• Reference Number: HEY-434/2021
• Departments: Breast Services
• Last Updated: 10 December 2021

Introduction

You will have been given an appropriate referral from the Gender Identity Service, supported by a specialist confirming your diagnosis. The referral confirms that funding is now in place for your surgery. Most of your questions should have been answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but If, after reading it you have any concerns or require any further explanation, please discuss this with a member of the healthcare team.

The surgical team comprises a group of surgeons who all work together to provide the best surgical care for you. It is important that if you decide to have your surgery with us, you are aware of the appointments schedule. You will need to attend all appointments both before and after.

• You will have the initial consultation and then be placed on the waiting list.
• There will be pre-operative assessment prior to the surgery
• A post-operative follow-up at around 10 days for drain  removal, nipple and wound check
• A post-operative follow up at 6 months to assess how the surgery has gone and to discuss if any further surgery is necessary.

You will need to agree to attend all of these visits before we can consider you for surgery.

What is this type of breast surgery?

This surgery is an operation to remove most of the breast tissue in order to help create a flatter chest shape and masculine appearance.

Your initial consultation

You will be seen by the consultant and asked various questions about your general health, as well as being given a physical examination, which will include several measurements of the breast being taken and recorded.  Consent will be required for clinical photography, involving before and after surgery pictures, to complete an accurate visual record.  Each option of surgery will be discussed with you including the risks, advantages and disadvantages of each, as relevant to you.

This consultation provides an opportunity to see pictures of previous pre and postoperative surgery results. You are encouraged to ask questions and discuss any concerns fully with your consultant and understand the potential issues of your surgery. It is important that you have realistic expectations of the final appearance of your chest.

Can there be any complications or risks?

As with all surgery, there can be complications or risks. Your consultant will go through these in detail with you as part of your consultation, we have listed some of these below for your information.  If you have additional concerns regarding risks or complications, please do not hesitate to discuss these with your consultant.

General complications and risks could include:

General surgery risks – bleeding, infection, bruising and scars. Steps are taken to reduce risks, such as injections to help prevent adverse blood clotting; use of compression stockings to help prevent deep vein thrombosis and antibiotic cover.

Haematoma – a collection of partially clotted blood under the skin at the site of the surgery. This may result in a return to theatre to drain depending on the severity.

Asymmetry – this is when both sides are uneven post-surgery. It may be possible to correct this with further surgery at a later date.

Synmastia – this is when the 2 scar lines meet at the central point and results in one long scar. This may be unavoidable, but may possibly be corrected by surgery at a later date

Loss of nipple graft – there is a small possibility that the nipple graft may not take and you may lose your nipple graft. It may be possible to have a nipple reconstruction at a later date.

Bruising – this may cause the breast area to become a little discoloured and may spread down towards the abdomen. Your body will absorb this bruising and rarely needs any intervention but if worried, contact your surgeon.

Seroma – this is a build-up of serous fluid between the tissues and the skin. This fluid is usually absorbed by the body but if it is present in large amounts, it can be uncomfortable. The fluid can be removed by inserting a fine needle and removing the fluid.  This is quite a common procedure undertaken in the breast clinic outpatient department.

Skin necrosis – occasionally the blood supply to the flaps of skin on either side of the surgical incision is inadequate.  This is significantly more common in people who smoke. The skin involved dies (necrotic) and gradually heals by scarring. If this area is quite extensive, surgical removal may be required, although this is not common.

Nipple necrosis –  if the nipple is retained there is a small possibility that the nipple may lose its blood supply and become necrotic. This means that a poor blood supply to this area may result in the loss of some colour and the nipple may not survive. If this happens, it is possible to have a nipple reconstruction at a later date.

Infection – this may occur despite the routine administration of antibiotics. Any signs of redness, heat, discharge or raised temperature needs to be reported to the doctor, consultant or the surgical ward. An earlier follow-up appointment can then be made to attend the ward or the breast clinic outpatient department.

Fat necrosis – this is a condition that can occur under the skin post-operatively. It results in hard lumps forming within the breast area which can be a concern for the patient. The condition is benign (harmless) and does not carry any risk of cancer, however all lumps should be investigated appropriately.

 Scarring – there will be scarring that will gradually fade, varying with each individual. If you do suffer from an infection, this can affect scarring; the scar can become thicker than expected and take longer to fade. Even without any infection, some scarring can become thicker and overgrown due to a condition called Keloid (excessive tissue growth in the wound area). This may require a special silicone dressing in order to help treat the scar.

Nipple sensation – this may be lost completely or there may be some small loss or even increased feeling in the cases of surgery retaining the nipple area. There can be no guarantee regarding this.

Skin sensation – it is quite normal for the skin sensation to change with areas of numbness, tingling, small sharp feelings after surgery due to the normal healing process. Again, this can vary greatly from one individual to another.

What will happen after your initial consultation?

After your initial consultation, you will be placed onto a waiting list. When a suitable date becomes available for your surgery, you will receive a letter with appropriate details including:

• A date for your pre-assessment appointment.
• A date for your surgery, times and where to attend.

 Pre-operative assessment

You will be sent an appointment about 2 weeks before your surgery to attend a pre op assessment. This will be performed by the nursing staff on the breast care unit.

You will have your blood pressure, pulse and temperature recorded along with height and weight.  You will be swabbed for MRSA (routine for all surgical procedures) and blood samples will be taken.  These need to be performed in readiness for your surgery and cannot be performed at your local hospital. At this appointment you will receive all the information about your surgery and recovery so it is important that you attend. We will answer any questions you may have. You will receive your fasting instructions for the day of your surgery. You will be able to eat until midnight and the have clear fluids up until 6am. Make sure you drink plenty prior to your surgery.

Your operation

You will need to take a Covid test 72 hours prior to your surgery. This may be sent to you through the post or you may need to attend the drive through at the hospital. You and your household will then need to isolate from this test until you attend for your surgery.

You will need to attend the ward at 07:30am alone and with your face covered. This will allow time for your surgeon to talk to you, explain the procedure, any risks or complications which may be involved. If you are still happy to go ahead he will ask you to sign a consent form and will mark the area for surgery. The anaesthetist will then review you and ensure that you are fit enough for the surgery. The ward will have a rough estimation of the time of your surgery, so your relative will be able to contact the ward following this.

There is no room for any relatives to stay at the hospital during your surgery so they will need to book into a nearby hotel or Bed and Breakfast.

You will then need to wait for your surgery, which may take some time so you may wish to bring something to read, phone or tablet. When your surgery time nears the ward staff will ask you to put on a surgical gown, this is backless so you will need a dressing gown to put on over it and a pair of soft shoes/slippers as you will walk to theatre. You will also be fitted with a pair of white anti embolic socks which help to prevent blood clots post-surgery. We do advise that you continue to wear these for 2 weeks post-surgery.

The operation is performed under general anaesthesia and involves the removal of most of the breast tissue with the preservation of the nipple and areola (coloured) area, if possible. The particular surgical technique used is dependent on the breast size of the individual patient and initial assessment:

• Liposuction may be used to remove breast tissue via small incisions.
• An Inframammary Fold Mastectomy and free nipple areolar grafts (removal of the breast from the fold underneath the breast) results in a scar along the crease of the skin directly under the breast. The nipples may be completely removed and repositioned. If the nipples are not preserved, both nipple and areola tattoos can be done at a later date.
• A peri-areolar reduction may be used by making a circular cut around the outer edge of the areola, leaving the nipple partially attached. Breast tissue is removed and the excess skin is trimmed. The nipple is then repositioned and a ‘purse-string’ (type of stitch) technique is used to pull the skin around the areola tighter together to close the reduced area.

All of these surgical options will be discussed fully as to which will be the most appropriate for you.

Post-operative

Following your surgery, you will wake up in recovery. This is a high observation area where you will be monitored until you are considered well enough to return to the ward. The staff will perform blood pressure and pulse checks and you may have an oxygen mask on. This will be removed once you have fully recovered from the anaesthetic.

You may have been fitted with a pair of Flowtron boots during your surgery. These are self-inflating bands that go around the lower leg, inflate and help to improve blood flow back up the leg to prevent blood clots. They will be removed once you have recovered. You will need to leave the white socks on.

The nursing staff will ensure that have appropriate pain relief medication but if you experience any pain you need to let them know. You will need to ensure that you have a supply of paracetamol or ibuprofen at home as you may not be discharged with pain relief medication.

You be fitted with a binder in theatre following your surgery. This will be padded with cotton wool and will help to ensure that your suture lines stay flat and are supported post-surgery. This will help to ensure your scars are flat and not raised. You will need to wear the binder for a full 6 weeks post you surgery but you will be able to take it off to wash.

You will have 2 drains following your surgery. These help to prevent any fluid build-up between the tissue and the skin. You will be discharged with the drains, but the nursing staff will ensure that you are shown have to empty and re-vacuum them. You will need to return approximately 10 days post-surgery to have these drains removed. It is important that you attend this appointment as we will check to ensure that your suture line is healing, check your nipple grafts have taken and give you important advice and instructions.

At this appointment we will remove the drains and all dressings. You will need to continue to wear the binder for a full six weeks post-surgery. You will need to buy micropore tape to cover the suture line whilst you have your binder on. This will help to keep your suture line flat and help to keep your scarring to a minimum. We will show you how to apply this and to care for your nipple grafts at this visit. You are not able to drive whilst you have yours drains in so you will need to arrange for someone to bring you to this appointment.

The normal length of stay for this type of surgery is 2 days. You will be reviewed by your surgeon the day following your surgery and if everything is OK and you have had had no problems there may be a chance that you could be discharged at this point. You would have to stay locally, so there would need to be a room in the hotel for you. You are not able to travel until the following day. You would need someone with you for this night. If you are travelling by car, it is advisable to put a cushion or soft pillow under your seat belt for comfort and protection. You still need to wear a seat belt by law. Before you go home your surgeon will advise you of any activities you will need to avoid and give you advice about the type of exercises you will need to perform.

The recuperation period post-surgery normally takes 4-6 weeks. It is normal to have some bruising and swelling, but this will settle within time.  You are able to go out the house and do your normal activates but avoid any heavy lifting and lifting your arms over your head. We do advise that you take some time off work, the length depends on the type of job you do. The ward will be able to provide a sick note. It is not advisable to drive a car in this period, as you will need to have full range of upper body movements and be able to perform an emergency stop. After six weeks you can remove your binder. You will need to continue to use the micropore tape for 3 months post-surgery. You can then start to use bio oil on your scars. At six weeks if everything is healed and healthy you can start to use the gym and go swimming. You can do more strenuous work and drive.

Follow up and further treatments

You will be reviewed at 6 months post-surgery which will allow your surgeon to access how well you have healed and whether any further surgery is necessary. Photographs will be recorded for audit purposes to ensure an accurate record.

The surgeries that may be considered are:

Liposuction – this involves the removal of extra fatty/glandular tissue from the breast/armpit area to help create a flatter contour. This procedure may sometimes be undertaken at the same time as the mastectomy (removal of the breast) or at a later date, when post-operative swelling has subsided, allowing particular areas of concern to be identified and discussed.

Dog-ear – this refers to the possible, puckered appearance of the skin at the end of the scar line, looking like a little flap. This can be removed by a minor operation at a later date.

Nipple reconstruction – a procedure can be undertaken to replace the lost nipple, if not retained, by creating a small lump projecting from the skin on the breast. This could be done at a later date, once the original wound area has healed properly.

Nipple / areola tattoo – the area around the nipple can be tattooed with colour onto the skin, either around an existing nipple or colour shading applied to provide definition of nipple and areola. This procedure can produce extremely realistic results.

Contact Information:

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Breast Care Unit (01482) 622679

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.