Top Surgery for Transgender Patients

According to a 2011 study by the Williams Institute, it is estimated that  700,000 people in this country identify as transgender. However, according to more recent federal and state data, that statistic is probably closer to 1.4 million or higher. Plastic surgeons such as Dr. Patricia McGuire of St. Louis, MO are definitely seeing a significant increase in transgender patients coming in for gender reassignment surgery.

While it is important to find a surgeon who has experience working with transgender patients, you also want someone who understands that every patient is unique. Dr. McGuire discusses some of the things that need to be considered when working with these patients.

What is Transgender?

People identify as transgender when their external anatomy does not match their gender identity. While biology, in the form of chromosomes, hormones and anatomy, determines our sex at birth, gender is different. For patients who are transgender, their sex and their gender do not align. They often describe themselves as having been born in the wrong body. To further confuse matters, gender has nothing to do with sexual orientation. Someone who is transgender can be gay, straight or bi-sexual.

There is also a spectrum of gender, from cis-gender, patients whose gender identify aligns with their biological sex; non binary, or gender non conforming, who don’t completely identify as one gender or another, to transgender. Gender non conforming patients also require individualized treatment plans to make them comfortable with their anatomy.

Treating Transgender Patients Requires Specific Skills

While shows such as “Transparent” and “Orange is the New Black” have helped to raise awareness and make being transgender more acceptable, transgender patients who finally find themselves in a plastic surgeon’s office have often undergone a long, and many times, painful journey to get there. They have typically endured:

• the emotional trauma of “coming out” to their family and friends
• the legal hassle of changing their name
• the physical ups and downs of starting hormone therapy

Because transgender patients are dealing with change on so many levels and are often misunderstood, it is paramount that your plastic surgeon have specific training in dealing with these issues. For example, Dr. McGuire is a member of the World Professional Association of Transgender Health (WPATH). She not only follows WPATH’s guidelines and criteria in both the treatment and management of her transgender patients, but her staff is trained as well. This helps to make the experience positive for everyone.

The wonderful thing about treating a patient who is transgender is once the surgery is complete and that patient’s external and internal bodies are aligned, “these patients are some of the happiest patients that we have,” explains Dr. McGuire. “Seeing these patients accept themselves and move on with their lives has been among the most gratifying patients that we’ve dealt with in our practice.”

Patients Are Diverse, So Then Are Surgeries

Each patient who comes in for gender reassignment surgery is unique. Their needs are individual and diverse which means that the surgeries need to be diverse. Plastic surgeons who work with transgender patients need to be acutely aware of tailoring the surgeries to each particular patient’s individual wants. For example, in a patient who is trans-male or going from female to male, a surgeon needs to examine your anatomy. Do you have a lot of excess skin on the chest that will need to be removed? Are you concerned with maintaining sensation in the nipple? Do you want to be able to go outside without a shirt? In short, what are your goals?

The most common procedure that Dr. McGuire performs in her trans-male patients is a double incision free nipple graft. In this procedure, the breast tissue is excised through a scar in the lower portion of the chest. The nipple and areola are both removed, reduced in size for a more male appropriate contour, and then placed back on the chest as a skin graft. The end result is a flat, male chest. While this procedure does result in a fairly significant scar, most patients, at a year or more post op, are completely comfortable changing their clothes at the gym or going out without a shirt.

This surgery allows them to be normal which is always the goal with transgender patients. With patients who don’t want a scar, surgeons can place the incision in the areola. However, this is really only effective for patients who do not have a lot of extra skin, and can simply have the breast tissue removed through a small incision. For patients who want to retain nipple sensation, surgeons will leave the tissue attached underneath the nipple, but those patients must understand that they will not achieve a super flat chest.

The most popular procedure for trans-women patients or those going from male to female is a breast augmentation. While this is a procedure that plastic surgeons routinely perform, “it is different in transgender patients. The anatomy is a little bit different. The chest wall can be different,” explains Dr. McGuire. Surgeons have to make accommodations for these differences when choosing an implant. Bottom line, it is important for patients to see a board certified plastic surgeon who is experienced and trained in dealing with transgender issues.