Chest Masculinization in Denver

Female-to-Male (FTM) Chest Recontouring is basically an extensive version of a standard breast reduction, and can be performed for patients seeking to undergo gender reassignment (although we believe “gender affirmation” is a better term). Usually trans-men have undergone counseling for gender dysphoria for months or years before seeking to undergo the more significant step of (relatively irreversible) surgery, to enable them to fully function in the male identity. We feel that this is both appropriate and helpful in the pre-operative phase, and therefore counseling and/or functioning in the male gender pre-operatively is highly recommended, but not formally required, especially in patients who have already made the lifestyle commitment by publicly “identifying male” via binding and/or the use of testosterone. Occasionally patients wish to be considered moreso “gender neutral” (i.e. “FTN”), and this procedure is appropriate for these patients as well.

The Denver-area FTM Top Surgery method developed by double-board certified Denver plastic surgeon Dr. Steinwald is a variation of the “tried-and-true” Inferior Pedicle/Wise-Pattern approach to breast reduction. This is designed to keep the nipple attached to its natural blood/nerve supply, and therefore preserve nipple-areolar complex viability and sensation as best possible. In consideration of male chest aesthetics, the areola is made much smaller and the nipple-areolar complex is elevated to a position higher than that used in breast reductions, generally approximately 4-5 cm higher and a total 16-18 cm from the sternal notch (the V at the top of the breastbone), with a shorter nipple-to-inframammary fold distance as well. The “trade-off” is an anchor-shaped (or “inverted-T”) scar, the horizontal portion of which runs along the natural lower breast fold (although this is made straighter), and which occasionally extends into the underarm area, depending on fullness there (liposuction of the axilla or other areas of the trunk may also be offered at a surcharge).

Dr. Steinwald has pioneered the use of the “ultrathin” inferior pedicle for this method of chest masculinization, by which the nipple in most cases can remain attached, and retain a degree of sensitivity that is just not possible with free nipple grafting (FNG). FNG chest recontouring, aside from denervating the nipple-areolar complex (by definition), is also fraught with nipple malposition issues, unpredictable healing and scarring, often with thickening of the nipples or frank discoloration. Conversely, with this inferior pedicle/anchor-incision closure technique, the nipple can be more predictably located, and heals much more naturally, again with at least partial, if not near-complete sensation preserved. Whereas Dr. Steinwald’s FTM procedure was originally performed in two or more steps, in most cases this can be performed in one stage, although nipple grafting still may be necessary in patients with very large/drooping breasts (D-cup+), and secondary “touch-up” revisions are necessary in some, usually for central fullness or unforeseeable scar issues.

Adjuncts to and Variations on the Procedure

In select, smaller patients with A or B cup starting points (and minimal skin excess), Dr. Steinwald has developed a modified version of the “double incision” technique, by which the nipple is brought up on an attached, inferior pedicle, but only a low transverse incision is necessary to excise a majority of breast tissue, and a smaller hole is created to deliver the nipple-areolar complex tissues (thereby avoiding the vertical incision). This is highly similar to the techniques used in abdominoplasty, where the belly-button is brought out through a new incision.

As stated above, occasionally patients require minor secondary revisions, especially in cases where the patient is fairly overweight and/or very full-breasted to begin with, and or undergoes significant weight changes (gains or losses) after surgery. This may include debulking residual (or newly developed) central fullness (which is often, in patients with D+ cup size preoperatively, maintained on purpose to a degree to keep the nipple alive), via liposuction or excisional techniques. These secondary procedures can often be performed under local anesthesia only, with much shorter downtimes and at a much lower cost than the original procedure. In patients with naturally large or stretched nipples (vs. areolae) to begin with, the nipple itself usually naturally shrinks down to a degree during FTM healing, although secondary procedures to address a disproportionately larger nipple at a later stage are also available.

Logistical Details

FTM/Top Surgery in Denver generally takes between 2-3 hours to perform, again mostly dependent upon starting breast size, and whether adjuvant (additional) procedures such as liposuction of the underarm areas are desired. It should NOT be considered equivalent to a mastectomy, in that some (approximately 10-20%) peripheral tissue thickness (including superficial breast tissue just under the skin) is preserved to avoid an unnatural, “skeletonized” (skin-on-muscle) look. This “leaving behind” of some natural breast tissue requires that mammography be performed when it otherwise would be recommended (usually around age 40, or earlier if the patient has a strong family history of breast carcinoma), as it might in an patient with an A-cup sized breast.