* For a given value of ‘everything’. So not really everything. But we tried our best.
A month ago I asked for questions about top surgery – so, with a flourish and a fanfare, I present answers from my amazing panel of trans people, all of whom are owed several drinks (and must remember to remind me of that fact).
There are already some fantastic answers under the original post - and now, for the longest post this blog has ever seen…
Our lovely panel
Max Zachs is a 27 year old writer, musician and academic currently living between Stockholm and London. Max was a former cast member of Channel Four’s ‘My Transsexual Summer’ which yi criticised for its emphasis on gender binary. Max had top surgery privately in Thailand in January 2010, yi had a double incision mastectomy with free nipple grafts and extensive body sculpting to remove/reduce the appearance of ‘curves’.
Hello, my name is Liam. I’m 26 years old and I have been on testosterone for 2 years and 2 months. I had a double incision by Dr Garramone, 1 year and 7 months ago in a same day surgical centre in Fort Lauderdale, Florida. Surgery photo album here.
I’m 21 and had top surgery 11.5 months ago. I’ve been on T 23.5 months. I had top surgery and hip liposuction privately with Dr Yelland and got referrals from Dr Curtis and James Caspian, although I started T on the standard NHS route. The surgery cost £5925 in total, if I recall correctly. I lost one and a half nipple grafts, but don’t know exactly why.
A is an anonymous friend of a friend who had peri.
I had a bi-lateral mastectomy with free nipple graft. I had my nipples resized and this was done by Andrew Yelland in Brighton (Nuffield Hospital). Prior to surgery, I had been on testosterone for ten months and I was a 38E in terms of chest / breast size.
I had peri three and a half years ago with Richard Sainsbury at The London Breast Clinic – no nipple/aerolar resizing – a short operation with one night in hospital. The drains were only in overnight, and I was AA/A before surgery.
Q & A
1. “Did you lose nipple sensation and if so how much?”
Max: Initially I was numb from about three inches below my collar bones to an inch below the incision, it was kinda like being at the dentist when they numb your mouth and you know you’re touching it but you just can’t feel it! Gradually over the last three years I would say 95% of the sensation in my whole chest has returned. After about 18months my nipples went hard in the cold for the first time, it was really funny and I probably looked like a fool standing in the street laughing at my own chest but being able to feel different pressures and temperatures was really exciting. I have not regained any ‘erogenous’ sensation unfortunately – those special tingling feelings you get never came back. However it does feel like I have gained a large area of ‘extra sensitive skin’ due in part to the presence of masses of scar tissue- so my chest is hyper responsive to touch and pain.
M: I lost one and a half nipple grafts. Neither my doctor nor surgeon was sure why. As a result I did lose sensation temporarily. A year later I have touch sensation and hot/cold sensation in both, although they do not react to heat/cold by hardening. I have some erotic sensation in both, and a patch of erotic sensation between the bottom of the nipple and the scar. Erotic sensation from them has improved psychologically because my breasts aren’t there. The scar tissue is much the same colour as nipple tissue so it doesn’t bother me especially. I had them pierced which gave the flatter one some shape back.
A: I have lost nipple sensation, but it is slowly coming back, I can feel the nerves joining together, and get a tingling sensation.
Liam: I still have touch sensation, but a lot of erotic sensation has gone. I generally don’t feel much when people are using their mouth on my nipples, but I do a bit if they are using their hands.
X: I lost all sensation in both nipples for the first 10 or so weeks of being post op. I am gradually getting sensation, but it is extreme sensation only. Its only when I apply serious pressure that I actually feel anything and the sensation I do get is pain. Its one of those things that you have to deal with when it comes to surgery. It is one of those very small downsides that is outweighed by the upsides.
CN: I had no nipple sensation before surgery – and have mild sensation now.
2. “Does anyone know much about options for people who identify as genderqueer and therefore might struggle with referrals?”
M: As I understand it Charing Cross – the clinic in London, is becoming more open to treating genderqueer people and seeing each transition pathway as separate, and in my experience private doctors are also more willing to work with genderqueer people. If you experience gender dysphoria you should be able to get a referral to a gender identity clinic regardless of how you identify, and you can discuss this there. I’d imagine privately most top surgeons would be willing to do this, whether you could get NHS funding might be harder. The only people I know who got top surgery funded by the NHS and identified as genderqueer chose to not express that in their appointments and express a binary transition desire. I am not advocating lying to them, but am putting all the information I have out there.
Max: All I can say to this is the truth, I never identified as a man’s man, or even a man at all but I knew accessing transitional therapies would be problematic if I presented my true self. So I read the DSM and bought some plaid shirts and lied to the gate keepers. I had a name change, hormones, surgery, and legal documentation within 13months of coming out which is pretty incredible. It wasn’t without an emotional cost but I think it was the best option for me and now I can run around being as Queer as I like. I wish it didn’t have to be like that but I wasn’t going to sacrifice my life to make a point about refusing to cooperate with a crap system.
CN: Because of what I’d heard about treatment of genderqueer/androgynous people by the NHS, I went totally private. I’ve never been diagnosed with GID, but I did have the full support of my therapist, psychiatrist and family. I’d seen examples of my surgeon’s work on Transster (remember Transster?) – made an initial appointment and told him the truth up front: that I didn’t feel like ‘a man’, that I’d had terrible bodily dysphoria since adolescence, that I couldn’t be on testosterone because of my career but did want to have a more traditionally masculine looking chest. He was totally relaxed about everything, respectful, and only required me to provide him with a letter demonstrating informed consent.
3. “I don’t know if this is the sort of question you’re after, but I’m curious anyway. How, as a non-male person, does one get top surgery? I identify as genderqueer/nonbinary, and top surgery is something that I’m more than a little interested in, at some point in the future. I get the feeling though that because I’m “not really trans” (i.e. I am AFAB and do not identify strongly as male) I’d just get laughed at by my GP if I even mentioned it.”
Liam: As far as I’m aware, the NHS route is very difficult for non-binary trans folk but there are options of going privately. For example, Dr Garramone (in Florida) operates on people who aren’t on testosterone. So consider trying to save up for that, and remember there is no such thing as not being trans enough. (Unless you completely identify as the gender you were assigned with at birth, of course!)
M: You’d probably have a lot more ease getting it privately, where the goal of referrals would, to quite an extent, be ensuring that you were able to make this decision in sound mind. If they are distressingly large you might also be able to get a significant reduction. If you did require the NHS path, your GP wouldn’t be the one making that decision anyway, you’d be asking them for a referral to a gender identity clinic and you could talk about your experiences with your gender and why you needed top surgery at that point.
A: I don’t have any problem with it, but I can see how others, can. Perhaps taking the space, and funding away from someone who does identify as trans, and can not live any longer with the chest they have. And also, my GP and I were discussing it and she said she would not class it as a medical condition and does not feel it should be funded for on the NHS. It is more of a plastic surgery for lifestyle choices. (Her words)
CN: From what I know of the current system, it seems to depend a lot on the individual doctor. My surgeon was fine, and I know that Stuart Lorimer at Charing Cross understands and supports gender pluralism and individuals who don’t fit the traditional trans narrative. There are quite a few forums and support groups online for people to share their experiences of trans-related medical care – do some research there? (Try Facebook)
4. “Getting top surgery when you’re fat and have huge breasts. Are huge scars inevitable? Will my nipples just have to go? Are they getting any better at keeping the nipples in place so you won’t lose all feeling in them?”
Liam: I believe that there are other methods to double incision and peri, like the T anchor method which may have a better chance at keeping nipple sensation, but they also do involve some scarring. It does seem like there is an increased chance of keeping sensation after DI now but how much and what kind varies from person to person. For example, I have touch sensation but not much erotic sensation.
X: Speaking as someone who was a 38E prior to surgery, I had massive scars. However, with the double incision technique, this is normal. The trick is lots of rest, shit loads of bio-oil / dermatix (if you can get your GP to prescribe it because its bloody expensive!!) and making sure that you are treating them in the same way you would treat any other surgery site. Also, prior to the surgery, hardcore working out really helps. (This helped with both confidence and helped me drop a half cup size….)
Your nipples wont just go…..it’s all dependent on the surgeon you have. In my case, I nearly lost my left one, it fell off a bit. You have to remember that they are removing your nipples, taking them away from their “normal” place and shoving them somewhere else. It’s about the technique, if you have a nipple graft then be prepared for anything. But generally, the nipples stay there….(if they do die or reject, you can have tattoos….).Sensation can take forever to return, mostly because you are doing some serious nerve damage to the nipples. If in any doubt, always chat to the surgeon. There isn’t a question that they haven’t heard or scenario they haven’t come across.
Max: I’ve always been a big guy and I had a very large chest before top surgery. However, my surgery result has been fantastic, equally as flat and with feeling as my super skinny friends. In fact I think I got a better result because they took one look at my chest and were like “let’s just take everything off!”.
The scars really depend on your skin, not necessarily the fat underneath, again in some cases my skinny friends have got much worse scars than me.
My advice to you would be, if you’re not interested in losing weight (I wasn’t and never have been) you can still go into surgery healthy as possible, smoke less or give up, eat some veggies etc… I’ve only met one guy who lost a nipple and that was a crazy fluke. You have an excellent chance of keeping your nipples, and that chance will only improve if you’re healthier.
M: They don’t throw nipples away usually – they take them, resize them, and reattach them. With that in mind, nerves can regrow – I lost one and a half grafts but have sensation in the remaining nipple and scar tissue. I believe some doctors use a method where they retain some sensation by keeping the nipple attached to the pedicle stalk – a stalk of nerves that goes to the nipple – but if you’re large and with large breasts this will be less possible without creating a lumpy chest, because the stalk will be too long. In terms of scars, no. It sounds like you’ll need to have double incision, which does leave scars, but there’s no reason why, if you’re careful and heal well, they can’t be fine and fade with time.
5. “The biggest question that comes to mind, that is the hardest to answer, is “how do I know if I should get top surgery / if I’m ready / if that’s what I really want?”
M: What kind of a person are you? I’m a worrier. I spent an hour choosing a sandwich in Subway once, then got the one I get every time anyway. That’s just who I am. I wasn’t sure before surgery. I wasn’t sure before I bought that sub either. I’m never sure about things, and I like having side alleys to duck down if I change my mind. Surgery felt very permanent. However, I’d been binding five odd years. My back had serious trapped nerves. Using a binder was making using my wheelchair very difficult. I was moving somewhere very hot that summer and couldn’t have survived binding. I knew that I wanted to be an old man with a flat chest. All these things came together and I decided to take the plunge. I’d generally advise you be sure, but some people genuinely never are sure, and that’s okay too, we just have to recognise that and be as sure as we can be.
Liam: Should I get top surgery? I’d ask yourself how much distress having your chest is causing you and whether you would feel happier about your body without it. It’s only for you to decide whether you should or not. It’s your body, your choice. Don’t feel pressured to have surgery. Not all trans masculine people do and it doesn’t make them any less trans.
Is it what I really want? – Again, something you can only answer for yourself. I knew because ever since I started puberty, it was fixed in my mind that I would have some kind of chest surgery. This was before I even recognised I was trans. My chest always felt wrong, uncomfortable, out of place and I was very self-conscious of it. Wearing binders and experiencing my chest as flat just felt right. I went for a breast reduction consultation and realised at that appointment I wanted them completely removed. I listened to myself and knew I was lying to the nurse when I asked for a B cup.
Am I ready? – Having decided it’s what you want, I’d assess your life to see if you are in a good place mentally for surgery. It’s a big deal that’s often underestimated. Have a look at your physical health and see if that can be improved too. Make sure you’ve done your research, weighed up all of the risks, are happy with your surgeon of choice, have seen results from them and have people around to support you afterwards.
Max: This is the easiest question to answer because really you never know if you really want surgery, you’d have to be crazy insane to go into a massive life changing surgery not to have some doubts. However the answer is to just weigh it up, I went through months and months of questioning and self doubt and in the end it came down to this:
Are you really unhappy with your chest as it is now to warrant doing something radical about it?
Have you looked at enough chests to say with reasonable certainty that if you had a chest like that it wouldn’t be worse than the chest you have now?
Have you minimised the risks of surgery by getting healthy and planning your after care?
You have realistic expectations that surgery is not going to solve all your problems.
Worst case scenario: after some pain and recuperation you will end up with a chest that may not be perfect but is probably better and more comfortable than the one you have now.
A: I couldn’t see my future the way I was, I f you could easily live another few years with a female body, (chest) and it not be a daily struggle to leave the house, worrying about people looking, not wanting to shower, or get naked at all. That is my story.
X: I honestly regret having surgery as quickly as I did. It alleviated a massive portion of my dysphoria, but it was so quick that it led me to question my motives. Talking about it to a friend / ally / partner is always a good idea. Also the good old pros and cons list wouldn’t hurt either. If you have any doubt at all (that’s even the tiniest little bit) stop yourself and think about what you are doing. The way to look at it is that if you change your mind and you havent had the surgery, no harm done. If you have it done and then challenge yourself, then you could end up being in a worse off position.
6. “Do you have to have a catheter when getting top surgery?”
Max was the only person to have had a catheter for top surgery (though M has had one for unrelated health reasons and wants to assure everyone that they’re uncomfortable, but not too bad).
Max: I think it depends on your doctor, I had surgery in Thailand and woke up with a catheter which I did not expect but actually looking back it was probably a good thing because the drugs knocked me out for days, however, having it removed was not a pleasant experience. If you’re going to be up and about very soon after I would avoid it!
7. “How does the Scottish system work for top surgery referral? Is it easier for non-binary folk to get top surgery funded there? (It’s different to England as NHS Scotland has gender reassignment protocol) A list of surgeons who perform the various top surgeries, and where one can find reviews, would be helpful too.”
M: I’m afraid I don’t know about Scotland. www.transbucket.com has a lot of reviews on it, and there are also lots of good discussions on the yahoolist ftm-uk and in the secret facebook groups TMUK and TMSA UK (to which you will need to be added by a member). Both of those have Scottish members I believe, as well as people who’ve had top surgery with a wide variety of surgeons.
CN: The best thing you could do is to contact Scottish Transgender Alliance – they’re a fantastic group, and will be able to advise on the recent changes to treatment protocol.
8. “Can you get top surgery and get nipples removed? Is this a ridiculous idea? Would people look at me crazily if I walked around on a beach with no nipples?”
CN: My surgeon gave me the option of keeping my nipples or going for a total removal, including nipple removal. He had patients before who just wanted everything gone, particularly those who had thick chest hair to cover the scars. It shouldn’t depend on the size of the breasts – I was only an AA cup. Would people stare? People tend to stare at anything unusual – it’s up to you to decide what’s the best compromise for you.
Liam: I’ve never heard of this being asked before, so I don’t know. However, speak to different surgeons and ask them if it’s something they’d do. You might get a few looks because it’s a little unusual but most people would be too wrapped up in their own business to be looking closely at your body.
X: I don’t know whether or not you could have your nipples removed, but if its what you want, then its not ridiculous! You have to ask yourself ten years down the line, would you be happy with that? Also, generally speaking, people aren’t looking at little details. I found after chest surgery, when I got back in the pool, people were so wrapped up in how they look that they didn’t notice the massive great red strips across my pecs.
Max: I guess it might make it more obvious that you’ve had surgery if you have no nipples but I guess you might not care about that… I wonder if you want no nipples because you don’t like the ones you have and if thats the case I just want to point out that they can make amazing ones either from the nipples you have or just from the skin (which can later be tattoo’d). If you just don’t want nipples for whatever reason, I know of some guys who opted to not keep them and later went back for “fake ones” so maybe you can do that and just not go back!?
M: This depends how big you are – if your chest is small then no, because there would be holes where the nipples were. If it’s big enough, then there’s no reason why not. Some people choose to have nipples tattooed on later if they find they want them, but don’t actually have them moved during surgery, though I don’t know what surgeons offer this procedure.
I lost a nipple and a half but had them replaced by scar tissue over time, so they look fine. I always think my scars look really awful but I came out to a friend who had seen me shirtless loads, stealth, and he’d never guessed, so I think a lot of the time people see what they expect to see, not what’s really there.
A: The whole point of my surgery was to live a normal male life, If I someone didn’t have nipples, through choice I think people would look oddly at them.
9. “Do I have to take out all oral/facial piercings (some of which would close up and be a pain to re-pierce) or can I use a plastic retainer/jewelry with tape over it so it won’t catch?”
X: I got away with a plastic retainer on my industrial piercing and the single bar I have on my other ear. I have just been( as in when I was typing this) told by a medical student that you cannot wear anything metal because the lights used in an operating theatre superheat metal.
CN: I’ve had a fair number of operations over the years, as have most of my family – I haven’t ever heard of any surgeons/anaesthetists who allow patients to keep piercings in. It’s not a question of catching, but of safety during surgery and the possibility of resuscitation. The general rule is to take them out just before going down to theatre, and then have someone you trust put them back for you when you come back from the recovery room. 2-7 hours shouldn’t be long enough to worry about.
Liam: You do have to remove them. I had my chest surgery with a lip piercing and the anaesthetist asked me to take it out because if they have to resuscitate you in an emergency, it would cause an obstruction. However, you can ask to keep your piercings by your bed and put it back in immediately after surgery. They hopefully won’t close up in the couple of hours of surgery.
A: I had to remove all jewlery.
M: This depends entirely on the surgeon – you’d have to ask them.
Max: I was very upset that when I got to the hospital with certificates stating all my piercings were surgical quality steel the surgeon wouldn’t accept it. So I agreed to have all my piercings removed once I was under anaesthetic and it was horrid waking up without things which I considered part of my face. In the end I never put them back in as they had already started to close, I was in so much pain already and I couldn’t lift my arms high enough. I would recommend you talk at length to your surgeon to avoid this!!
10. “If I got a therapist’s letter abroad would a U.S. surgeon accept it? Vice versa? Would I have to go through my country-of-residence’s standards of care?”
Max: I used all my letters and certificates from New Zealand in Australia, Thailand, Canada, UK, and Sweden without trouble. I have found doctors often take you at face value so turning up well presented and well informed has often gotten me further than the bits of paper in my hand. You could always check with the surgeons of your choice.
Liam: I got my letter from Dr Curtis in the UK and it was accepted by Dr Garramone in Florida.
M: This would depend from doctor to doctor. In terms of UK citizens getting surgery in the USA I’ve never heard of problems getting letters stating readiness. In terms of the other way round, I wouldn’t know, but I got surgery privately in the UK and had a letter from a GP specialising in gender dysphoria (Dr Curtis) and a letter from a counsellor who works with him and specialises in gender dysphoria. This was enough, and I don’t see why it would be any different if those doctors had been in America. Definitely best to speak to your surgeon before outlaying any money though.
X: Not got any experience of top surgery here, but according to the partner of my housemate (who is a medical student) referrals between ’western’ healthcare systems are generally accepted (so US should accept UK and vice versa) but you might struggle with getting a referral in a country with a less respected healthcare system and trying to convince a country with a more respected healthcare system to honour it.
11. “Does anyone (not on T) have experience with losing important nipple sensation and making up for it somehow? What is the best technique for keeping erotic sensation in nipples? (T-anchor or peri?)”
CN: I’m not on T, and actually gained sensation (which does make me laugh). Remember that it can take a while for sensation to come back to any surgery site, and it can come back in a slightly different way – with my other surgeries I experienced changes to the sensation of the site up to a year after the surgery. Peri is usually considered to offer a better chance of keeping sensation – my surgeon, and Fischer in the US perform peri on patients who aren’t on T.
M: I am (and was) on T but that didn’t really change my nipple sensation. Despite losing a nipple and a half sensation, as it were, came back quite quickly into the scar tissue, even erotic sensation, though that could be partly psychological as a result of having the right chest. I’d imagine anything that leaves the pedicle stalk intact has the same chance of retaining sensation, though that is not guaranteed.
A: I have had peri with a small 4 cm incision. I was warned there was a chance I may not have nipple sensation, but it was not a bother for me. But it is slowly returning. Only 5 months post op.
12. “I’m not yet on the state where i find top surgery something i need asap (i have those plans for future). But i’m just curious: is it possible to get breasts just removed, without any hormone stuff, without psychologist recognizing you as a transsexual, without making any sort of nipples or male-like breasts of it – just chop it off, make a nice flat scare and be done with it? I have something around F sized breasts and everything i dreamed of since late teens (i’m 26 atm) was to get those removed – they hurt, cause lots of discomfort, look terrible and don’t fit my agender/asexual personality at all. Just usual flat skin without any extra things, even if it’s scared, would do just fine for me and fit my aesthetic taste, and i don’t really care if whoever would find it weird (not like many could see me without cloth anyway and even if they did – well good for them). All i’m asking, is it possible/ever done in legal clinics?”
Liam: I believe, the normal course of action would to be referred for a breast reduction and then you could try and negotiate with your surgeon on how much they remove. I think it would be difficult to get them to agree if you don’t have a diagnosis of having gender identity disorder/gender dysphoria, though.
CN: From my experience (see above) I think it would be possible. I suspect you would have to go down a private route, and see a plastic surgeon who’s happy to offer ‘bespoke’ surgical solutions. I’ve certainly heard of cis women having pre-emptive radical double mastectomies because of family histories of breast cancer – you might find it easier to see a surgeon used to operating on breast cancer patients (as I did)
Max: I know you can get very radical breast reductions in plastic surgery clinics, and many of them will let you see the surgeon for free for a consultation, if I were you I would think about explaining your wish to one of these surgeons.
M: I don’t know for sure. From what I’ve heard surgery without a letter is harder to get than it used to be. You would probably need approval from some kind of doctor or psychiatrist, without which surgeons would probably be uncomfortable cutting off the tissue without a medical or psychiatric reason.
A: I am sure there has to be reason more than you just don’t want them, and the pain thing, they would normally just reduce the size of your chest. Not remove completely.
13. “Question! Dr. Garramone needs a letter from… Someone. Who? I don’t see a therapist, although my GP referred me to a psychiatrist-person back before she referred me to a GIC. I haven’t been to the GIC for an appointment yet either. So, is a letter from my GP okay or does it need to be someone else? (I find it all really confusing!)”
Liam: A friend of mine who went to Dr Garramone as well got a letter from his GP, so yes; the letter can come from your GP. Mine came from Dr Curtis, and he’s just a GP. As you haven’t been to the GIC or a private doctor yet, you may want to include your psych letter too.
14. “Does anybody have suggestions for flattening out nipples after surgery? Mine took well enough, but the right one is perpetually semi-hard and it makes me self conscious.”
X: Lots and lots and lots and lots and lots of bio-oil!
CN: Mine were hard for about five months after surgery? I was diligent with scar massage and silicone treatment, and they flattened out gradually.
A: I massaged mine every day twice a day with cocoa butter. They have flattened out completely, took about 2 weeks.
Liam: Mine are also semi-hard, but I’ve not tried doing anything about it since it doesn’t bother me and isn’t that noticeable (see the close up photos in my album). Maybe try massaging them regularly with something like Bio-Oil/moisturizer?
M: If you buy silicon scar pads you can tape them on tightly over the nipple, which will help flatten it out.
15. “Does anybody else experience like.. clogged nipple pores? Not quite zits, but like little white blackhead-esque plugs. Mostly on the areolas, but sometimes on the nipple itself. They don’t hurt, and I don’t know if it was a thing that I had before surgery (as I tried my damnedest to not ever look at my chest, ever, especially not close-up.) or if it’s new. I had surgery 10 months ago.”
X: I get these, you shouldn’t really pop them, I’d advise gentle exfoliating.
CN: I haven’t had that exact experience, but I have had blocked pores like that as an aspect of the acne that plagued me as a teenager. Using a very mild cleansing wash containing salicylic acid might help (make sure it’s something gentle enough to use on your face). If that’s no good then I would definitely advise asking for a referral to a dermatologist.
16. “Are there any particularly good things to do to help with keloid scarring? I’ve been just massaging it with normal lotion and it’s flattened out noticeably since surgery, but it’s still really pink and raised.”
Max: First of all are you sure you have actual keloid scarring, get your doctor to check. My and my best friend had surgery at the same time and we both thought we had keloid, turns out I didn’t and he did. Since his diagnosis he’s had injections of hydrocortisone into his scars (NHS funded) which has made a big difference.
M: I have this and dermatix gel has been a lifesaver. I got it on prescription from my GP despite having surgery privately, and I put it on daily, I started seeing a difference within a week or so.
Liam: Things with silicone in them are generally considered to work quite well. I used Scar Guard for a while. There are also other branded silicone strips and gels. Some people recommend Bio-Oil.
X: Dermatix gel or dermatix silicone strips. They have worked really well, however this was in combination with lots of bio-oil. Also if you can get hold of it, Silvex (silver nitrate cream) from Thailand (the stuff that Suporn recommends for scarring after vaginoplasty for MtF’s). Its amazing for easing up keloiding. Its expensive, but worth it.
CN: I’d echo Max and say check with your GP to see if they are actually keloid – if they are then you should get hydrocortisone injections. For everyone – scar massage, silicone treatment and patience are absolutely essential.
17. “My chest size varies depending on the time of month (which I know is common), so if I had surgery during the time it’s smallest, would any tissue left behind still periodically get bigger according to my menstrual cycle if I don’t start T? (Hopefully that made sense). Also, when it’s smallest it’s an A, but before my period it looks big enough to require double incision (or maybe I’m just paranoid). How does a surgeon approach this?”
CN: I have this problem, and it has made a difference to my surgical results. Most surgeons leave a little breast tissue behind so as not to create a concave appearance. My surgeon did the same, and the amount left is enough that my chest swells with PMS. Three and a half years on, I’m not convinced that my chest is as flat as is it was just after surgery – I’m not sure yet if it’ll need revising. I would document the changes in the size during your cycle, and discuss the options with your surgeon – it may well be that you might want to make sure that a bit more is taken out than usual.
Liam: I wouldn’t have thought it’d make a difference. I’d assume the swelling is due to fluid, but I could be wrong on that. Best bet is to talk to your surgeon about it.
M: That would depend whether there was breast or fatty tissue left I suspect. If you have a consult when it’s at its biggest your surgeon can make a better judgement call on how much to take out to leave it looking appropriately flat then as well. I believe that regardless of surgery, to some extent your chest will change with your monthly cycle.
A: Most surgeons that perform Peri, normally only do it if you are on T, because Peri relies a lot on the muscle and changes from T for it to be successful.
18. “i had my first consultation with my surgeon yesterday and she said that since i dont really have any breast tissue left, mainly skin, there may be an indent between the line under my pectoral muscle and the placement of the scar. i wanted to know if its possible to ask surgeons whether they are able to position scars higher up so that they sit under the line of definition under the muscle and, if not, how have other people deal with this kind of indentation (for example, are there any chest exercises that bulk out the lower pectoral muscle, which would fill out the indentation, if that makes sense)”
Liam: I think I have a slight indent, but it’s only noticeable when I’m feeling around for it (I think the 13th, 16th and 17th photos in my album show it best). I know that some surgeons position the scar so that it goes across just under the nipple or across the nipple, so it is possible to get them higher up.
Max: I see no reason why you can’t ask the surgeon if its possible to move the incisions, my surgeon let me draw on paper and on myself where I would like them to go and then did his best to incorporate my wishes.
M: Using a wheelchair really helps bulk that out! Possibly not that useful in terms of advice though. Generally top surgery surgeons will hide the scar the best they can, and if they can’t do it higher up I’m reasonably sure they’ll have a reason why. Discuss this with them though, and see what they say.
CN: You might want to consider a consultation with a good personal trainer? They can create a personalised programme to help you build muscle pre and post surgery. Whether you’re on T or not, weight training makes a big difference to the appearance of your chest (I’m a bit evangelical about it).
19. “Can you tell me how long does it take after a DI surgery to regain the range of motion that’s enough for everyday activities? Eg. how long did it take until you could dress by yourself? Thank you!”
M: I have some scar stretching from overdoing it. However, not significant, and it’s fading well. I could dress myself within about four hours after surgery, including stuff over my head within about a day. I could cook as normal within about a day, and go out as normal within about two days, though this was tiring. I was back at university full time in less than a week, though couldn’t push myself in my manual wheelchair for a few more weeks – I was told I could once it stopped hurting.
This was, I realise, a little excessive, and though it seems unlikely that it contributed to nipple loss it will have done to scar stretching. Regardless, I don’t regret it, I needed to keep busy, not dwell and stress about surgery results. I wouldn’t recommend anyone else follow my example.
Max: With difficulty in about 3-4 days like once the drains were out I could put on pyjamas as long as they buttoned up the front, after a week I could put on a baggy t-shirt but I couldn’t reach my laces!
X: Depends entirely on the surgeon. I was able to get about after about three days, but showering and things didn’t come until at least 3 weeks in. Its best to have someone with you and be prepared to smell like a corpse for a couple of weeks.
It took me about a week after that to be able to get dressed and washed properly on my own.
Liam: The key to this is to choose what you wear carefully. I was able to dress myself just after a week or two, but I wore clothes that could be buttoned or zipped up and avoided things which needed pulling on over my head. To reduce scars stretching, you should try to do as little as possible for as long as possible. Each everyday task will have a different timeframe.
Final thoughts, tips and hints
Energy level drop: I found even walking around quickly tiring. My flight was a week and a half after surgery and I still found using a wheelchair around the airport very useful.
Itching! The worst thing about the procedure for me was the itching that came while healing. There’s not much you can do about it either. I tried Benadryl which worked, but also made me very drowsy so I chose to suffer. My coping strategies involved itching elsewhere and distraction.
Hotel food prices: Very expensive where we stayed. The Holiday Inn was lovely, but it did mean going to a supermarket and making meals using the microwave in the hotel lobby. We were also lucky enough that the hotel allowed us to borrow a fridge without charge, because I’d had surgery.
Doors are heavier than they look: Get other people to open them for you. If you must open them yourself, then do so with as little arm movement as possible. For example, going through them backwards or pushing the handle down using your butt, and legs/feet to pull the door towards you.
You won’t feel like you’re overdoing it, but you probably are.
Listen to your body, be patient, let people love you. I had my surgery, I was all alone, scared, in pain and impatient, I rushed my recovery because there was no one to look after me and the emotional fall out over the next six months was awful. Emotionally and physically its a big stress to you so don’t underestimate the importance of having a nice place to go back to afterwards where someone can make you a nice cup of tea.
I think we place too much weight on ‘making the right decision’ because we imagine Top Surgery is more drastic that it really is- its not going to solve all of your problems, most people didn’t even notice I’d had surgery because I’d been binding so long and I’ve seen cis-people do way more radical things to their bodies without half of the drama. Some of my friends have tattoo’s on their faces and forked tongues! Human beings have been modifying their bodies since forever! The point is that its only a big deal because society says its a big deal to remove your breasts- try and tune out all the hysterical family members and judgmental friends for a few minutes, get some perspective and listen to yourself.
The best thing I did: initially I wanted the surgeon to give me a ‘man-boob’ shape, you know leave me a bit of fat. Once I got there I changed my mind and said to him to take it all off and leave no breast tissue behind, so he went in and gave it a really good scrape with scalpel and lipo. Now I have one of the best surgery results I’ve seen in ages, I’ve built up a nice bit of muscle and the layer of fat under my skin is more than enough to give me a little man-boob shape. I have none of that puffiness and you can see my muscles much better.
Especially if you’re going private, make sure all your referrals are ready in good time. You don’t want to be rushing around panicking trying to get paperwork done the week you’re meant to be having surgery.
Make sure before you go into surgery you have people to look after you who will know how much help you’re actually going to need – I had willing friends but didn’t want to ask because it felt like too much to ask of someone, sort it out in advance
If you’re a wheelchair user, organise an electric for about six weeks after your surgery. I think my chair was the biggest cause of scar stretching
If you’re putting stuff you might want by your bed, put it either side so you don’t keep stretching the same arm to get hold of it
Having wet wipes and straws is a good idea. Eight hundred straws and thirty packets of wet wipes might be a little excessive.
Move everything down a level in your house so that it’s all within easy reach without having to stretch your arms. If you have a pet make sure it knows not to jump at you, or that someone else is looking after it
Book a hotel for the night before if you’re going away for surgery and can afford it. That freedom meant the world to me – the ability to go in and out of my room at all hours, no need to worry about being a good guest, and the fact that I just had to grab my bag and I could go
General anaesthetic can be a depressant. Make sure, especially if you’re prone to depression, that you have things to occupy your mind and don’t risk tumbling into a pit of misery. I expected to be really happy, but instead I was more… slightly relieved I’d never have to bind again, terrified about how it would look, and really depressed. A year on, I love my chest. Remember that that temporary depression may change and doesn’t necessarily mean you shouldn’t have had surgery – it certainly didn’t for me
As soon as you’re allowed, start using dermatix gel – a silicon gel – on the scars. This stuff has taken mine from massive raised keloid in parts to pale squishy flattening pink with invisible bits
Be gentle with yourself. Surgery is a huge thing, and can be scary however sure you are. Don’t expect specific reactions from yourself or beat yourself up.
Regardless of what kind of surgery you have, proper scar management is vital – and no, I don’t mean slapping on a bit of old moisturiser and hoping for the best. Consult with your surgeon as to when you can safely start scar massage, and from then on I would recommend the regime I was given after my wrist operations, which I used on my chest surgery scars: twice daily massage for at least five minutes – there’s a good how-to here. Start gently, and apply more pressure as the scar grows older. I would usually advise starting with tiny little circles and, over the months, using fingers from both hands to work across the scar, vertically, horizontally and diagonally. I was taught to massage a scar with a small amount of very thick moisturizing cream (my wrist clinic used Nivea) – leave the cream to soak in in the morning but, before bed, wash it off, dry the area thoroughly and then apply silicone pads/sheets to the scars. The silicone pads are better than the gel, but more expensive – try to use them for at least six months if you can, and then switch to gel. And keep it up! Depending on how you scar and your skin colour, it can take a while for everything to calm down. More than three years later, my scars are mostly invisible – but if I’m overtired, angry or overheated then they still turn pink.
Prepare to be out of action for quite a while. I was on my back for a week, went back to work after two weeks, and performed my first concert after a month and a half – I don’t think I could have done anything sooner than that. Make sure you have these things on hand:
- Baby wipes. So many baby wipes.
- Someone to wash your hair for you for at least a week, if not two.
- A freezer full of meals you can reheat and serve.
- Button- and zip-up tops – enough for two weeks.
- All the pillows – enough to make a pillow mountain.
- Something to keep you occupied when you’re woozy from the drugs but bored from the enforced rest.
- Someone to force you to rest when the drugs make you feel like you’re invincible. You’re not. Promise
It’s normal to feel bruised and tender for a while afterwards. I didn’t start lifting weights again until about eight months after the surgery, and had quite dramatic bruises for at least three months after the op. There were also parts of my chest that were numb for a fair few months – the feeling came back to them gradually.
If I could have done anything different at all, it would have been to have a waited a little longer before diving in for surgery. There was so much I didn’t know and so much I wasnt prepared for. I went in with the mindset that “I needed this and I needed it now”. What I wasn’t prepared for was the inability to do even the basic of things, like having a proper shower, being able dress and also be able to get about. It took a lot out of me and as it stands at the moment, I need further revision owing to my chest size.
However, on the positive, it was one of the most amazing experiences I have ever had. The liberation of being able to wear small shirts, not have to bind in the pool/gym/everywhere, and just the simple pleasure of walking topless in the rain. (the last one was possibly the most amazing things I have ever done. I wandered to the shop, came back and decided because it was chucking it down, it was time to feel it on my back and freak out ALL THE NEIGHBOURS.)
I love my chest. I hate my stomach. I love the freedom of my chest now. I hate the scarring.
There are loves and hates with my chest, but the surgery was totally worth it, I saw an amazing surgeon and it was an amazing experience.
Thanks again to everyone who asked and answered – and good luck to everyone reading.