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Teh Surgery

Because I am lazy, I will again rely on the inimitable Jamison Green for a brief synopsis of the available options:

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.

(A few minor digs: virtually no surgeon will argue that keyhole is the better option regardless of the size of the pre-op chest. Some guys are just too big for that procedure; the amount of excess skin cannot be removed except by double mastectomy. IME, most surgeons will further argue that a pre-op chest must be pretty darn small in order to qualify. Some surgeons will perform keyhole on somewhat larger chests, but I think they’re in the minority. I should also point out that while no procedure guarantees that no revision will be necessary, it is more likely that someone undergoing keyhole will require a second procedure to remove leftover tissue.)

These are the two most common procedures. There are some variations–for example, I know someone who underwent a prophylactic mastectomy with masculine reconstruction.

I am going to undergo another less-common procedure: liposuction, or what they do for cissexual men with gynecomastia. I had a consultation a long time ago, with a surgeon who specializes in double-mastectomy and very much prefers to perform it. He does keyhole and seems to have decent results, but he doesn’t like to perform it on guys with anything there to begin with. He pronounced me borderline (candidate, not personality), and said that he would be willing to perform keyhole but wasn’t sure I’d have such great results.

Nine months of dithering and free weights later, I went in for a cheap consultation with another surgeon. He groped me for a little while,* took some measurements, and said, “You know, you’ve got a chest here, but…it’s pretty much all muscle. This is what I’d have to remove.” And he said that because of my ginormous pecs, I was a good candidate for liposuction. Liposuction is much cheaper and less invasive. It carries a higher risk for revision than keyhole, but will not compromise the results of a second procedure at all. The worst possible thing that could happen is that I’m forced to get keyhole afterward: out the price of lipo and the heartache of surgery, potentially a much better candidate for keyhole.

Liposuction differs from keyhole in that no skin is removed. After surgery, they stuff you into a chest-compression vest** like sausage meat into a casing, with the hope that your body will take the hint and start pulling that extra skin back in. They generally have some measure of success at this, even with older candidates with far more extreme cases of gynecomastia. I’m young and elastic, so the odds are pretty good (and I didn’t sag after going from a double D*** to a small A, so there’s that). I also have the option of a minor revision if I need one.

All in all, it seems like a pretty good match for my perfectionism, cheapness, and control issues.

Or it did, anyway.

That consultation was a little more than two months ago. I dithered for a few days, made my decision, and called back to say yes, please and schedule surgery. That was a little less than two months ago. I still don’t have a surgery date. I don’t mean I still haven’t gone under the knife. I don’t even know when I might be going under the knife. They’re pretty sure August is out of the question. They think September might be a possibility. I definitely won’t have to wait until February. I assume that means I almost certainly will be able to undergo surgery before the end of the year. But I don’t know. I don’t know! “Can you tell me when you have openings?” Sorry. “Can you ballpark it for me?” Well, I don’t think I can do that. “Can you tell me, in purely abstract and nonbinding terms, how long it might take in general for a hypothetical patient in a similar situation to get a date after requesting one?” That was when September was floated. But September is a fantasy. September is a pipe dream.

I am trying to look at this in perspective. First of all, I am on a waiting list because I am going through my insurer (it’s not covered, but I’m saving because they’re providing the services). I’m trading expedience for the several thousand dollars I’m going to save, as well as for the option of receiving care from people I otherwise trust and like very much. This is an option that very few people have. Second, it could be so much worse. A few months is nothing; I know people who have waited as long as ten years. There are other people who may never have resources available, and more whose provider options are far less safe, skilled, and conscientious than mine. Third, this delay will not prevent me from functioning, or from obtaining any necessary documents. Fourth, getting jerked around has given me an excuse to complain about it to everyone I know, which means that I have been able to say “surgeon” and “surgery” to my dad several times. Fifth, being deprived of something is a great way to figure out whether or not you really want it.

But it’s hard. I am already being asked to put my unpredictable human body in the hands of a fallible human surgeon. I am also being asked to accept a body whose popular reception is out of my control entirely. Now I have yet another variable to deal with, and it’s extremely unpleasant. It’s difficult not to revert to eating-disordered coping mechanisms**** in response. This is especially true in terms of this particular ambiguity. Look: something I’ve noticed about eating disorder sufferers is that they tend towards unrealistic goals in other spheres than the bodily one. I don’t mean that we go from one wild scheme to another. No, we formulate an impossible plan and then we commit to it, destroying ourselves in the process. My habitual hypothetical graph plots a very very steep line. If I had exactly forty-eight days, I would be planning to eat well, go hiking, and get a lot of sleep. Now that I have who knows how long–but definitely not eight months–the sky is the limit.

*Again, with total professionalism. There was no creepy groping. In fact, I should probably stop using the word “groping.”

**According to some people I’ve talked to, the post-op foundation garments are the worst part.

***Yup! Betty Page four-hook vintage bondage bras and everything!

****I’m not, mind you.


10 thoughts on Teh Surgery

  1. I’m sorry your date is hanging in the air like that. I hate not having the ability to make a concrete plan and see it out.

    I know they are somewhat–okay probably vastly–different, but the “keyhole” procedure is what they use for breast reductions. Skin is removed, lipo is done, the nipple is reduced and repositioned, etc. I had that done five years ago. The scarring is barely noticeable now. I have complete sensation in my nipples. They are in the right place.

    And yes, the post-op bra is horrible. But you’ll be thankful for it because if it goes anything like mine did, you’ll be black and blue, swollen and stiff for a few weeks and it does provide some relief. Maybe. Or maybe that was just the drugs.

  2. I know they are somewhat–okay probably vastly–different, but the “keyhole” procedure is what they use for breast reductions. Skin is removed, lipo is done, the nipple is reduced and repositioned, etc. I had that done five years ago. The scarring is barely noticeable now. I have complete sensation in my nipples. They are in the right place.

    From what I’ve heard, I think they are very similar. The difference is probably in the amount of tissue removed relative to what’s left. While I’m not familiar with the odds for reduction for women, I think the positioning problems with the ftm version might be with wanting nipples at a higher position than they, um, fall on most women.

    And yes, the post-op bra is horrible. But you’ll be thankful for it because if it goes anything like mine did, you’ll be black and blue, swollen and stiff for a few weeks and it does provide some relief. Maybe. Or maybe that was just the drugs.

    Heh. Yet another reason to go with a network. Thanks for the vote of confidence. I’m glad your result was so positive.

  3. I know the waiting is driving you batshit, but the procedure sounds great. Preserving all the skin and nipple sensation with minimal scarring sounds like it has the potential for a really good result. Once the post-surgical garments come off, I hope you’re really happy with what you see in the mirror.

    You keep reminding me that, before I had a house that needed work and a high-pressure job and a kid that needed parenting, I was a gymrat. I miss it.

    I do have questions about one thing: do guys with big nipples (not the areolas but the nipples themselves) have a way to make them smaller? In bilateral mast., are the “reshaped” nipples smaller? Does T, for example, tend to shrink them? Are there options for guys who are not pleased with the appearance of their nipples on their post-surgical chest?

  4. I do have questions about one thing: do guys with big nipples (not the areolas but the nipples themselves) have a way to make them smaller?

    Yes. You can get keyhole with nipple reshaping and repositioning. With bilateral mastectomy, AFAIK, the surgeon doesn’t trim the nipple from the circumference inward; they use part of the areola to make a man nipple.

    In bilateral mast., are the “reshaped” nipples smaller?

    See above.

    Does T, for example, tend to shrink them?

    I’ve never heard of this happening.

    Are there options for guys who are not pleased with the appearance of their nipples on their post-surgical chest?

    …Yes. Scars are yours to keep, unfortunately. Revisions with nipple repositioning are possible; it depends on the individual result. I’ll try to find a link with more info.

  5. Congratulations on finalizing your plans! Sorry about the unknown date though…When my boyfriend had his chest done, waiting for the final date was the most stressful part of the whole process! He had to have the bilateral mastectomy, but it’s been 8 months now, and it looks great. The scars are fading, and the surgeon did an excellent job reshaping his chest.

    Piny, I hope that the surgeon is able to come through for you, and I wish you the best of luck!

    Also as an aside to Thomas- when my boyfriend has his chest done, the surgeons actually took one nipple and areola and divided it in half, to create two smaller nipples for reattachment. Like so many other things, a lot depends on the past experiences/preference of the surgeon. There are many ways to get the same result.

  6. But I don’t know. I don’t know! “Can you tell me when you have openings?” Sorry. “Can you ballpark it for me?” Well, I don’t think I can do that. “Can you tell me, in purely abstract and nonbinding terms, how long it might take in general for a hypothetical patient in a similar situation to get a date after requesting one?”

    This is pretty typical for surgeons of any type, right? Either way – good luck! Hope you’re pleased with the results.

  7. This is pretty typical for surgeons of any type, right? Either way – good luck! Hope you’re pleased with the results.

    For elective procedures through any insurance provider, yes. Private surgeons will calendar you much more quickly, but they have no other obligations and you can take your business elsewhere.

  8. hey, piny. another step…sorry for the frustration. i’ve chosen to be non-op for a lot of reasons, but i’m always glad to hear someone get closer to the body they are meant to have.

    btw, i’ll see James on Friday. he’s coming to the conference I’m at to train a bunch of important people. wish you were nearby, i’d invite you to lunch. if you are in st. louis, that is.

    anyway, congrats on getting closer. the date will come.

  9. Lucky bastard, getting away without double incision scars. Hope they can give you a date soon.

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