Chest reconstruction

{{Expand section|date=July 2023}}

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

In 1942,{{Cite web |date=2012-07-05 |title=Michael Dillon (1915-1962) – The World's First Transsexual Man {{!}} Transgender Library and Information |url=https://library.transgenderzone.com/?page_id=635 |access-date=2023-07-19 |language=en-US}} 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,{{Cite web |title=Trans Pioneers – Trans and Gender-Nonconforming Histories {{!}} Historic England |url=https://historicengland.org.uk/research/inclusive-heritage/lgbtq-heritage-project/trans-and-gender-nonconforming-histories/trans-pioneers/ |access-date=2023-07-19 |website=historicengland.org.uk |language=en}} who is sometimes referred to as "the father of modern plastic surgery."{{Cite journal |last=Spencer |first=C. R. |date=June 2015 |title=Sir Harold Delf Gillies, the otolaryngologist and father of modern facial plastic surgery: review of his rhinoplasty case notes |url=https://pubmed.ncbi.nlm.nih.gov/25858011/ |journal=The Journal of Laryngology and Otology |volume=129 |issue=6 |pages=520–528 |doi=10.1017/S0022215115000754 |issn=1748-5460 |pmid=25858011|s2cid=34025904 }} 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.{{Cite book |last=Smith |first=Brice |url=https://books.google.com/books?id=yBUsEAAAQBAJ&dq=Dr.+Michael+Brownstein&pg=PA146 |title=Lou Sullivan: Daring To Be A Man Among Men |date=2017-03-15 |publisher=Transgress Press |isbn=978-0-9982521-1-7 |language=en}} In 1978, Dr. Michael Brownstein conducted his first chest reconstructive surgery under the request of a FTM (Female to Male) identified as "John L." The surgery was successful, and shortly thereafter, "FTMs were 'flocking to him,' including some who had not had any so-called gender counseling." 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." Brownstein became a "world renowned" surgeon,{{Cite web |title=Dr. Curtis Crane - Transgender Surgery in Austin, Texas |url=https://cranects.com/curtis-crane/ |access-date=2023-07-19 |website=Crane Center for Transgender Surgery |language=en-US}}{{Cite web |last=Broskay |first=Michele |date=2012-09-25 |title=Dr. Brownstein Retiring, Dr. Crane Taking Over Practice |url=https://www.transhealthcare.org/news/brownstein-crane/ |access-date=2023-07-19 |website=TransHealthCare |language=en-US}} with patients including Lou Sullivan in 1980Highleyman, Liz. [https://web.archive.org/web/20080906123232/http://www.sgn.org/sgnnews36_08/page30.cfm "Who was Lou Sullivan?"]. Seattle Gay News. February 22, 2008. Archived from [http://www.sgn.org/sgnnews36_08/page30.cfm the original] on November 4, 2015.[http://www.oac.cdlib.org/findaid/ark:/13030/tf9199n9v3/ "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. and Chaz Bono in 2009.{{Cite web |last=Wiegand |first=David |date=2011-05-09 |title='Becoming Chaz' review: inside transgender world |url=https://www.sfgate.com/tv/article/Becoming-Chaz-review-inside-transgender-world-2372449.php |access-date=2023-07-19 |website=SFGATE |language=en-US}} Brownstein retired in 2013, "after 35 years of serving the transgender and gender-non-conforming communities."

In 2017, German model Benjamin Melzer called top surgery "the most important surgery for all trans men".{{Cite web |last=Phillips |first=Jessica |date=2017-07-26 |title=Benjamin Melzer: meet the transgender model changing the industry |url=https://squaremile.com/style/benjamin-melzer-model-interview/ |access-date=2024-10-03 |website=Square Mile |language=en}} 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".

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."{{Cite web |last=Head |first=Ally |date=2021-05-26 |title=Elliot Page just shared his first shirtless photo since top surgery and we're very here for it |url=https://www.marieclaire.co.uk/news/celebrity-news/elliot-page-photo-top-surgery-738475 |access-date=2022-06-02 |website=Marie Claire |language=en}}

File:Six days later (4772334014).jpg

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.{{Cite web|last=Sangree|first=Colby|date=23 March 2017|title=A Non-Binary Perspective On Top Surgery|url=https://www.huffpost.com/entry/a-non-binary-perspective-on-top-surgery_b_58d27b27e4b062043ad4ae76|access-date=7 August 2021|website=HuffPost news}} All of the above listed may experience chest dysphoria and/or a desire to masculinize its size or shape.{{Cite journal|last1=Waltho|first1=Daniel|last2=Hatchell|first2=Alexandra|last3=Thoma|first3=Achilleas|date=2017|title=Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System|journal=Plastic and Reconstructive Surgery|language=en|volume=139|issue=3|pages=638e–648e|doi=10.1097/PRS.0000000000003059|pmid=28234829|s2cid=8519689|issn=0032-1052}}{{Cite journal|last1=Olson-Kennedy|first1=Johanna|last2=Warus|first2=Jonathon|date=February 2017|title=The Impact of Male Chest Reconstruction on Chest Dysphoria in Transmasculine Adolescents and Young Men; A Preliminary Study|journal=Journal of Adolescent Health|volume=60|issue=2|pages=S88|doi=10.1016/j.jadohealth.2016.10.354|issn=1054-139X}}

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.

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.

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).{{cn|date=February 2022}}

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.

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.{{cn|date=February 2022}}

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.

{{cite web |url=http://www.topsurgery.net/ftm-top-surgery-sensation.htm |title=FTM Top Surgery and Sensation |publisher=TopSurgery.net |access-date=17 June 2016}}

File:Towell (14765292799).jpg

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.{{Cite web|url=https://www.westendplasticsurgery.com/about/gender-affirmation/|title=Gender Affirmation Washington DC {{!}} Male to Female Surgery|website=West End Plastic Surgery|language=en-US|access-date=2019-09-20}}

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.

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.' {{Cite web|url=https://www.topsurgery.net/dog-ears.htm|title=What Are Dog Ears and How Can I Avoid Them?|website=TopSurgery.net|language=en|access-date=2019-09-20}} 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 grafts (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.{{Cite web|url=https://www.topsurgery.net/top-surgery-revisions.htm|title=All About Top Surgery Revisions: Stats, Causes, Costs and Tips{{!}}|website=Topsurgery|date=20 December 2016 |language=en-US|access-date=2023-01-21}}

• Subcutaneous tissue
• List of transgender-related topics
• Sex reassignment therapy
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Category:Masculinizing surgery

Category:Surgical procedures and techniques