Visible Man
Jamison Green offers a man's POV on life in the trans lane. Opinion,
advice, and information from an internationally respected leader of the
FTM community.
Under the Knife -- Part 1
Surgery for transsexual people is sometimes a hotly contested topic. Or
it's
easily dismissed out of hand. Viewed from the TS perspective as a
necessity,
from the outside it's seen as elective or cosmetic at best, mutilation
or
delusional at worst.
Most people who have come to terms with their own bodies, especially if
they
enjoy their genitalia, can't imagine letting even a trained,
board-certified
plastic surgeon anywhere near that good thing. The idea that someone
else
would want to have his or her body reconfigured in such an
intimate way can
seem pretty incomprehensible, if not downright abhorrent. Some people
think
it's such a crazy idea that it's not even worth thinking about, let
alone
discussing. But for those of us who can only change our bodies or else
face
stagnation or death, there is still a lot to consider before we go under
the
knife. And most transsexual people don't even have all the choices
our detractors think we have.
Many transsexual people cannot afford surgery. In the United States
there have been some instances of Medicare or state medical programs
paying
for TS surgery, but this is far from routine. Most insurance plans have
specific exclusions for transsexual treatments, so transpeople must pay
in
cash, up-front, or arrange for credit with the hospital or clinic. Some
people with high credit limits may be able to use plastic.
At least in the United States it
is possible (in most states) to get identification in the "new" sex,
including a revised birth certificate and (at the federal level) a
passport.
In some other countries, TS surgery is illegal and surgeons who try to
help
transpeople may be imprisoned along with the transpeople themselves. In
still other countries, notably the U.K., Scandinavia, the Netherlands,
and
Germany, TS surgical procedures are provided under national health
programs, though options may be limited. But in many of these
countries (and in Japan, where individuals must pay their own costs),
it is impossible for transpeople to obtain legal recognition of the
"new"
sex. In these countries where the identification of TS people is always
in
conflict with their identity and appearance, transpeople may be at
increased
risk of harassment and attack.
There are transsexual people who elect not to have surgery, and others
who
are precluded from having surgery due to preexisting medical conditions
or
deeply held religious beliefs. None of these factors -- economics,
medical
conditions, or religious beliefs -- invalidates a transsexual person's
identity. In other words, it isn't having surgery that makes someone a
"real"
transsexual.
There's no such discrete thing as a sex change operation for FTMs.
Transsexual men usually (but not always) want a male chest and male
genitalia. This usually means at least two, often more, trips to the
operating room. The order in which the procedures may be completed can
vary,
but it is common for transmen to have chest reconstruction as their
first
surgery unless a hysterectomy was required previously. Genital
reconstruction is usually last, unless a hysterectomy was avoided
previously
and becomes necessary later.
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.
Transmen having chest reconstruction in the United States can expect to
pay between
$1,500 and $8,500 depending on the region, the surgeon's fee
structure, and the cost of the operating room, the anesthesiologist, and
after-care. Expect to be completely incapacitated for 24 hours,
and try to have someone available to help you. The worst pain is during
the
first 48 hours, especially immediately after awakening at the hospital
or
clinic. Before you go in for surgery, move some food and food
preparation
materials to the countertop so you don't have to reach up or down to get
at
it. Do the same for soap and shampoo. It's a good idea to keep your
elbows close to your sides for at least four days, and don't strain the
arm
or chest muscles for at least six weeks. Time off work is usually two
weeks,
but if complications ensue, up to six weeks off work may be necessary.
Jogging may be resumed at two weeks post-operatively, and weightlifting
at
three months. And with the bilateral incision method it takes at least
six
months to heal up enough to get a real sense of the final results. Scars
do
fade over time.
With either technique results can vary widely. There are no guarantees
when
it comes to surgery. But even with the relative lack of complications in
chest reconstruction, I have seen some truly horrible results, even with
surgeons who have done many FTM procedures. Factors that may contribute
to poor results include poor patient
health, stress, smoking, overweight conditions, and tendency to keloid
(the
formation of thick, ropey scars, very common in dark skin types, but
occurring
in light-skinned people, too). The surgeon can have a bad day. One never
knows. Many plastic surgeons are able and willing to perform chest
reconstruction procedures, but there are very few who will attempt FTM
genital reconstruction. I'll discuss genital techniques next month.
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