Dr Lisa Friederich              1300 375 472

Mastectomy

FTM Top Surgery is more than surgery to remove the breasts with mastectomies. Rather it aims to transform a female chest to that of a male.  This is a growing area of surgery and has evolved from three main patient groups: MTF transgender patients, Gynecomastia and male massive weight loss patients.

 

The major differences between the male and female chests (apart from the presence of the breasts) are:

The female nipple areolar complex is larger and more medially placed compared to the male’s, which are smaller and more lateral.

The major landmark on the male chest in the pectoral bulk and the lower shadow this muscle produces- the subpectoral line.  This is more obvious with increased size of the pectoral muscles. In the female chest, this muscle is still present, but of significantly lower bulk. Further it is obscured by the overlying breast, instead we more readily notice the infra-mammary fold, the crease between the breast and the chest wall.  This is generally set lower on the chest wall than the lower border of the pectoral muscle

Surgical procedure

Although a mastectomy is the base procedure, there are two main techniques to do this. The choice depends on the size of the breast and the need to excise the associated excess skin.

Keyhole/Minimal scar/Periareolar Scar

This incision within the areola, thus reducing its size, and a second concentric incision around this at a distance of not much more than 2cm.  The top layer of skin is removed from the tissue between these incisions. The superior half of the outer incision is made all the way through to the underlying breast tissue and is used to perform the mastectomy. After this is done, the outer incision is reduced with a purse string suture and sutured to the areola.

This is really only suitable for very small breasts (A cup or those approx 100g), as it does not allow for the removal of much skin. The more skin remove, the more gathering to close the incision and this can compromise the blood supply to the areola and nipple.

Double incision Scar

This involves a much larger incision approximating the width of the breast, with an elliptical excision of skin and all of the underlying breast tissue. The scar is ideally placed underneath the pectoral muscle, curving upwards laterally towards the armpit so that it stays in the subpectoral shadow. This avoids dog ears on the lateral chest wall when the scar is kept as a horizontal line.

This is used in patients with larger breasts, where excess skin needs to be removed.

The nipple and areola can be managed in 3 ways when using a double incision technique.

My preferred technique is to maintain a connection to the lower skin flap with a bridge of tissue. This is kept relatively thin, yet thick enough to maintain a blood supply to the nipple and remaining areola.

In very large breasts this is not always possible,

If it it too long, it creates too much bulk and this causes a noticeable lump on the chest.

As the blood supply is drastically reduced to the nipple complex, this added bulk can increase the risk of nipple necrosis, owing to the increased perfusion demand.

Lastly a long pedicle is at greater risk of twisting and obstructing blood flow to the nipple complex.

I will generally try to maintain a pedicle and check the nipple complex viability and bulk before inset. If the blood supply appears inadequate, I will convert it to a graft. I do what I think will be safest.

The second method is to completely remove the nipple, reduce its diameter and it’s thickness and reapply it as a graft once the mastectomy is completed. A skin graft is a common technique used in plastic surgery and involves a new blood supply growing into the graft. As the nipple is thicker that most grafts, it is usual to have slower healing with this method.

The third method is to excise the nipples completely and discard them. This is less common and only done at specific patient request. It is possible to get nipple tattood, but the dyes used do not tend to last as long as regular tattoos. It is possible to perform nipple reconstruction surgery, which involves the elevation of flaps of skin and sewing them together to make a nubbin for the nipple. A skin graft or tattoo can then be used to make an areola.

 

To get the best results, I recommend increasing pectoral muscle bulk and making sure you are a healthy weight. 

 

The surgery is performed under a general anaesthetic and is approximately 3-4 hours in duration. At least one night in hospital is required. Drain are used, which may come out the day after surgery, or stay until the first postoperative visit.

At least 1-2 weeks should be taken off of work and you should avoid upper body exercise for at least 4 weeks.

 

Estimated Fees

There are 4 components to the fees;

The surgical fee will be between $6,000.00 – $7,000.00 depending on your physique and breast size.

Medicare offers approximately $1,100.00 in rebate for this, and private health another $400-500. Medicare and insurers will pay 100 % rebate for the first procedure, but then only 50% for the next (and 25% for any after) They assume that the more you do the easier and cheaper it is! But this is not the case and it often takes a little longer to match the second side to the first.

The anaesthesic fee  is approximately $2,000.00 – $2,400.00. There is some rebate on this fee.

The hospital fee will depend on whether you have private health insurance or not. The Medicare item numbers associated with the procedure (31524 x 2).  If you have the appropriate level of insurance you are covered for the hospital fees bar any excess. If you do not have insurance, the hospital fees are approximately $4300.00.

Laboratory fees Any breast tissue removed is sent to pathology for analysis. This incurs a separate fee with some medicare rebate available.

 

If you are insured, you should ring your healthfund and quote the item numbers above, they should be able to give you an idea of your coverage and expected rebates.

Please contact us if you have further questions.

 

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