Top surgery or Male Chest Reconstruction usually precedes below the waist surgery for FTM patients as protruding breast contours are a sin qua non of the female anatomy
While for very small breasts a peri-areolar skin excision can be performed, the problem of maintaining an adequate pedicle to support the nipple areolar complex without protrusion of the pedicle through the skin becomes challenging. Bringing skin into the borders of a contracted areola will cause puckering which hopefully with time will smooth out. A permanent fixation suture is often required to prevent tension on the suture line from causing a slowly expanding scar.
A transverse inframammary incision with free nipple areolar grafts is my preferred approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T). Most patients do not want an anchor incision.
The areola is trimmed to a pre agreed upon diameter and the nipple sectioned with a pie shaped excision and reconstituted. Once the transverse incision is closed with uniform tension, the nipple areolar complex can be placed symmetrically with a proper height and some laterality as is normal for a male chest. These details will be discussed during consultation. and perhaps you have some favorite male chest photos.
Although the patient must be cautioned there may be varying sensory loss because of nerve disruption, our limited experience has been favorable in this regard as distal nerves are known to regenerate.
Nipple areolar grafts must be kept wet with saline soaked gauze re-moistened every 3 hours for at least 5 days to maintain tissue viability until capillary buds grow into the graft.
Plan on having a roommate or spouse do this for you throughout the night.
Some crusting of the grafts is not unusual and will usually shed by the 3 or 4th week. By all means do not lift or pick them off as the adherence of the graft may be very tenuous and its viability very fragile.
After tissue settling some revision surgery may be required and is usually done for a nominal fee relating only to use of the facility and anesthetic services if required (as opposed to being done under local).
Breast sizes greater than a C, need to be done in hospital setting. Perhaps you have some favorite male chest or Top Surgery photos.
Harold M. Reed, M.D.
The Reed Centre for Transgender Surgery – Miami
Top Surgery done at the Reed Centre