Double Incision Bilateral Mastectomy
Chest reconstructive surgery is the most common surgical procedure for female-to-male transsexuals. The most common types of FTM chest surgery are 1) the double incision bilateral mastectomy with nipple grafts, and 2) the keyhole/peri-aeriolar incision.
Most FTMs who have medium to large breasts opt for the double-incision mastectomy. Two large incisions are made below the nipples, that run across the chest. The surgeon will remove the breast tissue without disturbing the pectoral muscles. The nipples will be completely removed and resized to create the appearance of male nipples, which are smaller than most females.
The excess skin of the breast tissue is removed by making two horizontal incisions along the underside of the pectoralis muscles. The fatty breast tissue is surgically cut and lipsuctioned out. The nipples are surgically relocated to an aesthetically appropriate location for a male chest. The pedical stalk (a bundle of nerve fibers that connects the nipple to the body) may or may not be severed. The nipples are surgically trimmed to appear smaller. If the nipples are completely removed, the surgery is called a “bilateral mastectomy with nipple grafts” because the nipples are removed and then grafted back onto the chest. Alternately, the less common bilateral mastectomy pedical technique may be used (see below).
The disadvantages of bilateral mastectomy include:
- Loss of sensation in the nipples, although some nerve sensation may recover over time. Sensation may be retained by using the less common pedical technique.
- Loss of peripheral sensation in the area below and/or around the nipples. The loss of sensation may be greater for larger guys who have more breast tissue removed.
- Large scars along the pectoral divide
- Minor revisions may be necessary to correct visual imperfections. These revisions are often offered free of charge.
The advantages of bilateral mastectomy include:
- Creation of a flat chest with little to no sagging skin, that may otherwise be present if the keyhole periaeriolar incision is performed on an individual who has more tissue than can adequately be removed with liposuction.
- Patients with large sized breasts may be able to have a breast reduction covered by insurance.
Alternate Methods of Chest Reconstruction
The Inverted-T Method
The “inverted-T” incision involves removing the breasts with an incision the scars to form an upside-down T that runs from the bottom of each nipple to the main horizontal scars across the chest. The inverted-T surgery is used for transmen with medium-sized breasts (B or C cup). The inverted-T method is very similar to the double-incision bilateral mastectomy, but it has the added scars that run down from each nipple. Thus, the double-incision bilateral mastectomy is the preferred method since it results in less scarring.
The Pedical Technique
Some surgeons perform the pedical technique where the nipples remain connected to the pedical stalk (a connective tissue of nerves between the nipple and the chest. The purpose of the pedical technique is to keep nipple sensation more intact than complete removal.
A risk of removing the nipples completely is that the nipples may be rejected during post-surgery recovery, resulting in necrotizing tissue death. Although this complication is uncommon, it can be alarming and cause for concern when making a surgery decision. If the nipples are lost during post-surgery recovery, individuals may opt to have nipples tattooed on.
The Pie Wedge Technique
The pie wedge technique results in an incision and scarring that run from the nipple outward to the underarm. The pie wedge method is designed for transmen with medium-sized breasts (B or C cup). It is rarely used since the double-incision method results in more aesthetic scarring.
Who is a candidate?
Bilateral mastectomy is optimal for patients who:
- Have a breast size of B-cup or larger
- Have a large amount of skin or excess tissue
Risks and Complications
Infections are rare. Excessive bleeding that requires a transfusion is rare. The most common complication of a bilateral mastectomy with nipple grafts is loss of blood supply to the nipples. Nipples may be damaged when they are re-grafted onto the chest. It is possible that the nipple might be lost if it does not receive proper blood supply during post operative recovery. This complication is becoming increasingly rare in surgeons with extensive experience in these techniques.
Scarring will usually fade over time. However, some patients experience keloid scarring that becomes raised and excessively wide.
Some breast tissue is usually left to avoid depression of the skin. Patients may still be at risk for breast cancer since some breast tissue remains.
The cost ranges from $2,500 to $8,000 US dollars. The average cost is approximately $6,000. Bilateral mastectomy with nipple grafts is usually considered a cosmetic procedure that is not covered by insurance. Some insurers who provide transgender surgical benefits may cover the cost of the procedure and, less commonly, a travel per diem.
Patients with large sized breasts may be able to have a breast reduction covered by insurance. However, breast reduction generally does not entail creating a flat chest. Insurer-provided breast reduction is generally reserved for individuals who have medically documented physical discomfort arising from breasts that exceed the capacity of their body frame. The most cited cause of pain or discomfort for breast reduction is back pain.