Top Surgery Q&A - Live event
Dr Giuseppe Di Taranto recently took part in a live question and answer session with members of a support group for trans and non-binary individuals. The session was focused on top surgery for trans masculine individuals and breast augmentation for trans feminine individuals. Hosted by Alice Spaccasassi, a communications consultant working with TransMission PR, the session was organised to mark the launch of GDT Gender Surgery, provide an opportunity for members of the community to get to know Dr Di Taranto a little better, and ask any burning questions they might have.
Alice began by introducing herself and invited Dr Di Taranto to do the same. The pair then moved on to cover some of the most frequently asked questions on the surgeon’s specialist area of gender affirming care, beginning with top surgery:
Q: What types of top surgery for trans masc individuals do you provide?
A: For transmasculine patients, and those looking for a flat chest profile, we offer a range of different techniques
Periareolar, Batwing and Keyhole: These techniques are tailored for patients with small to medium-sized breasts and tight skin. The advantage of this technique is that it leaves minimal scars just around the nipples, which tend to be less noticeable.
Double Incision Mastectomy (with or without nipple graft): These techniques are ideal for patients with larger breasts and saggy skin, seeking a flatter chest. They allow for the removal of excess skin and breast, tightening of the chest, and repositioning of the nipples. The surgery involves two incisions: one at the top of the breast and one at the bottom in the crease of the breast. The incisions are then joined together to create a single linear scar. The nipples are reduced in size, repositioned, and grafted back on. Some patients opt not to have the nipples spared, and as such we also offer the surgery without the option of a nipple graft.
Q: Do you perform liposuction?
A: Yes, all the techniques above can be combined with liposuction. Aside from the breast tissue, some patients present areas of stubborn fat on the sides or the front of the chest. Often, it is not possible to get rid of these fat pads with diet and exercise as they are mainly hormone-driven. If not treated during the surgery, these fat pads increase the risk of developing so-called dog ears, which are skin folds at the end of the scars, also known as contour deformity. These stubborn areas of fat might be different in size and are not conducive to the achievement of a flatter chest. Liposuction, which is normally performed through the same incisions as the mastectomy, involves using small cannulas to aspirate (or suck out) the fat, improving the contour of the chest and reducing the thickness of skin in this area.
Q: What is the cost of top surgery?
A: Procedures for trans masculine patients start at £7,000 (keyhole surgery). Double Incision Mastectomy starts at £9,000.
Q: Why is top surgery so expensive?
A: For top surgery, we need to take into account the time required to carry out the procedure, which can be up to two hours, together with the hospital or clinic fees, plus all of the medical instruments and the surgical materials used. What I can say is that prices are aligned with the cost of plastic surgery for cisgender patients.
Q: Do I need to stop binding before surgery and if so how far in advance?
Yes, it is advised to stop binding before top surgery. Binding and taping can cause inflammation and damage to the skin. As such, we recommend that patients stop binding at least 2-4 weeks prior to the surgery to ensure skin and tissue is in the best possible condition for the procedure.
Q: How long does top surgery typically take to heal?
A: The healing time for top surgery can vary significantly depending on several factors, including the type of surgery performed, individual healing responses, and adherence to postoperative care instructions. If no complications occur, the wounds typically heal within two to three weeks. Bruising, discomfort, and swelling should subside within the first six weeks, during which patients are required to wear post-operative compression garments and avoid heavy lifting or strenuous exercises. After six weeks, patients can gradually resume physical activities. And finally, it can take up to a year for the final results to fully stabilise, as scars continue to soften and the skin settles into its new contour.
The session then switched to breast augmentation…
Q: What types of feminisation surgeries do you provide?
A: For transfeminine patients and those looking for a female chest profile, we offer a range of options to suit the patient’s body type and desired aesthetic outcome:
Breast Augmentation with Implants: This procedure involves placing silicone breast implants to achieve fuller, enhanced breasts. Implants can be inserted through small incisions typically placed in the crease under the breast or around the areola, either above or under the muscle, depending on the desired outcome.
Fat Grafting (Autologous Fat Transfer): This technique involves using liposuction to remove fat from another part of the body (such as the abdomen or thighs) and injecting it into the breasts. It can be used alone or in conjunction with implants for a more natural look. The advantage of this technique is that it uses the patient’s own tissue to enhance the breasts.
Breast Re-augmentation and Revision Breast Surgery: These procedures are indicated for patients who have previously undergone breast augmentation and need to change their implants due to issues such as rupture or other complications or if they are not happy with the outcome of their breast enlargement.
Breast Lift (Mastopexy): This procedure can be performed in conjunction with re-augmentation to reshape sagging breasts by removing excess skin and tightening the surrounding tissue.
Q: What is the cost of breast augmentation?
A: Breast augmentation for trans feminine individuals starts at £6,000.
Q: Why is breast surgery so expensive?
A: Breast enlargement, or breast augmentation, can be expensive due to several factors, primarily the cost of high-quality implants. High-quality silicone implants are costly to produce and purchase because of the advanced materials and manufacturing processes required to ensure safety and durability. Some implant brands also offer a lifetime warranty in case of rupture or defects in the product.
Q: Do I have to go to a gender affirming surgeon for breast augmentation or can I just go to a generalist plastic surgeon?
A: Choosing a surgeon that is right for you is particularly important. WPATH guidelines recommend that chest surgery on transfeminine patients be performed by a surgeon who specialises in gender surgery and who regularly treats transgender patients. This is because transgender and non-binary patients have specific anatomical characteristics and needs that differ from those of cisgender patients. As gender surgeons, we must also stay updated with international guidelines, evidence from new research and innovations in the field, providing patients with the best standards of care.
Q: To what size can my breasts be increased?
A: It is important to understand that everyone is different. A lot of patients come to the consultation with a photo of someone else’s results and asking for the same. However, we have to base the outcomes on the individual patient. Any attempt to place too large an implant is not advisable as it will lead to complications and ultimately the removal of the implant. It is also important to note that implants are not manufactured in bra cup sizes, but in the volume of silicone that they contain. During the consultation, after we have discussed desired outcomes and possible restrictions based on the patient’s physical make up, I perform a sizing test which involves trying a range of implant sizes in a sports bra. This provides a good indication of what is possible and how it will look. Together we then come to the best conclusion on the right fit according to your body’s natural guidelines.
Q: Will my breasts look and feel natural?
A: While there will be some initial swelling and your breasts will feel firm as the breasts settle after the operation, the expectation is that they should soften resulting in a natural look and feel.
Then there were questions relevant to both groups…
Q: Will I need to take time off work?
A: Yes. The exact downtime depends on multiple factors, including the nature of the procedure, the patients’ fitness and the type of work to which you will be returning. Most people take about a week off work following surgery. However, if you have an extremely physical job, you may need to take longer or ask to be assigned to less strenuous duties. I will provide individualised advice on the best timing for patients to return to work and will issue a sick note that maintains confidentiality by not specifying the nature of the surgery performed.
Q: What age patients do you treat?
A: We operate in line with international guidelines for gender surgery which states that patients must be of the age of the majority (18) to be fit for any surgery. Minors are encouraged to have counseling and medical support until then.
Q: What referrals do you take?
A: We require receipt of a referral letter from a licensed practitioner. This can be a psychiatrist accredited as a gender specialist.
Q: What are your waiting times?
A: One month for the consultation and a further two months for surgery from the point of the initial consultation.
Q: In your opinion, why are the waits for the gender clinics so long?
A: The long waits for gender clinics in the UK can be attributed to several factors including:
- Limited Resources. Within the NHS, Many gender clinics operate with very limited resources, including a shortage of specialist staff such as endocrinologists, surgeons, and mental health professionals. There has also been a significant increase in the number of people seeking gender-affirming care, which exceeds the capacity of existing clinics to provide timely services. The NHS is now working with different new providers and pilot studies to open new Gender Identity Clinics such as Trans Plus.
- There is also a need for more professionals interested and trained in gender-affirming care. Trans healthcare is not currently part of the curriculum adding it would make a significant difference. In my hospital there is a gender service so we provide all staff with an induction on transgender healthcare but this is non-standard.
- Addressing these challenges requires systemic changes, including increased funding, expanded training programs, and more efficient administrative processes to improve access to gender-affirming care and reduce waiting times.
Q: Do you need to have been on masculinising hormones before you can have masculinising top surgery?
A: No, you do not have to have been on T in order to access top surgery.
Q: Do you need to have been on testosterone before a surgeon will consider masculinising bottom surgery?
A: Yes. The WPATH guidelines advise individuals to be on masculinising hormone therapy for a recommended period, usually 12 months or more, to ensure adequate tissue growth which provides more material to work with, resulting in a better patient outcome.
Q: Do you need to have been on feminising hormones before you can have breast augmentation?
A: It is not mandatory but it is recommended that trans feminine patients are on gender affirming hormones for a period of 12 months before surgery, in order to have more tissue to work with.
Q: Do you need to have been on feminising hormones before a surgeon will consider feminising bottom surgery?
A: Yes, it is mandatory to be on feminising hormones for 12 months or more before a surgeon will consider performing feminising bottom surgery.
Q: I am diabetic and in the past it has taken longer than average for my wounds to heal. Would the cost of this extended period of healing be greater in my case than it would be for someone without this condition?
A: If the diabetes is under control, the chance of healing well will be similar to those of the general population and any complications would be included in the aftercare provided.
Q: Are there long-term healing consequences for trans women having a breast augmentation, as there might be in the case of someone undergoing a C-section?
A: In the case of a C-section the incision goes through the muscle to the uterus, creating an area of weakness in the core muscle which may have long-term consequences. For top surgery, we can place the implant over the muscle, if the patient has enough thickness of tissue on the chest, avoiding this issue altogether. In cases where we do have to place the implant under the muscle, we use a dual plane technique, where the top of the muscle covers the upper part of the implant and the breast tissue covers the lower part of the implant. Also we don’t completely detach the muscle from the chest, we only detach a few fibres of the muscle from the lower part which may create some discomfort and weakness in the first few months, but once the body adjusts it shouldn’t cause any long-term issues.
Q: Are you able to perform revisions from other practitioners?
A: Yes, I offer revision surgery for both masculinising and feminising top surgery. For feminising surgery normally the dissatisfaction is related to an implant that is old and has ruptured, or has been dislocated and might require adjustment. For top surgery the main request is to adjust the result in larger patients. Not many surgeons might offer lipo with top surgery, if we leave areas of fat around the chest it might not look in proportion. I have had a few patients coming to me because they still don’t feel comfortable in their own body, they don’t feel comfortable wearing tight clothes and some of them have even gone back to wearing a binder.
Q: What are the most common complications to consider when it comes to top surgery? What about breast augmentation?
A: Top Surgery and Breast Augmentation are both common procedures and share general surgical complications such as infection (1%), hematoma and bleeding (<1%), seroma (fluid collection in the wound), blood clots, wound dehiscence, and delayed healing.
Top Surgery carries specific risks including:
- Nipple Loss: Especially in cases involving nipple grafts.
- Loss of Skin Sensitivity: Changes in sensitivity around the nipple and chest area.
- Abnormal Scarring: Such as hypertrophic scars and keloids.
Breast Augmentation has its own set of specific complications related to implants:
- Capsular Contracture: Formation of scar tissue around the implant that can make the breast feel firm or change its shape.
- Implant Rupture or Leakage: Implants can rupture, leading to leakage of silicone. Regular follow-up and monitoring are essential.
- Implant Position Issues: Implants may shift or become displaced, requiring surgical correction to reposition them.
- Breast Symmetry: Achieving perfect symmetry can be challenging. Some asymmetries may be present, which may require revision surgery to correct.
Q: Do you offer top surgery to those with a higher BMI?
A: Patients with a stable BMI and no other medical issues can be candidates for surgery. I believe more in the fitness of a patient for surgery rather than the number itself. BMI can be a useful tool to quickly evaluate a patient but it’s not always very reliable. An example of this would be someone who goes to the gym and has a lot of muscle. Their BMI might tell us they are not appropriate for surgery, when in fact they are very fit. Patients need to be fully evaluated before surgery in terms of comorbidities, any medical problems, if they smoke, if they take any medication, all this together will tell us if a patient is fit for surgery or not.
We also need to adhere to the facility’s guidelines. Up to a BMI of 40 I assess the patient and evaluate if they are fit for surgery and I provide a supportive letter to the medical director of the hospital regarding the surgery, which is elective but is not cosmetic, it is a life completing surgery. Over 40 BMI there are restrictions in most of the clinics I work in London and these restrictions are there for patient safety because operating on a patient of a high BMI without access to an intensive care facility may be very risky. In that case I may refer them to a dietitian and recommend a healthy lifestyle and weight management program to help them get fit for the operation. I find that in many cases the desire to have the operation is a great motivation.
Q: Is top surgery performed as a day case?
A: Yes, we strongly believe that patients recover better in their own bed and that it is important to encourage them to mobilise quickly after surgery for a faster and smoother recovery. This reduces the risk of blood clots and contracting infections in hospital. A day case surgery also minimises the amount of time that the patient spends in an unfamiliar environment, which can be overwhelming for some individuals.
Q: What is your approach to drains?
A: As part of our approach to enhanced recovery, we discharge patients with very fine drains which are the same ones used in face lift patients. The use of drains reduces concerns around fluid collections (seroma, hematoma) which are quite common in the literature relating to chest/breast surgery. Drains are removed at the first follow up appointment. Furthermore, in patients with a higher BMI, who have had liposuction, the drains collect the fluids from the lipo and seal the wound, allowing for better contouring and helping the skin to shrink and settle in the right positions.
Q: Can I access surgery on the NHS?
A: Top surgery is currently offered under the NHS but comes with long waiting lists. The NHS doesn’t traditionally fund breast augmentations, but there are channels to make a special request if you believe an exception should be made in your case. You can read the NHS England policy on individual funding for more information.
Q: Is there anything I can do to improve my chances of a better surgical outcome?
A: Get fit and conduct a healthy lifestyle. Stop smoking and vaping as any nicotine products can significantly hinder the skin’s ability to heal, leading to a slower recovery process. To achieve the best outcome from your surgery, it is highly recommended that you stop smoking at least four weeks before and after the operation. Additionally, maintain fitness, stay hydrated and avoid aspirin and vitamin supplements for two weeks before the surgery. Following a healthy diet can also contribute positively to the surgical outcome.
The pair then thanked the audience for joining and invited any additional questions to be emailed to info@mrditaranto.com. The session has also been uploaded to YouTube. You can watch the video here.
To book a consultation with Dr Di Taranto click here.