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Gender Reassignment Surgery

Gender reassignment Female-to-Male Breast Surgery

Gender dysphoria occurs in 0.3% of the population. The female-to-male (FTM) gender reassignment surgery in our Alameda and Brentwood practice involves removing both breasts: termed mastectomy, with preservation of the nipple areola complex and with the creation of a contoured, male-looking chest.

To learn more about FTM breast surgery, request a  consultation with Dr. Moulton-Barrett.

People undergoing gender reassignment surgery, desire to make their body as congruent as possible with their preferred sex through surgery and/or hormone treatment.

Sex reassignment surgery, along with hormone therapy and real-life experience, has been proven to be effective in persons with transsexualism or profound Gender Identity Disorder (GID). Persons seeking this procedure should have received a letter from their current psychologist and or psychiatrist, in support of their proposed surgery.

Mastectomy Procedures:

There are several FTM techniques for breast surgery. Typically, surgery is performed under general anesthesia, with or without overnight observation at the surgical facility and usually the surgery takes 3 hours or less to complete.

Inframammary Horizontal Wedge Excision with Free Nipple Graft

This procedure is performed if the breasts exhibit significant sagging: called ptosis and / or medium to large sized breasts (full B or greater cup size). A wedge shaped Incision is made horizontally – across each breast, one at the infra-mammary crease and another above the areola. Skin, mammary gland and fatty tissue are removed. Liposuction may be used to remove fatty tissue near the armpits and to create the desired contour. Once the excess tissue has been removed, the excess skin is trimmed and the incision is closed, leaving a single scar at the infra-mammary crease. Usually the original nipples are completely removed, trimmed to a smaller size, and then are replaced as a free nipple graft in position to give a more masculine appearance.

Inframammary Horizontal Wedge Excision with Central Mound Nipple Areola Preservation

Using a pedicle technique, the nipples are left partially attached to the body via a pedicle of tissue. This option is sometimes chosen a. if it is desired to preserve nipple sensation, b.  a larger mound is requested or c. there is a small breast and preservation of the natural skin appearance of the nipple areola is wanted. This procedure requires that the breast tissue with nipple and areola are preserved on at least a 4cm width and 4cm height central mound which is attached to the underlying chest wall. After the mound is created, it is then sutured tightly down to the chest wall. Following this, the skin is tightly redraped over the mound and  the overlying skin is cut out exactly to receive the underlying nipple areola. The advantage is a more natural nipple and areola often with preservation of sensitivity. The disadvantage is that if the original breast is larger than a small B cup, the mound may be perceived as being too big and if it is attempted to further reduce  the mound, nipple areola loss may occur as a result of insufficient vascularity.

Keyhole Incision

The keyhole procedure usually reserved for FTM patients with a smaller breast (cup size B ) who has less breast tissue, and less ptotic breast skin. In the keyhole method, the nipple is left attached to the body via a stalk of tissue in order to preserve sensation.  Once the breast tissue is removed, the incision is closed in the form of an anchor incision and the nipple can be resized and repositioned if necessary.

Periareolar Incision

The periareolar (purse string) method, utilizes a circumferential incision around the areola.  The nipple is left attached via a central pedicle in order to preserve sensation and blood supply. The breast tissue is removed by scalpel and liposuction is used to provide gentle contour around the remaining breast mound.  The areola may be trimmed to reduce its size.  Excess skin on the chest may also be trimmed away along the circumference of the incision.  The skin is the pulled toward the center of the opening and the nipple is reattached.  The nipple may be repositioned slightly, depending on the original breast size.  Because a purse string closure is used, there may be some puckering, depending on the diameter of the skin defect of the chest wall. The scar puckering may resolve over several months after surgery.

Anatomical Considerations in Nipple Areola Complex Positioning In the Male Chest

The male nipple areola complex is slightly oval in the horizontal plane and most often is 2.67cm in longest width.

The inter-nipple distance is most accurately determined using a calculation of 0.21x the chest circumference.

The vertical location of the nipple areola complex is ideally 20cm from the Suprasternal Notch, 18cm from the Mid-Clavicular Line and the lateral border of the areola should touch a tangent from the Axillary Fold to the Umbilicus.

Insurance Criteria of Covered Procedure

Insurance company approval is highly variable not only company by company but also company by State, and even by region within a State for a given company. There are significant ongoing changes in the way SRS is being evaluated by insurance companies as well as changes in the actual diagnostic codes to be used to request authorization for surgery.

For example, the ICD-9 code 302.6 refers to Gender Identity Disorder in children and 302.85 refers to adolescents or adults. The new ICD-10 diagnosis is one code F64.1-F64.9 for Gender identity disorders and insurance guidelines are likely to use the term “gender dysphoria” in the place of “gender identity disorder”, based on anticipated changes in the upcoming DSM-V, expected to be released in 2012.

The criteria for Standard of Care and SRS are supported by evidence-based peer-reviewed journal publications. Several studies have shown that extensive long-term trials of hormonal therapy and real-life experience living as the other gender, as well as social support and acceptance by peer and family groups, greatly improve psychological outcomes in individuals undergoing Gender reassignment surgery (Eldh J, Berg A, Gustafsson M. Long-term follow up after sex reassignment surgery. Scand J Plast Reconstr Surg Hand Surg. 1997; 31(1):39-45.; Landen M, Walinder J, Hambert G, Lundstrom B. Factors predictive of regret in sex reassignment. Acta Psychiatry Scand. 1998; 7(4):284-289).

A study reported by Monstrey and colleagues (2001) described the importance of close cooperation between the many medical and behavioral specialties required for proper treatment of individuals with GID who wish to undergo gender reassignment surgery ( Monstrey S, Hoebeke P, Dhont M, et al. Surgical therapy in transsexual patients: a multi-disciplinary approach. Acta Chir Belg. 2001; 101(5):200-209 ).

One study of 188 subjects undergoing gender reassignment surgery found that dissatisfaction with surgery was highly associated with sexual preference, psychological co-morbidity, and poor pre-operative body image and satisfaction (Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005; 35(1):89-99).

Psychological and Insurance Criteria for Approval of SRS

Ideally a patient who desires SRS should have had a 3 stage approach to achieve their goal. The first is a psychological evaluation to confirm the appropriateness of the request using well-defined criteria see below . The second is a ” real-life test” in which the patient assumes the opposite sex. Some centers defer hormone therapy until one year thereafter. Surgery is deferred until 2 years following contact. There are no well-established protocols to guide the surgical sequence.

Most insurance carriers do not include SRS benefits. In the instance that SRS is a covered benefit, which is stated in the insurance contract, or can be ascertained by calling the carrier and asking for the benefits department, surgery is considered medically necessary when all of the following criteria are met:

I. Member is at least 18 years old; and

II. Member has met criteria for the diagnosis of “true” transsexualism, including:

– A sense of estrangement from one’s own body, so that any evidence of one’s own biological sex is regarded as repugnant; and

– A stable transsexual orientation evidenced by a desire to be rid of one’s genitals and to live in society as a member of the other sex for at least 2 years, that is, not limited to periods of stress; and

– Absence of physical inter-sex of genetic abnormality; and

– Does not gain sexual arousal from cross-dressing; and

– Life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood; and

– Not due to another biological, chromosomal or associated psychiatric disorder, such as schizophrenia; and

– Wishes to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and

III. Member has completed a recognized program of transgender identity treatment as evidenced by all of the following:

– A qualified mental health professional* who has been acquainted with the member for at least 18 months recommends sex reassignment surgery documented in the form of a written comprehensive evaluation; and

– For genital surgical sex reassignment, a second concurring recommendation by another qualified mental health professional * must be documented in the form of a written expert opinion**; and

– For genital surgical sex reassignment, member has undergone a urological examination for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex reassignment includes the invasion of, and the alteraton of, the genitourinary tract (urological examination is not required for persons not undergoing genital reassignment); and

– Member has demonstrated an understanding of the proposed male-to-female or female-to-male sex reassignment surgery with its attendant costs, required lengths of hospitalization, likely complications, and post surgical rehabilitation requirements of the planned surgery; and

– Psychotherapy is not an absolute requirement for surgery unless the mental health professional’s initial assessment leads to a recommendation for psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real life experience (usually a minimum of 3 months); and

– For genital surgical sex reassignment, the member has successfully lived and worked within the desired gender role full-time for at least 12 months (so-called real-life experience), without periods of returning to the original gender; and

– For genital surgical sex reassignment, member has received at least 12 months of continuous hormonal sex reassignment therapy recommended by a mental health professional and carried out by an endocrinologist (which can be simultaneous with the real-life experience), unless medically contraindicated.

* At least one of the two clinical behavioral scientists making the favorable recommendation for surgical (genital) sex reassignment must possess a doctoral degree (e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy.D., or M.D.). Note: Evaluation of candidacy for sex reassignment surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. **Either two separate or one letters with two signatures is acceptable.

Medically necessary core surgical procedures for female to male persons include mastectomy.

Before and After Photos

Before and After of Female to Male Gender Re-assignment Surgery

To find out more about available treatments and procedures, request a consultation with Dr. Moulton-Barrett at one of his Bay Area offices. Board certified plastic surgeon Rex Moulton-Barrett, M.D., offers advanced care and procedures for Bay Area residents. He has offices in Alameda and Brentwood, CA.

To schedule your one-on-one consultation with Dr. Rex Moulton-Barrett



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2070 Clinton Ave, Alameda, CA 94501

(510) 379-7919

1280 Central Blvd, Suite J-5, Brentwood, CA 94513

(925) 350-8752