Cool Case of the Week

Ftm Double incision mastectomy with nipple grafts

 

 

This pleasant 28 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. He also has had good hair growth from testosterone therapy. *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: Aug 3 2020
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Bilateral breast augmentation with silicone breast implants and abdomen and flank liposuction

     

                   Breast Augmentation with 405 cc silicone breast implants before and after photos

 

 

This pleasant 34 year old woman came to see Dr. Daniel A. Medalie of Cleveland Plastic Surgery at his Beachwood office to inquire about breast augmentation and liposuction of her abdomen and sides. She is 5’5″ and 120 lbs and wanted to be a D cup after surgery. She chose to proceed with the surgery in an outpatient setting and had a successful 1.5 hour procedure. The implants placed were Allergan silicone 405 cc silicone breast implants. The patient is shown 3 months after her breast enhancement and body contouring 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: Mar 30 2020
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  • Posted on: Jul 16 2020
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FtM DI top surgery for gender affirmation with body contouring

FtM DI top surgery and body contouring for gender affirmation

Before Top Surgery and lower abdominoplasty    After Top Surgery and lower abdominoplasty

     

 

This pleasant 27 year old trans man came to see Dr. Medalie in regards to FtM “top surgery”. He had too much loose skin for the peri-areolar approach and was scheduled for a double incision mastectomy with free nipple grafting and chest contouring by limited liposuction. He was also interested in contouring his lower abdomen and decided on a lower abdominoplasty with liposuction. His gender confirming surgery was performed as an outpatient and took approximately 2 hours to perform. In his after picture he is shown 1 year post DI and body contouring and is very pleased with his contour. He has begun an extensive work out regimen and in combination with his lower abdominoplasty and testosterone, his newly contoured body demonstrates excellent musculature and chest 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
  • By: 
  • Posted on: Jul 6 2020
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Liposuction of Flanks Before and After

Liposuction of flanks Before picture

 

Liposuction of flanks After picture

This cosmetic surgery patient desired body contouring by liposuction. She discussed treatment of her flanks, sides and abdomen with Dr. Medalie at his Beachwood office. Surgery was performed and 4 liters of fatty tissue was removed from her flanks, sides and abdomen in an outpatient surgery at the Brainard Surgery Center. Her post-operative results were excellent and she was very happy with her new contour after her body contouring procedure.

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

The liposuction procedure includes the following steps:

Step 1 – Anesthesia

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

Step 2 – The Incision

Liposuction is performed through small, inconspicuous incisions.

First, diluted local anesthesia is infused to reduce bleeding and trauma. Then a thin hollow tube, or cannula, is inserted through the incisions to loosen excess fat using a controlled back and forth motion. The dislodged fat is then suctioned out of the body using a surgical vacuum or syringe attached to the cannula.

Problem Areas That Can Be Addressed With Liposuction

Liposuction problem areas

Liposuction problem areas

Step 3 – See The Results

Your improved body contour will be apparent once the swelling and fluid retention commonly experienced following liposuction subside. Get more information about liposuction results.

Liposuction rear and side after

Liposuction front and face after

  • Posted on: Jun 1 2020
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Mommy Makeover with Tummy Tuck and Breast Implants

Abdominoplasty, liposuction and breast augmentation with silicone breast implants (before surgery) *Surgery results may vary
Abdominoplasty, liposuction and breast augmentation with silicone breast implants (3 months after surgery) *Surgery results may vary

This 29 year old patient from Cleveland, Ohio came to see Dr. Daniel A. Medalie of Cleveland Plastic Surgery at his Beachwood office to discuss a mommy makeover by tummy tuck surgery and liposuction as well as breast enhancement. She had two pregnancies and also lost around 75 lbs. She is 5’5″ and 145 lbs . On exam she has a great deal of loose skin and muscle of the abdomen as well as some extra fatty tissue. Dr. Medalie proposed an abdominoplasty procedure with muscle plication (tightening) and side and flank liposuction as an outpatient. She agreed and is shown 3 months after her body contouring surgery. She also desired bilateral breast augmentation to help correct her deflated breast appearance. She chose 405 cc silicone implants to be placed in a dual plane technique. In her post op photos, she has excellent reduction of loose skin and stretch marks as well as good tightening of the abdominal wall and is very happy with her body contouring results. Her breasts are fuller and more symmetric and complement her new abdomen.

What Is A Mommy Makeover?

The goal of a mommy makeover is to restore the shape and appearance of a woman’s body after childbearing. Many women notice changes in their bodies post-pregnancy. There are many areas of the body that can be addressed, most commonly the breasts, abdomen, waist, genitalia, and buttocks. A mommy makeover is typically performed as a single stage procedure. There are many techniques used to perform a mommy makeover, and many factors should be taken into consideration when choosing which techniques are best:

  • Desired amount of restoration
  • Placement of the incisions
  • Type of implant used

Possible Procedures In A Mommy Makeover

Abdominoplasty

Liposuction

Breast Augmentation

Breast Lift

Vaginoplasty

Labiaplasty

Thigh Lift

Arm Lift

  • Posted on: May 5 2020
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Mommy makeover with right breast lift and left breast implant placement

Abdominoplasty and right breast lift with left breast augment before photo
Abdominoplasty and right breast lift with left breast augment after photo

This 36 year old patient from Cleveland, Ohio came to see Dr. Daniel A. Medalie of Cleveland Plastic Surgery at his Beachwood office to discuss a mommy makeover by tummy tuck surgery and liposuction as well as breast enhancement. On exam she has a great deal of loose skin and muscle of the abdomen as well as some extra fatty tissue. Dr. Medalie proposed an abdominoplasty procedure with muscle plication (tightening) and side and flank liposuction as an outpatient. She agreed and is shown 6 months after her body contouring surgery. She also desired a breast lift on the right side with more volume on the left to match the right. She underwent a full right breast lift (mastopexy) and a small silicone breast implant on the left. She has excellent reduction of loose skin and stretch marks as well as good tightening of the abdominal wall and is very happy with her body contouring results. Her breasts are much more symmetric and complement her new abdomen.

What Is A Mommy Makeover?

The goal of a mommy makeover is to restore the shape and appearance of a woman’s body after childbearing. Many women notice changes in their bodies post-pregnancy. There are many areas of the body that can be addressed, most commonly the breasts, abdomen, waist, genitalia, and buttocks. A mommy makeover is typically performed as a single stage procedure. There are many techniques used to perform a mommy makeover, and many factors should be taken into consideration when choosing which techniques are best:

  • Desired amount of restoration
  • Placement of the incisions
  • Type of implant used

Possible Procedures In A Mommy Makeover

Abdominoplasty

Liposuction

Breast Augmentation

Breast Lift

Vaginoplasty

Labiaplasty

Thigh Lift

Arm Lift

  • Posted on: Apr 30 2020
  • By:

Cleveland Plastic Surgery breast augmentation with IDEAL saline implants

Breast augmentation with Ideal saline implants, before photo
Demonstration of breast augmentation before and after insertion of ideal saline implants
Breast augmentation with Ideal saline implants, after photo

This pleasant 35 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 116 lbs and wanted to be a C cup to small D after surgery. She chose to proceed with the surgery in an outpatient setting and had a successful 1 hour procedure. The implants placed were IDEAL saline 330 cc breast implants. The patient is shown 1 year 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: Mar 30 2020
  • By:

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
  • By:

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
  • By:

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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