When an individual identifies with a different gender, to the gender they have been born with, this is referred to as gender dysmorphia. The majority of transgender individuals will begin their journey to change to the gender they identify with by having counselling and hormone therapy. The hormone therapy will help to either feminise or masculinise the anatomy and facial features of the transgender individual. Male to female transgender individuals (MTF) identify as female and female to male transgender individuals (FTM) identify as male. When hormone therapy has not resulted in the change desired transgender individuals may choose to have surgical procedures to change their anatomy.
MTF and FTM Top Surgery
Top surgery is sought after by MTF and FTM individuals who want to physically look more like the gender they identify with. MTF top surgery is a breast augmentation procedure. This is normally performed with breast implants, although fat transfer, also called autologous fat grafting, is opted for by individuals who do not want to have breast implants.
FTM top surgery is also referred to as transgender mastectomy or just double mastectomy and involves the removal of breast tissue and excess skin to create a flat, masculine looking, chest. Top surgery should always be performed by a plastic surgeon or a surgeon that has a history of special training and experience performing top surgery for transgender individuals.
Scars From Transgender Top Surgery
As with all surgery, scars are inevitable. Taking care of yourself and your incision scars by wearing compression garments has been shown to help reduce swelling and reduce the appearance of scars. Scar treatments can also help to significantly improve the appearance of scars by supporting the healing process. There are various scar treatments on the market including topical silicone gels and silicone gel sheets.
Following scientific research into the best ways to support the healing process, CicaLux Energized Scar-Care is different as it uses a combination scar therapy device. The device consists of the CicaLux silicone sheet over which a disposable CicaLux tape is applied, the combination ensures the scar stays moist and also helps to limit tension as the scar heals. Additionally, the tape adds helpful pressure on the scar tissue. The CicaLux Energized Scar-Care combination scar therapy device also comes with a unique CicaLux stone that can be placed into the silicone sheet and increases the blood flow by providing infrared heat. Massaging the scar with the CicaLux stone has also been shown to improve the final appearance of the scar. This combination therapy when used as instructed should help to make the scar tissue softer resulting in a flatter, thinner, paler, less noticeable scar, once healed.
FTM Transgender Mastectomy
Double incision top surgery – This method is often recommended to individuals with larger breasts, typically cup size C and above. When the breasts are a certain size this will mean more limited choices and the surgery recommended is likely to be a bilateral mastectomy, with nipple grafts. This involves 2 incisions that can be either curved or straight and are positioned above and below the pectoral muscle. Nipples are removed and repositioned once adequate breast tissue has been excised. This procedure often causes a reduced nipple sensation and has a higher risk factor as nipples may not survive the graft and the risk of infection is also greater. This procedure can also be performed without repositioning the nipples if desired.
Inverted-T top surgery – This is another option recommended to individuals with a significant amount of breast tissue and excess skin, who are concerned about losing nipple sensation. As with double incision top surgery 2 incisions are positioned above and below the pectoral muscle. Another incision is made around the edge of the areola and a fourth incision is made vertically between the bottom of the areola and the lower scar below the pectoral muscle. The areola can be reduced if desired and due to the nipples not being removed, sensation is normally maintained.
Periareolar top surgery – This incision option is normally offered to individuals that are smaller busted, typically cup size A and B with high skin elasticity. The first incision is positioned around the outer edge of the areola, the second incision is positioned in a bigger circle a little further out. Breast tissue is then removed and the skin between the areola and the second circle is excised. The skin is restitched to the edge of the areola which can also be reduced if desired. Once healed the scar should be difficult to detect and nipple sensation should not be affected.
Keyhole top surgery – This method is only suitable for individuals with very little breast tissue and high skin elasticity. Only one incision is made in a semi-circle around the bottom of the areola. Liposuction is used to remove excess breast tissue and a semi-circle of skin might be excised before the edge of the areola is restitched to the skin. This method is also referred to as scarless top surgery as the scar once healed will be difficult to detect and nipple sensation should remain the same. The optimum result of all FTM top surgery should be a nicely contoured masculine chest with nipples that sit in a pleasing position.
MTF Transgender Breast Augmentation with Breast Implants
Transgender women more than often desire breasts, hormone therapy can help small breasts to grow, however most transgender women are not happy with their overall size and shape. To achieve a fuller bust and more cleavage, breast implants can be used to augment the breasts that have developed. Breast implants can also be placed in transgender women who have decided against having hormone therapy, although the results may look less natural. Another option is to have tissue expanders which can be gradually filled with saline to increase their size and either sealed once the size desired is achieved and left in place or replaced with a second procedure with silicone breast implants. When breast implants are not wanted it may be possible to enhance breast size and improve shape with fat transfer also known as autologous fat grafting or autologous fat breast augmentation.
Breast Implant Placement Options
Submuscular placement – Many surgeons prefer to use this placement option due to the extra layer of cover the pectoral muscle provides over the breast implant. This placement option is also associated with lower rates of capsular contracture (excessive thickening and tightening of the scar tissue capsule that forms around the breast implant).
Dual Plane placement – This option is also used when there is sufficient breast tissue to cover the lower pole (portion) of the implant. As only the top section of breast implant is covered by the pectoral muscle the breast shape will appear more natural and the breast implants will have more movement and the breasts may also feel softer.
Sub glandular placement – This method of placement is only possible when there is sufficient breast tissue to cover all of the implant. When this is the case this placement is less painful and often considered to provide the most natural breast shape, unless this is not desired. The breasts may also feel softer, than with the submuscular and dual placement options.
Breast Incision Options
Inframammary (natural crease) incision – A curved incision is made in the inframammary crease. This option makes all placement options easier as it provides greatest access and is often preferred by surgeons due to lower rates of infection and capsular contraction.
Periareolar (nipple) incision – This option may be offered if the breast shape that has developed following hormone therapy is generally acceptable. An incision is made in the lower outer edge of the peri-areolar and the implant is put through the gap.
Transauxillary (underarm) incision – This is the least preferred option due to higher infection rates and limited access. Breasts that have developed following hormone therapy need to be a reasonable size and shape to enable a pleasing result.
Breast Implant Options
Breast implants come in a puzzling choices of different shapes, volumes and profiles, as well as different filling options. Your surgeon should be able to recommend the shape, cc volume and profile of breast implants that will give you the result you desire.
Both silicone filled and saline filled breast implants have an outer silicone shell and come in both anatomical and non-anatomical shapes, with profiles from low to extra high (extra, extra high may also be available depending on the manufacturer). As a general rule low and medium profile, non-anatomical implants will provide a more natural breast shape as they will produce less volume in the upper pole (upper part) of the breast and tend to look less round in shape. High profile non-anatomical breast implants tend to provide a fuller, rounder breast shape. Extra high profile implants will almost certainly provide a full, round breast shape. Anatomical implants are shaped to create a more natural breast shape and the profile is normally chosen based on individual anatomy and the cc volume desired.
Scar Treatments
Regardless of the procedure, scars may be a concern. Ensuring you follow all post-operative instructions and use scar treatments (as soon as your surgeon advises it is safe to do so) is important to help support healing and prevent the formation of a Keloid (darker, thicker and wider scars) or Hypertrophic (raised) scar. Per numerous scientific studies to better understand how to support the healing process, the medical community agrees that there is not one single therapy approach but rather a combination scar therapies is best to improve the final appearance of a scar. CicaLux Energized Scar-Care is a combination scar therapy device inspired by this research and unmet need.
Risks and Complications
Take your time to find your surgeon and remember there are serious risks and complications associated with all surgery. Prior to having top surgery, you should seek specialist counselling and support. The benefits of top surgery have been well researched and the majority of transgender individuals do not regret having gender confirmation procedures.
Check your plastic surgeon is qualified and registered with one of the worldwide professional bodies.
About the author:
Annabelle has had 3 breast augmentation procedures to achieve the size and shape she wanted and went from a 32A cup to a 32F cup. She has also had 3 rhinoplasty procedures and abdominal liposculpture and writes regular blog posts about advancements in plastic surgery. Her mission is to make it safer to find a qualified plastic surgeon online. Her cosmetic surgery website features a consultant register and the qualifications of every consultant listed are checked on a rolling 3 month basis.
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