Spotlight on Subcutaneous Mastectomies for Transgender Patients

When we’re talking about mastectomies and post-op recovery, there’s another procedure to highlight in terms of post-mastectomy care. You might hear it called “top” surgery, FTM (female-to-male) or FTN (female-to-nonbinary) top surgery, “chest masculinization,” “chest reconstruction,” or the more clinical “subcutaneous double mastectomy for a transgender patient.” Whichever the wording, the procedure involves removing a person’s breast tissue and often reducing the size of and changing the location of the nipple and areola.

This can be achieved with the more commonly thought-of double-incision approach, spanning across the pectoral muscle region. The location of the incisions and the surgical technique are cosmetically designed to provide contouring and to enhance the appearance of the pec muscles. Alternatively, the nipples and areolae can be removed using a periareolar incision, also called a “keyhole” or “donut” approach, and the breast tissue can be removed through this opening. The amount of breast tissue a person has, their body habitus, the properties of their skin and their desired outcomes all help determine which surgical route will be the best fit.

While this type of surgery may differ from cancer-related mastectomies in that lymph nodes are not being removed and the skin is not affected by radiation treatments, there are similar post-op experiences that our transgender clients might be dealing with, including:

  • swelling
  • pain
  • navigating and emptying surgical drains
  • wearing of compression vests or tank tops
  • scarring (including the “dog-ear” extra skin at the ends of the incisions) and pain or itching at the incision site
  • possible adhesions or “binding down” of the tissue onto the chest wall
  • decreased range of motion in the shoulder and chest
  • activity restrictions
  • the discomfort of sleeping in a reclined position with pillows or in a recliner chair for weeks following surgery

Specialized massage can help support the body as it recovers. Manual lymphatic drainage (MLD) can help decrease swelling and pain. Scar rehabilitation techniques can aid in combatting adhesions, puckering, pulling, and discomfort. Gentle shoulder mobilization techniques can help restore range of motion and the ability to get back to activities of daily living a little sooner.

I also want to touch on where a client might be in terms of psychological or psychosocial feelings. Studies suggest that when someone’s physical body lies in contrast to their gender identity, it can be among their largest source of dissatisfaction. And so if this mastectomy allows a person to achieve a body that is more in line with their self-identified gender, they may be feeling more positive about the results of the surgery than someone who had a mastectomy as cancer treatment and as something they “didn’t sign up for.”

But it’s never fair to make assumptions or blanket statements. Transgender folks may have had to jump through many hoops to have this surgery.

Many states and hospitals require that a transgender patient submit referrals from both an M.D. and a mental health professional stating that they have the capacity to provide informed consent and perhaps that they have been officially diagnosed with Gender Dysphoria and accompanying anxiety or depression. (Contrast this with an individual getting any number of other types of plastic surgery that do not have to do with gender reassignment which can be just as invasive to the body but do not need special clearance, especially from a psychologist.) There may also be stress and concern about how they may be received in their new body by family, friends, and others in their social sphere; how large is their support network?

And while the Affordable Care Act makes it illegal for insurance companies to automatically deny coverage for transition-related surgeries, medications, and other care, many people still have issues with actually getting their insurance company to cover costs and may not be able to easily afford to pay for these procedures out-of-pocket.

All of these factors are to be given space on the massage table. Massage therapy can and should gracefully weave into the fabric of support for transgender clients following surgery, with skilled hands-on therapeutic work, listening and empathy, respectful and thoughtful language, inclusion, and accessibility of care.