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The thong brassiere after synmastia surgery

Had an MTF patient who had saline implants and a urethral spongiosum rest from surgery done elsewhere who requested an exchange from saline to silicone cohesive gel.  Prior to  revision of breast augmentation done by an accomplished plastic surgeon, synmastia (often spelled symmastia) or in layman’s talk (uniboob) was noted.  The medial borders of the implants seemed to touch each other at the upper sternum and lifted the skin upwards more than expected.  This is the inherent danger when one releases pectoralis muscle attachment to the sternum above the 7th rib.   Most synmastias occur with subpectoral implants.  Women normally do not have cleavage unless they wear a bra which pulls their breast together.   Doctors who try to comply and get too close may over-dissect the tissues.

The implants were dealt with first.  “Always do the most sterile part of the case initially.”   Some adhesions in the capsule were opened which allowed the new implants to move more laterally and downwards.  This caused the nipple areolar complex which was unusually lateral in this patient to assume a more central position.   A male nipple areolar complex tends to more lateral, so thought must be given to avoid pushing it even more laterally with too medial a placement of the implant.

To prevent reentry of the implant into the sternal area, a thong bra is being used for 8 post-operative weeks.  The central strap has a soft wedge underneath which compresses the midline skin and keeps the implants somewhat laterally.

Today she was quite excited about their appearance and feel.  That’s her job; had my chance.  Did look really nice though.

Perhaps a photo soon.

Harold M. Reed, M.D.

We see an occasional “go it alone” MTF vaginoplasty patient, but this is to be discouraged.  If there is anytime a friend, lover, family member, spouse is needed to be nearby, this is the primal call for togetherness.  They are helpful in so many ways and with patient permission are encouraged to be present at all interviews and consultations, and if possible even during examinations.  This ensures every word bite is heard and understood.  Discharge instructions on the final day (putting it all together) is so important.  We do this with a typewritten sheet, but we have to make this come alive with emphasis and foresage what may happen if instructions are not followed.   The use of stents afterwards is key.  Without the mast, the sail will not stand.  So until the vagina  becomes well fixated to the surrounding tissues and hopefully enlarges to better fulfill the needs of penetrating sex, stents are de rigueur.  “Please no more anal sex, you may get a recto-vaginal fistula.” 

Togetherness is seen in many ways.  Often a previous patient of ours will accompany another.  At times such as this week, both may have a touch up together, usually under local.   Great friendship and comfort in each other’s presence.   

 Imagine this scene.  Our office is loaded with patients in every examination room, office and waiting room, as well.  So taking advanatge of 2 clean beds in the recovery room, both postops and placed there for a wound check. 

They lie on adjoining beds, with their skirts up, no partition drape is drawn per their request, and to speed things along, after they are in this postion I am called in to see both  the same time.  “Gorgeous” I exclaim, but that is not all.  Hand held mirrors are always nearby, and both patients are encouraged to see how it turned out and confirm that every detail has been revised to their complete satisfaction.  While this had been done before they got off the OR table 4 days ago, today is a new day and let’s do this once again just to be sure. 

Smiles and thanks… the tips we work for.  Oh happy day.

Harold M. Reed, M.D.

French chefs have long said the pleasure of fine dining is in the
sauce. And before the advent of nouveau cuisine, they said the flavor
of meat is in the fat.

Changing the subject, how often have you seen photos of a mother dog
adopting a kitten, or a mother sheep adopting a kid goat, see this in
the news every so often. Learned in comparative anatomy mother goats
will not adopt baby sheep, so it is not always reciprocal.

But today upon visiting one of my favorite patients in her 3rd post op
day, her boyfriend left yesterday to return to work, there is her mom
and another of my previous well healed MTF vaginoplasty patients all in the same
room. Two beds… the mother slept with the healed patient so her
daughter could have the remaining bed to herself.

For this mother she had 2 daughters, not one. Contrast this with a
nervous mom coming to me with a pre-op MTF and half of the time
referring to her child as him, him?. Of course this is a Freudian slip
of the tongue. Usually. But at times this is a subtle communication
saying “I regard you as a son not what you want to be.”

So here we have 2 beautiful MTF patients, one black who could be
walking down a fashion runway and the more recent Hispanic also very,
attractive, will have some recent photos of her up soon, and one proud
mother.

That’s all the news this morning from Bay Harbor Islands.

Thought you should know, it’s in the mother.

Harold M. Reed, M.D.

Two patients done last week are doing well.  Each quite attractive,  youthful and with responsible and mature (mentally)boyfriends.  Both had vaginal augmentation with scrotal grafts.  Without that, they would have not easily been able to have penetrating sex.  When a patient starts to ask me as soon as I walk into the room, how am I doing, rather than the other way around, I know she’s well on the road to recovery.  The first on her 3rd post-operative day is already walking aorund the neighborhood.  Told her to slow down, but she is very energetic and aside from a dressing, hard to tell she had quite a bit of surgery.   Also a very subtle observation, she looks and sounds even more feminine than before surgery.  Can’t explain that, but the way she relates to her boyfrioend, I can see clearly this is a woman.  Wish you could be here to see it as I do, but the difference is unmistakable.  Did she have an MTF sex change or did I merely remove some trappings that didn’t belong to her?

Harold M. Reed, M.D.

On June 3rd, did a scrotal augmentation of penile inversion vaginoplasty.  Patient is doing quite well and her devoted fiance is in attenance.  Lost very little blood  intraoperatively but her strict vegetarian status is of course the lowest of 3 categories for wound healing, the intermediate being chicken and fish, but no red meats.  She is now taking oral iron, Ferrosequels.   She has her leg bag by her bedstand and tomorrow big out of bed and visit to the breakfast bar.

I’ll be making rounds at 6 AM, another MTF scrotal vaginoplasty in the morning.

Yesterday did a long in time (careful, careful), male chest reconstruction, D cup without question.  Able to do a strict window-shade incision and avoid the vertical anchor which is not relished by most patients.  Trimmed out most of the bulky nipple with a wedge resection and “pasted” a male looking nipple-areolar complex over a granular base.  We are using saline soaks every 3 hours, to keep the graft moist.  Some say this heals better.  Many excellent surgeons do it dry and that works also.  Specimen picked up for pathological examination as is recommended for all mastectomy patients.    Again very little blood loss thanks to Arnica montana, Bromelain, Vitamin C, and adrenalin infiltration and packing.   I had not thought we could do D’s so easily, but was tempted because the pedicle was very narrow based.  Perhaps years of binding pushes the breast mass down.

After the inframammary incision is closed, the patient is again sat up on the table (under anesthesia of course) and everyone gets to look and comment.  With great precision the chest is marked for placement of the center of the N-A complex.   I like to keep in mind the male N-A complex is more lateral than the female and usually starts about 3/4 to 1 inch above the inferior mammary fold.   To further insure accuracy, markings are done transversely on a grid as well as radially from the notch just above the sternum.   X which marks the spot should coincide for both layout techniques.  Patient had preoperatively determined the new diameter.  We aim to please.

Patient seen this morning.  Jackson Pratt (grenade) drainage nil, no pain and all smiles (all gone). The great flat expanse.

Harold M. Reed, M.D.