be reported right away.
One drain is used for each breast. These are attached to suction bulbs that are emptied by the patient when they become one third to one half full. The drains are removed 3-4 days after surgery.
Because a pocket is created under the skin, a potential space is available for blood and fluid to accumulate. A hematoma (blood collection) may develop despite the presence of a drain. This usually happens within 24 hours of surgery. It is treated in the office with evacuation of the hematoma.
Contour irregularities are not unusual. These may respond to a touch-up liposuction or sometimes additional breast tissue resection if they are quite noticeable. Perfect symmetry is not realistic.
In patients with greater amounts of breast tissue, the skin may not contract adequately to avoid skin folds. Such folds may be treated later with excision.
Occasionally a hypertrophic scar may form that can be revised to make it less noticeable.
- A small amount of bloody drainage on the dressing is normal.
- The dressing is removed on the day after surgery. You can then bathe and shower when you return home. There are semitransparent adhesive tape (Steri-Strips) on the incisions. These tapes usually stay on for several days. If one is starting to peel off, go ahead and trim it or remove it. Avoid strenuous activities for 2 weeks after surgery. Avoid any heavy lifting for 2 weeks. This helps prevent excessive swelling.
- Drains are removed in the office in 3-4 days.
- Sutures come out in 1 week.
- Most patients are able to return to work within a week after surgery. If your work is physical you will require 2 weeks off.
- Strenuous exercise (examples: running, aerobics, tennis) should be avoided for 3 weeks. However, gentler exercise such as walking can be resumed 1 week after surgery. You may return to unrestricted activity 1 month after surgery. Your body will tell you—if your breasts are sore you are probably overdoing it.
- Once the tapes are removed, apply antibiotic ointment to the incisions, particularly any areas of crusting, twice daily. The crusts gradually come off on their own.
- Bruising is normal and usually goes away within a few weeks. It extends to the sides and abdomen because of gravity. Swelling is also to be expected and takes a month or two to resolve.
- Notify the office immediately if one breast appears to be getting much larger than the other. This could signal a hematoma, which requires prompt surgical attention.
- The compression garment with Velcro straps may be replaced with a less cumbersome garment that provides gentle compression of the chest, such as a tight-fitting athletic shirt (Under Armour is one brand). Usually this is done after the drains come out. The garment helps limit swelling, and most patients feel more comfortable wearing it. Most patients wear such a garment for 3-4 weeks and later while exercising.