Upper gender affirming surgery

In this episode of PodMD, accredited plastic and reconstructive surgeon Dr Katie-Beth Webster will be discussing the topic of upper gender affirming surgery, including what type of patients ask for this type of surgery, the requirements needed before being seen and treated, pre and post operative factors, the regret rate of the surgery and more.


  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Katie-Beth Webster.

    Dr Webster is a specialist Plastic and Reconstructive surgeon and completed her medical degree (MBBS) at the University of Queensland, graduating in 2010. She then entered specialist plastic surgical training at major centres in Queensland and NSW and was awarded a Fellowship of the Royal Australasian College of Surgeons in 2020.

    Katie-Beth has undergone additional training in craniofacial trauma and aesthetics and has also undertaken research in several areas including microsurgical breast reconstruction, flap reconstruction, head and neck surgery, skin grafting, hand injuries, and outcomes following surgery. She has presented this research at national and international conferences.

    Today, we’ll be discussing the topic of upper gender affirming surgery.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Katie, thanks for talking with us on PodMD today.

    Katie : Thank you for having me

    Question 1
    The topic of today’s discussion is upper gender affirming surgery. Katie, Can you give us a brief overview about this type of surgery?

    Katie: Yeah. So upper gender affirming surgery or gender affirming surgery in general relates to a pretty broad scope of procedures that certain individuals may choose to undergo to affirm their gender. So today I’ll specifically be talking more about gender affirming surgery of the chest known as top surgery. And the differences between that and what options are available.

    Question 2
    Which type of patients present to you asking for this type of surgery?

    Katie: Yeah. So the patients I see in my practice looking for upper gender affirming surgery are patients that are trans or non-binary gender diverse backgrounds and they’ve usually been diagnosed with gender dysphoria. So, when I meet them, I have a discussion to figure out where they’re at in their journey, there’s a pretty broad spectrum of whether this is the first time they’ve ever had a discussion or looked into gender affirming procedures and other patients who are really well read, have spoken to a lot of people and have a lot of knowledge about what’s out there and what’s available and come to me pretty much knowing exactly what they want.

    Basically with my specialty, plastic surgeons, we tend to do a lot of these procedures in CIS patients like we’ll do breast augmentation, we’ll do mastopexy’s, we’ll do mastectomies, so it’s all very comfortable for us, these types of procedures and just tailoring them to the trans and non-binary patients.

    Question 3
    What requirements are needed in order to be seen and treated?

    Katie: So requirements for me to see the patients is the same as any of my other patients. So, GP referral letter is required and that basically just needs to have some information about what I can do to help the patient. Any significant past medical history. Things that are important for me to know for trans patients if they’ve had any hormone replacement therapy or hormone treatments and for how long, and also any past mental health conditions and how they’re being managed and what they are being managed with is important.

    To proceed with surgery, the WPATH guidelines are generally what the college plastic surgeons encourage us to follow, and that defines us to need a psychologist or a psychiatrist diagnosis of gender dysphoria to go ahead with surgery, and generally the recommendation is that the patient would have been living in their current gender for at least six months.

    Question 4
    What are the treatment options?

    Katie: So. Patients generally have a pretty good idea themselves about what order they want to have procedures in, what procedures they want to undergo themselves, and there’s no prescriptive defined pathway that suits every patient. So it’s a very individual journey. Very dependent on their goals of treatment. And for this the nature of this podcast we’ll sort of define it into two main groups, which is the feminising top surgery and masculinising top surgery.

    So for feminising top surgery, their hormone therapy does make a really big difference. There a lot of patients that have had estrogen replacement therapy and testosterone blockers. They will develop a degree of chest or breast development and for a period of time, you want to give them the opportunity to experience those changes to a degree before you go and then augment it. So if they’ve only just started hormone therapy and they’re starting to get some breast development, you’re probably better waiting before you go and do a breast augmentation, Fat grafting or a mastopexy. But they’re the generally the main options so. You just want to enhance and feminise the chest and in some people that have a lot of breast development already from hormones, they might be happy with just a lift or a or reshaping procedure and that would be usually done with the mastopexy or fat grafting. However if they want a much larger volume chest or a different shape chest, more prominent chest than we’d be looking at breast augmentation with implants.

    For masculinizing top surgery once again so spectrum I see some patients and they just especially patients that have large breasts that aren’t 100% certain that they want everything removed and they may sometimes opt for a breast reduction as a initial step to see how they feel about it, how that changes their feeling about their chest. It also people with large breasts have a lot of issues with back and neck pain rashes, so it’ll alleviate a lot of those symptoms for the patient anyway. And some of those patients do then decide later to convert to having a full mastectomy and others are happy with just a reduction.

    For patients that want to completely flat male appearing chest, the options that I offer them are a double mastectomy and that usually I offer them a free nipple graft as well. So we basically remove the breast tissue. There’s a scar underneath where the peck sort of line would normally be, so give them a male appearing chest and the nipple areola complex is made smaller to a more masculine size and also then grafted onto the chest and a masculine line of aesthetics.

    The patients that have very small amount of breast tissue may also opt for a periareolar mastectomy and grafting where we don’t actually make an incision underneath the chest. It’s just around the nipple. It’s a bit harder to change the position of the nipple in those patients. So that’s something to keep into consideration. But some patients chest allow for that type of procedure and it looks really great on them. So it’s really important that I see them have a figure out what their goals are and try and get the right surgery for them to get them to achieve the what they want.

    Question 5
    Have there been any developments in treatment in recent years?

    Katie: From a surgical perspective, we’ve been doing obviously, breast augmentation and mastectomies for a very, very, very long time. Major changes, I guess I’ve found is we weren’t doing fat grafting to the chest for a really long time because there was some sort of concerns about when we’re doing a fat graft, we’re basically doing liposuction, removing fat from somewhere in the body, and then we’re injecting it somewhere else. And that process does come with stem cells from the fat tissue, and there were some original concerns that whether that would have any links to breast cancer because you’re importing new tissue with stem cells into the chest. However, after doing it for many, many, many years, we found that that wasn’t actually found to be the case. So we’re now able to, and many insurers will cover patients to have fat grafting to the chest. Which has opened our options a lot for non-sort of prosthesis-based breast reconstruction both in cancer patients and also in patients that want to change the shape of their chest.

    So that’s probably the main thing that I’ve found that we’ve really had a lot of uptake in sort of last 5to 10 years. And the other major change I guess I found was that there’s a recent change that these procedures have become a lot more visible to both society, media, patients themselves. When I first started doing plastic surgery training procedures, gender affirming procedures weren’t really talked about. They weren’t really something that we’re exposed to a lot, and I’ve definitely found in the last sort of 6-7 years. It’s definitely been at the forefront and a lot. It’s a lot more accessible for people, which I think is really great.

    Question 6
    What pre and post operative factors should GPs be aware of?

    Katie: So when referring a patient, things that are really important for them to get the best results possible are I caution patients to stop smoking wherever possible. It really reduces the blood supply to the areas that we’re operating on. So something that’s really good to do and the other thing would be some patients see me when they’re going through sort of a body transformation journey and they’re often changing their weight or fitness levels. And when you’re having chest altering surgery, there are limits on certain gym activities and fitness activities immediately post operatively, so keeping that in mind.

    And also when I’m augmenting the chest if they’re currently undergoing a weight loss journey and then they lose more weight after they’ve had their chest surgery, it will impact their results and their cosmetic results of their chest, so I generally would recommend patients come to me sort of closest to their ideal weight and that would give them the best cosmetic result. It’s not saying that I won’t offer them surgery, but it’s just something to keep in mind for them. Uhm.

    So the other thing to keep in mind is, it’s. It’s a big-ish operation, so it may take them some time to go back to work, go back to gym, go back to the normal sort of lifestyle activities. So that’s some. Thing that I warn all my patients about and I warn my patients and also my referring GP’s any concerns with any of my post operative patients or there be bleeding infection swelling or any wound healing issues to contact me as soon as possible and I usually get the patients in for an urgent review.

    Question 7
    What is the regret rate for this type of surgery?

    Katie: So one of the reasons why this surgery isn’t offered as widely as it could be as a lot of practitioners are quite concerned that many of these body changing procedures are very permanent. And they’re concerned that patients will inverted commas, “change their mind”, and then it’s irreversible. So that’s one thing that a lot of people concerned about.

    However, there’s been some pretty large studies that have presented figures of around A1 to 2% patient regret rate following gender affirming surgery and that is sort of all types of gender affirming surgery. Which interestingly, is exceptionally low compared to some of the rates of CIS people having similar procedures like breast augmentation or facial rhinoplasty, genioplasty, facial sort of feminizing or masculinizing procedures in the general populace, the rate of regret is around 10 to 15%.

    There’s also a large study published in JAMA last year that was done by some Harvard researchers that showed an association between gender affirming surgeries and mental health outcomes. They did a large scale survey of patients that have undergone gender affirming process and compared their psychological distress, substance abuse and suicide risk. There was over sort of 3000 patients that were in the study that had had already undergone gender affirming surgery, and there was about 16,000 who were on wait list or wanting gender affirming surgery but hadn’t been able to attain that yet and they found that there was around a 42% reduction in distress, 35% reduction in smoking and a 44% reduction in suicidal ideation in patients that had had their gender affirming surgery.

    The improvement also appeared to be additive, so patients who were midway through their journey and had had some of their procedures, but not all of them had some improvement. But the patients had the maximal improvement were ones that had all the procedures that they desired to have, and they had really profound mental health benefits following that.

    Question 8
    When should a GP refer?

    Katie: So I generally recommend if any patients are curious and just want some more information about gender affirming surgery in general, what’s out there, what things might be suitable for them, and they just want to have a discussion then refer. There’s often a lot of information and misinformation out there on the internet, so it’s really good for if you have a patient who’s curious to just send them along and we can sit down together and have a discussion about what things might be right for them.

    Question 9
    What role does the GP play in the treatment of the condition?

    Katie: So GP’s have a really important role in supporting gender diverse patients, so general support they often have, like I said earlier, levels of psychological distress related to their current state referring them to psychologists can help to ascertain both give them support. Themselves, but also will allow to them to get a diagnosis of gender dysphoria. In saying that, I’ve spoken to psychiatrists who say that qualified GP or subspecialty sub specialist person can diagnose with some with gender dysphoria themselves. But I think it’s good to refer to a mental health professional because they do give that extra support there and they’re trained to do that.

    Supplying hormone treatment is another thing that some GP’s choose to do, which can be really useful if GP’s weren’t comfortable doing that, then referring a patient to an appropriate endocrinologist who’s happy to do that. Also referring to other health workers involved in experience with gender affirming care, and that may be things like a speech therapist or vocal coach to help with vocal training, gynecologist to help with hysterectomy or oophorectomy in some trans patients. ENT surgeons for vocal cord surgery or tracheal shave and also obviously plastic surgeons for the outward feminising or masculinising procedures.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on upper gender affirming surgery.

    Katie: Yeah. So I guess the main three things that I would like GP’s to be aware of are that these surgeries exist, they have a huge positive impact on patients lives. If that’s something that they’re curious about, so it’s worthwhile to refer anyone for a discussion. The other main things are that there is a bit of a lag with Medicare at present with item numbers that don’t specifically cover these surgeries and there are item numbers that can be used, but the College of Plastic Surgeons and AUSPATH are working really closely with Medicare to enable this care to be more accessible and eventually hopefully accessible in the public sector. But at this stage, with the current climate, we’re only able to offer these surgeries privately. And the field is complex. There’s a lot of options available for treatment, so I’d say don’t hesitate to contact a clinician if you have any questions.

    Thanks for your time and the insights you’ve provided.

    Katie: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.