Chest reconstruction

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Chest reconstruction
Double mastectomy.jpg
Transgender man with healed double incision chest reconstruction, 2020
ICD-9-CM 85

Chest reconstruction refers to any of various surgical procedures to reconstruct the chest by removing breast tissue or altering the nipples and areolae in order to mitigate gender dysphoria. Chest reconstruction may be performed in cases of gynecomastia and gender dysphoria. People may pursue chest reconstruction, also known as top surgery, as part of transitioning.

Contents

The removal of breast tissue in chest reconstruction is a type of mastectomy called a subcutaneous (under the skin) mastectomy. This type of mastectomy removes tissue from inside the breast (subcutaneous tissue), as well as excess skin. The surgeon then contours the chest, altering the size and position of the areolae and nipples as needed or as indicated by the patient.

Those undergoing chest reconstruction may opt to forgo nipple grafts, with the intent of having a completely blank, flat chest, or, to have them tattooed on at a later date. Some patients may also request specific shapes for the nipples that will be reattached, such as hearts or stars; some surgeons may have no qualms with providing this service, while others may feel less skilled or experienced in creating 'non binary' top surgery chests. [1] [2] [3]

History

German model Benjamin Melzer (left) has called top surgery the "most important surgery for all trans men". Benjamin Melzer und Verena Ahmann (2).jpg
German model Benjamin Melzer (left) has called top surgery the "most important surgery for all trans men".

In 1942, [4] British physician and author Michael Dillon underwent a chest masculinizing mastectomy as part of his transition to male. This would be among the first of Dillon's 13 gender-affirming surgeries. All were performed by Harold Gillies, a New Zealand plastic surgeon, [5] who is sometimes referred to as "the father of modern plastic surgery." [6] It is possible this was the first top surgery performed.

In the mid-1970s, Chicago surgeon Dr. Michael Brownstein (having graduated from UCSF) opened a plastic surgery practise in San Francisco. [7] In 1978, Dr. Michael Brownstein conducted his first chest reconstructive surgery under the request of a FTM (Female to Male) identified as "John L." [7] The surgery was successful, and shortly thereafter, "FTMs were 'flocking to him,' including some who had not had any so-called gender counseling." [7] Brownstein continued to provide the plastic surgery until healthcare misconduct defense attorney Paul Walker contacted him, stating that he was violating the Standards of Care. Following this, Brownstein requested referrals from trans patients and Brownstein became known for his "outstanding results." [7] Brownstein became a "world renowned" surgeon, [8] [9] with patients including Lou Sullivan [7] in 1980 [10] [11] and Chaz Bono in 2009. [12] Brownstein retired in 2013, "after 35 years of serving the transgender and gender-non-conforming communities." [9]

In 2017, German model Benjamin Melzer called top surgery "the most important surgery for all trans men". [13] It was one of the 11 surgeries he had during his own transition. Right after his healing process was over, Melzer went to a public pool and jumped into the water with just shorts on, which he described as "the best". [13]

Canadian actor Elliot Page underwent the surgery circa March 2021; he stated, "It has completely transformed my life... [It's] not only life-changing but lifesaving." [14]

Patients

A patient six days after having top surgery Six days later (4772334014).jpg
A patient six days after having top surgery

Chest reconstruction surgery candidates desire a flat chest, which may or may not include masculinization. These candidates may include cisgender men with gynecomastia; transgender men who are medically transitioning and have chest dysphoria; and non-binary people with breasts. [15] All of the above listed may experience chest dysphoria and/or a desire to masculinize its size or shape. [16] [17]

Gynecomastia is a common breast deformity that can occur in cisgender men, which may require surgical intervention. Causes of gynecomastia may vary but may include drug side effects or genetics. [16]

People assigned female at birth with male, masculine, or non-binary genders may experience gender dysphoria caused by their chest and/or gender euphoria after the surgical recovery. [17]

Procedures

Inverted "T"

A transverse inframammary incision with free nipple areolar grafts may be one approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T).[ citation needed ]

The areola is trimmed to a pre-agreed-upon diameter and the nipple sectioned with a pie-shaped excision and reconstituted. There may be varying sensory loss because of nerve disruption.

Double incision

One of the most common chest reconstructive procedures, double incision involves an incision above and below the breast mass, the removal of the fatty and glandular tissue, and the closure of the skin. This method leaves scars under the pectoral muscles, stretching from the underarms to the medial pectoral.[ citation needed ]

Double incision is usually accompanied by free nipple grafts to make male-looking nipples. The areola and nipple is removed from the breast tissue, cutting away along the circumference and removing the top layer of flesh from the rest of the tissue. After the chest has been reconstructed, the nipples are grafted on in the appropriate male position. The areolae are often sized down as well as the nipples themselves, as female areolae are often larger in circumference and the nipples protrude farther.

Nipple grafts are generally associated with double incision style chest reconstruction, but may be used in any reconstruction procedure if necessary.

With nipple grafts comes the possibility of rejection. In such cases, the nipple is often tattooed back on cosmetically or further surgical procedures may be applied.

Sensation may return to the grafted nipples over time. However, the procedure severs the nerves that go into the nipple-areola and recipients may experience complete or partial loss of sensation. [18]

Keyhole

A transgender man 4 years after keyhole top surgery, 2014. Towell (14765292799).jpg
A transgender man 4 years after keyhole top surgery, 2014.

To remove the glandular and fatty tissue which constitute the breast mass and the added skin that drapes the mass, there are three basic approaches.

For petite breasts, such as an A or a small B, a peri-areolar incision can be done. That is a circular incision around the areola, combined with an inner circular incision to remove some of the excess areola. Drawing the skin into the center will result in some puckering, but this often smooths out with time. There will be significant tension on the scar line, and to prevent spreading of the scar, a permanent fixation suture is needed. Leaving outer dermis (raw skin) underneath the marginalized areola helps in its survival.

The keyhole incision (i.e., skeleton key) augments the periareolar incision further by making a vertical closure underneath (lollipop), which results after the unwanted skin is pulled in from side to side and the excess is removed. [19]

An anchor incision adds to that a transverse incision usually in the infra mammary fold to further remove excessive skin. Draping or blousing is not desirable. This is reserved for much larger breasts or topographically a larger surface area as seen in women with postpartum breast atrophy.

The nipple areolar complex may be supported by a pedicle which has the advantage of leaving some sensation and blood supply intact, but can have the disadvantage when the pedicle has sufficient bulk not to provide the flat look most FTM patients desire.

"Dog ear"

Occasionally, the side limbs may be quite long, and the expression doctors use is "chasing a dog ear" into the axilla (or underarm). A dog ear may occur when the skin at the edge or corner of an incision 'flows over,' when there is too much gathering, usually at an angle greater than 30 degrees. This usually becomes more apparent after several months of healing, and can be caused by things like weight gain (excess skin or fat changing the shape in areas like torso, hips, stomach, or buttocks, may also occur along the incision line), or due to 'poor surgical planning and execution.' [20] Using a curved incision can reduce the chances of dog ears developing because it requires less gathering of skin to be done, but some patients dislike the appearance of the curved scar as it can mimic the appearance of breasts.

Not uncommonly, a surgeon may revise the incision lines after 3 or more months of settling shows some residual problem areas. Other revisions may include changing 'slight irregularities,' such as reshaping of the nipple that may have stretched 'out of shape' due to too much upper arm/over the head arm movement, or general 'overextension' during the healing process (which may also cause asymmetry), bulges or puckering (typically along incision lines), failed nipple graphs (which may result in one or both nipples 'failing' to 'take' to the patient's healing chest, or scarring patterns a patient may not be happy with. [21]

See also

Related Research Articles

<span class="mw-page-title-main">Breast reconstruction</span> Surgical rebuilding of a breast

Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Areola</span> Pigmented area on the breast around the nipple

The human areola is the pigmented area on the breast around the nipple. More generally, an areola is a small circular area on the body with a different histology from the surrounding tissue, or other small circular areas such as an inflamed region of skin.

<span class="mw-page-title-main">Mammaplasty</span> Surgically modifying the appearance of the breast

Mammaplasty refers to a group of surgical procedures, the goal of which is to reshape or otherwise modify the appearance of the breast. There are three main types of mammoplasty:

  1. Augmentation mammaplasty is commonly performed to increase the size, change the shape, and/or alter the texture of the breasts. This usually involves the surgical implantation of breast implants.
  2. Reduction mammaplasty is commonly performed to reduce the size, change the shape, and/or alter the texture of the breasts. This involves the removal of breast tissue.
  3. Reconstructive mammoplasty is breast reconstruction that is done after mastectomy to give the breasts an appearance that is more normal/familiar.

Masculinizing gender-affirming surgery for transgender men or transmasculine non-binary people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

<span class="mw-page-title-main">Breast augmentation</span> Surgical procedure

Breast augmentation and augmentation mammoplasty is a cosmetic surgery procedure, which uses breast-implants and/ or fat-graft mammoplasty technique to increase the size, change the shape, and alter the texture of the breasts. Although in some cases augmentation mammoplasty is applied to correct congenital defects of the breasts and the chest wall in other cases it is performed purely for cosmetic reasons.

<span class="mw-page-title-main">Breast reduction</span> Plastic surgery procedure

Reduction mammoplasty is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the patient's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (NAC), to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the patient's self-image, and of the patient's mental health.

<span class="mw-page-title-main">Paget's disease of the breast</span> Medical condition

Paget's disease of the breast is a rare skin change at the nipple nearly always associated with underlying breast cancer. Paget's disease of the breast was first described by Sir James Paget in 1874. The condition is an uncommon disease accounting for 1 to 4% of all breast cancers cases. 92% to 100% of patients with Paget's disease of the breast have an underlying breast cancer.

<span class="mw-page-title-main">Breast implant</span> Prosthesis used to change the size, shape, and contour of a persons breast

A breast implant is a prosthesis used to change the size, shape, and contour of a person's breast. In reconstructive plastic surgery, breast implants can be placed to restore a natural looking breast following a mastectomy, to correct congenital defects and deformities of the chest wall or, cosmetically, to enlarge the appearance of the breast through breast augmentation surgery.

Mastopexy is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. In a breast-lift surgery to re-establish an aesthetically proportionate bust for the woman, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity of the breasts for lactation and breast-feeding.

Amastia refers to a rare clinical anomaly in which both internal breast tissue and the visible nipple are absent on one or both sides. It affects both men and women. Amastia can be either isolated or comorbid with other syndromes, such as ectodermal dysplasia, Syndactyly and lipoatrophic diabetes. This abnormality can be classified into various types, and each could result from different pathologies. Amastia differs from amazia and athelia. Amazia is the absence of one or both mammary glands but the nipples remain present, and athelia is the absence of one or both nipples, but the mammary gland remains.

A DIEP flap is type of breast reconstruction where blood vessels, fat, and skin from the lower belly are relocated to the chest to rebuild breasts after mastectomy. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. This is a type of autologous reconstruction, meaning one's own tissue is used.

<span class="mw-page-title-main">Tuberous breasts</span> Medical condition

Tuberous breasts are a result of a congenital abnormality of the breasts which can occur in both men and women, one breast or both. During puberty breast development is stymied and the breasts fail to develop normally and fully. The exact cause of this is as yet unclear; however, a study in 2011 of the cells in the breasts of both males and females with tubular breasts suggested a genetic link in a disorder of collagen deposition. The condition is thought to affect one to five per cent of breast augmentation patients; however, the proportion of the general population affected is unknown as surgery is not always sought.

Trans-umbilical breast augmentation (TUBA) is a type of breast augmentation in which breast implants are placed through an incision at the navel rather than the chest.

Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.

<span class="mw-page-title-main">Nipple prosthesis</span>

Nipple/Areola prostheses are made of silicone by breast prosthesis manufacturers and anaplastologists for breast cancer survivors who were treated for breast cancer with a mastectomy. Prostheses can be worn weeks after a mastectomy, breast reconstruction, or even nipple reconstruction. As an inexpensive and convenient alternative to surgery, patients may choose to wear them anytime during treatment. Patients who ultimately find nipple prostheses thought that they should be informed of them during the consultation prior to mastectomy.

<span class="mw-page-title-main">Adipomastia</span> Medical condition

Adipomastia, also known colloquially as fatty breasts, is a condition defined as an excess of skin and/or a flat layer of adipose tissue in the breasts without true gynecomastia. It is commonly present in men with obesity, and is particularly apparent in men who have undergone massive weight loss. A related/synonymous term is pseudogynecomastia. The condition is different and should be distinguished from gynecomastia, which involves female-like protruding fat tissue and/or glandular tissue in a male. The two conditions can usually be distinguished easily by palpation to check for the presence of glandular tissue. Another difference between the conditions is that breast pain/tenderness does not occur in pseudogynecomastia. Sometimes, gynecomastia and pseudogynecomastia are present together; this is related to the fact that fat tissue expresses aromatase, the enzyme responsible for the synthesis of estrogen, and estrogen is produced to a disproportionate extent in men with excessive amounts of fat, resulting in simultaneous glandular enlargement.

Aesthetic flat closure after mastectomy is contouring of the chest wall after mastectomy without traditional breast reconstruction. Vernacular synonyms and related vernacular and technical terms include "going flat", "flat closure", "optimal flat closure", "nonreconstructive mastectomy", "oncoplastic mastectomy", "non-skin sparing mastectomy", "mastectomy without reconstruction", and "aesthetic primary closure post-mastectomy".

<span class="mw-page-title-main">Nipple reconstruction surgery</span>

Nipple reconstruction, specifically nipple-areola complex (NAC) reconstruction, is a procedure commonly done for patients who had part or all of their nipple removed for medical reasons. For example, NAC reconstruction can apply to breast cancer patients who underwent a mastectomy, the surgical removal of a breast. NAC reconstruction can also be applied to patients with trauma, burn injuries, and congenital or pathological abnormalities in nipple development.

<span class="mw-page-title-main">Nipple-sparing mastectomy</span> Breast cancer treating method

Nipple-sparing mastectomy (NSM), also known as nipple delay, is one of the surgical approaches for treating or preventing breast cancer. It involves the removal of all breast tissue, except the nipple-areolar complex (NAC), and the creation of new circulatory connections from the breast skin to NAC. By preserving the NAC, NSM has provided patients with higher cosmetic expectations and the opportunity to undergo a mastectomy while maintaining a more natural appearance.

References

  1. ↑ "Photo Gallery". The Cosmetic Concierge.
  2. ↑ "The Ultimate Primer on Top Surgery and Nipples". Top Surgery Guide.
  3. ↑ "Non-Binary Nipple and Areola Options". Gender Confirmation Center.
  4. ↑ "Michael Dillon (1915-1962) – The World's First Transsexual Man | Transgender Library and Information". 2012-07-05. Retrieved 2023-07-19.
  5. ↑ "Trans Pioneers – Trans and Gender-Nonconforming Histories | Historic England". historicengland.org.uk. Retrieved 2023-07-19.
  6. ↑ Spencer, C. R. (June 2015). "Sir Harold Delf Gillies, the otolaryngologist and father of modern facial plastic surgery: review of his rhinoplasty case notes". The Journal of Laryngology and Otology. 129 (6): 520–528. doi:10.1017/S0022215115000754. ISSN   1748-5460. PMID   25858011. S2CID   34025904.
  7. 1 2 3 4 5 Smith, Brice (2017-03-15). Lou Sullivan: Daring To Be A Man Among Men. Transgress Press. ISBN   978-0-9982521-1-7.
  8. ↑ "Dr. Curtis Crane - Transgender Surgery in Austin, Texas". Crane Center for Transgender Surgery. Retrieved 2023-07-19.
  9. 1 2 Broskay, Michele (2012-09-25). "Dr. Brownstein Retiring, Dr. Crane Taking Over Practice". TransHealthCare. Retrieved 2023-07-19.
  10. ↑ Highleyman, Liz. "Who was Lou Sullivan?". Seattle Gay News. February 22, 2008. Archived from the original on November 4, 2015.
  11. ↑ "Guide to the Louis Graydon Sullivan Papers, 1755-1991 (bulk 1961-1991)". The Gay, Lesbian, Bisexual, Transgender Historical Society. San Francisco, 1999. Accessed November 4, 2015.
  12. ↑ Wiegand, David (2011-05-09). "'Becoming Chaz' review: inside transgender world". SFGATE. Retrieved 2023-07-19.
  13. 1 2 Phillips, Jessica (2017-07-26). "Benjamin Melzer: meet the transgender model changing the industry". Square Mile. Retrieved 2024-10-03.
  14. ↑ Head, Ally (2021-05-26). "Elliot Page just shared his first shirtless photo since top surgery and we're very here for it". Marie Claire. Retrieved 2022-06-02.
  15. ↑ Sangree, Colby (23 March 2017). "A Non-Binary Perspective On Top Surgery". HuffPost news . Retrieved 7 August 2021.
  16. 1 2 Waltho, Daniel; Hatchell, Alexandra; Thoma, Achilleas (2017). "Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System". Plastic and Reconstructive Surgery. 139 (3): 638e–648e. doi:10.1097/PRS.0000000000003059. ISSN   0032-1052. PMID   28234829. S2CID   8519689.
  17. 1 2 Olson-Kennedy, Johanna; Warus, Jonathon (February 2017). "The Impact of Male Chest Reconstruction on Chest Dysphoria in Transmasculine Adolescents and Young Men; A Preliminary Study". Journal of Adolescent Health. 60 (2): S88. doi:10.1016/j.jadohealth.2016.10.354. ISSN   1054-139X.
  18. ↑ "FTM Top Surgery and Sensation". TopSurgery.net. Retrieved 17 June 2016.
  19. ↑ "Gender Affirmation Washington DC | Male to Female Surgery". West End Plastic Surgery. Retrieved 2019-09-20.
  20. ↑ "What Are Dog Ears and How Can I Avoid Them?". TopSurgery.net. Retrieved 2019-09-20.
  21. ↑ "All About Top Surgery Revisions: Stats, Causes, Costs and Tips|". Topsurgery. 20 December 2016. Retrieved 2023-01-21.
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