Cool Case of the Week

FtM double incision Top Surgery before and after photos

FtM Double Incision Top Surgery Before Picture
FtM Double Incision Top Surgery After Picture

This pleasant 23 year old trans man came to see Dr. Medalie in regards to FtM “top surgery”. He had too much tissue for the peri-areolar approach and was scheduled for a double incision mastectomy with free nipple grafting and chest contouring by limited liposuction. His gender confirming surgery was performed as an outpatient and took approximately 90 minutes to perform. In his after picture he is shown 1 year post DI and is very pleased with his contour. *Results may vary

Below I have attached some information from my main web page that discussed the surgical options for top surgery. Here is a link to that page:

Top Surgery for Transgender Patients

The procedure is based on the following:

  • Size and shape of breast
  • Elasticity of skin
  • Patient’s needs and preferences

PERI: In general, patients who have smaller breasts can have the entire surgery performed by having a small incision at the outer edge of the areola from 12:00 to 6:00 o’clock. A lighted retractor and surgical scissors are used to perform a complete sub-cutaneous mastectomy. Liposuction of the chest is also performed as needed.This provides the most optimal results and can be almost invisible after it heals. If the skin appears a little looser at the start of the case then a complete peri-areolar incision is made. A small amount of skin is removed (in a doughnut pattern , also known as-“peri-areolar or “purse-string” mastopexy”). A subcutaneous mastectomy is performed and then the outer edge of the skin is closed with a purse-string to the newly down-sized areola. By necessity, the edges of the incision around the nipple will be “scalloped” or bunched up initially. This settles down to a great degree over time. If the patient understands that scar revision may be necessary, this is a very reasonable approach. The nipple may experience compromise of its blood supply and also have sensation or erectile capacity changes.

Double Incision: In those patients with a large amount of breast tissue with excessive skin of poor quality and droop, it is usually recommend to remove the excess skin and breast tissue in the crease of the pectoralis muscles (elliptical or double incision mastectomy) and put the nipples and areolae back on as grafts. This surgery has the advantage of immediate and predictable results. I can contour the skin flaps and place the nipples where I want to. It has the disadvantage of permanently altering the sensation and erectile capacity of the nipples (and sometimes the pigmentation), and it leaves larger scars on the chest. Over time they fade and flatten out. At each end of the scar, “dog-ears” may form. These are small bunches of tissue created by the closing of the ellipse as a straight line. They tend to settle down over time, but may need to be revised. I always try and address the dog ears at the time of surgery but this may extend the length of the scar. Dog ears are more likely in patients who are heavier and have more tissue to start with. I always perform liposuction of the central and lateral chest (to flatten the dog ears) as well as the area in front of the armpit. I have been asked why a scar may meet in the center of the chest on some top surgery results but not on others. This is dependent on pre-existing anatomy. If the tissue meets in the middle (such as in the example right below) then the scar by necessity will meet in the middle (this can’t be seen in the example because of the patient’s chest hair.)

  • Posted on: Feb 10 2020
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Breast Augmentation with Silicone Breast Implants

This pleasant 33 year old woman came to see Dr. Daniel A. Medalie of Cleveland Plastic Surgery at his Beachwood office to inquire about breast augmentation. She is 5’2″ and 158 lbs and wanted to be a full D after surgery cup. She chose to proceed with the surgery in an outpatient setting and had a successful 1 hour procedure. The implants placed were Allergan, smooth, round, moderate profile plus 415 cc silicone breast implants. The patient is shown 4 months after her breast enhancement and is very pleased with the results.

breast augmentation procedure includes the following steps:

Step 1 – Anesthesia

Medications are administered for your comfort during the surgical procedure. Dr. Medalie prefers light general anesthesia with the patient breathing fully on her own.

Step 2 – The Incision

Incisions are made in inconspicuous areas to minimize visible scarring.We will discuss which incision options are appropriate for your desired outcome. Incision options include: along the areolar edge (peri-areolar incision), the fold under the breast (inframammary fold) and in the armpit (axillary incision). I prefer the IM fold approach because recent literature suggests that it is associated with a lower incidence of capsular contracture. Ths incision for a silicone implant is by necessity larger than one for a saline implant because the silicone implant is pre-filled and the saline implant starts empty.

breast augmentation incisions

Incisions vary based on the type of breast implant, degree of enlargement desired, your particular anatomy and patient-surgeon preference.

Step 3 – Inserting And Placing The Breast Implant

After the incision is made, a breast implant is inserted into a pocket either:

submuscular and subglandular breast implant placement

A. Under the pectoral muscle (a submuscular placement)

B. Directly behind the breast tissue, over the pectoral muscle (a submammary/ subglandular placement)

C. Dual-plane which is partly under the muscle (in the upper pole) and partly under the breast (lower pole). This procedure is more frequently used in women who have had children and have some droop to their breasts.

The method for inserting and positioning breast implants depends on the type of implant, degree of enlargement desired, your body type and your surgeon’s recommendations.

Step 4 – Closing The Incisions

Incisions are closed with layered sutures (that dissolve) in the breast tissue and with sutures, skin adhesive and surgical tape to close the skin.

breast augmentation incision locations

Over time the incision lines will fade. The quality of scar depends on many things, including your genetics, exposure of your body to nicotine and infection.

Step 5 – See The Results

The results of breast augmentation are immediately visible. Typically they start high and then over time settle to a lower and more natural appearance. I usually tell patients that what they see is not what they get until 3 months after the surgery.

*Plastic surgery results can vary from patient to patient and are not guaranteed

  • Posted on: Jan 30 2020
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FtM top Surgery Before and After Results

FtM top surgery before peri procedure
FtM top surgery after peri procedure

This 19 year old transgender patient contacted my office seeking FtM top surgery. He was scheduled for a peri-areolar approach to his double mastectomy. This is also known as the keyhole approach or partial peri procedure. He is now shown 14 months after the procedure. He has excellent symmetry and contour and barely visible scars and is very pleased with the aesthetic result.

  • Posted on: Dec 5 2019
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FtM Top Surgery Results

Top Surgery double incision pre-op photo
FtM top surgery double incision post-op photo

This very pleasant trans man contacted Dr. Medalie of Cleveland Plastic Surgery seeking FtM top surgery. Because of his starting chest size and skin excess it was decided that he would be a better candidate for the double incision mastectomy with nipple grafting procedure versus the peri- areolar surgery. Chest contouring with liposuction was also performed. The DI took place on an outpatient basis at Brainard Surgery center in Beachwood , Ohio. It lasted 1.5 hours and the patient did very well post-operatively. He is shown 9 months out from his double mastectomy and has an excellent contour with good nipple placement and sizing. He is fully active and working on his chest musculature.

  • Posted on: Oct 17 2019
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Cleveland Plastic Surgery Breast Augmentation with IDEAL Implants

Breast augmentation before surgery
Breast augmentation after surgery

This 35 year old mother of two came to see Dr. Medalie at his Beachwood office to discuss breast augmentation surgery. She is 5’8″ and 135 lbs. She was interested in the IDEAL saline type breast implants and after careful consultation decided to proceed with 390 cc IDEAL breast implants during her surgery. She is shown three months after the insertion of the breast implants (which was done in a small 1 hour outpatient procedure at the Brainard surgery center). She is delighted with the results of her breast enhancement.

breast augmentation procedure includes the following steps:

Step 1 – Anesthesia

Medications are administered for your comfort during the surgical procedure. Dr. Medalie prefers light general anesthesia with the patient breathing fully on her own.

Step 2 – The Incision

Incisions are made in inconspicuous areas to minimize visible scarring.We will discuss which incision options are appropriate for your desired outcome. Incision options include: along the areolar edge (peri-areolar incision), the fold under the breast (inframammary fold) and in the armpit (axillary incision). I prefer the IM fold approach because recent literature suggests that it is associated with a lower incidence of capsular contracture. Ths incision for a silicone implant is by necessity larger than one for a saline implant because the silicone implant is pre-filled and the saline implant starts empty.

breast augmentation incisions

Incisions vary based on the type of breast implant, degree of enlargement desired, your particular anatomy and patient-surgeon preference.

Step 3 – Inserting And Placing The Breast Implant

After the incision is made, a breast implant is inserted into a pocket either:

submuscular and subglandular breast implant placement

A. Under the pectoral muscle (a submuscular placement)

B. Directly behind the breast tissue, over the pectoral muscle (a submammary/ subglandular placement)

C. Dual-plane which is partly under the muscle (in the upper pole) and partly under the breast (lower pole). This procedure is more frequently used in women who have had children and have some droop to their breasts.

The method for inserting and positioning breast implants depends on the type of implant, degree of enlargement desired, your body type and your surgeon’s recommendations.

Step 4 – Closing The Incisions

Incisions are closed with layered sutures (that dissolve) in the breast tissue and with sutures, skin adhesive and surgical tape to close the skin.

breast augmentation incision locations

Over time the incision lines will fade. The quality of scar depends on many things, including your genetics, exposure of your body to nicotine and infection.

Step 5 – See The Results

The results of breast augmentation are immediately visible. Typically they start high and then over time settle to a lower and more natural appearance. I usually tell patients that what they see is not what they get until 3 months after the surgery.

*Plastic surgery results can vary from patient to patient and are not guarantee

  • Posted on: Oct 3 2019
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Labiaplasty Before and After

Labiaplasty patient pre-op with central labial hypertrophy
Labiaplasty patient 3 month post-op with excellent reduction in her central labial hypertophy

This pleaseant 41 year old came to see Dr. Medalie in his Beachwood office. She complained of difficulty with exercise and sexual activity due to the large size of her inner labia and desired vaginal rejuvenation by reducing her labia minora . She underwent the labiaplasty under local anesthesia and mild oral sedation at Dr. Medalie’s Beachwood office, and the pictures show her three month after her labiapasty surgery. She has excellent reduction in the size of her labia minora with no protrusion of the labial tissue beyond the labia majora. She is very pleased with her outcome.

Dr. Medalie of Cleveland Plastic Surgery is an expert in labia minora reduction and vagina rejuvenation. He also performs clitoral hood reduction and fat injection to the labia majora. He has presented his techniques and results at national meetings and in book chapters. His labiaplasty and vaginoplasty patients travel from all over Ohio, the midwest and east coast. Please visit his photo gallery to see examples of his work!

  • Posted on: Aug 5 2019
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Breast Augmentation with silicone breast implants

This 40 year old woman came to Dr. Medalie seeking breast augmentation. She is 5’1″ and 120 lbs and was an “a” cup, and was interested in being a “c” cup after the surgery. After careful consultation she chose 345 cc smooth round silicone inspira breast implants (allergan). She is shown 6 months after her breast augmentation surgery and is very happy with her natural appearance.

Breast Augmentation Before
Breast Augmentation 6 Months After

Steps for Breast Augmentation (from the American Society of Plastic Surgery)

Step 1 – Anesthesia

Medications are administered for your comfort during the surgical procedure. Dr. Medalie prefers light general anesthesia with the patient breathing fully on her own.

Step 2 – The Incision

Incisions are made in inconspicuous areas to minimize visible scarring.We will discuss which incision options are appropriate for your desired outcome. Incision options include: along the areolar edge (peri-areolar incision), the fold under the breast (inframammary fold) and in the armpit (axillary incision). I prefer the IM fold approach because recent literature suggests that it is associated with a lower incidence of capsular contracture. Ths incision for a silicone implant is by necessity larger than one for a saline implant because the silicone implant is pre-filled and the saline implant starts empty.

breast augmentation incisions

Incisions vary based on the type of breast implant, degree of enlargement desired, your particular anatomy and patient-surgeon preference.

Step 3 – Inserting And Placing The Breast Implant

After the incision is made, a breast implant is inserted into a pocket either:

submuscular and subglandular breast implant placement

A. Under the pectoral muscle (a submuscular placement)

B. Directly behind the breast tissue, over the pectoral muscle (a submammary/ subglandular placement)

C. Dual-plane which is partly under the muscle (in the upper pole) and partly under the breast (lower pole). This procedure is more frequently used in women who have had children and have some droop to their breasts.

The method for inserting and positioning breast implants depends on the type of implant, degree of enlargement desired, your body type and your surgeon’s recommendations.

Step 4 – Closing The Incisions

Incisions are closed with layered sutures (that dissolve) in the breast tissue and with sutures, skin adhesive and surgical tape to close the skin.

breast augmentation incision locations

Over time the incision lines will fade. The quality of scar depends on many things, including your genetics, exposure of your body to nicotine and infection.

Step 5 – See The Results

The results of breast augmentation are immediately visible. Typically they start high and then over time settle to a lower and more natural appearance. I usually tell patients that what they see is not what they get until 3 months after the surgery.

  • Posted on: May 28 2019
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Breast augmentation with IDEAL breast implants

Breast Augmentation Before
Breast Augmentation After

This patient came to see Dr. Medalie at his Beachwood office to discuss breast augmentation surgery. She was interested in the IDEAL saline type breast implants and after careful consultation decided to proceed with 360 cc IDEAL breast implants during her surgery. She is shown three months after the insertion of the breast implants (which was done in a small 1 hour outpatient procedure). She is delighted with the results of her breast augmentation.

breast augmentation procedure includes the following steps:

Step 1 – Anesthesia

Medications are administered for your comfort during the surgical procedure. Dr. Medalie prefers light general anesthesia with the patient breathing fully on her own.

Step 2 – The Incision

Incisions are made in inconspicuous areas to minimize visible scarring.We will discuss which incision options are appropriate for your desired outcome. Incision options include: along the areolar edge (peri-areolar incision), the fold under the breast (inframammary fold) and in the armpit (axillary incision). I prefer the IM fold approach because recent literature suggests that it is associated with a lower incidence of capsular contracture. Ths incision for a silicone implant is by necessity larger than one for a saline implant because the silicone implant is pre-filled and the saline implant starts empty.

breast augmentation incisions

Incisions vary based on the type of breast implant, degree of enlargement desired, your particular anatomy and patient-surgeon preference.

Step 3 – Inserting And Placing The Breast Implant

After the incision is made, a breast implant is inserted into a pocket either:

submuscular and subglandular breast implant placement

A. Under the pectoral muscle (a submuscular placement)

B. Directly behind the breast tissue, over the pectoral muscle (a submammary/ subglandular placement)

C. Dual-plane which is partly under the muscle (in the upper pole) and partly under the breast (lower pole). This procedure is more frequently used in women who have had children and have some droop to their breasts.

The method for inserting and positioning breast implants depends on the type of implant, degree of enlargement desired, your body type and your surgeon’s recommendations.

Step 4 – Closing The Incisions

Incisions are closed with layered sutures (that dissolve) in the breast tissue and with sutures, skin adhesive and surgical tape to close the skin.

breast augmentation incision locations

Over time the incision lines will fade. The quality of scar depends on many things, including your genetics, exposure of your body to nicotine and infection.

Step 5 – See The Results

The results of breast augmentation are immediately visible. Typically they start high and then over time settle to a lower and more natural appearance. I usually tell patients that what they see is not what they get until 3 months after the surgery.

*Plastic surgery results can vary from patient to patient and are not guarantee

  • Posted on: May 9 2019
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Limited breast lift (peri-areolar mastopexy)

This 26 year old patient came to see Dr. Medalie of Cleveland Plastic Surgery at his Beachwood office. She had a chief complaint of large areolae and slightly drooping breasts. Dr. Medalie proposed a peri-areolar mastopexy which could be done as an outpatient under local anesthesia. The surgery was confined to the peri-areolar skin so that the scar rested at the junction of the pigmented skin and normal color skin.The patient agreed to the surgery, and is shown 8 months after her procedure. The surgery was very successful and the patient was pleased with her smaller areolae and perkier breasts.

peri-areolar mastopexy before
peri-areolar mastopexy after

What are the steps of a breast lift procedure?

Your breast lift procedure can be achieved through a variety of incision patterns and techniques.

The appropriate technique for you will be determined based on:

  • Breast size and shape
  • The size and position of your areolas
  • The degree of breast sagging
  • Skin quality and elasticity as well as the amount of extra skin

Step 1 – Anesthesia

Medications are administered for your comfort during the surgical procedure. The choices include intravenous sedation and general anesthesia. Your doctor will recommend the best choice for you.

Step 2 – The incision

There are three common incision patterns:

Around the areola

Breast lift incision around areola

Around the areola and vertically down from the areola to the breast crease

Breast lift incision vertical

Around the areola, vertically down from the breast crease and horizontally along the breast crease

Breast lift incision horizontal

Step 3 – Reshaping your breasts

After your doctor makes the incisions:

  • The underlying breast tissue is lifted and reshaped to improve breast contour and firmness.
  • The nipple and areola are repositioned to a natural, more youthful height.
  • If necessary, enlarged areolas are reduced by excising skin at the perimeter.
  • Excess breast skin is removed to compensate for a loss of elasticity.

Step 4 – Closing the incisions

After your breasts are reshaped and excess skin is removed, the remaining skin is tightened as the incisions are closed.

Some incision lines resulting from breast lift are concealed in the natural breast contours; however, others are visible on the breast surface. Incision lines are permanent, but in most cases will fade and significantly improve over time.

Many women desire the smallest scar possible. However, your plastic surgeon will recommend the incisions which best suit your anatomy.

Listen to your surgeon and do not diminish your result by demanding an incision that will not be appropriate for you.

Sutures are layered deep within the breast tissue to create and support the newly shaped breasts. Sutures, skin adhesives and/or surgical tape may be used to close the skin.

  • Posted on: Apr 23 2019
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Labia Minora Reduction

Labiaplasty in a patient with extreme anterior hypertrophy

   

This 26 year old patient came to see Dr. Medalie at his Beachwood office. Her chief complaint was labial hypertrophy with extreme irritation in tight clothes and during physical activity. On exam she had a great deal of excess and thick  labial tissue as well as fullness of the clitoral hood. Dr. Medalie performed a labiaplasty under local anesthesia with mild oral sedation in his clinic. The wedge techniques was used and the post appearance is shown at three months. It can be seen that the labia minora are now no longer protruding beyond the labia majora and run in a straight line as opposed to being quite redundant. The clitoral hood was not operated on  but has become more streamlined because of the pull of the labiaplasty. Her overall appearance is much improved and she has much less irritation during all activities. She was extremely pleased with her result.

Below is my Labiaplasty FAQ: Click on each question to see the answer!

Do I need general anesthesia?
No – Labiaplasty can be performed with mild oral sedation and local anesthesia.
How long does it take?
Typical surgery time is around 1-1.5 hours.
What is the chance of infection?
I typically give my patients antibiotics for three days around the surgery. I have NEVER had a post-operative infection. Sometimes patients who take antibiotics get yeast infections and this has happened to several of my patients. The treatment consists of stopping the antibiotics and applying a topical anti-yeast agent. Please be aware that smoking is the number one reason for post-operative infections and healing problems. I thus require my patients to STOP SMOKING at least 6 weeks prior to any labiaplasty procedure.
Are there bleeding risks?
The labia are very vascular and bleed easily. During the surgery local anesthetic is injected into the tissue-this blocks the sensation and also constricts blood vessels. As a result, there is very little bleeding during the surgery. I have NEVER had a patient have a bleeding complication post-op.
What is the recovery?
While it may seem that this is a very bad area to have surgery on, in fact, the labia are very resilient and heal speedily. Pain that may require narcotic pain medicine typically lasts only a few days. After that, ibuprofen (Motrin and Advil) is sufficient. I recommend that patients take a week off from work, but if you have a desk job, you can go back sooner. The post-op care is fairly easy and involves cleansing several times per day and the application of antibiotic ointment for a week. Most of the swelling and all of the external stitches have disappeared by two weeks.
When can I resume my normal activity?
I recommend that patients refrain from intercourse for at least 4 weeks after surgery. This does not mean that other types of sexual activity cannot take place. Even after 4 weeks, the labia incisions may be sensitive and patients need to use caution and plenty of lubrication.
When will I be completely healed?
Some of the deep sutures under the skin can take up to three months to completely dissolve. For this reason, some patients may report sensitivity issue such as itching for up to three months post-op. After that, sensation issues are very uncommon. Damage to the clitoris with resulting changes in the ability to have orgasm has never happened in my patient population.
Can other procedures be performed at the same time as labiaplasty?
Yes – I frequently perform multiple procedures on labaiplasty patients. Sometimes I perform clitoral unhooding. This procedure removes some of the skin overlying the clitoris to allow for greater stimulation during intercourse. The labia majora can also be reduced (this is more typically asked for by my older patients or patients who have lost significant amounts of weight). Vaginoplasty or vaginal rejuvenation is a procedure to tighten the vaginal introitus after child bearing. This is easily performed in conjunction with labiaplasty. Finally, all the other cosmetic procedures that I perform (e.g. breast augmentation, tummy tuck etc.) can be performed at the same time as labiaplasty. These would require a trip to the operating room and general anesthesia.
What does it cost?
Simple labiaplasty under local anesthesia and mild sedation costs around $3800 at Dr. Medalie’s outpatient procedure clinic. Clitoral hood reduction can be added for $500. Labia majora reduction is an additional $1500 (or $3000 as a stand alone procedure). All procedures are less expensive when combined with other procedures such as vaginoplasty or breast augmentation.
What if I am from out of town?
I frequently perform labia reduction and vagina rejuvenation surgery on patients who live out of town and are unable to easily to see me in consultation prior to the procedure. I have several requirements for these patients: I must see pictures of them prior to scheduling surgery. They need to contact my office and have my patient care manager fax or e-mail them a history and physical form to be filled out and sent back. Typically the patient will come in to town 1 day prior to the procedure, and I will see them the day of surgery.  A phone consultation will be performed about 3 weeks prior to surgery. I will then perform the operation and see them back in my clinic in several days to check the surgical site and answer any questions. This means that the patient will spend around 4-7 days in the Cleveland area. Some patients have stayed only for 24 hours and had family doctors check on them. Patients who live far away, but can drive to Cleveland (2-6 hrs.), can go home the next day and drive back to see me for their first post-operative appointment. I will then follow the progress of the patient via e-mailed pictures on a weekly basis. My patient care mananger has information about hotels in the area as well as financing. You may contact her at [email protected]
Where can I get more information?
Please visit Dr. Medalie’s vaginal surgery specific web site at www.LabiaplastySurgery.net. There you can see multiple before and after labiaplasty and vaginoplasty photos as well as watch his live labia and vagina surgery video or call him at 216-393-9924. You can also e-mail his patient care manager at [email protected].
  • Posted on: Mar 26 2019
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