Top SurgeryEXPLORING YOUR SURGICAL OPTIONS

Surgery PreparationSETTING YOURSELF FOR A SUCCESSFUL OUTCOME

Why Surgery?❑Gender Affirming❑Feeling the body better reflects identity

❑Reduce dysphoria ❑Improving emotional connection with the body

❑Stop Binding❑Reduce strain

❑Improve breathing

❑Decrease skin irritation

“ I don’t avoid mirrors or hunch my shoulders all the time any more.”

“My clothes fit the way I want them to.”

“I can’t express how free I finally feel!”

“It’s the best decision I’ve made.”

“I can swim comfortably.”

Sample Timeline for Surgery Preparation

Go homeSame day

3Months

1 month

Day 7-14

4-16Months

3-15Months

3-15Months

1-7Days

Day 14-30

1-7Days

Optimal Surgery Preparation IncludesSecuring safe housing with private space

Stabilizing Medical Conditions

Optimizing Emotional Wellbeing

Eliminating or Reducing Substance Use

Researching surgery and surgeons

Planning for bills and financial needs

Eating healthy balanced meals

Exercising and moving the body

Setting up a Support System

Information Gathering and Research❑ Clarify your personal goals related to surgery

❑ Weigh pros and cons of surgery options

❑ Clarify surgical plan with surgeon

❑ Learn from others❑ Online forums and groups, support groups

❑Research surgeons and look at results❑Interview surgeons and ask questions❑Considerations: location, wait times, technique,

comfort and fit

❑ Remember everyone’s healing is unique

Physical Emotional SocialHopes and Expectations

Fears and Concerns

Questions

Envisioning a Successful Surgery

Physical Emotional SocialHopes and Expectations

I hope that my chest looks how I expect it to look after surgery.

I hope I feel more comfortable with my body after surgery.

I hope I will feel more comfortable in gendered spaces (i.e.locker rooms) after surgery.

Fears and Concerns

I am concerned that I might lose sensation or not have a flat chest.

I am worried this surgery may not resolve all my feelings of dysphoria.

I am worried that I will still experience harassment and discrimination based on gender even after surgery.

Questions Will my new chest lookand feel the same as a masculine chest?

Is it normal to feel anxious or ambivalent about surgery?

How will surgery affect my close relationships?

Envisioning a Successful Surgery

Common Hopes and Expectations❑Physical❑ Clothing

❑ Physical activity/Range of motion

❑ Self care

❑ Breathing

❑ Posture

❑Emotional❑ Confidence

❑ Pride

❑ Alignment

❑ Ease/Relief

❑Social❑ Comfort in gendered spaces (bathrooms/locker rooms)

❑ Increased confidence in physical contact

Common Concerns (1 of 2)Surgery is always a risk❑ Guideline of any medical intervention is that benefits outweigh risks

❑ Highly skilled and trained medical team

❑ Well informed patients

This is permanent/What if you change your mind❑ Delaying/not having surgery can have negative impacts physically, emotionally, and socially

❑ Satisfaction with surgery can improve overall quality of life

❑ Self-determination is key to health decision making

Common Concerns (2 of 2)What will other people think/say

❑ Identity is complex; helpful to set healthy boundaries about educating others and answering questions about your process and encouraging others to utilize other resources and support.

❑ It’s up to you who you tell and how much detail you want to share

❑ Important to encourage caregivers to have their own supports

What does this mean about your identity/relationship

❑ Identity is complex.

❑ Chest size/shape ≠ identity/gender

❑ Surgery is gender affirming, may increase the visibility of someone's identity

❑ How surgery is related to identity is varied

Resources for Family and Friends❑ PFLAG “Our Trans Loved Ones” Online Resources

❑ Gender Spectrum -> Resources -> Parenting and Family

❑ Oakland MST Department Support Groups❑ Parents Support Group (1st and 3rd Monday; 6 – 7:30)

❑ Partners Group (2nd and 4th Mondays; 6 – 7:30pm)

Physical / Medical Preparation❑ Being in your best physical health will support your recovery❑ KP Wellness Coaching

❑ KP Classes – Exercise Classes and Nutrition Support

❑ You may want to moderate or abstain from caffeine, marijuana

❑ Focus on getting enough sleep, adequate nutrition, body movement, hydration

❑ If you have ever experienced addictive substance use or are in recovery, you will want a solid support plan in the case of stress-related cravings.❑ Abstinence vs. harm reduction

❑ Alternative (safe) coping mechanisms

❑ Substance use or abuse may affect:❑ How your body responds to anesthesia

❑ How well your body recovers from surgery

❑ Your mood while preparing for or recovering from surgery

Mental Health Before Surgery❑ Remember that even positive life events can come with stress or bring up challenging feelings.

❑ Take time to think about your own ways of coping with stress or change.❑ Which of these will be available to you while preparing for surgery?

❑ What other resources might be needed (e.g., relaxation techniques)?

❑ Who in your life can be a sounding board (e.g., friend, therapist)?

❑ KP.org resources❑ Health & Wellness Podcast: “Preparing for Surgery” guided imagery audio file

❑ Wellness Coach

❑ Wellness Classes

Prepare for consultation appointment

• Surgeons perform this surgery every week but this is your first time

• What are your concerns, goals, expectations?

Self-Advocacy

• Surgery consultation FAQs

• Bring list with your questions

• Bring a support person with youQuestions

What to Expect at Consultation

❑ Discuss your surgical goal

❑ Review Risks and Benefits

❑ Review result photos

❑ Exam

❑ Pre-Operative photos

❑Remember:❑Every surgeon approaches consult differently

❑ Goal of consult is to develop a surgical plan that fits your needs

Will I have enough support after surgery? Is now the right time?

Decide What Timing Is Right for You

Understanding Your Benefits❑ Contact Kaiser Permanente Member Services 1-800-464-4000❑ Ask for your co-pay for an: “Outpatient transgender surgery”

❑ Note: If your insurance changes, your share of cost may change❑ Make sure your insurance is active

❑ Payment plans may be available through Patient Financial Services.❑1-800-498-2748

❑ Program to assist patients with medical bills and co-pays❑ Medical Financial Assistance: 1-866-399-7696

❑http://share.kaiserpermanente.org/article/northern-california-medical-financial-assistance

Coordinating Time Off Work❑Learn your job protection rights and benefit programs❑ FMLA (Family Medical Leave Act) (job protection)

❑ Disability Programs (monetary compensation)

❑ Everyone’s coverage and leave programs are different

❑ Have a conversation about medical leave with your HR department approximately 30-60 days before surgery

❑ Confirm with surgeon exact date for returning to work

❑Documentation▪ You do not have to tell your employer the specific surgery you are having,

use the language: “medically necessary procedure”

▪ Paperwork will either be blank with dates of leave or say “Aftercare for Non-Cosmetic Surgery”

How to talk about surgeryDepending on level of closeness you may want to let people know:

❑ “I’m going to be away from work/school for the next 2-4 weeks recovering from a planned medical procedure.”

❑ “I’m having surgery to improve my health.”

❑ “I’m having top surgery that I’m really looking forward to.”

❑ “I’m really looking forward to being able to ________ after I recover.”

Requesting Help and Setting Limits❑ Who do you want to be part of your healing process?

❑ You will need AT LEAST one person to help you ❑ Top surgery – 1 person for first 2-4 days after discharge from hospital minimum

❑People may want to help but may not be physically, financially or emotionally able. It’s ok to tell someone you’d like to see them after you recover.

❑ Caregiving❑ Primary caregiver needs breaks and emotional support as well

❑Assign people concrete tasks so they can be successful in helping you

❑ Help your support team coordinate your care by setting up a care calendars❑ http://www.caringbridge.org http://lotsahelpinghands.com/

Prepare Your Care TeamRoles for caregivers

❑ Driver

❑ Emotional support by phone or in person

❑ Movie and low key activity partner

❑ Errand/Grocery runner

❑ Meal preparer/deliverer

❑ Walking partner

❑ Personal care provider including dressing and toileting

❑ Wound care assistant

❑ Laundry Doer

❑ Create backup Plans B and C and D!!!

CaregiversInformed consent is for caregivers too

When agreeing to be a caregiver through surgery, it is important to:◦ Be conscious of your own needs and limits

◦ Recognize your strengths and what you have to offer

◦ It’s okay to say no (and better to if you really can’t!)

◦ Remember you can’t do it all – ask for help

◦ Have clear communication about expectations

◦ Put together your own care team

◦ Stay on top of self-care (hydration, food, rest, breaks, etc.)

For people nearby, MST offers a partners support group 2x/month

6-8 weeks before surgery prep checklist❑ Talk to work / school / volunteer organizations

❑ Complete FMLA and begin SDI paperwork, if applicable

❑ Review Discharge Instructions (re-read at least 2-3 times!); share with your caregivers

❑ Purchase and gather supplies

❑ Complete labs if requested by your surgeon

❑ Set up your home❑ Clean sheets, towels, and clothes, move important items to waist level, create easy path to bathroom

❑ Cook and freeze meals

❑ Confirm care team and assign roles to caregivers

❑ Practice Stress Reduction Exercises

Enhanced Recovery

Protocol developed to speed recovery

Box picked up or mailed to you prior to surgery

Instructions included regarding beverage before surgery and skin wipes

MST Oakland Support Groups▪Call MST to sign up (510) 752-7149▪ See MST lobby or MST website for fliers!

▪ Partners Group

▪ Trans Masculine / Non-Binary Group

▪ Non-Binary Group

▪ Middle School Group

▪ High School Group

Surgical Techniques

Objectives

❑ REVIEW your surgical options

❑ UNDERSTAND the goals of top surgeries

❑ IDENTIFY possible surgical complications

Surgery Options❑ Double incision❑ Free nipple grafts (optional)❑ Nipple tattooing is possible

❑ Peri-areolar (Keyhole) / Doughnut incision

❑ Buttonhole incision

❑ Inverted T /Anchor incision (reduction)

Identifying Goals

Scarring

Flatness Nipple Sensation

Flatness

Nipple Sensation

Scarring

Chest Defined

Sternum

NippleAreola

Axilla

Clavicle

Subclavian

Intercostal

Supraclavicular

Internal mammary

Lateral thoracic

Chest Anatomy Defined

http://intimatehealthhelp.net/wp-content/uploads/2012/07/breast-anatomy1.jpg

Top Surgery Goals❑ Masculine chest / flat chest / reduced chest size

❑ Minimize chest scars

❑ +/-Reduce and re-position the nipple areola complex (optional)

❑ Gender affirmation

Double Incision with free nipple grafts

http://www.topsurgery.net/procedures/double-incision-top-surgery.htm

Peri-areolar/Doughnut/Keyhole incision

https://www.visageclinic.com/blog/top-surgery-in-toronto/

Inverted T incision/ Reductions

http://www.topsurgery.net/procedures/inverted-t-anchor-top-surgery.htm

• Possible size restrictions based on anatomy• Some patients may need multiple surgeries to achieve

desired size • Inverted T is most typical technique• Nipple grafts are also possible

Buttonhole incision

https://s-media-cache-ak0.pinimg.com/originals/9b/41/98/9b41983fcb5f2150998d8a5ca0cc3463.jpg

Summary of ComplicationsPeri-areolar(Doughnut/Keyhole)

Reduction Double incision with free nipple graft

Bleeding Bleeding Bleeding

Swelling Swelling Swelling

Wound Healing Complications (widened areola, widened scars)

Wound Healing Complications (widened areola, widened scars)

Wound Healing Complications (dehiscence, dog ears, widened scars)

Infection Infection Infection

Loss of nipple grafts

Loss of nipple sensation

Risks of complications in chest surgery increase with smoking

❑ Abnormal Swelling / Bleeding ❑ Sudden swelling or bleeding require urgent medical attention❑ Some swelling and light bleeding can be normal after surgery ❑Drainage of a small or moderate amount of blood-tinged fluid is not uncommon and is not

indicative of active bleeding

❑ Opening of wound along incision line❑ Can result in drainage❑ May require wound care or revision

❑ Scar widening/Dog ears❑ Could occur anywhere along the incision/ two ends❑ Wait for revision❑ Limit activity postoperatively, follow instructions

❑ Infection❑ Increasing redness, pain, warmth, swelling, or drainage with pus at the surgical site

Possible complications after surgery

Other possible surgical outcomes

http://68.media.tumblr.com/536e8de4505faeab479970f577046574/tumblr_inline_nwznigHgip1qesqi5_500.jpg

Widened scars

A note about scar careTalk with your surgeon about recommendations for scar treatment and when to begin

❑ Extended compression (wearing a binder) after surgery can decrease scar widening

❑ Scar care usually starts about 4-12 week post-op when no scab is left on incision ❑ Silicone sheets (check with surgeon about when to start applying after surgery)

❑ Scar massage – gently in small circles to help flatten and soften scars

❑ Steroid injections can be used to treat Keloid scars (thickened, raised scars)❑ Injections given in doctor’s office

Other possible surgical outcomes

Seroma

https://ftmjasper.files.wordpress.com/2010/03/seroma1.jpg

https://i.ytimg.com/vi/JWoYG_B5noQ/maxresdefault.jpg

Possible surgical outcomes

Excess skin/tissue, AKA “Dog Ears”

https://68.media.tumblr.com/fc9a4df5f8244d0446441c01830d4984/tumblr_ntcl5uj7mE1qdnvvro1_500.jpg

Optimizing Recovery after surgery❑ Stop nicotine products prior to surgery

❑ healthy nutrition and body movement/exercise before surgery

❑ Follow all discharge instructions

❑ Attend all follow up appointments

❑ Be in touch with surgeon if you have any concerns about healing

❑ Keep the surgical area clean and dry

❑ Listen to your body and check in with surgeon before resuming activities

Surgery,Recovery and HealingYOUR SURGICAL AND RECOVERY JOURNEY

The Surgery Center❑ Check in early and meet your surgical team, including anesthesiologist.❑Discuss any negative experiences with general

anesthesia with your anesthesiologist and surgeon.

❑ Top surgery/reduction time = 2-5 Hours

❑ Top surgery revision = 1-4 Hours

❑ After surgery: You will recover in the PACU for 2-3 hours. You may feel nauseous, elated, groggy, tearful, thirsty/hungry.

❑ Depending on surgery/surgeon, you will most likely be discharged from PACU.

Surgery Center Discharge❑ Helpful to have a friend or family member present to remember details provided by nurse and surgeon

❑ You may be asked to walk before you feel ready. Walking will help you recover more quickly and help decrease complications.

❑ Main tasks when you wake up are: hydrate, manage nausea, control pain, ask questions, prepare for discharge

Surgery Center Discharge❑ You will need someone to drive you home from surgery. You can’t be discharged without a companion.❑Pillow between your chest and seat

belt is helpful for car ride home

❑ You will need someone to be present when you are given discharge instructions❑ Anesthesia impairs short term

memory functioning

Normal Healing❑ Pain

❑ Swelling: Expect quite a bit of swelling for a few months post operatively. Sudden swelling requires urgent attention.

❑ Nausea/vomiting: Common reaction to anesthesia as well as narcotic pain medications.

❑ Itching: Common reaction to anesthesia as well as narcotic pain medications. Also can be caused by adhesive dressings.

❑ Constipation: Take stool softeners to minimize strain

❑ Sensation changes: It is normal to experience changes in sensation after surgery. Some areas of numbness may regain sensation as nerves regrow (can take at least 9-12 months).❑ Nipple Sensation: Some surgical techniques carry a higher risk of loss of nipple sensation

A Note About Pain❑ It is normal to experience some pain and discomfort after surgery

❑ Stress associated with untreated and excessive pain can prevent healing

❑ While you are in the surgery center, communicate with your nursing team about your pain level

❑Discuss past negative experiences with pain medication or addiction history with your surgeon.❑ DO NOT take NSAIDS (ibuprofen, aspirin, Aleve) without consulting with

your surgeon first

❑ DO NOT take Tylenol in addition to prescribed pain medications as sometimes prescribed pain medications contain Tylenol (acetaminophen)

Discharge and Recovery Summary❑ Discharged from surgery center the same day

❑ What may be on your body at discharge:❑ Sutures

❑ Compression garment or binder

❑ Drains

❑ Bolsters over nipple grafts

❑ Typical healing times❑ First stage of recovery is typically 2-4 weeks

❑ May take up to 6-9 months to feel back to 100%

❑ Follow up appointments (varies by surgeon)❑ Obtain post-op appointment schedule in advance

❑ Arrange rides for doctors visits for the first 3-4 weeks after surgery

Chest Bindero Chest is wrapped tightly in binder in operating room

o Surgeon will instruct you on length of time to wear binder after surgery; Usually 4-6 weeks after surgery; may wear for up to 3 months after surgery

o Compression binder helps to: oReduce swelling and bruising

oPrevent infections

oKeep incision site closed

oReduce scar stretching

o Important to keep in on at all times, including during sleep, until instructed otherwise by your surgeono Okay to take it off to shower after clearance from surgeon

DJ OrthopedicsProCare Premium 3-Panel

Elastic Binder Universal

Drainso Drains may be placed during surgery to help with fluid drainageoHigher BMI, certain surgical techniques and more chest

tissue correlated with drain placement

o Drains operate using vacuum suction and will need to be stripped, emptied, and fluid measured a few times each day

o Drains typically removed at first post-op appointment, usually 1 week after discharge

Modified Activity After Surgeryo Take it easy! o You may be physically able to do things before you’re cleared to restart.

Follow your doctor’s guidelines.

o Lifting / Stretching oNo lifting over your head for 2 to 3 wks; put important items at waist level

o Drivingo Not while on prescription pain meds, be mindful of straining when closing

car doors/trunks

o Sleepingo Sleep on your back in semi-propped position for first few weeks; pillows to

prop knees to reduce strain on lower back

o Exercise o Normal to feel low energy for 3-4 weeks after surgery; can last longero Walking is recommended every day to help reduce blood clots,

pneumonia, and constipation

Sutures / Incision Careo Most sutures are dissolvable and will not require any special care

o Drains held in place with sutures that are removed when drains are taken out

o There may be a few longer lasting sutures in nipple area to keep areola small

o Keep dressings dry (NO SHOWERING UNTIL SURGEONS SAYS OK; 1-2 weeks)

o Do not start scar care treatment until cleared by surgeon

Nipple Graft Careo If nipple grafts, bolsters over nipples usually removed at first

post-op appointment

o After bolsters are removed, gauze over nipples, antibiotic ointments

o Change gauze once or twice a day as directed

Post-Op Visits❑ Typically you will be scheduled for a follow up visit one week after surgery. If you have drains, they are often taken out at this 1 week post-op visit.

❑ You may have a few follow up visits in the first 1-2 months after surgery to check on healing, depending on your surgeon and how you are recovering

Sample Timeline for Surgery Recovery

Go homeSame day

2 weeks1 week 6 weeks

Able to return to work/schoolWith restriction

4 weeks

Mild activity Moderate activity

12 weeks

Increase moderate activity as directed by surgeon

9-12 months

May resume strenuous activity and no work restrictions

Lift less than 5lbs All activity

Helpful Supplieso Pillows o Propping in bed and on couch; under your knees to sleep

o In the Car - place pillow between your chest and your seat belt

o Neck pillow

o Button-up / Zip-up Shirts

o Baby Wipes / Body Wipes / Washcloths / Dry ShampoooMost likely not showering for about 1 week after surgery

o Cetaphil Gentle Cleanser (no water needed)

o Bendy Straws

o Smoothies, Vitamin C, Lots of liquids

Icingo Many surgeons recommend using ice to reduce swelling after surgery

o General guidelines: o Put ice or a cold pack over chest for 10 to 20

minutes at a time.

oIce every 1 to 2 hours for the next 3 days (when you are awake) or until the swelling goes down.

Resuming Activities after Surgery❑ Each person’s healing is different

❑ Listen to your body and if hurts, use caution or stop!

❑ General guideline is wait to restart activities and obtain clearance from surgeon

❑ Best to abstain from all nicotine and not to even be around cigarette smoke for 3 months. If resuming nicotine use, wait at least 3 months and avoid excessive alcohol intake.

A Note About Binding Before SurgerySafe Binding Guidelines:

• Bind for less than 8 hours a day

• Take binder off before you sleep

• Binders are not recommended for exercise – sports tops are recommended for working out

• Never use duct tape or ace bandages • They don’t move with your body and can cause breathing

problems, fluid build-up in the lungs and other injuries like broken ribs

• If it hurts stop, try a larger or different binder • Binders that are too small can also be harmful to the body

Binding Tips:https://transguys.com/features/chest-binding

Binder Varieties and Companies

Bareskin Binders, FLAVNT

Trans-Vormer

Underworks

Cool Mesh Velcro Half Length(Amazon)

Shapeshifters

GC2bSizes XXS – 4XL

Binder Donation Program:http://point5cc.com/chest-binder-donation/

T-Kingdom

Keep in Touch• Multi-Specialty Transitions Department (MST)• 3779 Piedmont Ave G41, Oakland, CA 94611 | PHONE: 510-752-7149

• https://thrive.kaiserpermanente.org/care-near-you/northern-california/eastbay/departments/transgender-care/

• Gender Pathways Clinic• 1635 Divisadero Street, 6th Floor, San Francisco CA 94115 | PHONE: 415-833-8767

• https://thrive.kaiserpermanente.org/care-near-you/northern-california/sanfrancisco/departments/gender-pathways-clinic/

• Gender-Affirming Care at Kaiser Permanente• https://mydoctor.kaiserpermanente.org/ncal/mdo/presentation/healthpromotionpage/index.jsp?prom

otion=transgendercare