Susan's Place Transgender Resources

Hi, guys. Apologies in advance if it's weird to launch into a post like this without a proper introduction first, I keep trying to write an introduction forum post and it's very difficult for me. Not sure why, or how to get past that.

Basic info in case it's helpful to the situation: haven't legally changed my name yet or gone on HRT, so unless a surgeon is already in the know about trans issues, they're probably just going to see a female who wants their breasts removed if I don't tell them otherwise. (Trying to figure out if wearing a binder to a consultation would be a bad idea - "Yes, I'm sure I want a flat chest, I've experienced it on a temporary basis and want it permanently, all the time, forever and ever")

I'm not talking about chest contouring like Dr. Garramone and other top surgeons do (nothing against their work at all, it looks great, it's just not my personal first choice). Just a simple mastectomy leaving a flat chest, no nipples, just scars. The first time I saw a photo like that blew my mind. Cue the cliche choir music, "Nothing there at all - you can do that?? Sign me up!" It'll look about the same under a shirt anyway and I don't want to take my shirt off in public.

I'm pretty sure there would even be surgeons within a reasonable drive's distance who can perform bilateral mastectomies so that simplifies things a lot, not having to fly anywhere. The only issue is, how difficult it might be to find a surgeon willing to do it since I don't have cancer, or a known high genetic risk, or anything like that. If I'm willing to sign some sort of informed consent waiver that says I won't sue them for this later, how hard do you think it'd be to find someone to do this? How do I even ask? Do I go to my doctor and ask for a referral to somebody who does mastectomies, or just start calling up local plastic surgeons and ask their offices directly?

Any thoughts or experience on this would be appreciated. Thank you.

Expressing your positive thoughts on having no nipples and just scars might send some red flags up, so you probably shouldn't mention that for fear of scaring the doctor away. I understand where you're coming from but it's not a normal look and naturally a doctor might be a bit weirded out by that.

Anyway, you can probably just go to your primary care provider/usual doctor and ask for a referal for a breast reduction. I attempted this route and explained to the surgeon that I wanted as flat a chest as possible so much so that there was almost nothing there. He told me he could do it and explained the process which sounded exactly like regular top surgery (two long scars, cutting off and resizing the areola and nipples, etc.). I'm not sure if he had experience with trans patients and understood what I was asking without me being specific or if more women than I assumed come in with the desire for an extremely flat chest, either way, I'd say this is a better course of action; especially if dealing with insurance. My insurance turned me down but I feel like it had a lot to do with the secretary who handled the paperwork at the surgeons office more so than the doctor not providing adequate reason for a reduction. So you could always try that method. Just remember that the way you phrase things has a lot to do with how a doctor may view your request, so calling it a reduction and requesting they make it as flat as possible without throwing in any comments that might make them think twice (ex: mentioning your trans) might yield you some good results.

Quote from: ttim0324 on October 31, 2013, 10:19:10 PM
Expressing your positive thoughts on having no nipples and just scars might send some red flags up, so you probably shouldn't mention that for fear of scaring the doctor away. I understand where you're coming from but it's not a normal look and naturally a doctor might be a bit weirded out by that.

Not necessarily.  Some surgeons do the initial surgery without nipple grafts and construct them at a later date.  It could be implied to the surgeon that the OP wants to go that route, even if he knows he won't go back for the nipple reconstruction.

Quote from: ttim0324 on October 31, 2013, 10:19:10 PM
Anyway, you can probably just go to your primary care provider/usual doctor and ask for a referal for a breast reduction. I attempted this route and explained to the surgeon that I wanted as flat a chest as possible so much so that there was almost nothing there. He told me he could do it and explained the process which sounded exactly like regular top surgery (two long scars, cutting off and resizing the areola and nipples, etc.). I'm not sure if he had experience with trans patients and understood what I was asking without me being specific or if more women than I assumed come in with the desire for an extremely flat chest, either way, I'd say this is a better course of action; especially if dealing with insurance. My insurance turned me down but I feel like it had a lot to do with the secretary who handled the paperwork at the surgeons office more so than the doctor not providing adequate reason for a reduction. So you could always try that method. Just remember that the way you phrase things has a lot to do with how a doctor may view your request, so calling it a reduction and requesting they make it as flat as possible without throwing in any comments that might make them think twice (ex: mentioning your trans) might yield you some good results.

I've heard that sometimes insurance requires a surgeon to report exactly how much tissue was removed vs how much was left, making it harder to request that you be taken to total flatness.

Quote from: wheat thins are delicious on October 31, 2013, 10:27:00 PM
Not necessarily.  Some surgeons do the initial surgery without nipple grafts and construct them at a later date.  It could be implied to the surgeon that the OP wants to go that route, even if he knows he won't go back for the nipple reconstruction.

Walking into a surgeons office and saying "I think scars and no nipples looks great because I dont plan on ever taking my shirt off in public" isn't a good way to get them to take you seriously. I know sometimes people aren't judgmental, but most of the times they are. Also not sure if you can request the nipple grats be done at a later date or if the surgeon would honor that request. I doubt OP would want to bounce around to multiple offices in the case of the latter. After all, it is in a doctors rights to refuse service.

QuoteI've heard that sometimes insurance requires a surgeon to report exactly how much tissue was removed vs how much was left, making it harder to request that you be taken to total flatness.

If OP has a larger chest there should be absolutely zero issues in regards to how much tissue is removed. How much is left is up to personal preference. This is assuming they're dealing with insurance.

Quote from: ttim0324 on October 31, 2013, 10:44:24 PM
Walking into a surgeons office and saying "I think scars and no nipples looks great because I dont plan on ever taking my shirt off in public" isn't a good way to get them to take you seriously. I know sometimes people aren't judgmental, but most of the times they are. Also not sure if you can request the nipple grats be done at a later date or if the surgeon would honor that request. I doubt OP would want to bounce around to multiple offices in the case of the latter. After all, it is in a doctors rights to refuse service.

The OP can specifically seek out a surgeon that does such procedures, not just bust in an office and say "I think scars and no nipples looks great because I don't plan on ever taking my shirt off in public," where did you get such an implication from my post?  And no it's not nipple grafts that are done at a later date, it's construction of nipples from scar tissue that is the typical procedure in such and even that nipple grafts are opted out of in the initial surgery.  If the OP were to go to a surgeon who typically does surgery for trans men, lack of nipple grafts is not uncommon.  There are plenty of guy out there who opt to not have nipple grafts and instead go back at a later date to have nipples constructed from scar tissue, opt to not have nipple grafts and instead get surgical tattooing to create nipples and areolas.  It's not unheard of, and if the surgeon is reputable and knows their stuff they shouldn't have an issue with it and it certainly shouldn't "raise red flags" as you put it.

My insurance covers the top surgery but not putting the nipples back on. I'm sure a surgeon would understand that you don't want to pay extra for nipples. Medalie is charging me $500 for the nipples.

Where are you located?

Dr. Steinwald in Chicago will respect your decision to not put nipples on. You will be paying at least $8400 though. More if you are a big person. He does informed consent, no letter needed.

I'm no expert but those with the BBRCA1 and BBRCA2 gene have a high risk of cancer and it is better to get them boobs removed. It's not a matter of if, it's a matter of when. I believe the testing for that can be a couple hundred dollars though. http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA Something to ask around about.

Call up your insurance and give them these codes. "The codes for the surgery will be simple mastectomy and nipple reconstruction (CPT 19303, 19350) and the diagnosis codes will be gender identity disorder (ICD-9: 302.85)" Least then you know if it's covered. Then you can worry about a letter which is pretty much a guarantee from Dr. Graham for $320. From there is finding the surgeon that accepts insurance if it is covered. That's from Medalie's site.

Oh another point that I just remembered. Some guys opt to have the nipples tattooed on later. You could say that's the plan due to risk of nipple death and all that.

Quote from: Alexthecat on November 02, 2013, 09:12:47 AM
I'm no expert but those with the BBRCA1 and BBRCA2 gene have a high risk of cancer and it is better to get them boobs removed. It's not a matter of if, it's a matter of when. I believe the testing for that can be a couple hundred dollars though. http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA Something to ask around about.

Call up your insurance and give them these codes. "The codes for the surgery will be simple mastectomy and nipple reconstruction (CPT 19303, 19350) and the diagnosis codes will be gender identity disorder (ICD-9: 302.85)" Least then you know if it's covered. Then you can worry about a letter which is pretty much a guarantee from Dr. Graham for $320. From there is finding the surgeon that accepts insurance if it is covered. That's from Medalie's site.

Oh another point that I just remembered. Some guys opt to have the nipples tattooed on later. You could say that's the plan due to risk of nipple death and all that.

I'll have to look into that as well. Planning on doing something similar (no nipples), though I'm still trying to stick with FtM top surgeons for this.
You can easily find more than enough reasons for not wanting to keep the nipples, and tissue death is just one. Bring up a list of those and hopefully there shouldn't be a problem with convincing somebody you're certain that you don't want the nipples reattached during surgery.

Don't expect to actually spend less. I think that's the expectation for guys that post this. They reason, this is less expensive because more of them are done and they just rip off trans guys and so on. Except its not really true. Mastectomies actually cost MORE. They are trying to get cancer and work to take everything. They expect to be covered by insurance. They expect other things than surgeons who preform top surgery. But what they are expecting isn't less important, it's really more important as it is life and death. (Well top surgery can be, talking more of the immediate thing.) There may be some doctors who would be willing to go the no nips route, I think that's your best route. BTW, I have read average figures for mastectomy at 10K. I also wouldn't think that doctors performing this would typically be sensitive re: trans guys.


--Jay

Quote from: blink on November 11, 2013, 08:00:43 PM
If it doesn't work out, then I'll go to a top surgeon who accepts informed consent.
Speaking of, for anybody else who might need to find a doctor who doesn't require a therapist letter, in addition to Dr. Steinwald in IL there's also Dr. Mangubat (Seattle, WA) and Dr. Gary Lawton (San Antonio, TX). Possibly Dr. Sherman Leis (PA) too, their site says HRT and "mental health clearance" not required for chest surgery.
(I've been making a list, yeah, haha)

Heh. Oddly enough, I've been planning to ask about Dr. Steinwald on the forum. Thank you for listing these folks, it's good to have more options.

Quote from: Alexthecat on November 02, 2013, 09:12:47 AM
I'm no expert but those with the BBRCA1 and BBRCA2 gene have a high risk of cancer and it is better to get them boobs removed. It's not a matter of if, it's a matter of when. I believe the testing for that can be a couple hundred dollars though. http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA Something to ask around about.

Call up your insurance and give them these codes. "The codes for the surgery will be simple mastectomy and nipple reconstruction (CPT 19303, 19350) and the diagnosis codes will be gender identity disorder (ICD-9: 302.85)" Least then you know if it's covered. Then you can worry about a letter which is pretty much a guarantee from Dr. Graham for $320. From there is finding the surgeon that accepts insurance if it is covered. That's from Medalie's site.

I don't think the BRCA test is that cheap, and then if you are negative (odds are you are) then you have just put out a few hundred to thousands of dollars (just because it's just a blood test doesn't mean it's automatically cheap). I think other options here sound better. Including the one in this post.

--Jay

Quote from: blink on November 11, 2013, 08:00:43 PM

You're right, surgeons performing mastectomies probably wouldn't be familiar with trans issues, but I'm not going to tell them I'm trans. Unless they're knowledgeable enough to ask me if this is trans-related I won't even have to lie - I'll tell them that I have a family history of breast cancer (true), want the risk minimized/removed (also true) and am not interested in a breast reconstruction (so very true). There are enough cis women out there in that position that hopefully it should make sense to them.

Are you wanting a male contoured chest?  I don't believe a surgeon who is doing a preventative mastectomy is going to contour your incisions in the same way a top surgeon or someone who knows you are trans is going to contour is. 

Quote from: wheat thins are delicious on November 12, 2013, 12:27:55 AM
Are you wanting a male contoured chest?  I don't believe a surgeon who is doing a preventative mastectomy is going to contour your incisions in the same way a top surgeon or someone who knows you are trans is going to contour is.

I also don't think that the average surgeon is just going to go cut into you. It's radical. It would be-- they would not just do it with a family hx. they'd want you to be positive for the gene. Even then. I heard that they pay a lot for this, so that "not saving money" may end up costing $10K." Because all insurance cos. do not cover this. It's considered radical and elective. They might also want to check out  you mentally make sure you had your screws in tight. The average woman just doesn't want to do it. I know you aren't a woman.... You may actually end up spending more.

BTW, the whole thing, if I didn't have a doctor who would have treated me like a guy-- not sure you know just how crazy dysphoric it would be. I think the whole thing was tolerable because Dr. G respected me and treated me like a guy. I'm sure the other doctors that do this do also treat you with respect and so on.

I think the extra cost for travel is overdone... I know of guys who did very well with this aspect. They stayed at the absolute cheapest place. They used public transportation. They stayed somewhere with a refrig. and lived off PB&J and pot pies. They get the tickets months ahead on Expedia (I did that, was not very expensive). The Extended Stay motels are cheap and they have little kitchens. You could probably cut the costs down for this to a thousand extra. Also go somewhere you are traveling to a hub or something. Don't fly to the middle of Kansas somewhere. You will pay a lot. I'm older and paid more on all this but you wouldn't need to. You won't have the most fun ten days of your life but you will survive it.


--Jay

I don't quite get why you'd consider this over top surgery.

For what you want, you won't get good results. You'll get rid of them, but the surgeon is only concentrating on getting rid of everything without shaping the result to a male looking chest because in just mastectomy operations, it's designed to be for women, and that means it's assumed that the woman will get rid of the risk/affected tissue and proceed to be a woman and thus wear padded bras and continue as a woman. I was a home carer and cared for many women with mastectomies and they never looked good or male.  One woman had both sides done and they didn't look the same, I'd imagine it'd actually be noticeable when wearing anything fitted or through a thinner tee.  It's really just a more butchered approach.  Surgeons go in there knowing how they look isn't such a concern because women are going to hide the scars under bras. This simple fact also means they try to do the scars higher than where they do regular top surgery because they'd expect the woman to carry on wearing bras and therefore try to avoid scars where the main part of the bra goes round as that would aggravate scars and cause pain and/or itching. The only people that'd see the scars would be doctors, nurses, carers and their partners. Aesthetics are their last concern, the real concern is getting the tissue.

In top surgery the scars are done in a particular way with hopes to blend better with the shape of regular male pectoral muscles. The idea being that hair or developed pecs will actually help hide the scars, not completely for many people but the idea is to try and minimise scars as much as possible. Contouring means that liposuction is done to remove fat from sides (to avoid dog ears, which aren't so much a concern for mastectomies) and possibly in the shoulder area and even centre. Trimming of the subcutaneous fat before stitching also tries to give a flat, equal look to both sides without going so far that it's unnaturally flat and caves in.  The primary focus of the surgery is to create a male chest, not something that will be hidden by bras!

So essentially what you're looking at is a more expensive operation with little care for aesthetic look VS a cheaper, more specialised surgery for a male chest.

Quote from: blink on November 12, 2013, 05:13:43 AM
Jay, some mis-gendering is unavoidable in my life right now. Temporarily dealing with yet another situation where I'd be mis-gendered, and ending up with a flat chest, is a much better outcome than I usually get for keeping my mouth shut about it.

I figure, it's a phone call, and depending on how the phone call goes, a consultation. If a local surgeon can't or won't help me, or is out of my price range, I can go to a top surgeon.

wheat thins are delicious, I'm not sure what you mean by contouring the incisions. Do you mean the overall shape of the chest, the shape of the scars, or something else?

I am not talking about casual misgendering-- "Ma'am, I mean sir." or "birth name, I mean Mike". I am talking about the sense of being treated as a male in the wrong body, for lack of a better way to put this. It was a world of difference dealing with Dr. G (for an example), than someone who would not be trans friendly in the slightest. It might seem expedient but you are going for something that is going to feel highly dysphoric. They draw on your chest and see you open chested and so on. It might seem temporary, but it it's not that temporary while you are going thru it.

I think JackM is right here. I think actually I think worded things very well re: your result as well. It's likely to be more expensive, why is it more expensive--- because it is expected to be covered by insurance. But unless, and even if you have the BRCA gene, it isn't the recommended treatment (I think it's done but the recommended treatment is drugs I believe). But the aim is completely different. They don't care where scars are, and so on.

Work on raising figuring out the cheapest place to fly (for instance a hub is cheaper to fly into than a small city that might be closer), how to stay and so on that word be the cheapest and cut out the cash that way.

A local surgeon treating severe gynecomastia seems a more logical local solution. I would expect great results, but it might be possible to find someone who is sympathetic.



--Jay

Quote from: blink on November 12, 2013, 05:13:43 AM
Night Haven, I should probably mention that more than one guy on transbucket has complained Dr. Steinwald's surgery notes are full of female pronouns, despite correct pronouns "in person". He's still on my list of surgeons to consider, but others might feel differently, knowing this information.

So long that his results are good and he listens to what his patients want, I don't think I'll mind the pronouns - it's only the results I'm after, pronouns couldn't matter less after the fact. I'll have to look at his reviews, though. Dr. Steinwald I'm considering because he seems well-known and he's closer to where I live (Virginia) than the others I've found.

Quote from: blink on November 12, 2013, 05:13:43 AM
wheat thins are delicious, I'm not sure what you mean by contouring the incisions. Do you mean the overall shape of the chest, the shape of the scars, or something else?

Jack pretty much said everything I mean with his reply.

Medalie is cheaper than Steinwald and closer for you. You just need a letter which you can get from Dr. Graham for $320.