Female to Male Procedures Miami

FTM and Non-binary Top Surgery

Every transgender patient requires individualized care. We understand that there is no “one story” for a patient’s transition. As such we offer a range of procedures for our FTM and Non- Binary patients.

Dr. Gallagher encourages patients to look through the picture gallery, or bring pictures themselves, to make sure she meets their goals as closely as possible.

Chest Masculinization/Top Surgery

The most common top surgery requested is to create a natural masculine look to the chest. Dr Gallagher will choose the best procedure for your body type with you. There are two main options double incision or Keyhole.

Drain free Double Incision Top Surgery or Masculoplasty^®

At Dr. Gallagher’s practice, we offer a variety of gender affirming procedures to help our patients feel confident and comfortable in their bodies. One of the most common procedures we perform is the Drain-Free Double Incision Top Surgery with Free Nipple Graft or Masculoplasty®. Dr. Gallagher has published on and taught this procedure widely.

What is the Drain-Free Double Incision Top Surgery with Free Nipple Graft or Masculoplasty^®?

This procedure involves the removal of extra breast skin and tissue to create a more masculine (or androgynous) chest appearance. The nipples are resized, reshaped, and repositioned on the chest (if the patient opts to keep their nipples). This procedure requires the removal and replacement of the nipples. Typically, if the patient requests a natural masculine look, we will design the scars underneath the patient’s pectoral muscles. Patients with larger or closely placed breasts may require a single incision across the chest to ensure no lumps are left behind. The sides of the chest are just as important as the front and everything is done to eliminate the “side boob”, avoid dog ears and create a smooth natural look.

Drain Free Top Surgery

A major reason patients travel in from all over the world to have Dr. Gallagher do their top surgery is her innovations in the area of drain free top surgery.

Drains can cause a lot of confusion. Most surgeons still place them for double incision type top surgery. Are they really needed?

Why are drains placed anyway?

Drains are placed to get rid of fluid (serum) that your body produces whenever a space is made (in this case where the breast tissue has been removed). If that fluid is allowed to collect in there it will cause swelling that can take a long time to go away and may get infected.

What are the downsides of placing drains?

Patients hate drains with many patients complaining that they are the most uncomfortable part of the process.

If drains are placed, they must stay in until they stop draining which is usually about a week (or longer!). It can be annoying having them hanging out of the chest till then and make showering difficult or impossible.

Getting the drains out can be uncomfortable and requires an extra trip to the office.

Drains aren’t fool proof – if they accidentally come out too early or fall out the space is still left behind which can lead to seromas anyway.

If drains are left in for a long time, it is thought that bacteria can “crawl” up there and cause infections. For this reason, most surgeons will keep patients on antibiotics while the drains are in. Antibiotics can cause their own problems such as diarrhea and fungal infections.

How does Masculoplasty / drainfree surgery work?

If there is no space left behind there is no need to place a drain. To simplify we get rid of the space by using a technique of placing multiple internal stitches to “tack down” the tissue and eradicate dead space.

This technique has been shown to essentially eliminate the risk of significant seromas and also decrease the risk of hematoma in Dr. Gallagher’s scientific publications.

With Drains

Without Drains

The Procedure: The patient is put under general anesthesia for the two to three-hour surgery (some patients will add on another procedure which can lengthen the time in the OR) . The nipples are removed, breast tissue is removed, and then the masculinized nipples are repositioned on the chest. A special dressing called a bolster is sewn into position to reattach the nipple.

Post-op: Most patients leave the hospital or surgery center shortly after the surgery. We encourage out of town patients to stay in the area for at least the first 24 hours after surgery. Many patients stay for about 7 days. A binder is worn to help with swelling, and patients return a few days later to have the bolsters removed. Antibiotic ointment and band-aids are required until the nipples are healed. We go into a lot of detail with this and scar care recommendations at the first visit.

Pain: We use various techniques to reduce pain, including a pain management plan, no drains, and lots of numbing medication. Most patients rate their pain at no worse than 4/10 for the first few days.

Nipple Sensation: While patients may not initially have sensation in their nipples, about 80% of patients eventually regain sensation, though it may not be as sensitive as before.

Recovery Time: Most patients can return to work within one to two weeks, depending on their job’s physical demands. No strenuous upper body workouts are allowed for six weeks, and the binder is typically removed after one week.

If you’re interested in the Drain-Free Double Incision Top Surgery with (or without) Free Nipple Graft or Masculoplasty®, contact Dr. Gallagher’s office for a consultation.

High Body Mass Index Patients

In an effort to be as inclusive as possible we do not have an absolute cut off BMI requirement for patients who are interested in undergoing top surgery. Sure, in an ideal world a patient should not be obese before surgery. This however is not always possible and it’s Dr. Gallagher’s  philosophy that often times the benefits of surgery outweigh the risks. These benefits not only include relieving dysphoria but also the physical problems such as back pain and binding problems. Dr Gallagher specializes in providing top surgery to higher BMI patients and ensuring safe and natural results. Masculoplasty – Dr. Gallagher’s drain free technique has been proven safe in higher body mass index patients and she has published on this. With the upmost regard to your safety, we will do our best to accommodate all body types.

Often patients with higher BMIs may require the scar to go all the way across the chest and out to the sides in order to avoid un-natural looking lumps or “dog-ears”.

When we are removing larger amounts of tissue some patients may understandably have a slightly longer recovery and therefore a few extra days in the area may be a good idea.

Patients with a BMI of over 45 will need to have surgery in one of our facilities that allows an overnight stay. All patients with sleep apnea should bring their CPAP machine on the day of surgery.

Recovery from top surgery

As a general rule I tell patients that they won’t feel back to normal for about 6 weeks after top surgery. Even though there are less incisions keyhole requires longer binding and can, even though there are less incisions to heal, feel like a longer recovery. For both surgeries it can take a few months to start seeing the final results as there will be a lot of swelling and nipples in particular can look very strange initially.

In the first few days after surgery patients typically won’t want to move their arms round much and will be acting like a “T-rex”.

Lifting and Mobility

Patients will be able to move around the house, feed themselves and go to the bathroom but any sort of heavy lifting is out. No more than 10lbs is recommended. Listen to your body it has a great built in warning system, if it hurts, don’t do it.

Most patients feel exhausted and “gross” in the first couple of weeks after surgery.

Driving

In order to drive the patient must be completely off narcotic medication and able to make sudden movements. For most folks this is at least a week but more commonly 2.

Sleeping Position

As long as it’s comfortable the patient’s sleeping position doesn’t matter too much. Many patients will prefer sleeping on more pillows than usual or even in a recliner. Sleeping on the back for the first couple of weeks is typical and then slowly side sleeping can be re-introduced. Belly sleepers find this time of recovery toughest. The rule is just sleep whatever way is comfortable.

Work

The soonest folks return to work would be one week after surgery but typically 2 weeks are needed. If heavy lifting or a lot of reaching / strenuous activity is part of the job up to 6 weeks may be needed off work.

Working Out

Gentle walks are a good idea in the first few days after surgery but remember you will get tired quickly. Lower body low impact work outs can usually begin about 2 weeks after surgery and patients are released to regular working out at 6 weeks. Patients who avoid overhead (shoulder) exercises for 6 months after surgery seem to have better appearing scars so if that’s an option, I encourage patients to do that.

Compression

After Masculoplasty patients require compression for just one week or less after surgery. We prefer patients to wear it 24/7 to decrease swelling however breaks are of course allowed. If you hate it we can get rid of it immediately.

Showering

It’s up to the patient’s surgeon when showering is allowed. Sometimes patients have to wait a week or more (for drains to come out).

In our practice both keyhole and Masculoplasty patients have waterproof dressings underneath the compression vest so whenever they feel strong enough a shower is possible. For most this is 2 days after surgery.

The Months after Surgery

In the weeks and months after surgery patients will often have larger areas of numbness over the chest. As a general rule these areas of numbness will shrink over the first year so that everything begins to feel normal again. Sensation will come back in the nipples typically also during this time. Some patients will notice weird sensations in the chest during this time such as “lightning bolts” of pain that vanish quickly. We attribute this to the nerves “waking up”.

Key-hole surgery

What is it?

This is for patients with small breasts who want to avoid scars. A small (approx. 1 inch) incision is hidden in either nipple and the breast tissue is removed through this. Liposuction may be used also. if the nipples are large they may be reduced in projection at the time of surgery at a later date to masculinize them. This surgery doesn’t do anything to get rid of extra skin so the patient needs to be small chested to begin with and relies on the elasticity of the chest skin to shrink down. Wearing a binder is extremely important and needs to stay on six weeks after surgery to help with this.

The Procedure

This takes about two to three hours and is usually done as an outpatient.

What then?

The patient wears a binder 24/7 or as much as possible for six weeks after surgery. The stitches are all dissolvable.

How painful is it?

We use a lot of techniques to cut down on the patient’s pain. Firstly we can safely do the surgery with no drains. Secondly we use a lot of numbing medication. Most patients rate their pain at no worse than 4/10 for the first few days.

What is the recovery like?

Most patients are back to work in one to two weeks depending on what work they do.

Top Surgery Revisions

We welcome patients who have had their original surgeries elsewhere. There are a range of problems we can help patients with to align the appearance of their chest better with their transition goals.

• Scar revisions – unfortunately the greatest predictor of how patient is going to heal in the future is how they have healed in the past. However we can often get improvements by removing scars – especially in the case of “train-track scars”.
• Nipples in the wrong place– this can be a tricky one to fix but in some patients we can move one or both nipples if needed. In cases where the nipple is way off we can take it off and graft it back on in a more appropriate place.
• Nipples too big– it is possible to masculinize the nipple.
• Nipple Removal– Nipples aren’t for everyone and they can be easily removed in exchange for a short scar.
• Loose skin – Patients are advised to wait at least six months as the appearance of the chest will continue to improve after surgery. (This is especially true in key-hole procedures). But removing a lot or a little extra skin is usually straightforward.
• Chest unevenness– in some patients we see a “sunken in” appearance on one or both sides of the chest. It is sometimes possible to fill in one or both sides with the patient’s own fat to correct this.
• Dog Ear excision– in some patient’s breast tissue may extend round the sides and back – they can be left behind with lumps after the first surgery – these are usually easily removed.
• Too much tissue left behind– this can be a common problem when the patient has had a breast reduction at the first surgery, instead of top surgery. This is usually easily converted into masculinizing top surgery. Sometimes we see patients who have had keyhole surgery but still have too much tissue left. Sometimes a patient will do well with a revision, via the small incision, or otherwise we can convert to a double incision to get a better appearance.

What to Expect with Top Surgery

Consultation

Depending on the time of year we can usually get you scheduled for a consult within a couple of weeks. Any consult fees will go towards the cost of surgery if and when you decide to schedule. The first consult is usually virtual. Beforehand we will gather some information about your health which we talk about in the first part of the consult and then we talk about surgery and your goals. Consults are never anything to be nervous about! We like to keep the mood light and friendly.

What’s Next?

After the consult we will reach out to you via email usually with a quote as well as information about financing, insurance and timing.

Depending on the time of year, the wait list can sometimes be just a few weeks.

Next a date is set the patient will need to consult with their own doctor for any health checks.

Nonbinary AFAB Top Surgery

What is affirming to a patient is such a personal choice and therefore Dr. Gallagher offers a range of different choices. Folks can choose from different techniques in order to get a result that is as affirming as possible.

With “masculinizing” top surgeries patients may choose a size or position of nipple that is not typical for a binary male chest.

Some other examples of “alternative” top surgery options include:

Nipple Free Top Surgery

Most patients coming for top surgery will know exactly how they feel about having nipples or not. About 15% of my patients have dysphoria surrounding their nipples and the more affirming procedure for them is just to create a nipple free chest.

If this is a well thought out choice this is of course very reasonable.

Some patients prefer to get 3-D tattoos instead of nipple grafts. This allows them to control exactly the size and position of the nipple with the artist – which isn’t possible in the operating room. If a patient does decide to go nipple free – this is a simpler procedure, and the recovery is more straight forward as there is no nipple care involved.

“Non-flat” Top Surgery

It is critical to remember that a flat “masculinized” chest may not be the goal for everyone. It is very important that patient and surgeon decide what would be most affirming for the individual. As such Dr Gallagher can certainly offer other options. An example of this would be a radical reduction in the breast size but not removing as much breast tissue as in a typical masculinizing procedure so that the patient still has some breast mound. The same thing goes for the size and shape of the nipples – we do not have to stick to the typical “male” nipple dimensions.

Non-flat top surgery can be done with the same scars as regular double incision top surgery – usually designed to be underneath the pec muscles however we leave behind “mounds” which can vary in size according to the patient’s preference. This can be done with or without the nipple.

According to the patient’s preference we can do a breast reduction – designing a smaller but still “feminine” shaped breast. Genderfluid patients may opt for this to facilitate easier binding. This is usually done with an anchor shaped scar.

Getting Rid of Extra Upper Abdominal Tissue at the Time of Top Surgery- Masculoplasty Plus

Some patients may carry a lot of loose skin or tissue at the top of the abdomen because of weight loss or just the way their anatomy is. It can be disappointing if we remove the breasts at top surgery only to expose this extra tissue.

It is often possible to get rid of this extra tissue at the same time as top surgery with no extra incisions. This is essentially a reverse tummy tuck which will help somewhat smooth out the rest of the belly.

For this surgery, Dr Gallagher designs the incisions to remove the extra tissue and still land the incision in the crease underneath the pectoral muscles as we usually do.

Who is a Candidate?

Patients who are undergoing double incision top surgery and have loose skin or extra tissue at the top of the abdomen. Often the scars must meet in the middle of the chest, so we don’t leave any lumps of chest or belly skin there.

What is Involved?

This usually adds a little bit of time to your top surgery which takes approximately 2 hours. Some patients notice a little bit of extra discomfort as compared to regular top surgery, but most don’t notice a difference as we use extra numbing medications. Most return to work or school in 2 weeks and strenuous activity in 6-8 weeks.

FTM Bottom Surgery options

Metoidioplasty

 

What is it?

At this time Dr Gallagher does not offer urethral lengthening. This is a procedure where we use the patient’s clitoris which has been enlarged after the effects of testosterone. This can be made into a small penis and the labia re-designed to form a scrotum. At a later surgery testicular implants may be placed.

Is this the procedure for me?

Usually the penis made from the clitoris is not big enough to be used for penetration. The surgery is best done when the full effects of testosterone are seen on the clitoris – this usually means two years of testosterone before surgery. Often this procedure can be combined with a mons lift which brings the penis closer to the front of the body. It can be done with or without the creation of a scrotum and placement of testicular implants.

What is the recovery like?

Usually this procedure takes 2-3 hrs and can be done as an outpatient procedure. Because we are not doing urethral lengthening usually a catheter is not needed for recovery. Most patients return to work in about 2 weeks.

Phalloplasty

Dr Gallagher at this time does not offer urethral lengthening.

What is it?

In order to create a larger penis skin and tissue need to be brought in from elsewhere in the body. This usually involves the use of a “flap”. This is called microsurgery. A range of phalloplasty options are available. Some patients will opt to just have the penis created, and keep their anatomy unchanged so that they are urinating from below. Dr Gallagher specializes in non-microsurgical options for phalloplasty using the extra tissue from the abdomen or the thigh. These can be often done as an outpatient and can be much more affordable than some of the other techniques.

Most commonly the tissue taken to create a new penis is from the fore arm, thigh or back.

Is this procedure for me?

Phalloplasty is major surgery and unfortunately comes with some possible complications. If urethral lengthening is not important to you then Dr Gallagher may be the right surgeon for you. Depending on the patients needs more than one surgery may be required.

What is the recovery like?

Most patients can be off work about six weeks. Often a few surgeries are needed depending on the patient’s goals.