Top Surgery

EXPLORING YOUR SURGICAL OPTIONS

Surgery Preparation
SET TING YOURSELF FOR A SUCCESSFUL OUTCOME
Why Surgery?
❑Gender Affirming “ I don’t avoid mirrors or hunch my shoulders all
❑Feeling the body better reflects identity the time any more.”

❑Reduce dysphoria “My clothes fit the way I want them to.”
❑Improving emotional connection with the body
“I can’t express how free I finally feel!”
❑Stop Binding
❑Reduce strain “It’s the best decision I’ve made.”
❑Improve breathing
❑Decrease skin irritation “I can swim comfortably.”
 Sample Timeline for Surgery Preparation

4-16 3-15 3-15 3 1 1-7 1-7 Go home Day Day

Months Months Months Months month Days Days Same day 7-14 14-30
Optimal Surgery Preparation Includes
Securing safe housing with private space Planning for bills and financial needs

Stabilizing Medical Conditions Eating healthy balanced meals

Optimizing Emotional Wellbeing Exercising and moving the body

Eliminating or Reducing Substance Use Setting up a Support System

Researching surgery and surgeons

Information Gathering and Research
❑ Clarify your personal goals related to surgery
❑ Weigh pros and cons of surgery options
❑ Clarify surgical plan with surgeon
❑ Learn from others
❑ Online forums and groups, support groups
❑Research surgeons and look at results
❑Interview surgeons and ask questions
❑Considerations: location, wait times, technique,
comfort and fit
❑ Remember everyone’s healing is unique
 Envisioning a Successful Surgery
Physical Emotional Social
Hopes and
Expectations

Fears and
Concerns

Questions
 Envisioning a Successful Surgery
Physical Emotional Social
Hopes and I hope that my chest I hope I feel more I hope I will feel more
Expectations looks how I expect it to comfortable with my comfortable in
look after surgery. body after surgery. gendered spaces (i.e.
locker rooms) after
surgery.
Fears and I am concerned that I I am worried this surgery I am worried that I
Concerns might lose sensation or may not resolve all my will still experience
not have a flat chest. feelings of dysphoria. harassment and
discrimination based
on gender even after
surgery.
Questions Will my new chest look Is it normal to feel How will surgery
and feel the same as a anxious or ambivalent affect my close
masculine chest? about surgery? relationships?
Common Hopes and Expectations
❑Physical
❑ Clothing
❑ Physical activity/Range of motion
❑ Self care
❑ Breathing
❑ Posture

❑Emotional
❑ Confidence
❑ Pride
❑ Alignment
❑ Ease/Relief

❑Social
❑ Comfort in gendered spaces (bathrooms/locker rooms)
❑ Increased confidence in physical contact
Common Concerns (1 of 2)
Surgery is always a risk
❑ Guideline of any medical intervention is that benefits outweigh risks
❑ Highly skilled and trained medical team
❑ Well informed patients

This is permanent/What if you change your mind

❑ Delaying/not having surgery can have negative impacts physically, emotionally, and socially
❑ Satisfaction with surgery can improve overall quality of life
❑ Self-determination is key to health decision making
 Common Concerns (2 of 2)
What will other people think/say
❑ Identity is complex; helpful to set healthy boundaries about educating others and answering questions about
your process and encouraging others to utilize other resources and support.
❑ It’s up to you who you tell and how much detail you want to share
❑ Important to encourage caregivers to have their own supports

What does this mean about your identity/relationship

❑ Identity is complex.
❑ Chest size/shape ≠ identity/gender
❑ Surgery is gender affirming, may increase the visibility of someone's identity
❑ How surgery is related to identity is varied
Resources for Family and Friends
❑ PFLAG “Our Trans Loved Ones” Online Resources
❑ Gender Spectrum -> Resources -> Parenting and Family
❑ Oakland MST Department Support Groups
❑ Parents Support Group (1st and 3rd Monday; 6 – 7:30)
❑ Partners Group (2nd and 4th Mondays; 6 – 7:30pm)
Physical / Medical Preparation
❑ Being in your best physical health will support your recovery
❑ KP Wellness Coaching
❑ KP Classes – Exercise Classes and Nutrition Support
❑ You may want to moderate or abstain from caffeine, marijuana
❑ Focus on getting enough sleep, adequate nutrition, body movement, hydration
❑ If you have ever experienced addictive substance use or are in recovery, you will
want a solid support plan in the case of stress-related cravings.
❑ Abstinence vs. harm reduction
❑ Alternative (safe) coping mechanisms
❑ Substance use or abuse may affect:
❑ How your body responds to anesthesia
❑ How well your body recovers from surgery
❑ Your mood while preparing for or recovering from surgery
Mental Health Before Surgery
❑ Remember that even positive life events can come with stress or bring up challenging feelings.

❑ Take time to think about your own ways of coping with stress or change.
❑ Which of these will be available to you while preparing for surgery?
❑ What other resources might be needed (e.g., relaxation techniques)?
❑ Who in your life can be a sounding board (e.g., friend, therapist)?

❑ KP.org resources
❑ Health & Wellness Podcast: “Preparing for Surgery” guided imagery audio file
❑ Wellness Coach
❑ Wellness Classes
 Prepare for consultation appointment
Self- • Surgeons perform this surgery every week but this is
your first time
Advocacy • What are your concerns, goals, expectations?

• Surgery consultation FAQs

Questions • Bring list with your questions
• Bring a support person with you
What to Expect at Consultation
❑ Discuss your surgical goal ❑Remember:
❑Every surgeon approaches consult differently
❑ Review Risks and Benefits
❑ Goal of consult is to develop a surgical plan that
❑ Review result photos fits your needs

❑ Exam
❑ Pre-Operative photos
Decide What Timing Is Right for You
Will I have enough
support after surgery? Is now the right time?
Understanding Your Benefits
❑ Contact Kaiser Permanente Member Services 1-800-464-4000
❑ Ask for your co-pay for an: “Outpatient transgender surgery”

❑ Note: If your insurance changes, your share of cost may change

❑ Make sure your insurance is active

❑ Payment plans may be available through Patient Financial Services.

❑1-800-498-2748

❑ Program to assist patients with medical bills and co-pays

❑ Medical Financial Assistance: 1-866-399-7696
❑http://share.kaiserpermanente.org/article/northern-california-medical-financial-assistance
Coordinating Time Off Work
❑Learn your job protection rights and benefit programs
❑ FMLA (Family Medical Leave Act) (job protection)
❑ Disability Programs (monetary compensation)

❑ Everyone’s coverage and leave programs are different

❑ Have a conversation about medical leave with your HR department
approximately 30-60 days before surgery
❑ Confirm with surgeon exact date for returning to work
❑Documentation
▪ You do not have to tell your employer the specific surgery you are having,
use the language: “medically necessary procedure”
▪ Paperwork will either be blank with dates of leave or say “Aftercare for
Non-Cosmetic Surgery”
How to talk about surgery
Depending on level of closeness you may want to let people know:

❑ “I’m going to be away from work/school for the next 2-4 weeks recovering from a planned medical
procedure.”

❑ “I’m having surgery to improve my health.”

❑ “I’m having top surgery that I’m really looking forward to.”

❑ “I’m really looking forward to being able to ________ after I recover.”

Requesting Help and Setting Limits
❑ Who do you want to be part of your healing process?
❑ You will need AT LEAST one person to help you
❑ Top surgery – 1 person for first 2-4 days after discharge from hospital minimum
❑People may want to help but may not be physically, financially or emotionally able. It’s ok to tell someone
you’d like to see them after you recover.

❑ Caregiving
❑ Primary caregiver needs breaks and emotional support as well

❑Assign people concrete tasks so they can be successful in helping you

❑ Help your support team coordinate your care by setting up a care calendars
❑ http://www.caringbridge.org http://lotsahelpinghands.com/
Prepare Your Care Team
Roles for caregivers
❑ Driver
❑ Emotional support by phone or in person
❑ Movie and low key activity partner
❑ Errand/Grocery runner
❑ Meal preparer/deliverer
❑ Walking partner
❑ Personal care provider including dressing and toileting
❑ Wound care assistant
❑ Laundry Doer
❑ Create backup Plans B and C and D!!!
Caregivers
Informed consent is for caregivers too
When agreeing to be a caregiver through surgery, it is important to:
◦ Be conscious of your own needs and limits
◦ Recognize your strengths and what you have to offer
◦ It’s okay to say no (and better to if you really can’t!)
◦ Remember you can’t do it all – ask for help
◦ Have clear communication about expectations
◦ Put together your own care team
◦ Stay on top of self-care (hydration, food, rest, breaks, etc.)

For people nearby, MST offers a partners support group 2x/month

6-8 weeks before surgery prep checklist
❑ Talk to work / school / volunteer organizations
❑ Complete FMLA and begin SDI paperwork, if applicable
❑ Review Discharge Instructions (re-read at least 2-3 times!); share with your caregivers
❑ Purchase and gather supplies
❑ Complete labs if requested by your surgeon
❑ Set up your home
❑ Clean sheets, towels, and clothes, move important items to waist level, create easy path to bathroom
❑ Cook and freeze meals
❑ Confirm care team and assign roles to caregivers
❑ Practice Stress Reduction Exercises
Enhanced Recovery
Protocol developed to
speed recovery

Box picked up or mailed to you prior to

surgery

Instructions included regarding beverage

before surgery and skin wipes
MST Oakland Support Groups
▪Call MST to sign up (510) 752-7149
▪ See MST lobby or MST website for fliers!

▪ Partners Group
▪ Trans Masculine / Non-Binary Group
▪ Non-Binary Group
▪ Middle School Group
▪ High School Group
Surgical Techniques
Objectives
❑ REVIEW your surgical options

❑ UNDERSTAND the goals of top surgeries

❑ IDENTIFY possible surgical complications

Surgery Options
❑ Double incision
❑ Free nipple grafts (optional)
❑ Nipple tattooing is possible

❑ Peri-areolar (Keyhole) / Doughnut incision

❑ Buttonhole incision

❑ Inverted T /Anchor incision (reduction)

Identifying Goals
Flatness

Flatness Nipple Sensation

Nipple Sensation

Scarring

Scarring
 Chest Defined
Clavicle

Sternum Supraclavicular Subclavian

Intercostal Lateral
Axilla
Nipple thoracic
Areola
Internal
mammary
Chest Anatomy Defined

http://intimatehealthhelp.net/wp-content/uploads/2012/07/breast-anatomy1.jpg
Top Surgery Goals
❑ Masculine chest / flat chest / reduced chest size

❑ Minimize chest scars

❑ +/-Reduce and re-position the nipple areola complex (optional)

❑ Gender affirmation
Double Incision with free nipple grafts

http://www.topsurgery.net/procedures/double-incision-top-surgery.htm
Peri-areolar/Doughnut/Keyhole incision

https://www.visageclinic.com/blog/top-surgery-in-toronto/
Inverted T incision/ Reductions
• Possible size restrictions based on anatomy
• Some patients may need multiple surgeries to achieve
desired size
• Inverted T is most typical technique
• Nipple grafts are also possible

http://www.topsurgery.net/procedures/inverted-t-anchor-top-surgery.htm
Buttonhole incision

https://s-media-cache-ak0.pinimg.com/originals/9b/41/98/9b41983fcb5f2150998d8a5ca0cc3463.jpg
 Summary of Complications
Peri-areolar Reduction Double incision with
(Doughnut/Keyhole) free nipple graft
Bleeding Bleeding Bleeding
Swelling Swelling Swelling
Wound Healing Wound Healing Complications Wound Healing Complications
Complications (widened (widened areola, widened scars) (dehiscence, dog ears, widened
areola, widened scars) scars)
Infection Infection Infection
Loss of nipple grafts
Loss of nipple sensation
Risks of complications in chest surgery increase with smoking
Possible complications after surgery
❑ Abnormal Swelling / Bleeding
❑ Sudden swelling or bleeding require urgent medical attention
❑ Some swelling and light bleeding can be normal after surgery
❑Drainage of a small or moderate amount of blood-tinged fluid is not uncommon and is not
indicative of active bleeding

❑ Opening of wound along incision line

❑ Can result in drainage
❑ May require wound care or revision

❑ Scar widening/Dog ears

❑ Could occur anywhere along the incision/ two ends
❑ Wait for revision
❑ Limit activity postoperatively, follow instructions

❑ Infection
❑ Increasing redness, pain, warmth, swelling, or drainage with pus at the surgical site
Other possible surgical outcomes

Widened scars

http://68.media.tumblr.com/536e8de4505faeab479970f577046574/tumblr_inline_nwznigHgip1qesqi5_500.jpg
 A note about scar care
Talk with your surgeon about recommendations for scar treatment and when to begin
❑ Extended compression (wearing a binder) after surgery can decrease scar widening
❑ Scar care usually starts about 4-12 week post-op when no scab is left on incision
❑ Silicone sheets (check with surgeon about when to start applying after surgery)
❑ Scar massage – gently in small circles to help flatten and soften scars
❑ Steroid injections can be used to treat Keloid scars (thickened, raised scars)
❑ Injections given in doctor’s office
Other possible surgical outcomes

Seroma

https://i.ytimg.com/vi/JWoYG_B5noQ/maxresdefault.jpg
https://ftmjasper.files.wordpress.com/2010/03/seroma1.jpg
Possible surgical outcomes

Excess skin/tissue, AKA “Dog Ears”

https://68.media.tumblr.com/fc9a4df5f8244d0446441c01830d4984/tumblr_ntcl5uj7mE1qdnvvro1_500.jpg
Optimizing Recovery after surgery
❑ Stop nicotine products prior to surgery
❑ healthy nutrition and body movement/exercise before surgery
❑ Follow all discharge instructions
❑ Attend all follow up appointments
❑ Be in touch with surgeon if you have any concerns about healing
❑ Keep the surgical area clean and dry
❑ Listen to your body and check in with surgeon before resuming activities
Surgery,
Recovery and Healing
YOUR SURGICAL AND RECOVERY JOURNEY
The Surgery Center
❑ Check in early and meet your surgical team,
including anesthesiologist.
❑Discuss any negative experiences with general
anesthesia with your anesthesiologist and surgeon.

❑ Top surgery/reduction time = 2-5 Hours

❑ Top surgery revision = 1-4 Hours
❑ After surgery: You will recover in the PACU for 2-3
hours. You may feel nauseous, elated, groggy,
tearful, thirsty/hungry.
❑ Depending on surgery/surgeon, you will most
likely be discharged from PACU.
Surgery Center Discharge
❑ Helpful to have a friend or family member present to
remember details provided by nurse and surgeon

❑ You may be asked to walk before you feel ready.

Walking will help you recover more quickly and help
decrease complications.

❑ Main tasks when you wake up are: hydrate, manage

nausea, control pain, ask questions, prepare for
discharge
Surgery Center Discharge
❑ You will need someone to drive you
home from surgery. You can’t be
discharged without a companion.
❑Pillow between your chest and seat
belt is helpful for car ride home

❑ You will need someone to be

present when you are given
discharge instructions
❑ Anesthesia impairs short term
memory functioning
Normal Healing
❑ Pain
❑ Swelling: Expect quite a bit of swelling for a few months post operatively. Sudden swelling
requires urgent attention.
❑ Nausea/vomiting: Common reaction to anesthesia as well as narcotic pain medications.
❑ Itching: Common reaction to anesthesia as well as narcotic pain medications. Also can be
caused by adhesive dressings.
❑ Constipation: Take stool softeners to minimize strain
❑ Sensation changes: It is normal to experience changes in sensation after surgery. Some areas
of numbness may regain sensation as nerves regrow (can take at least 9-12 months).
❑ Nipple Sensation: Some surgical techniques carry a higher risk of loss of nipple sensation
A Note About Pain
❑ It is normal to experience some pain and discomfort after surgery
❑ Stress associated with untreated and excessive pain can prevent
healing
❑ While you are in the surgery center, communicate with your nursing
team about your pain level
❑Discuss past negative experiences with pain medication or addiction
history with your surgeon.
❑ DO NOT take NSAIDS (ibuprofen, aspirin, Aleve) without consulting with
your surgeon first
❑ DO NOT take Tylenol in addition to prescribed pain medications as
sometimes prescribed pain medications contain Tylenol (acetaminophen)
Discharge and Recovery Summary
❑ Discharged from surgery center the same day
❑ What may be on your body at discharge:
❑ Sutures
❑ Compression garment or binder
❑ Drains
❑ Bolsters over nipple grafts

❑ Typical healing times

❑ First stage of recovery is typically 2-4 weeks
❑ May take up to 6-9 months to feel back to 100%

❑ Follow up appointments (varies by surgeon)

❑ Obtain post-op appointment schedule in advance
❑ Arrange rides for doctors visits for the first 3-4 weeks after surgery
Chest Binder
o Chest is wrapped tightly in binder in operating room
o Surgeon will instruct you on length of time to wear
binder after surgery; Usually 4-6 weeks after surgery; may
wear for up to 3 months after surgery
o Compression binder helps to:
o Reduce swelling and bruising
o Prevent infections
o Keep incision site closed
DJ Orthopedics
o Reduce scar stretching ProCare Premium 3-Panel
Elastic Binder Universal
o Important to keep in on at all times, including during sleep,
until instructed otherwise by your surgeon
o Okay to take it off to shower after clearance from surgeon
 Drains
o Drains may be placed during surgery to help with
fluid drainage
o Higher BMI, certain surgical techniques and more chest
tissue correlated with drain placement
o Drains operate using vacuum suction and will need
to be stripped, emptied, and fluid measured a few
times each day
o Drains typically removed at first post-op
appointment, usually 1 week after discharge
Modified Activity After Surgery
o Take it easy!
o You may be physically able to do things before you’re cleared to restart.
Follow your doctor’s guidelines.
o Lifting / Stretching
o No lifting over your head for 2 to 3 wks; put important items at waist level
o Driving
o Not while on prescription pain meds, be mindful of straining when closing
car doors/trunks
o Sleeping
o Sleep on your back in semi-propped position for first few weeks; pillows to
prop knees to reduce strain on lower back
o Exercise
o Normal to feel low energy for 3-4 weeks after surgery; can last longer
o Walking is recommended every day to help reduce blood clots,
pneumonia, and constipation
Sutures / Incision Care
o Most sutures are dissolvable and will not require
any special care
o Drains held in place with sutures that are removed
when drains are taken out
o There may be a few longer lasting sutures in nipple
area to keep areola small
o Keep dressings dry (NO SHOWERING UNTIL
SURGEONS SAYS OK; 1-2 weeks)
o Do not start scar care treatment until cleared by
surgeon
Nipple Graft Care
o If nipple grafts, bolsters over nipples usually removed at first
post-op appointment
o After bolsters are removed, gauze over nipples, antibiotic
ointments
o Change gauze once or twice a day as directed
Post-Op Visits
❑ Typically you will be scheduled for a follow
up visit one week after surgery. If you have
drains, they are often taken out at this 1
week post-op visit.

❑ You may have a few follow up visits in the

first 1-2 months after surgery to check on
healing, depending on your surgeon and how
you are recovering
 Sample Timeline for Surgery Recovery

1 week 2 weeks 4 weeks 6 weeks 12 weeks 9-12 months

Go home
Same day
Increase moderate activity
Lift less than 5lbs Mild activity Moderate activity All activity
as directed by surgeon

Able to return to May resume

work/school strenuous activity
With restriction and no work
restrictions
Helpful Supplies
o Pillows
o Propping in bed and on couch; under your knees to sleep
o In the Car - place pillow between your chest and your seat belt
o Neck pillow

o Button-up / Zip-up Shirts

o Baby Wipes / Body Wipes / Washcloths / Dry Shampoo
o Most likely not showering for about 1 week after surgery
o Cetaphil Gentle Cleanser (no water needed)

o Bendy Straws
o Smoothies, Vitamin C, Lots of liquids
Icing
o Many surgeons recommend using ice to reduce
swelling after surgery
o General guidelines:
o Put ice or a cold pack over chest for 10 to 20
minutes at a time.
oIce every 1 to 2 hours for the next 3 days (when
you are awake) or until the swelling goes down.
Resuming Activities after Surgery
❑ Each person’s healing is different
❑ Listen to your body and if hurts, use caution or
stop!
❑ General guideline is wait to restart activities and
obtain clearance from surgeon
❑ Best to abstain from all nicotine and not to even
be around cigarette smoke for 3 months. If
resuming nicotine use, wait at least 3 months and
avoid excessive alcohol intake.
A Note About Binding Before Surgery
Safe Binding Guidelines:
• Bind for less than 8 hours a day
• Take binder off before you sleep
• Binders are not recommended for exercise – sports tops
are recommended for working out
• Never use duct tape or ace bandages
• They don’t move with your body and can cause breathing
problems, fluid build-up in the lungs and other injuries like Binding Tips:
broken ribs https://transguys.com/features/chest-binding
• If it hurts stop, try a larger or different binder
• Binders that are too small can also be harmful to the body
 Binder Varieties and Companies

Bareskin Binders, FLAVNT

Cool Mesh Velcro Half Length T-Kingdom
(Amazon)
Shapeshifters

Binder Donation Program:

http://point5cc.com/chest-binder-donation/ Trans-Vormer
Underworks GC2b
Sizes XXS – 4XL
Keep in Touch
• Multi-Specialty Transitions Department (MST)
• 3779 Piedmont Ave G41, Oakland, CA 94611 | PHONE: 510-752-7149
• https://thrive.kaiserpermanente.org/care-near-you/northern-
california/eastbay/departments/transgender-care/

• Gender Pathways Clinic

• 1635 Divisadero Street, 6th Floor, San Francisco CA 94115 | PHONE: 415-833-8767
• https://thrive.kaiserpermanente.org/care-near-you/northern-
california/sanfrancisco/departments/gender-pathways-clinic/

• Gender-Affirming Care at Kaiser Permanente

• https://mydoctor.kaiserpermanente.org/ncal/mdo/presentation/healthpromotionpage/index.jsp?prom
otion=transgendercare