Top surgery vs breast reduction
October 15, 2019 11:41 AM Subscribe
My nonbinary partner has always wanted top surgery but due to cost and Medicaid restrictions didn't think it was a viable option. They began pursuing breast reduction for pain/nausea reasons beyond the dysphoria. Breast reduction just got approved by their insurance, but Medicaid restrictions on gender-affirming surgery were also just lifted in their state and now they're not sure how to proceed. Snowflakes inside.
My partner is nonbinary and has wanted top surgery pretty much since they developed breasts, but due to Medicaid restrictions in our state did not think it was a possibility. They also have significant back pain and stomach problems from their breasts, and so began pursuing breast reduction as a middle ground, with the vague hope that the surgeon would be willing to remove their breasts entirely.
They consulted with a surgeon who seemed surprised when they said they wanted their breasts removed entirely (they did not talk about being nonbinary) but did not outright say he wouldn't do it. He said that, "Usually we try to keep things proportionate," and said about a C cup is what would be proportionate for them (they're currently, depending on who the hell measures them, somewhere around a 40F). Partner wasn't sure if insurance would even approve it at all so didn't push at the time. Based on previous reading they were expecting that insurance would require 6 months of physical therapy (which they started a few months ago), losing weight (which has been a struggle), etc. before approval. We just heard back and it was approved with no stipulations and the surgery can be scheduled for January. We also just found out that Medicaid restrictions have recently been lifted in our state on gender-affirming surgery.
Partner's dilemma is now whether to continue along the breast reduction route or go the top surgery route. Part of the complication is that neither procedure is necessarily traditionally intended for their situation. They don't want a "masculine" chest, just a flat one. They just want clothes to lie flat on them (and they prefer loose to tight clothes) and to never have to wear a bra again (the compression has always made them feel sick). They would be fine with an A cup if they could go braless and not look "indecent."
Pros and cons of each procedure:
Breast reduction pros -
1) Already approved, can happen quickly, the surgeon is one of the best in the area.
2) It's possible the surgeon will agree to remove everything, or at least go as small as possible, would be acceptable if partner got to a size where they didn't need to wear a bra
3) If they go as small as possible but not complete removal, there's less risk of losing feeling in their nipples, which they're pretty concerned about
4) They aren't looking for any masculine contouring and are more concerned with how clothes look on them than how they look naked
Breast reduction cons -
1) Surgeon may not agree to remove everything, and partner may find small as possible is not satisfactory and will regret all the time and complications involved
2) Surgeon may not be skilled in complete removal or know how to make a flat chest look "good"
3) If partner decides to do top surgery afterwards there's a higher risk of complications and scarring
Top surgery pros -
1) Removes everything, will not have to argue for a flat chest
2) Surgeon would likely better know how to do this specific surgery
3) Environment would be more trans-positive and partner would not have to hide their gender or dysphoria
Top surgery cons -
1) Don't know if their insurance will actually cover top surgery or what the requirements will be (e.g. some require documentation of long-term gender dysphoria, and they've never talked to a doctor about it before)
2) Will be a longer wait because they have to schedule a consult and wait for insurance to approve/deny, which means not only months to years more of gender dysphoria but also back pain and nausea every time they wear a bra, which is a contributing factor in them being unable to work
3) Higher chance of losing feeling in their nipples, which is again, a big concern of theirs
4) May be unnecessary re:above and not needing a "masculine" chest
They did call our local LGBTQ+ health clinic to get an appointment to consult with someone about all of this. But the earliest they can get them in is early January. Which would be after all of the upcoming consult appointments with the surgeon, and they would rather have a clearer perspective on this before consulting with the surgeon again. But pushing that off means, again, months more dysphoria, pain, and nausea. It seems like the simple solution is "just wait," but they've been doing that a long time and it's getting harder to "just deal with it."
I'm posting this at their request--does anyone have insight into or experience with this situation? Are any of the pros or cons unrealistic or ill-informed? Is there more they aren't considering? (Weird bonus question: at the LGBTQ+ clinic, they happened to be scheduled with my GP, who I have only seen once so far due to me just switching to her in June, but she has also met my partner--is there any way to use that connection to get them a sooner appointment?)
My partner is nonbinary and has wanted top surgery pretty much since they developed breasts, but due to Medicaid restrictions in our state did not think it was a possibility. They also have significant back pain and stomach problems from their breasts, and so began pursuing breast reduction as a middle ground, with the vague hope that the surgeon would be willing to remove their breasts entirely.
They consulted with a surgeon who seemed surprised when they said they wanted their breasts removed entirely (they did not talk about being nonbinary) but did not outright say he wouldn't do it. He said that, "Usually we try to keep things proportionate," and said about a C cup is what would be proportionate for them (they're currently, depending on who the hell measures them, somewhere around a 40F). Partner wasn't sure if insurance would even approve it at all so didn't push at the time. Based on previous reading they were expecting that insurance would require 6 months of physical therapy (which they started a few months ago), losing weight (which has been a struggle), etc. before approval. We just heard back and it was approved with no stipulations and the surgery can be scheduled for January. We also just found out that Medicaid restrictions have recently been lifted in our state on gender-affirming surgery.
Partner's dilemma is now whether to continue along the breast reduction route or go the top surgery route. Part of the complication is that neither procedure is necessarily traditionally intended for their situation. They don't want a "masculine" chest, just a flat one. They just want clothes to lie flat on them (and they prefer loose to tight clothes) and to never have to wear a bra again (the compression has always made them feel sick). They would be fine with an A cup if they could go braless and not look "indecent."
Pros and cons of each procedure:
Breast reduction pros -
1) Already approved, can happen quickly, the surgeon is one of the best in the area.
2) It's possible the surgeon will agree to remove everything, or at least go as small as possible, would be acceptable if partner got to a size where they didn't need to wear a bra
3) If they go as small as possible but not complete removal, there's less risk of losing feeling in their nipples, which they're pretty concerned about
4) They aren't looking for any masculine contouring and are more concerned with how clothes look on them than how they look naked
Breast reduction cons -
1) Surgeon may not agree to remove everything, and partner may find small as possible is not satisfactory and will regret all the time and complications involved
2) Surgeon may not be skilled in complete removal or know how to make a flat chest look "good"
3) If partner decides to do top surgery afterwards there's a higher risk of complications and scarring
Top surgery pros -
1) Removes everything, will not have to argue for a flat chest
2) Surgeon would likely better know how to do this specific surgery
3) Environment would be more trans-positive and partner would not have to hide their gender or dysphoria
Top surgery cons -
1) Don't know if their insurance will actually cover top surgery or what the requirements will be (e.g. some require documentation of long-term gender dysphoria, and they've never talked to a doctor about it before)
2) Will be a longer wait because they have to schedule a consult and wait for insurance to approve/deny, which means not only months to years more of gender dysphoria but also back pain and nausea every time they wear a bra, which is a contributing factor in them being unable to work
3) Higher chance of losing feeling in their nipples, which is again, a big concern of theirs
4) May be unnecessary re:above and not needing a "masculine" chest
They did call our local LGBTQ+ health clinic to get an appointment to consult with someone about all of this. But the earliest they can get them in is early January. Which would be after all of the upcoming consult appointments with the surgeon, and they would rather have a clearer perspective on this before consulting with the surgeon again. But pushing that off means, again, months more dysphoria, pain, and nausea. It seems like the simple solution is "just wait," but they've been doing that a long time and it's getting harder to "just deal with it."
I'm posting this at their request--does anyone have insight into or experience with this situation? Are any of the pros or cons unrealistic or ill-informed? Is there more they aren't considering? (Weird bonus question: at the LGBTQ+ clinic, they happened to be scheduled with my GP, who I have only seen once so far due to me just switching to her in June, but she has also met my partner--is there any way to use that connection to get them a sooner appointment?)
Response by poster: Spinifex23, your comment made me wonder, and after some Googling I did find him listed on transhealthcare.org as someone who does facial feminization surgery. Which means he may work with trans clients, though I don't know info on that site is verified. Which means that maybe my partner could bring up their gender dysphoria to them, but that's a whole 'nother list of pros and cons to consider...
posted by undisclosed at 12:08 PM on October 15, 2019 [2 favorites]
posted by undisclosed at 12:08 PM on October 15, 2019 [2 favorites]
I had a breast reduction over a decade ago and my experience really doesn’t align with what your partner is looking for. My surgeon also talked about keeping everything proportional, but despite my small frame I was still a D cup (from 34G) after I healed and was never able to go without a bra. And as I’ve put on weight over the years and had two pregnancies, my breasts have been slowly regrowing and I’m now a larger size than before. I enjoyed a couple of pain free years, but if the ultimate goal is a flat chest, I wouldn’t recommend going through the pain and lengthy recovery process of a reduction.
posted by galvanized unicorn at 12:10 PM on October 15, 2019 [8 favorites]
posted by galvanized unicorn at 12:10 PM on October 15, 2019 [8 favorites]
Another thought - when I was on Medicaid and pursuing Top Surgery, there were only a few doctors that they worked with for Gender Confirmation Surgery, and those doctors were overburdened with patients. I ultimately switched to private insurance because of a new job, but when I was on Medicaid, my timeframe from consultation to the surgery was 10 months.
That was also *after* meeting all of the Medicaid requirements of a therapist's documentation, statement from my GP, etc. They basically needed a diagnosis of 'Adult Persistent Gender Dysphoria', and didn't really understand nonbinary folk at all.
(I am also happy with my male nipple placement, but my sensation is about nil. This doesn't bother me, but might other folk.)
posted by spinifex23 at 12:33 PM on October 15, 2019
That was also *after* meeting all of the Medicaid requirements of a therapist's documentation, statement from my GP, etc. They basically needed a diagnosis of 'Adult Persistent Gender Dysphoria', and didn't really understand nonbinary folk at all.
(I am also happy with my male nipple placement, but my sensation is about nil. This doesn't bother me, but might other folk.)
posted by spinifex23 at 12:33 PM on October 15, 2019
My experience was the same as galvanized unicorn's. I had a breast reduction and told the surgeon that I wanted the smallest breasts possible; he was polite and listened, I thought, but definitely also kept things 'proportional' - so much so that my hip and breast measurements were IDENTICAL post-healing. I was happy with my results and I look great and feel better but I do not think the doctor did what I asked. I think he looked at my body and came up with his idea of the best aesthetics for a feminine shape and went with that. I happen to agree after the fact, but it's just because our ideas about my gender happen to align well enough. For your partner, I think an experience like this could be devastating. It is an incredible amount of work to go through healing - full healing takes nearly a year - if you're going to do that, go for what you want.
Spinifex23 also makes a good point about the shaping. The techniques may be similar, but they are not the same. I understand what you're saying about not wanting masculinization but there are many options. I think your partner should go back to the surgeon and be honest about their desires, try to have a conversation about the options, especially their concerns about nipple sensitivity. There are things the surgeon can do to prevent that, but it's important to be clear that it's a priority.
posted by Seven Windows at 12:34 PM on October 15, 2019 [6 favorites]
Spinifex23 also makes a good point about the shaping. The techniques may be similar, but they are not the same. I understand what you're saying about not wanting masculinization but there are many options. I think your partner should go back to the surgeon and be honest about their desires, try to have a conversation about the options, especially their concerns about nipple sensitivity. There are things the surgeon can do to prevent that, but it's important to be clear that it's a priority.
posted by Seven Windows at 12:34 PM on October 15, 2019 [6 favorites]
Also - your list of top surgery cons - I think these can be resolved with a little more research, which might give you a stronger basis for a decision if this is what your partner thinks they want but are hesitant because of the cons.
Item 1 has a definite answer which can be found out through some tedious phone calls or research with the health insurance handbook. Item 3 doesn't have a definite answer but the surgeon can give you more information about possible techniques and their typical results. As for item 2, my friend just had their consult on Friday and is scheduled for surgery on 11/12, another friend waited only 3 months...we're in a different state, but still, you don't know. It may be worth the wait and the wait might not be as long as you think.
posted by Seven Windows at 12:40 PM on October 15, 2019
Item 1 has a definite answer which can be found out through some tedious phone calls or research with the health insurance handbook. Item 3 doesn't have a definite answer but the surgeon can give you more information about possible techniques and their typical results. As for item 2, my friend just had their consult on Friday and is scheduled for surgery on 11/12, another friend waited only 3 months...we're in a different state, but still, you don't know. It may be worth the wait and the wait might not be as long as you think.
posted by Seven Windows at 12:40 PM on October 15, 2019
Response by poster: After some more discussion, partner identified this (image is a shirtless woman after a double mastectomy, whether that's safe for your workplace is up to your discretion) as their absolute ideal, though they'd like to keep their nipples if possible. They did state that if it was necessary losing the nipples would be an "acceptable loss" to achieve a chest that looks like that. Just to help clarify what exactly they're looking for. Any suggestions on how to approach explaining this to a surgeon who may or may not be familiar with nonbinary as a concept would also be appreciated.
posted by undisclosed at 12:52 PM on October 15, 2019 [1 favorite]
posted by undisclosed at 12:52 PM on October 15, 2019 [1 favorite]
I'm an AFAB nonbinary person, and from my perspective I'd encourage your partner to really consider whether they'd feel okay with smaller breasts, or if that would be an unsatisfactory half measure.
Before I discovered binders, back when I wore bras I wore a AA or AAA cup, and my breasts still cause me gender dysphoria. There's a qualitative difference between having small breasts and having a flat chest without breasts. If I were considering whether to undergo a major surgery like this, I think I would not want to go through the pain and healing and possible complications to eventually realize that my issue isn't the size of my breasts, but that they're there at all.
Doctor statements about "keeping things proportionate" are based on the assumption that the patient is female. For your partner, this isn't appropriate. If at all possible, please try to consult with a trans-affirming doctor, who (hopefully) is more likely to understand these issues.
(On preview, having looked at the photo you posted, I don't think breast reduction would give the results your partner is hoping for.)
posted by Lexica at 12:57 PM on October 15, 2019 [5 favorites]
Before I discovered binders, back when I wore bras I wore a AA or AAA cup, and my breasts still cause me gender dysphoria. There's a qualitative difference between having small breasts and having a flat chest without breasts. If I were considering whether to undergo a major surgery like this, I think I would not want to go through the pain and healing and possible complications to eventually realize that my issue isn't the size of my breasts, but that they're there at all.
Doctor statements about "keeping things proportionate" are based on the assumption that the patient is female. For your partner, this isn't appropriate. If at all possible, please try to consult with a trans-affirming doctor, who (hopefully) is more likely to understand these issues.
(On preview, having looked at the photo you posted, I don't think breast reduction would give the results your partner is hoping for.)
posted by Lexica at 12:57 PM on October 15, 2019 [5 favorites]
Bring the picture. That's not at all what I was envisioning from your description so the picture will likely be helpful to open a dialogue with the surgeon.
I know your partner really wants this and as soon as possible but, living in the land of plastic surgery, I can't emphasize enough how careful you need to be choosing a surgeon to do this kind of work! It's a long recovery so if they're not really comfortable with this surgeon or can't be honest then try someone else. A ridiculous percentage of people who get this kind of surgery have to go back again, sometimes more than once.
posted by fshgrl at 1:00 PM on October 15, 2019 [6 favorites]
I know your partner really wants this and as soon as possible but, living in the land of plastic surgery, I can't emphasize enough how careful you need to be choosing a surgeon to do this kind of work! It's a long recovery so if they're not really comfortable with this surgeon or can't be honest then try someone else. A ridiculous percentage of people who get this kind of surgery have to go back again, sometimes more than once.
posted by fshgrl at 1:00 PM on October 15, 2019 [6 favorites]
I really don't think a breast reduction will achieve a result like that picture unless they show the surgeon the pic and are clear that that is what they are aiming for, possibly with nipples. If the surgeon does not seem open to it, hold out for top surgery with someone who is experienced with it, or maybe try to find a reduction surgeon who is open to what your partner wants. But they will not get what they want without being clear and firm about it and eliminating talk of proportionality.
I had a reduction and, like others, the surgeon kept things proportional, which meant larger than I really wanted but I wasn't unhappy with the result. I have gained weight since due to reasons, and my breasts are a different shape now but I'm wearing the same size bra - or bigger -
as before surgery. I can only imagine how devastating that would be if I were dysphoric.
posted by Athanassiel at 1:30 PM on October 15, 2019 [3 favorites]
I had a reduction and, like others, the surgeon kept things proportional, which meant larger than I really wanted but I wasn't unhappy with the result. I have gained weight since due to reasons, and my breasts are a different shape now but I'm wearing the same size bra - or bigger -
as before surgery. I can only imagine how devastating that would be if I were dysphoric.
posted by Athanassiel at 1:30 PM on October 15, 2019 [3 favorites]
I'm non-binary and am looking into chest surgery with similar goals as your partner, though I care less about nipple sensation. Anyway, I have C cup breasts right now and while they don't cause me physical pain or constant emotional torment, they regularly make me feel weepy or vaguely panicky or slightly nauseous so ... take that as a piece of anecdata about chest dysphoria at that size. If reduction surgery were easy to do and easy to recover from, then maybe that could be a compromise on the way to full top surgery, but the recovery is pretty arduous for both and it would be such a shame to go through all that for something that still causes dysphoria.
Addressing this to your partner: You deserve to feel OK in your body, and unfortunately that might require some difficult conversations with potential surgeons. Definitely do not go through with the current surgeon unless you feel 100% confident that they are on-board with what you want. I personally think this should involve being honest about your dysphoria. If that means the surgeon won't want to do the surgery, well, that also probably means you couldn't trust them to do what you want. And that's a scary prospect.
You also may need to be very explicit with the LGBTQ surgeon as well, so that they don't just slot you into the "FTM" category and assume you want masculinization.
Also: I just want to offer some solidarity in that I really, really understand the feeling of urgency. I recently decided to go on a low-dose of testosterone, and I KNOW I need to do some stuff first but it is EXCRUCIATING to wait. But you deserve to have what makes you feel whole and good.
Oh, and look up both surgeons on transbucket. Trans and non-binary people upload pics and give reviews of their gender-confirming surgeries, and you can search by surgeon - it's a great resource for helping you find surgeons.
posted by the sockening at 1:40 PM on October 15, 2019 [4 favorites]
Addressing this to your partner: You deserve to feel OK in your body, and unfortunately that might require some difficult conversations with potential surgeons. Definitely do not go through with the current surgeon unless you feel 100% confident that they are on-board with what you want. I personally think this should involve being honest about your dysphoria. If that means the surgeon won't want to do the surgery, well, that also probably means you couldn't trust them to do what you want. And that's a scary prospect.
You also may need to be very explicit with the LGBTQ surgeon as well, so that they don't just slot you into the "FTM" category and assume you want masculinization.
Also: I just want to offer some solidarity in that I really, really understand the feeling of urgency. I recently decided to go on a low-dose of testosterone, and I KNOW I need to do some stuff first but it is EXCRUCIATING to wait. But you deserve to have what makes you feel whole and good.
Oh, and look up both surgeons on transbucket. Trans and non-binary people upload pics and give reviews of their gender-confirming surgeries, and you can search by surgeon - it's a great resource for helping you find surgeons.
posted by the sockening at 1:40 PM on October 15, 2019 [4 favorites]
Get any surgeon to sign off to surgery details in writing. I don't want something like this to happen to your partner! Leave nothing to chance.
Bring in a folder of Yes, This and No, Not That photos you can show. And say the words "I don't want to be 'proportional,' I want a flat chest without reconstruction. Leave no breast tissue. I don't even want an A cup. I also don't want a 'male' chest, so no masculinizing features either. I'd like to prioritize saving my nipples and preserving feeling in them. Is this something you could comfortably do?"
posted by aw jeez at 1:53 PM on October 15, 2019 [7 favorites]
Bring in a folder of Yes, This and No, Not That photos you can show. And say the words "I don't want to be 'proportional,' I want a flat chest without reconstruction. Leave no breast tissue. I don't even want an A cup. I also don't want a 'male' chest, so no masculinizing features either. I'd like to prioritize saving my nipples and preserving feeling in them. Is this something you could comfortably do?"
posted by aw jeez at 1:53 PM on October 15, 2019 [7 favorites]
This is me too , really. And, a someone with a current C cup for me I know nothing but flat Iis going to be good enough. I'm female presenting but I really really hate breasts.
You have funding which is the hard part, please advocate for what you want. You deserve what you want. It's for you.
posted by AlexiaSky at 1:56 PM on October 15, 2019 [4 favorites]
You have funding which is the hard part, please advocate for what you want. You deserve what you want. It's for you.
posted by AlexiaSky at 1:56 PM on October 15, 2019 [4 favorites]
My surgical experience is from the other side - I got a double mastectomy 4 years ago due to breast cancer - but I did want to chime in and agree with aw jeez. There is a tremendous amount of sexism and just general crappy behaviour from surgeons and when they say "proportional" they basically mean that they are going to leave you with bigger breasts because they don't want to get yelled at for taking "too much" because as a society we put so much importance on bigger breasts = better. And that without being able to articulate your partners non-binaryness and dysphoria surgeons will pigeonhole your partner into a 'female' box which won't fit in the end.
posted by machine at 2:08 PM on October 15, 2019 [3 favorites]
posted by machine at 2:08 PM on October 15, 2019 [3 favorites]
I am transmasculine and had double incision with nipple grafts a number of years ago. I am willing to send pictures if that is helpful. (I think I still have old pics on transbucket, too, from 2-3 years post-op.) I am going to me-mail you because some of what I have to say involves the experience of someone I'm close to.
Like everyone else has said, "proportional" is code for "not as small as you want". I have two further thoughts (which may be fairly useless given the Medicaid constraint):
posted by hoyland at 4:54 PM on October 15, 2019 [2 favorites]
Like everyone else has said, "proportional" is code for "not as small as you want". I have two further thoughts (which may be fairly useless given the Medicaid constraint):
- A reduction doesn't close off the possibility of top surgery (or further reduction) later. Not optimal from a money or pain and suffering perspective, but the door is not closed
- There are a whole host of top surgery techniques out there, resulting in different scar and nipple placement, as well as different likelihoods of retaining nipple sensation (and, of course, no nipples is an option). A surgeon who works with patients to find the right technique for their body, rather than doing their favorite technique on everyone, is probably the route to maximising chances of a satisfactory result. Even if they come down on the side of reduction, I think looking for someone who does top surgery using multiple techniques is probably the best bet for having their objectives listened to and respected.
posted by hoyland at 4:54 PM on October 15, 2019 [2 favorites]
Cis f here ... I agree that partner should firstly consider whether remaining breasts are ok at all, but my experience is that all of my physical discomfort of back pain and bras that were simultaneously suffocating and yet still not "supportive" enough went away after reduction. I went from who knows? maybe f or g, to a c or d, but the important thing is that almost any bra works now. I certainly don't need and will never, ever wear underwire again. The boobs just sort out stay in place mostly in their own now, which was the biggest source of discomfort previously. I'm so, so much more comfortable overall now. Best wishes to partner.
Also, if you haven't found it yet, there is a great forum here that you have to prove real identity to join, but once you do, you see all the different varieties of people and outcomes, which was really helpful to me. Im unsure of the non-binary part, but the huge emphasis was in support no matter who you are or what you look like or what your goals are, and of course heavily moderated, so I'd guess a safer place (it's been a while since I've visited).
posted by Dashy at 9:58 PM on October 15, 2019
Also, if you haven't found it yet, there is a great forum here that you have to prove real identity to join, but once you do, you see all the different varieties of people and outcomes, which was really helpful to me. Im unsure of the non-binary part, but the huge emphasis was in support no matter who you are or what you look like or what your goals are, and of course heavily moderated, so I'd guess a safer place (it's been a while since I've visited).
posted by Dashy at 9:58 PM on October 15, 2019
I went from a 32FF to a 32D and in the past 5 years have grown a bit back with weight gain; my surgeon could not go smaller without having to do skin flap reconstruction/nipple recentering, which I absolutely didn't want to deal with. I don't think a reduction is what your partner is looking for or will be happy with, as the primary purpose of the surgery is to continue having the kind of breasts associated with cis female appearances.
I get that every day that passes with continued dysphoria is a day of unwanted and unnecessary suffering but I think that still having that suffering after a month or more of recovery time and surgical bras and gross itchy surgical drains hanging from their chest will only increase that suffering.
posted by poffin boffin at 11:49 PM on October 15, 2019 [2 favorites]
I get that every day that passes with continued dysphoria is a day of unwanted and unnecessary suffering but I think that still having that suffering after a month or more of recovery time and surgical bras and gross itchy surgical drains hanging from their chest will only increase that suffering.
posted by poffin boffin at 11:49 PM on October 15, 2019 [2 favorites]
Gender-complicated queer pursing breast reduction, here. There are a few things your partner might want to consider:
- Is nipple function and sensation important, or just the appearance of nipples? Masculine chest reconstruction typically involves a free nipple graft. The nipples will no longer respond to stimulation and loss of sensation is pretty much inevitable. (I believe there is a newer technique where the nipple stalk is sort of folded up inside a typically masculine chest, but this isn't commonly performed).
- With breast reduction, it's usually possible to keep the "stalk" of the nipple attached, which means there's a better chance of maintaining nipple sensation and function - although this is not guaranteed. The exception to this is if the breasts are very large or droopy to start with, and/or they're going down to a very small size. For example, I'm a G cup, and was told I probably couldn't go smaller than a C without a free nipple graft. Going past this limit is risky, because if the "stalk" gets folded over too much, blood supply can be compromised, and there's a risk of losing the nipple complex entirely. I've seen photos of this outcome and it's horrific - imagine a deep, round hole in the breast and months of suction dressings just to safely close the wound.
- If you haven't already, it's worth looking at videos/animations of how both breast reduction and masculine chest reconstruction are done. In particular, it helps to visualise what happens to the nipple stalk in a reduction, so you can understand the practical/anatomical limitations on taking large breasts down to a very small size while maintaining nipple sensation - it's all about how long the nipple stalk is to begin with, and how it's located inside the new breast. Of course there are also surgeons who discourage smaller breasts for dubious aesthetic reasons, but that doesn't mean there aren't actual anatomical limits on what's possible/safe.
- I would run a mile from a male surgeon who used the term "proportional" in the way you describe. It's code for "Well, we still want you to look like a lady, so whatever size you say you want, will make that decision for you while you are unconscious, using conventional feminine beauty standards as a guide". Anyone having this type of surgery, but especially a non-binary person, needs to work with a surgeon who operates from a truly informed consent model. The conversation should be about the individual's preferred outcomes, what is anatomically possible, and what the risks/benefits of each approach are. "Proportional" should only come into it if that's a concern for the patient themselves. (As an example, I have big hips, and I told my surgeon that I absolutely did not want my tits to be proportional to them).
- I'm fairly sure that what I want is breast reduction, but my surgeon really took the time to check that this was my preferred option, and I wasn't just taking "baby steps" to a masculine chest. She said that while it's possible to do a masculine chest reconstruction following a breast reduction, the previous surgery can make it much harder to achieve good outcomes. She wanted me to be absolutely sure about the type of surgery I actually wanted.
- It sounds like what your partner really wants is a flat chest. The decision then is whether that outcome is so important to them that they're willing to lose nipple sensation. Breast reduction might enable them to keep nipple sensation, but there's going to be a limit to how small they can go. If they do pursue breast reduction, it probably shouldn't be with a surgeon who prioritises "proportional" outcomes. If they choose to pursue masculine chest reconstruction, it should be with a surgeon who specialises in it. I wouldn't take the fact that this surgeon also does facial feminisation surgery as an indication that they're competent to do masculine top surgery. Surgical skills aside, they also need to be competent at talking about bodies and gender outside conventional binary notions of beauty.
posted by embrangled at 5:11 PM on October 16, 2019 [5 favorites]
- Is nipple function and sensation important, or just the appearance of nipples? Masculine chest reconstruction typically involves a free nipple graft. The nipples will no longer respond to stimulation and loss of sensation is pretty much inevitable. (I believe there is a newer technique where the nipple stalk is sort of folded up inside a typically masculine chest, but this isn't commonly performed).
- With breast reduction, it's usually possible to keep the "stalk" of the nipple attached, which means there's a better chance of maintaining nipple sensation and function - although this is not guaranteed. The exception to this is if the breasts are very large or droopy to start with, and/or they're going down to a very small size. For example, I'm a G cup, and was told I probably couldn't go smaller than a C without a free nipple graft. Going past this limit is risky, because if the "stalk" gets folded over too much, blood supply can be compromised, and there's a risk of losing the nipple complex entirely. I've seen photos of this outcome and it's horrific - imagine a deep, round hole in the breast and months of suction dressings just to safely close the wound.
- If you haven't already, it's worth looking at videos/animations of how both breast reduction and masculine chest reconstruction are done. In particular, it helps to visualise what happens to the nipple stalk in a reduction, so you can understand the practical/anatomical limitations on taking large breasts down to a very small size while maintaining nipple sensation - it's all about how long the nipple stalk is to begin with, and how it's located inside the new breast. Of course there are also surgeons who discourage smaller breasts for dubious aesthetic reasons, but that doesn't mean there aren't actual anatomical limits on what's possible/safe.
- I would run a mile from a male surgeon who used the term "proportional" in the way you describe. It's code for "Well, we still want you to look like a lady, so whatever size you say you want, will make that decision for you while you are unconscious, using conventional feminine beauty standards as a guide". Anyone having this type of surgery, but especially a non-binary person, needs to work with a surgeon who operates from a truly informed consent model. The conversation should be about the individual's preferred outcomes, what is anatomically possible, and what the risks/benefits of each approach are. "Proportional" should only come into it if that's a concern for the patient themselves. (As an example, I have big hips, and I told my surgeon that I absolutely did not want my tits to be proportional to them).
- I'm fairly sure that what I want is breast reduction, but my surgeon really took the time to check that this was my preferred option, and I wasn't just taking "baby steps" to a masculine chest. She said that while it's possible to do a masculine chest reconstruction following a breast reduction, the previous surgery can make it much harder to achieve good outcomes. She wanted me to be absolutely sure about the type of surgery I actually wanted.
- It sounds like what your partner really wants is a flat chest. The decision then is whether that outcome is so important to them that they're willing to lose nipple sensation. Breast reduction might enable them to keep nipple sensation, but there's going to be a limit to how small they can go. If they do pursue breast reduction, it probably shouldn't be with a surgeon who prioritises "proportional" outcomes. If they choose to pursue masculine chest reconstruction, it should be with a surgeon who specialises in it. I wouldn't take the fact that this surgeon also does facial feminisation surgery as an indication that they're competent to do masculine top surgery. Surgical skills aside, they also need to be competent at talking about bodies and gender outside conventional binary notions of beauty.
posted by embrangled at 5:11 PM on October 16, 2019 [5 favorites]
Surgery isnt easy on the body so after looking at the picture, i say go straight for the top surgery. While consults and doctor finding and insurance bull may take a bit longer than a reduction, i think there will be a proportionate increase in the satisfaction from the results. I would definitely avoid a reduction if there was an inkling of it being a temporary stepping stone to full top surgry because i would want to avoid more surgery if at all possible.
posted by WeekendJen at 6:05 AM on October 18, 2019
posted by WeekendJen at 6:05 AM on October 18, 2019
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One thing that my surgeon offered - and I chose to get - was not only the breasts being removed via a Double Incision procedure, but sculpting a distinctly male chest. So - my nipples are smaller, they were replaced on the chest in a more cis male location, and they kept some 10% of the breast tissue to form 'pecs'. That is something to consider. This is what I wanted, as a more binary-leaning transgender person, but it may not be what your partner wants.
My surgeon was a Plastic Surgeon who also does breast reductions, so I could have went that route if I wanted. I also could have had the nipples not reattached. If the breast reduction route is taken, I'd recommend a surgeon who works with trans patients so that names and pronouns are respected, the waiting room is a comfortable place, they are competent in billing/insurance issues, etc.
posted by spinifex23 at 11:55 AM on October 15, 2019