Top Surgery: The Keyhole Technique


Over the past couple months, we’ve heard from Dr. Scott Mosser about the double incision approach to top surgery, as well as the circumareolar approach. Today, Dr. Mosser tells us about another popular approach: the keyhole technique.

As with other top surgery techniques, the keyhole approach has some upsides and some downsides. The biggest reason that many trans men and transmasculine folks are interested in keyhole is the limited scarring that results from this surgery. The biggest downside of keyhole is that only folks with a very small amount of breast tissue and excess skin in the chest area are good candidates for this procedure. Very few patients fall into this category, and thus most folks will not be able to pursue keyhole.

One clarification we want to make about the video explanation of the keyhole technique is that the skin flaps that Dr. Mosser describes are simply the patient’s original chest skin — the surgeon does not create these flaps with donor skin or any other technique. The procedure simply involves making a small incision around the areolae and excavating the breast tissue that lies between the skin and the chest wall.

What’s New, What’s Next for Informing Consent


The last few months have been a whirlwind of activity, and thank you to everyone who has liked and shared our videos! We wanted to take a breath this week, talk a little bit about what we’ve done so far, and give you a sneak peak into what we’re doing next!

So far we’ve published eight short videos, covering a variety of surgeries that folks in the trans communities may be interested in. In our series on Facial Feminization we’ve created an introduction, a video dedicated to forehead contouring and a video dedicated to hairline advancement. The FTM top surgery series currently covers the double incision procedure and the periareolar technique. The phalloplasty series contains a video on choosing your donor site, as well as the incredibly popular video on sensation and nerve hook ups (please be aware, this one address medical and physical aspects of sex, and viewer discretion is advised).

October will be a busy month for all of us here at Informing Consent. We are wildly excited to offer Spanish translations of the video captions for our videos starting next month, and we’ll share out as each one is updated. We’re also publishing videos about name and gender marker changes on identity documents like driver’s licenses and passports, as well as navigating the court system. Finally, we’re launching a more comprehensive social media presence on both Facebook and Twitter. We know it’s been pretty quiet on our pages, unless we’re announcing a new video, and we’re planning to bring you more curated content and news impacting the trans communities.

All of this in addition to videos about facial feminization and top surgery coming up in October, and more procedures being filmed each month- Stay tuned!

Facial Feminization Surgery: Forehead Contouring


Please note: this week’s video contains animated diagrams of invasive surgical procedures. These animations may be hard to watch for some viewers. Discretion is advised.

Our first post gave you an introduction to facial feminization surgery. As you may recall, this surgery is not a single procedure, but a collection of procedures, any of which a patient may opt in or out of depending on their needs and desires. This week, we hear Dr. Thomas Satterwhite discuss one of these procedures: forehead contouring.

With forehead contouring, the surgeon addresses two primary areas: the frontal sinus, which is the bone directly above the bridge of the nose, and the supraorbital ridge, which is comprised of the bony structures underneath the eyebrows. Depending on how pronounced these bones are, and whether they are solid or contain air spaces, the surgeon may use one of several different approaches. “The best way of deciding what is the right approach for you is by starting out by getting an X-ray,” says Dr. Satterwhite. He goes on to detail some of the most common approaches to surgically feminize this area of the face.

In a few weeks, Dr. Satterwhite will be telling us about one more procedure that’s commonly performed during FFS on the upper portion of the face, and that is the brow lift. Keep an eye out for that post very soon!

Phalloplasty: Sensation & the Nerve Hook-Up


Reader advisory: this week’s post talks frankly about the medical and physical aspects of sex, and the video contains diagrams illustrating these concepts. Discretion is advised.

A few weeks ago, we introduced you to free flap phalloplasty, which is one type of genital reconstruction (or “bottom surgery”) for transgender men and transmasculine folks. This week, we address one of the primary concerns raised by people considering this surgery: sensation and the ability to orgasm.

One of the most common misconceptions about trans male bottom surgery is that it results in a partial or total loss in sexual sensation. It’s not unusual to hear the sentiment, “I’d consider bottom surgery, but I don’t want to lose my ability to orgasm,” in trans male circles. In reality, free flap phalloplasty can include a nerve hook-up, a microsurgical technique in which nerves taken from another part of the body are attached to the clitoral nerve or other pelvic nerves and embedded into the new penis. This allows the patient to retain sexual sensation and function in the vast majority of cases. “In my experience, about 85% of free flap phalloplasty patients get erotic sensation, and 98% get tactile sensation,” says Dr. Curtis Crane. “And I’ve never had a patient lose the ability to orgasm.”

Although these numbers are promising, and certainly better than common bottom surgery lore, it’s important to remember that nerve regrowth is a slow, gradual process. Nerves must regrow through the axon sheath, and the rate at which this growth occurs is about 1 millimeter per day. At this rate, full sensation can take up to 2 years to reappear after surgery.

This video is captioned in English. To access the captions, click the CC button on the bottom right of the video.

FTM Top Surgery: The Periareolar Technique


A few weeks ago, we posted about the double incision technique, a common top surgery procedure among trans men and transmasculine folks. This week, we bring you information on another kind of top surgery: the periareolar technique, presented by Dr. Scott Mosser.

First, we need to clarify our terminology a little bit. The procedure that trans folks often refer to as periareolar is more accurately called circumareolar. Within the trans community, periareolar usually refers to top surgery that’s performed by removing skin in a donut shape around the nipple, excavating the breast tissue, and pulling the skin together around the nipple like strings on a purse. Among plastic surgeons, the correct name for this type of surgery is the circumareolar technique, and is only one of many kinds of periareolar procedures (the keyhole technique, which we’ll discuss in a later post, is, medically speaking, another type of periareolar top surgery).

Dr. Mosser explains that, as with the double incision technique, there are pros and cons to choosing the cirumareolar procedure. “The upside of the circumareolar approach is…reduction of the incisions on the chest to just an incision that’s around the areola,” says Dr. Mosser, meaning that the scarring associated with the donut incision is far less obvious than that of the double incision approach. But, this reduced scarring can come at a cost. “You can imagine almost as if we were dealing with fabric, there would be a potential…to end up with a degree of pleating around the edges,” explains Dr. Mosser. By pleating, he means small folds in the skin, which protrude out in a starburst pattern from the nipple.

“In the absolute worst case, [a circumareolar result] can be converted to a double incision,” Dr. Mosser adds, meaning that a patient could potentially have their chest operated on a second time if they were not happy with their result. As more and more of us begin to rely on insurance to cover our surgeries, however, it’s important to note that insurance plans that would otherwise cover chest surgery may deny coverage for a revision.

We’ll continue to bring you information on even more FTM top surgery techniques in the coming weeks, including the keyhole and the T-anchor approaches.

Note: this video is captioned in English. To access the captions, click on the CC button in the bottom right on the video.

Facial Feminization Surgery: Hairline Advancement


Facial Feminization Surgery (FFS) is not a single procedure, but a bundle of many different procedures. As we discussed about in the first post of this series, Facial Feminization Surgery: An Introduction, there is no one way to decide on what (if any) surgical options are right for you. Each patient must decide which individual procedures they want to undergo, based on their personal preferences and priorities, and what their facial structure is prior to surgery.

In an earlier post, Dr. Thomas Satterwhite told us that the individual FFS procedures are often grouped into three categories: the upper face, the middle face, and the lower face. This week, we’re talking with Dr. Satterwhite about hairline advancement, one of the procedures that helps to feminize the upper part of the face.

“A more masculine hairline is going to be square, and you’re going to have what’s called temporal recession,” explains Dr. Satterwhite. He goes on to discuss various techniques that are typically used to surgically create a rounded hairline, which is often read as feminine. Which technique is used depends on the amount of hairline recession and hair loss a patient has, as well as whether the patient has had any previous surgeries in the forehead area.

In the coming weeks, we’ll bring you information on two other procedures that help to feminize the upper face: forehead contouring and the brow lift. Stay tuned!

Note: this video is captioned in English. To access the captions, click the CC in the bottom left of the video frame.

Phalloplasty: Choosing Your Donor Site


For trans men, transmasculine folks, and others who were assigned female at birth, there are two major types of genital reconstruction or “bottom surgery”: metoidioplasty and phalloplasty. Metoidioplasty is a procedure that relies on the clitoral enlargement resulting from testosterone, in which the surgeon releases the ligaments around the clitoris, freeing it and bringing it forward to create a small phallus. In later blog posts, we’ll cover metoidioplasty, but today, we’re focusing on the second option: phalloplasty.

Phalloplasty comes in many different varieties, and can utilize different surgical techniques depending on the surgeon’s expertise and the patient’s preference. Today, Dr. Curtis Crane will introduce us to free flap phalloplasty. The term free flap means that the surgeon harvests tissue — skin, fat, arteries, veins, and nerves — from another part of the body, and creates a penis using that tissue.

The first decision a free flap phalloplasty patient must make is which donor site to use. “The most common donor sites are the forearm, the back, and the thigh,” explains Dr. Crane. “There are positives and negatives to each of these.”

Indeed, choosing the right donor site for you can be challenging. There are many factors to consider, including the number of individual surgeries (referred to as stages in the video), the location of the donor site scar, the aesthetics of the resulting penis, and the amount of sensation typically expected from a donor site. In this video, Dr. Crane gives a detailed description of each of the three major donor sites, and discusses the pros and cons of each. “Really take some time and think about this,” he says. “This is the phallus you’re going to have for the rest of your life.”

Keep an eye out for more great information on phalloplasty from Informing Consent with Dr. Curtis Crane in the near future.

Note: this video is captioned in English. To access the captions, click the CC button on the bottom right of the video.

FTM Top Surgery: The Double Incision Procedure


For many trans men and transmasculine people, the double mastectomy procedure (better known as “top surgery”) is a vital part of medical transition. In addition to relieving dysphoria related to the chest, top surgery can also ease the difficulty of accessing spaces such as locker rooms, swimming pools, and beaches.

There are many different types of top surgery, but the most common is known as the double incision procedure. Today, Dr. Scott Mosser discusses the mechanics of this procedure as well as its pros and cons. “The downside of the double incision procedure is the visible scarring which is persistent after surgery,” explains Dr. Mosser. And although scarring is a concern for many people who access top surgery, double incision has some big upsides as well.

One significant advantage of DI is that virtually all patients are candidates for DI, whereas other procedures such as keyhole or periareolar are only available to patients with certain chest shapes and sizes. Second, according to Dr. Mosser, “[Double incision gives] the surgeon by far the best command control of the overall flatness of the chest. … It’s also the best control the surgeon has over placing the nipples,” meaning that double incision tends to produce the best results in terms of obtaining a flat chest and correctly sized and placed nipples.

Informing Consent and Dr. Mosser will bring you more information on top surgery in the near future, including videos on other techniques, such as the keyhole, the T-anchor, and the circumareolar procedures.

Note: this video is captioned in English. To access the captions, click the CC button on the bottom left of the video.

Facial Feminization Surgery: An Introduction


Welcome to Informing Consent’s first entry in our video blog on medical and legal gender transition.  This week, we’re taking our first look at a complicated procedure for trans women and transfeminine folks: facial feminization surgery, or FFS for short.

FFS does not refer to a single procedure, but rather a collection of procedures, ranging from hairline advancement to rhinoplasty (nose job) to Adam’s apple shaving and more.  Usually, a doctor will perform multiple procedures in one surgery.  As a result, FFS can mean a lot of time in the operating room: up to 12 hours, in some cases.

In this week’s video, Dr. Thomas Satterwhite gives us an overview of FFS, and discusses how a patient and doctor decide which procedures to include in the surgery.  “I certainly have some patients come in and say, ‘I want everything done,'” explains Dr. Satterwhite.  “And I have other patients who are more concerned with certain aspects of their face.  I recall one patient who said, ‘You can do whatever you want, but don’t touch my nose, because my nose is a part of me, it’s part of my family, it’s part of my heritage.’  It’s what’s important to you and what your particular goals and wishes are that are of utmost importance.”

Check out the video to learn more, and keep an eye out for many more FFS videos in the near future.

Note: our videos are captioned in English. To access the captions, hit the CC button on the bottom right of the video.


Informing Consent: Empowering Trans Folks through Information


Five years ago, I was lying in a hospital bed, excited and nervous for my life to change for the better. I was two years into my transition from female to male, and I was about to get top surgery. My mind bubbled with fantasies of shirtless adventures in my near future. I’d lie on the beach with my friends, carefree as the sun beat down on my bare chest. I’d strip off my tank top in a gay bar, tuck it casually into the waist of my pants, and a hot man would buy me a drink, seeing me as my true gender. Life was going to be so much better.

It didn’t turn out so well.

I’d chosen to have the periareolar (more correctly called the “circumareolar”) procedure, a tricky surgery in which a donut of skin is removed, leaving a scar only around the nipple itself. I was drawn in by the surgeon’s promise that I’d maintain nipple sensation and have no noticeable scarring. What I didn’t know was that few trans men are good candidates for this procedure, and my surgeon didn’t know how to correctly judge my candidacy. My chest was too large, and I had too much extra skin. As a result, my incisions split open, became infected, and my chest had a lumpy, strange contour that looked wholly unnatural. It wasn’t at all what I’d imagined.

My original surgeon attempted to revise my result with two follow-up surgeries, neither of which improved things much. Finally, I lost faith in him, and sought the opinion of Dr. Michael Brownstein, a well-known and highly respected top surgeon. From him, I learned that I never should have undergone the peri procedure; double incision was a far better choice for me. He performed this procedure on me, resulting, finally, after more than two years, thousands of dollars, and four surgeries, in the chest I’d dreamed of.

Certainly, part of my bad experience with top surgery was because I didn’t see enough doctors beforehand. I was a student at the time, and although my university insurance covered a large percent of the cost of surgery, I didn’t have the luxury to travel around the country consulting with lots of surgeons. But in this day and age of digital information, there is no reason that I, or any trans person, should have to rely on in-person consultations to glean the necessary information about medical transition.

Transitioning should be easier, in all regards. Our medical options should not be mysterious. We should no longer need to rely on the limited information available from local doctors and our local trans communities. And with more and more doctors implementing the forward-thinking “informed consent” model of care, the onus is on us to educate ourselves. To do that, we need resources. We need reliable sources of information.

And this is the impetus for Informing Consent. We partner with surgeons who are regarded as experts in their fields and asked them to discuss, on video, the medical procedures that are essential (for some of us) to making our lives worth living. Over the next few months, we will release videos weekly, presenting information on Facial Feminization Surgery with Dr. Thomas Satterwhite, Phalloplasty with Dr. Curtis Crane, and FTM Top Surgery with Dr. Scott Mosser. Eventually, we will have information on other procedures as well, including vaginoplasty, metoidioplasty, breast augmentation, hysterectomy, and others.

We also know that surgery is not the only topic trans folks need information on. In addition to surgical videos, we’re working hard on tutorials on changing your name and gender on essential documents such as your driver’s license, passport, birth certificate, and social security card.

This Monday, August 3, 2015, we’ll officially launch with an overview of Facial Feminization Surgery presented by Dr. Thomas Satterwhite. Stay tuned, follow our blog, and keep up with us on Facebook or Twitter.