Female to Male Surgery (FtM top surgery)
Dr. Medalie in Cleveland, Ohio is an internationally recognized expert in the field of Female to Male chest or “top” surgery. He has been featured in several documentaries about transgender surgery including ones on MTV and LOGO tv. Click on the logos below to view the documentaries and to view more of Dr. Medalie’s patient photos.
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.)
I have patients that ask to opt out of having the nipple grafts and consider just getting tattoos. This is something that I am unwilling to do. Nipples are part of the normal human anatomy and I am only comfortable performing surgery to create natural results. Additionally the nipple/areolar complex is unique and can’t be reconstructed once thrown away. Below is a typical result of nipple grafting in a double incision mastectomy. *Plastic surgery results can vary
Many prospective patients ask for FtM top surgery before and after photos. Above is one of my top surgery patients several years out from double incision mastectomy and testosterone therapy. For more, I recommend that you visit TRANSBUCKET.COM. You will need to create an account (but it is free). At this site many of my patients have posted their own photos without my input. This is the best way to see true top surgery before and after photos. I also recommend searching for me on Youtube and Instagram.
CONTACT US Let Us Know What You Think
FtM Top Surgery Revisions
I get contacted by many patients who have had FtM top surgery and are now seeking a revision of their chest. If they are my own patients seeking revision, the problems are almost always small and can be taken care of under local anesthesia in my clinic (touch up liposuction or dog ear revision). Usually when I am contacted by a patient who has had a procedure by another physician the results are quite poor (because otherwise the patient would have gone back to his original surgeon), and the patient needs to go back to the OR for a successful outcome. Below is the before and after photos of a patient who initially had his FtM top surgery by another surgeon. There is obvious loose skin and retained fatty tissue with stretching and distortion of the nipple areolar complex. I completely revised the scars and nipples and was able to give him a much improved chest contour. He is shown two months after the surgery and is very happy with his early result. I would be happy to review any before and after photos a prospective patient wishes to send me, and I will do my best to give an idea of what might be necessary to improve the cosmetic outcome.
FtM Top Surgery Scarring
Many patients ask about what the scars will look like (especially for the double incision surgery DI). The patient below posted these himself on Transbucket. He shows how his scars have evolved from 1 week after top surgery to 1 month, to 3 months and finally to 2 years post mastectomy. The scars which are quite visible initially fade over time and fall into the line of the pectoralis major muscle of the chest. This is an important point because many patients are afraid of the DI because of how the scars look. I think that the DI can give a better result with better contouring of the chest and nipple position than a peri-areolar procedure in the right patient. That does not mean that it is the best choice for all people and this is an important conversation that I have with all of my top surgery patients. But it should reassure prospective surgery patients that very good results are possible with DI surgery.
Scheduling Top Surgery
I frequently perform operations on FtM 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 (all of these must be fulfilled prior to scheduling):
- I must have a therapist letter. This letter must adhere to WPATH standards and state that you meet the criteria for gender dysphoria and are a good candidate for this irreversible and life-changing surgery. You must have a relationship with the therapist for a minimum of six months. This must be sent to us (e-mail, fax or mail) before we schedule the surgery.
- I must see pictures prior to scheduling surgery (front and side with arms down). Please do not hold the camera yourself.
- Patients need to download a history form (please click on link), fill it out, and send it to my patient care manager, Valerie.
- We are no longer accepting insurance for any type of transgender surgery. We do provide a letter with all surgery codes to help you get reimbursed by your insurance company for your top surgery.
Typically I will perform a phone consultation several weeks prior to the procedure. I will then perform the operation and see the patient back in my clinic in 5-7 days to remove drains and change the dressing. This means that the patient will spend around 1 week in the Cleveland, Ohio area. 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. Occasionally, I have had patients who have gone home and had their primary care doctor remove the drains and perform the first dressing change. I do not prefer this but do allow it if the patient can assure me of good care. My patient care manager has information about hotels in the area as well as financing. For all logistical details she is the best person to contact. Her e-mail is [email protected]
Insurance Coverage and Fees (This is important!)
For more information please see my informational PDF by clicking on the button at the top of this page. We are no longer accepting insurance for any transgender surgeries. We will not give you a pre-determination letter, but after the surgery we can give you our standard letter with the standard surgical codes that you may send to your insurance company and ask for a reimbursement (this is the one and only letter that will be provided). The codes for the surgery will be simple mastectomy and nipple reconstruction (CPT 19303 x 2, 19350 x 2) and the diagnosis code will be gender dysphoria (ICD-10-F64.9).
Other Procedures for FtM Patients
Many patients ask whether other procedures can be performed concurrently with the top surgery. The most common procedure asked about is liposuction of the flanks, hips, abdomen and thighs. I do this frequently to help contour the whole trunk and would be happy to discuss this with any prospective patient. Please include the whole trunk (front and back) in the photos sent to me so that I can effectively evaluate you. The cost is variable and depends on the extent of extra liposuction performed and the anticipated time that it will take. To see some of my typical results for liposuction and body contouring, please Click Here.
In this operation, the surrounding skin of the clitoris is removed and it is released from the pubis to give the appearance of more length. The glands will appear circumcised in most patients. The final result is a normal appearing, but very small, penis. Actual result will depend on various factors as described below. The outcome is largely dependent upon how much enlargement of the clitoris has occurred with Testosterone. The best results from the metoidioplasty are in patients who are near their ideal body weight and do not have an overhanging mons pubis. In most patients, removal of some skin and liposuction of the fat of the mons will also improve the result. The principal advantage of the metoidioplasty is that it is noninvasive, maintains the sensitivity of the clitoris, and does not create apparent surgical scars. Furthermore, it does not prevent future genital surgery from being done at a later time should one decide. The penis will not, however, appear adult in size, and it is not large enough for vaginal intercourse. Dr. Medalie does not perform urethral lengthening with metoidioplasty. Dr. Medalie typically performs simple metoidioplasty as an outpatient procedure. If a patient desires scrotal construction from the labia majora and insertion of testicular implants, this procedure can be done simultaneously with the non-urethral metoidioplasty.