Understanding Top Surgery - Swedish Hospital/media/Images/Swedish/CME1...Understanding Top Surgery:...

LGBTQ Health 101 4/7/2017

Dr. Tony Mangubat, tony@mangubat.com 1

Understanding Top Surgery: The Art, the Math and the Results

Copy of Lecture Available

E. Antonio Mangubat, MD

Seattle, WA

tony@mangubat.com

DISCLOSURE OF

CONFLICTS OF INTEREST

Introduction

• Trans Continuum

• Aesthetics of Gender Recognition

• Art & science of chest reconstruction

• Preparation for surgery

• FTM procedure spectrum

• Post-Op Care

• Complications

Common Questions

• What are your pre-operative instructions

for chest surgery?

• What’s the need for preop hormone

cessation?

• What is the expected recovery time?

• How does the PCP handle common

complications?

WARNING!!

• By the nature of this surgical lecture,

explicit nude photographs will be

presented.

• Some of the images and/or videos of

surgery contain bloody surgical images.

• TG surgical lectures tend to focus on the

binary….but be assured gender

nonconforming patients are considered

The Trans Continuum

• There’s no one way or right way to transition.

• Our responsibility: help our patients find their

place on the Trans Continuum

• Physical transition may not include surgery.

• Many trans wish only to blend-in.

• Passing for identified gender is Critical

Safety issue.

– 6 trans women murdered in first 6 weeks of

FTM Gender Affirming SurgeriesSpectrum

• Bilateral Mastectomy (Top surgery)

• Hysterectomy/Oophorectomy

• GRS/SRS: (Bottom surgery)

–Metoidioplasty

–Phalloplasty

Pre-Op ConsiderationsPreparing for surgery

• Understand:

– your procedure

– your doctor

– each other

• Informed consent

• Risks and complications

• Achieving goals requires explicit

communications.

Gender- Affirming Surgeries

• This is permanent!

• Consider sperm banking/egg harvesting

• Most patients have started counseling,

informed consents, and hormones

• Informed consent is mandatory

• Letters from therapists are required for

genital surgeries

• Insurance coverage, co-pays changing

Pre-Op Considerations Optimizing Health

• Address current medical issues

• Age appropriate health maintenance:

– mammogram

– colonoscopy

• NO SMOKING!!!

• Weight limits: BMI > 32 increases risks

• Support system (sometimes, the “neo-family”)

Pre-Op Considerations Specifics

• Stopping hormones – Estrogen stopped at least 2 weeks preop

– Testosterone, maybe

• No ASA for ten days prior to surgery

• DVT/PE precautions– Risk factors

– Prophylaxis

• Many common medications can increase bleeding– Aspirin

– Ibuprofen

– Fish oil

– B Vitamins

– Don’t stop any medication without doctor’s order

• Practical support systems:– Work

– Travel

Pre-Op ConsiderationsList of Meds to Avoid (incomplete)

• 4-Way Cold TabletsAscriptinAscriptin with CodeineAdvilAleveAlka-SeltzerAnacinAnaproxArthopan LiquidASA and CodeineAsprinAscriptinAspergumBayerBC Tablets and powderBromo-SeltzerBufferinBufferin with Codeine #3Cama Arthritis Pain RelieverClinorilCongesprin Chewable TabletsCope TabletsCoricidin "D" Congestant TabletsCoricidinCoumadinDarvon with ASADarvon CompoundDisalcidDoan's PillsDolobidDri

• DuragesicEasprinECOTRINEmpirinEmperin with CodeineEquagesic

• Excedrin

Feldene

Fenoprofen

Florinal Tablets

Florinal with Codeine

Ibuprofen

Indocin

Indomethasin

Lodine

Micrainin

Motrin

Nalfon

Naprosyn (Naproxen)

Norgesic and Norgesic Forte

Nuprin

Nyquil

Orudis

Oxycodone

Pamprin

Percodan

Persantine

Phenaphene

Propoxyphene

Robaxisal

Synalgos - DC Capsules

Talwin

Trilisate

Zorpin

Pre-Op ConsiderationsWhat can you take?

• Tylenol

• Your regular prescriptions that are

cleared by your doctor

Other Pre-Op Considerations• Electrolysis

– FFS: Stop 4 weeks prior and 6 weeks after

– Pre-op scrotum/penile shaft for MTF GRS: Stop

3 weeks prior

• Weight limits (examples)

– Obesity lengthens surgery & increases risk

– FFS: 200 lbs (Ousterhout)

– GRS: 210 lbs (Bowers)

– Top Surgery-FTM / BA-MTF: ?

Pre-Op Considerations

• Approximate Costs (Self Pay examples)

– FFS (The works): $25,000 - $47,000

– GRS MTF: $19,000 - $26,000

– GRS Metoidioplasty: $20,000

– GRS Phalloplasty: $50,000 - $75,000

– Breast Augmentation: $5,000 - $7,000

– Top Surgery FTM: $6,000 - $12,000

– Electrolysis:$60/hrx100-600 hrs=36000

– Laser Hair Removal: Per body part

• ~$1800 for 6 Tx genitals pre GRS

Aesthetics

• “[You] can’t define it, but you know it when

it walks into the room” --Aaron Spelling

• Greek mathematics of ideal aesthetics

• Leonardo Da Vinci (1452-1519)

– Anatomic studies

– Proportions of human anatomy

– Vitruvian Man

Gender AestheticsMasculine vs. Feminine

• Body shape

– Male straight / boxy

– Female curve

• Facial shape

– Male square

– Female triangular/heart shaped

• Imaging Demo

Greek “Golden” Proportion Rectangle Triangle Pentagram

AB/BC = BC/AC

Greek Facial Aesthetics

How to Learn Aesthetics

• Art class

• Hard work

• Passion for excellence

Top Surgery in FTMWhat is Chest Reconstruction?

• Chest masculinization

– Making a male chest

– Removing female shape

– Not complete removal of breast tissue

– Not for cancer treatment

• Gender Identity

– FTM

– Gender Queer

– Gender Fluidity – NOT recommended

Chest ReconstructionTechnique

• Tumescent infusion advantages– Less pain

– Less bruising

– Less drain time

– Less bleeding

• Double incision, most common– Larger breasts

– Excess skin

– Sagging breast

– Longer incision, greater potential for scarring

• Key hole, least common– Small breast

– No sag

– Small nipples in good position

– Short incision, minimal scars

AestheticsChest Reconstruction

• Study the human form

• Critical proportions

• Every person is different

• Model after existing anatomy

• Body builders give excellent clues

Proposed Classification FtM Chest AnatomyGrade I

• Minimal gland

• NAC of appropriate size & positioned

• NAC appropriate level w/o ptosis

• Procedure: Keyhole

Grade III

• Larger breast gland

• Significant ptosis

• Excess skin with poor elasticity

• Procedure: DI Mastectomy

Grade IV

• Large gland with significant ptosis

• Excess adjacent tissue requiring excision

• Procedure: DI Mastectomy + back lift + liposuction

Grade II

• Mild to moderate gland size

• Large low NAC w/ adequate skin elasticity

• Procedure: Keyhole, unlikely;

• Probably double incision mastectomy

Personal Aesthetic GuidelinesChest Reconstruction

• Tissue above nipple is masculine– Should be sculpted

– Avoid the emptiness of complete removal

• Tissue below nipple is feminine

• Liposuction should be used to sculpt chest

• Loose skin must be removed

• Chest reconstruction conceptually is:

– NOT a breast reduction

– Creation of a masculine chest

• ANATOMY EXAM CRITICAL

6/26/2014

Feminine

Fat Pads

Masculine to be sculpted

Feminine to be removed

6/26/2014

Feminine

Fat Pad

Masculine to be sculpted

Feminine to be removed

6/26/2014

Chest Reconstruction Video

Warning – surgery details

• Time-lapse sequence

• “Finding Kim”

• Full length feature film

• Seattle International Film Festival

• Benefits our Trans-Community

• No financial interest

Finding KimI Have NO Financial Interest

• Uplifting film presenting the gender

spectrum challenges

• Three Dollar Cinema Film Festival

• Supportive of the trans community

• Spring May 4-17, 2017

7/22/2014

6/26/2014

Deviation From Guidelines

• Produces suboptimal results or

• Can produce odd looking results

4/30/2014

Post-Op

5/8/2014

5/21/2014

5/8/2014

7/28/2014

6/29/2015

How to Learn Aesthetics

• Art class

• Hard work

• Passion for excellence

Post-Operative Considerations

“Major vs. Minor Surgery Depends on Which Side

of the Mask You’re On!”

-Linda’s PCP

Complications

• Bleeding

• Scarring

• Infection

• Cosmetic deformity, unnatural look

• PE/DVT

Postop Challenges

• Racial/Ethnic groups respond differently to surgical and medical treatments

• Scarring– Wide scars

– Hypertrophic scars

– Keloids scars

• Dischromia-color irregularities

– Hyperpigmentation-darker color

– Hypopigmentation-lighter color

• Not knowing before surgery

• More visible for longer time

Postoperative Scarring

• Most scars fade over time without treatment

• Wide scars often need revision

• Enlarged (hypertrophic) scars

– Mederma, Cimeosil, Scarguard

– Silicone gel sheets

• Keloid scars are special

– Act like a cancer and continue to grow

– Difficult to control

– Identify and treat early

Post-Op Tips for the PCP

• See patients postop ASAP

• They’ll tell you things they will not tell their

surgeon

• Focus on rest, nutrition (protein and fluids!)

• Depression is common; ask about it

• ALL surgeries carry risk

• Some surgeries are characteristically

exhausting, long recovery time (FFS)

Post-operative ConsiderationsChest Reconstruction

• Chest reconstruction Recovery: 7days-2 weeks off

• Bleeding & Hematomas: uncommon but not zero

• Ischemia & Necrosis: very uncommon

• Infections-redness and swelling. Typically soft

tissue requiring antibiotics

• Hormones-Skip one testosterone dose

Warnings for DVT/PE

DVT (Deep Vein Thrombosis)

• Swelling in leg

• Tender lump in leg

• Tender “cord in leg”

• Tightness in one leg

• Pain with walking

because of above

PE (Pulmonary Embolism)

• Pain at the “peak” of each breath

• Chest pain

• Upper abdominal pain*

• Shortness of breath

• Hemoptysis (coughing up blood)

• Dizziness/agitation

*Think gall bladder also!

Summary

• Surgery is a partnership– Doctor responsibilities

– Patient responsibilities

• Respect

– Goals

– Points of view

• Education

– Many procedures

– Each are unique

– Know what you are asking for

– Understand how to achieve it

QUESTIONS

& ANSWERS

THANK YOU!

Understanding Top Surgery: The Art, the Math and the Results

Copy of Lecture Available

Seattle, WA

tony@mangubat.com

Understanding Top Surgery - Swedish Hospital/media/Images/Swedish/CME1...Understanding Top Surgery:...

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