SURGERY for transsexual people is
sometimes a hotly contested topic. Or it's
easily dismissed out of hand. Viewed from the TS
perspective as a necessity, from the outside
it's seen as elective or cosmetic at best,
mutilation or delusional at worst.
Most people who have come to terms with their
own bodies, especially if they enjoy their
genitalia, can't imagine letting even a trained,
board-certified plastic surgeon anywhere near
that good thing. The idea that someone else
would want to have his or her body reconfigured
in such an intimate way can seem pretty
incomprehensible, if not downright abhorrent.
Some people think it's such a crazy idea that
it's not even worth thinking about, let alone
discussing. But for those of us who can only
change our bodies or else face stagnation or
death, there is still a lot to consider before
we go under the knife. And most transsexual
people don't even have all the choices our
detractors think we have. Many transsexual
people cannot afford surgery. In the United
States there have been some instances of
Medicare or state medical programs paying for TS
surgery, but this is far from routine. Most
insurance plans have specific exclusions for
transsexual treatments, so transpeople must pay
in cash, up-front, or arrange for credit with
the hospital or clinic. Some people with high
credit limits may be able to use plastic.
At least in the United States it is possible
(in most states) to get identification in the
"new" sex, including a revised birth certificate
and (at the federal level) a passport. In some
other countries, TS surgery is illegal and
surgeons who try to help transpeople may be
imprisoned along with the transpeople
themselves. In still other countries, notably
the U.K., Scandinavia, the Netherlands, and
Germany, TS surgical procedures are provided
under national health programs, though options
may be limited. But in many of these countries
(and in Japan, where individuals must pay their
own costs), it is impossible for transpeople to
obtain legal recognition of the "new" sex. In
these countries where the identification of TS
people is always in conflict with their identity
and appearance, transpeople may be at increased
risk of harassment and attack.
There are transsexual people who elect not to
have surgery, and others who are precluded from
having surgery due to preexisting medical
conditions or deeply held religious beliefs.
None of these factors -- economics, medical
conditions, or religious beliefs -- invalidates
a transsexual person's identity. In other words,
it isn't having surgery that makes someone a
"real" transsexual.
There's no such discrete thing as a sex
change operation for FTMs. Transsexual men
usually (but not always) want a male chest and
male genitalia. This usually means at least two,
often more, trips to the operating room. The
order in which the procedures may be completed
can vary, but it is common for transmen to have
chest reconstruction as their first surgery
unless a hysterectomy was required previously.
Genital reconstruction is usually last, unless a
hysterectomy was avoided previously and becomes
necessary later.
Chest reconstruction is usually done as an
outpatient procedure using one of two
predominant techniques. The bilateral mastectomy
by double incision technique is most effective
for contouring the masculine chest in cases
where there is a large amount of breast tissue.
In this method, large incisions are made below
each breast and the mammary glands, and fatty
tissue are exposed and removed. The excess skin
is cut away and the incision closed below the
pectoral muscle. Chest musculature is not
touched. The original nipples and areolas,
removed with the excess skin, are used to shape
new nipples, and these are grafted onto the
chest in the proper position relative to the
pectoral muscle. Drawbacks of this method
include prominent scars on the chest and some
(often complete) loss of nipple sensation.
Sometimes the nipple grafts may be lost (the
tissue dies and cannot be replaced), the nipples
may be improperly located, or their shape may
lack aesthetic quality.
The "keyhole" procedure was developed to
combat these drawbacks. Some surgeons feel that
good results may be obtained with this technique
regardless of original breast size, while others
feel this technique is most effective when
applied only in cases where there is a small
amount of breast tissue. In this method, a small
incision is made near the areola and the breast
tissue is removed by liposuction. In some cases
the areola is reduced somewhat without removing
the nipple or resecting the nerves that carry
erotic sensation. Advantages of this technique
include minimal scarring and retained erotic
sensation in the nipples. Disadvantages are that
the nipples may end up in the middle of the
chest instead of properly related to the
pectoral muscle, or breasts may be reduced but
not eliminated in appearance. In other words,
the results may be aesthetically great, or
tolerable, or awful.
Transmen having chest reconstruction in the
United States can expect to pay between $1,500
and $8,500 depending on the region, the
surgeon's fee structure, and the cost of the
operating room, the anesthesiologist, and
after-care. Expect to be completely
incapacitated for 24 hours, and try to have
someone available to help you. The worst pain is
during the first 48 hours, especially
immediately after awakening at the hospital or
clinic. Before you go in for surgery, move some
food and food preparation materials to the
countertop so you don't have to reach up or down
to get at it. Do the same for soap and shampoo.
It's a good idea to keep your elbows close to
your sides for at least four days, and don't
strain the arm or chest muscles for at least six
weeks. Time off work is usually two weeks, but
if complications ensue, up to six weeks off work
may be necessary. Jogging may be resumed at two
weeks post-operatively, and weightlifting at
three months. And with the bilateral incision
method it takes at least six months to heal up
enough to get a real sense of the final results.
Scars do fade over time.
With either technique results can vary
widely. There are no guarantees when it comes to
surgery. But even with the relative lack of
complications in chest reconstruction, I have
seen some truly horrible results, even with
surgeons who have done many FTM procedures.
Factors that may contribute to poor results
include poor patient health, stress, smoking,
overweight conditions, and tendency to keloid
(the formation of thick, ropey scars, very
common in dark skin types, but occurring in
light-skinned people, too). The surgeon can have
a bad day. One never knows. Many plastic
surgeons are able and willing to perform chest
reconstruction procedures, but there are very
few who will attempt FTM genital reconstruction.
I'll discuss genital techniques next month.
