Q&A - Top Surgery & Breast Augmentation.
Top surgery and breast augmentation for trans and non-binary people:
Your questions answered
Recently Dr Giuseppe Di Taranto took part in a question and answer session for members of a Facebook group which offers support to trans and non-binary individuals. He was interviewed by Alice Spaccassassi, a communications consultant at TransMisssion PR, about his work specialising in top surgery for trans masculine and AFAB non-binary individuals and breast augmentation for trans feminine and AMAB non-binary folk.
Here we cover the key questions asked by members of the group:
Are there any special considerations for top surgery when it comes to treating those with larger cup sizes?
Every patient is unique and performing top surgery on individuals with larger cup size requires special consideration to ensure we are giving the patient the best possible outcome. For larger breasts, normally a double incision mastectomy is advised, combined either with nipple graft (the removal and replacement of the nipple) or no nipple graft (where the nipple is removed but is not replaced).
Also, larger breasts with a narrow cleavage typically require more extensive tissue removal, leading to the need for a longer incision, which in some cases may be joined at the center of the midline.
It is important to discuss all the details of the surgery and the possible outcomes with the patient in order to set realistic expectations and to create a custom-made surgical plan.
Is there a minimum age for top surgery?
We operate in line with international guidelines from WPATH for surgery, which state that patients must be of the age of the majority. In the UK this is 18. Minors are encouraged to have counseling and medical support until they reach that age.
How does the referral process work through the NHS?
I will provide an overview of the process in relation to top surgery specifically as, unfortunately, breast augmentation is not routinely available to trans and non-binary individuals on the NHS.
Your GP will refer you to a Gender Identity Clinic (GIC) who will send a referral letter to the Gender Dysphoria National Referral Support Services or GDNRSS. Once the referral is received by the GDNRSS it is processed, triaged, and then referred to the healthcare provider. In my particular case this is Chelsea and Westminster Hospital. I am one of the surgeons who will perform the surgery once the referral is received.
How soon after an initial consultation can surgery be scheduled?
If you are coming to see me privately, surgery can be scheduled one or two months after the consultation. The waiting time on the NHS is longer and between the referral and the consultation it might take months or years.
Is there anything patients can do to physically prepare for surgery, to promote a better outcome?
I advise all my patients to get fit and lead a healthy lifestyle. A diet rich in protein can contribute positively to the surgical outcome and promote healing.
If a patient is a smoker, I advise them to stop smoking or vaping, ideally permanently, but at least four weeks before and after surgery. This is because nicotine products can significantly hinder the skin’s ability to heal, slowing down the recovery process.
Additionally, in the two weeks before surgery, do what you can to maintain fitness, stay hydrated, and avoid aspirin or any vitamin supplements that may increase the risk of bleeding.
Are there any specific counseling sessions or appointments that need to happen before surgery?
In line with the international guidelines and we require a referral letter from a licensed practitioner. This can be a psychotherapist or a psychiatrist, who will write a letter on behalf of the patient supporting their decision to have surgery.
How long, on average, does it take to heal, post op?
Healing time for feminising or masculinising procedures can vary significantly depending on several factors. These include: the type of the surgery performed, the individual healing response, and the compliance to post operative care restrictions. If no complications occur, the wounds typically heal within two or three weeks Bruising, discomfort, and swelling can take longer to clear up but should subside within the first six weeks.
During this time, patients are required to wear a post-operative compression garment and avoid heavy lifting or strenuous exercise. After six weeks, the patient can gradually resume physical activities. It can take up to a year for the final result to be fully stabilised, as the scars continue to soften and the skin settles into its new position.
When would you say that somebody could get back to doing normal day-to-day activities after surgery?
Again, this varies from person to person and on the type of surgery performed. If you’re looking to take time off work, I tend to recommend a minimum of one week, especially if it’s an office job. Instead, if you have an extremely physical job, you may need longer or to request that you be assigned to less strenuous duties for a period of six weeks.
Do you have before and after pictures of your feminising and masculinising surgeries?
Yes, you can see examples of my work on my Instagram account. If you would like more information or you do not have access to Instagram, get in touch info@mrditaranto.com
Do you use a full anesthetic? Or a spinal sedation?
Spinal anesthesia is used for surgery on the lower part of the body, as it numbs just the lower half of the body, while the patient remains awake. For top surgery and breast augmentation, which involves chest reconstruction and is performed on the upper part of the body, we typically use a general anesthetic, because it ensures the patient is fully asleep and comfortable throughout the procedure.
Where can people who have undergone top surgery buy post operative binders?
Postoperative binders are medical grade garments, and they are specifically designed to:
- reduce swelling
- provide support to the tissue as it heals
- minimise discomfort
- improve the final outcome and contour after surgery
These are included in the cost of the procedure.
What is the best way to tone the chest area after surgery and how long after surgery can you begin this type of exercise?
I recommend exercising for at least a month before your operation as this will improve the healing process and also the outcome.
Post operative exercise involving the chest and the chest muscle, should commence no earlier than six weeks after the surgery, once everything is settled and the patient has met with the surgeon for the first follow up consultation.
How long does it take for surgical scars to fade?
Generally, the scars start to fade and become less noticeable within six to 12 months after the surgery. The most significant improvement can be seen after one year. Over time, the scar color usually changes from red to pink to a lighter color that finally matches the natural skin tone. There are a lot of treatments for scar care, including gel, cream and silicone sheets, and while these certainly help, the best treatment for scars is time.
How soon can people go topless after top surgery?
The risks of sun exposure are well documented and not insignificant. It is also important to note that scars are particularly sensitive to burning. Ideally, scars should be covered up for at least three months after surgery. When patients do expose their skin to the sun they should apply a high factor sunscreen of 50 or above to protect themselves from sun damage as scars might get pigmented if exposed to the sunlight in the first period after the surgery. If they get pigmented, it’s very difficult for them to fade away.
When you carry out nipple grafts on your top surgery patients, does that nipple retain any sensation after a surgery?
We offer a wide range of surgical options for transmasculine and AFAB non-binary individuals, including nipple grafts. When a patient opts for a graft the nipple is completely detached and reattached. While some sensation might return over time, it is usually minimal. If maintaining sensation is important to the patient, I would recommend other procedures such as periareolar or buttonhole.
Do I need to stop taking any testosterone before my top surgery?
There is no evidence to suggest that testosterone carries with it any increased risks or complications for surgery. As such testosterone can be continued as normal.
Will I need to stop oestrogen before breast augmentation?
This is a risk we would discuss in the consultation, but as a general rule, patients don’t need to stop hormones before surgery.
How many cases of top surgery have you performed on trans and non-binary individuals?
To date, I have performed more than 300 cases
How many breast augmentations have you performed on trans and non-binary individuals?
To date, I have performed more than 200 cases.
How long will I need to wear a support bra after breast augmentation surgery?
We recommend patients wear a support bra, which is a compression garment provided by myself, for six weeks after the operation. In some cases, I also recommend the use of a binder to stabilise the implants, which needs to be worn for two weeks after the procedure.
If a nipple graft is required but doesn’t take, do you have options around surgical nipple tattoos?
Yes. There are different options for reconstructing the nipple, either with another small surgery, that can be performed under local anesthetic, or through 3D tattooing which is normally performed by a professional specialising in this area.
I am non-binary and plus sized, is it possible to leave a small amount of breast tissue in place when performing top surgery, or would a different procedure be more appropriate?
Absolutely. Breast reduction is one of the main pillars in top surgery for non-binary individuals. Some patients might want a reduction in the breast or in the size of the areola without removing the breast completely.
Is the surgery outpatient, or does it require an overnight or longer stay?
I strongly believe that to enhance the recovery of the patient they should be encouraged to mobilise soon after surgery. I also believe that the patient heals better in their own bed instead of an unfamiliar environment like a hospital, where there might be an increased risk of exposure to infection. As such all surgeries are performed as day cases, unless there’s any concern or any patient comorbidities that require an overnight stay.
What hospitals or clinics is the surgery carried out at?
I operate out of the Cadogan Clinic and Chelsea and Westminster Hospital, these are both located in London.
If any corrective surgery is required, is this covered within the initial price?
All follow up appointments and post operative care are included in the initial cost, including any eventual revisions that may be needed. Please note the patient will still need to pay the hospital fee, the facility, and the theatre booking, but the surgeon’s fee is included.
I now have my gender recognition certificate, would I still need a surgery referral if I decided to have breast augmentation?
Yes, according to the guidelines, we would still need a referral letter.
When performing masculinising top surgery, do you use drains?
I tend to adopt an enhanced recovery approach to my surgery, and as part of that approach, we discharge patients on the same day of the surgery with very fine drains. The use of drains reduces the concern around the fluid collection, which is something that is very common after top surgery.
When are the drains removed?
Drains are removed at the first follow-up appointment, which is normally a week after the procedure.
If somebody wants to go home on the same day after surgery, is there a limit for how far the patient lives from the hospital?
If a patient lives more than one and a half hours from the hospital, we recommend that they book a hotel or find other accommodation around London for the first night. The majority of complications happen in the first 24 hours so if the patient is closer to the hospital we will be better able to treat them.
With breast augmentation, how long do breast implants last?
The modern generation of implants, which use medical grade silicone, are very safe and durable and do not come with an expiry date. We recommend having regular check-ups with your surgeon to ensure everything is as it should be. The average lifespan of a modern implant is 15 – 20 years and our recommendation tends to be that an implant only needs to be removed if and when it creates an issue.
Is there a top surgery that doesn’t leave scars?
Unfortunately, any surgery that involves making an incision leaves a scar. Even if it’s the smallest incision possible, like in the keyhole surgery. The right question is whether there is any way for your surgeon to make the scars less noticeable. As a trained plastic surgeon I can confidently say that the answer is yes. If we place the scars in the line of your body, if we use a very neat suture, the risk for the scar to be visible is reduced.
What are the requirements for being a candidate for keyhole surgery?
The requirements for having a key-hole top surgery, or a periareolar mastectomy are as follows:
- Small breasts
- Tight skin
- No excess skin on the chest
- Good skin quality
Can I get chest contouring without loss of nipples?
It depends on the type of surgery performed. With a nipple graft, the risk of losing the nipple is less than one percent. If you are concerned about retaining the viability of the nipple, there are other techniques such as button hole surgery that can be considered. Button hole surgery leaves the nipple attached to a flap of tissue, maintaining the blood supply and the sensitivity of the nipple. This technique is advised for some patients with medium sized breasts and good skin quality and can be performed if a patient is seriously concerned about losing the nipple.
When it comes to top surgery, how great is the risk of loss of sensation?
This depends on the technique used. In the case of both buttonhole and keyhole procedures, the risk of losing sensitivity is lower than with other techniques. With double incision mastectomy for example, sensation might eventually return but it will take time and it is not guaranteed.
How long do you have to be on testosterone before you can have top surgery?
You don’t have to be on testosterone to access top surgery.
To book a consultation with Mr Di Taranto email: info@mrditaranto.com. If you would like Mr Di Taranto to attend a Q&A session with your support group, get in touch.
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