 Good evening, everyone. Thank you for joining us for tonight's webinar, Fundamentals of Chest Masculinization with Dr. Alyssa Golis from JFK University Medical Center. If you have any questions, you may ask them anonymously by clicking on the Q&A button at the bottom of your screen. But please note that if you type it into the chat, it will not be anonymous and all attendees will be able to see your question. We will make sure that all questions are answered at the end of the webinar. This webinar will be recorded and sent to the email address that you registered with, along with being uploaded to the Hackensack Meridian Health YouTube channel. Thank you again for joining us tonight and I'll pass the floor over to Dr. Golis. Good evening. Thank you for joining us. Thank you for that introduction. My name is Alyssa Golis. I'm a plastic surgeon. I'm the Director of Plastic and Reconstructive Surgery at JFK University Medical Center, as well as Associate Professor of Surgery at the Hackensack Meridian School of Medicine. The only thing I have to disclose is that I'm sometimes a consultant for Ethicon, Johnson & Johnson, which doesn't really pertain to the content of this lecture. So the first thing we'll start with are some definitions. It's good to have a background to start with and I'm going to go in the right direction. So the first thing we'll talk about is sex. So sex is determined when you're born. When you are born, the doctor looks between your legs and makes a determination based on your external genitalia. So you would be either assigned female at birth or assigned male at birth. But sex is not the same thing as gender identity or sexual orientation. We'll talk about the differences. So gender identity is how you see yourself. It can be either as male or female or both or neither. It also can be along a continuum or spectrum of those things. Your gender identity may be the same as the sex that you were assigned at birth, but also it may not be. So that's where we start to hear the words cis and trans. So those that come from Latin words, cis means on the same side and trans means on the other side or across. So we use those terms as cisgender or it's transgender. So cisgender meaning on the same side is someone whose gender identity aligns with the sex they were assigned at birth. And trans is transgender is when some of the gender identity does not align with the gender, with the sex that they were assigned at birth. Those are two very dichotomous things. It's either one or the other. And we also have to remember that gender identity occurs across the spectrum. So we also use the term gender diverse to represent that it doesn't have to be just one or the other. So gender identity can include people who see themselves as non-binary, as gender queer, as gender neutral, agender meaning no gender, gender fluid, or even a third gender in some cultures. And that brings us to the point that gender identity and the expectations and understanding of what gender identity is are culturally tied. We tend to approach it from a very Western perspective, but just keep in mind that this varies across the world and across cultures. So sexual orientation is who you're into, who you're attracted to. It's different from sex and from gender identity. So we've heard the terms heterosexual, homosexual, bisexual, which sort of suggests either or but really is across a continuum. So we can use the word pansexual attracted to everybody or asexual attracted to no one. And the way that these terms interact with gender identity is heterosexual meaning a person is attracted to someone with the same gender identity. So a transgender woman attracted to a male would be a heterosexual, a transgender woman. Homosexual means like if you have a transgender woman attracted to a woman, that would be a homosexual, transgender woman. If there's questions about this at the end, it can get a little bit tricky with the words, but we can come back to that one. So gender dysphoria are the feelings of distress that a person may feel when their sex assigned at birth is not aligned with their gender identity. That patients who are transgender have increased rates of depression, anxiety, suicidality and non suicidal self injuries compared with cisgender populations. There is an ICD-11 diagnosis, but this is only for insurance purposes. So we would assign a diagnosis of gender dysphoria to a patient coming into the office. And it doesn't mean that there's anything wrong with the patient if they have some sort of pathologic condition, it's just a mechanism that we can use for insurance companies so that they can give, so they can cover your care. They won't cover any services unless we give a diagnosis, so it's sort of a dummy filler so that we can get care for patients. For similar reasons, it's in the mental health, it's defined as a mental health condition in the DSM-5, which is a manual that psychiatrists use. But again, it's not a pathological disorder, it's not a mental disorder. It's just words that we need to use so that we can get patients the gender affirming care that they need. And so gender dysphoria can be addressed sometimes with gender affirming treatment options. So transition is the process by which some people change their gender expression to better align with their gender identity. And transition is a personal choice and it looks different for everyone. It's a very individualized process. There's social aspects to it, which could mean changing your name, changing your pronouns, changing how you wear your hair or your clothes, or the way that you move and speak and interact with other people. It could involve hormones, it could involve surgery, and it can occur more than once in a person's lifetime. So gender affirmation is the process of recognizing a person in their gender identity. We talked already a little bit about the social aspects and the medical aspects. It also has legal dimensions. How do you change your name on your driver's license? How do you change your gender? How do you change your name with your insurance company? And how do you get care if your legal name does not align with your chosen name? So there's a lot of nuances to it. So us as medical professionals, we need guidelines we need recommendations from experts in the field to help us know how to best care for our patients just like with any patient that comes to the office. So for gender affirming care, we look to the World Professional Association for Transgender Health or WPATH. And they put forward standards of care or SOC that gives expert based recommendations from experts across the world and how to best care for transgender and gender diverse patients. So these are the WPATH criteria for adults because it's different for children. But for adults, these are the criteria that patients need to meet in order to be candidates for surgery. So I'm going to paraphrase them a little bit. But the first one is that the gender incongruence, meaning that your gender identity is not aligned with the sex or sign adverse, has to be significant and be consistent over a significant period of time. In countries like our country where people have to have a diagnosis in order to get access to healthcare, they have to meet the diagnostic criteria for that diagnosis. Patients have to have the ability to consent for treatment. So they have to understand what's going on and understand the risks and benefits of having interventions. They also have to understand if those surgical interventions can affect your ability to reproduce. We have to talk about that. Other possible causes of gender incongruence have been identified. So what does that mean? So that can be a lot of things, but for example, say a patient is taking or a person is taking hallucinogenic drugs and one of the effects of the drug is that they think that they are a transgender and it's just a result of the medication. That person would not be criteria for getting treatment, obviously. It seems like pretty self-explanatory. And then for people having surgery, their medical conditions, their mental health conditions that could affect surgery, things like diabetes, asthma, depression have been talked about and how those conditions could affect the alkyma surgery have been addressed. Basically, you want to be as healthy as possible before having a surgery. And then for those patients who are taking gender-affirming hormones, which is not everybody, you have to be stable on your treatment regimen to be a candidate for surgery. So what are the surgeries that are available? Well, this is the list of some of them. So there's lots and lots of surgeries. It can be surgeries on the face, on the breasts or chest. It can be genital surgery. It can be body contouring, hair treatments, lots of different kinds of things. So there's a slew of options for people and this really reflects that the process of gender affirmation and transitioning is really different for everybody because not everybody undergoes all these procedures on the list. Probably they undergo a few of them and it's really whatever is most important to that particular person. And so tonight, we're going to focus on chest masculinization. So chest masculinization is also known as top surgery because it's on the top half of your body. And the more common techniques, one of them is called periareolar mastectomy. Another one is a double incision mastectomy with a free nipple graft. I also listed breast reduction here because sometimes patients, instead of undergoing a traditional chest masculinization, some patients with larger breasts opt for breast reduction for a variety of reasons. But sometimes it allows for patients to have the ability to bind because it's difficult to bind if you have very large breasts. Sometimes it allows patients to wear different kind of clothing than they could wear if they had large breasts or allows them to be sometimes more gender fluid. And so again, there's a lot of reasons why people would opt for this, but we're not going to focus on that particular surgery tonight. So the first technique, periareolar mastectomy is also known as the keyhole procedure. The reason why is that we make a very small incision around the border of the areola, which is essentially a keyhole. And through that small hole, we remove the breast tissue. This is ideal for patients who have small breasts and minimal extra skin because once we remove the breast tissue, we rely on the skin envelope to shrink down. That happens really well when you're young. And as we get older, your skin is less elastic. So the sort of shrinking down process is more difficult to predict. It does leave the least amount of scarring because the scar is only at the border of the areola. But some of the downsides are that there's only limited changes in the nipple position that we can make. And people who have the surgery have higher rates of needing a revision later. One thing I do want to say about the scar is that the scar around the border of the areola is actually a great place to have it because it's our eye is used to seeing a line. It's used to seeing the line between the more pigmented skin and the less pigmented skin. So the scar blends in really well on that spot. So this is an example of a patient who had a periareola or a keyhole mastectomy. Patients very athletic, has small breasts, minimal extra skin and had a great result. So the next procedure we'll talk about is a bilateral mastectomy with a free nipple graft. This is also known as a double incision procedure. So what does all that mean? So for the mastectomy part, the first portion, the breast tissue and the extra skin are removed through two cuts. So the double incision, one goes above the areola and one goes in the fold underneath the breast with the goal of having the scar placed at the lower border of the pectoralis muscle major, pectoralis major muscle, excuse me. And again, the reason why we put the scar there is because that is where our eye is used to seeing a line. So the scar blends in nicely as the shadow of the pectoralis muscle, your peck muscle. So this procedure is better suited for patients who have medium to large breasts because it includes a way of getting rid of not just the breast tissue, but the extra skin. The free nipple graft, what that means is that we remove the nipple, we make the areola smaller, and then we reattach it in a new location as a graft. Typically, we put it in a more traditionally masked position, like low and out to the side, but the location is really flexible. That's one of the benefits of doing it as a free graft. So it's really important that if you have preferences about nipple position, that you discuss them with your surgeon because it's very easy to adjust the location as long as you know beforehand where you want it to go. And some people actually opt to not have their nipples reconstructed. That's a personal choice and certainly an option, if that's something that's interesting to you. So this is a cartoon, obviously, of the double incision procedure. You can see, I'm not sure if you can see my mouse, but you can see, hopefully you can, that there is an incision going along the above the areola, and the other incision is in the fold underneath the breast. The result is that you have a single line scar that's in the lower border of the peck. I'm not crazy about the shape of this incision of the scar. I try to have it more as a straight line, maybe a little bit curved at the inside and the outside, but I think the cartoon gives you an idea of the mechanics of the operation. And then you can see that the areola is removed, made smaller, and then put on, again, in the new location. And this is an example of a patient who had, I would say, large breasts, who had a double incision procedure and had a great result. He ended up needing a little bit of revision at the inside of one of his scars, but as his scars settled down, the result was really nice. Okay, so we've talked about the definitions, we talked about options. Now, if you're ready for chest maskization, you have an appointment with the plastic surgeon, what should you expect? And I can only tell you about how it works in my practice, but I would assume that a lot of practices would function very similar and there'd be only small variations. So what should you expect? So what happens during your first office visit? So during your first visit, we'll talk about the timing and the details of your transition, what your goals are for surgery, we'll talk about the people in your social support network in your orbit, because you're going to need help after surgery with things like groceries, laundry, food preparation. So it's important to have people around you that can help you out. We'll talk about your medical history, any surgeries you've had, your behavioral health history, talk about any alcohol, tobacco and drug use. I will insist that patients stop all tobacco or nicotine use before surgery because it increases the risk of having a wound healing complication and it increases the risk of that nipple graft dying. So really important, no smoking. We'll talk about your breast cancer risk, any family history of breast cancer. If you're somebody over the age of 40 or who otherwise needs to have screening, you unfortunately have to have a mammogram before the surgery. And then we'll talk about letters of support. You're supposed to, the WPATH criteria that we talked about before recommend one letter, but insurance companies are more and more requesting two letters. So a letter from a mental health provider, like a psychologist, psychiatrist, a licensed clinical social worker, and then a letter from someone like your primary care doctor, PCP. If you have those letters over ready, bring them with you to your appointment so that we can go over them and scan them into your chart. Also during this visit, we'll do a physical exam, including a breast exam. We fill for lumps and bumps, take some measurements. Also need to take some photographs. These are for documentation purposes. Also for your insurance company, it's going to want them. And then we can discuss what your surgical options are and what procedure is best for you. And then we'll have a chance to talk about any questions or concerns that you have. What are the risks of surgery? It's really important to talk about the risks. So any surgery risks, bleeding, infection, wound-telling complications, no matter what. Also after this kind of surgery, patients sometimes develop something called a saroma, which is fluid building up underneath the skin. If that happens, it could be drained with a little needle in the office. It sounds worse than it is. That nipple graft that we talked about, that nipple graft in really, really rare circumstances could not survive. More commonly, sometimes it loses some of the pigmentation. If you lose some pigmentation and it bothers you down the road, you can always do a tattoo to fill in those little spots. And then need for revision. What's revision? So that is fine-tuning of the scars down the road in a few months. So that could mean making things more even, changing the curvature of the scars, things like that. There's always a risk to no matter any surgery that you could need a revision. Are there drawbacks? So I always say that we're always a little bit different left and right. So during the surgery, I try to make the two sides as similar as possible, but our rib cages are different. Our collar bones are different. The placement of the breasts on the chest wall is different. So I can't make the two sides totally, totally identical. So you're always going to expect some degree of asymmetry or differences between the two sides after surgery. You will lose sensation in the nipples. So that's something to keep in mind, because that's really important to some people for sexual function. Some people regain sensation in the nipples, some sensation, but not like before. And then you won't be able to breastfeed after any of these procedures. So in preparation for surgery, if we pick a surgery date and you're ready to go ahead, get your letters of support as soon as possible. We can't ask your insurance company for pre-authorization until we have those letters. Be as healthy as possible. The time before surgery is not a time to do a crash diet or do a cleanse. You want to have good nutrition, lots of good healthy protein, no nicotine use. I ask patients to stop using nicotine at least six weeks before surgery. We do a urine test to make sure it's out of your system, because it's so, so important. And it's such a controllable risk factor that we can really, just by stopping smoking, your risk of having a surgical complication goes way down. Again, identify the people who can help you after surgery. Even if you don't think you will, you will need help. This is not something that people can do all by themselves. Wear a shirt with buttons the day of surgery. It sounds a little bit silly, but it's really helpful because after surgery, you don't want to have to put your arms through the sleeves. You want to be able to slip your arms into a shirt with buttons. The hospital is going to call you the day before surgery to go over the address, the time, when to stop eating and drinking. And then you should have a plan in place already for taking time off for work or school. So usually recovery time for this surgery is about a month. So for patients who are people who have a kind of job where they're really active on their feet, like waiting tables or chasing after kids at school, like those people should plan to have four weeks off from school. Once in a very well, people will need longer. For people who can sit at a desk or quietly at a desk or work from home, sometimes those people can go back after two weeks, but you have to be feeling up to it. You have to be healing well. So that's not everybody. But sometimes that can be a possibility. One of the reasons for that is that after surgery, you're going to be really tired. We'll talk about that more later. But it's good to have a plan in place for what to do for work so that you're not scrambling to figure it out during your recovery time. So what's going to happen the day of surgery? So the day of surgery, you're going to come in and go home the same day. You'll have a chance to speak in the preoperative area and go over the details again, go over your instructions, answer any questions that you have, do a little bit of drawing on you. You'll have a chance to speak with the anesthesiologist to answer, ask any questions of the anesthesiologist. The surgery will be done under general anesthesia. So you're going to be totally asleep. You won't feel or remember anything. And the operating time is between two and three hours. But you're going to be there for most of the day because you have to come in in the morning, get registered, go to the surgery after surgery to go to recovery room. So it's like a whole day affair. You'll wake up wearing a compression vest and you'll have two drains and just a word to the queasy. There's a couple of medical surgical pictures on the next slide with pictures of drains. So if you want to close your eyes, that now would be a good time. We'll teach you how to take care of the drains. You have to have an adult to bring you home. Someone over the age of 18, doesn't have to be a family member and they don't have to come with you in the morning, but somebody has to pick you up because you're going to be sort of out of it and on pain medication. So you're not going to be able to be like responsible for yourself. And then we'll send you with prescriptions for pain medication and antibiotics. The pain medications only if you need it. If you're okay with Tylenol and Motrin, that's better. But the pain medications there, if you do. I would say on average, people need it around the clock for a couple of days and then just at night for a couple of days and then are fine with Tylenol and Motrin, but everyone experiences pain differently. So you'll see how you feel. The antibiotics you take until they're gone. So this is a picture of the drain and the left, this is a cartoon. This area will be inside underneath the skin. This part's coming out and what it does is it collects fluid into this little bulb and twice a day, you'll have to empty the little bulb into a cup. You'll measure it. You'll toss the fluid down the toilet. You'll write down the amount of fluid and then you bring that with the date and the time and the amount and then you bring that log with you to the office and you come for your first visit. These are a couple of other pictures from different kinds of surgery just showing what those drains look like. This is what they look like in the first couple of days, sort of red and bloody. And as time goes by, the fluid turns more yellow. It sounds worse than it is. We remove them in the office when they're ready to come out, when the fluid coming out is below a certain level. I've never had a drain, but patients tell me it feels really weird having it taken out, but it doesn't hurt. So it's nothing to be afraid of. I promise it sounds a lot worse than it is. So in the day after surgery, you're going to be really tired because your body is sending all of your, it's energy towards healing. Instead of sending energy towards walking to the bathroom, now walking to the bathroom is going to make you feel exhausted. So you're going to have to rest. You're not going to be stuck in bed, but you're going to be tired. We talked about pain control already. We talked about emptying, measuring, and recording the drain output twice a day. This one, next one's a really important one. So no heavy lifting, like nothing more than five or 10 pounds, and no exercise for a month. Even if you feel awesome, you need to take it easy because there's a risk of bleeding two or even three weeks out. If you do anything to raise your blood pressure, you can have bleeding. I've seen patients who do things like yoga or lift a case of water, who've had to go back to the operating room for bleeding. So even if you feel good, you have to take it easy. Keep your arms below shoulder level. So no, like waving your arms in the air, but you can still like wash your hair, certainly brush your teeth and eat, but try to keep your arms to your sides as much as you can. That compression vest that you woke up wearing, leave it on, and you keep it dry until you come to your first visit. The drains will be taken out in the office like we talked about after usually a week or two, and you'll wear the vest for one more week after that. And when you come to the office, we'll teach you how to take care of the nipples. That's about for two weeks. You'll have to put on some antibiotic ointment and some gauze until the nipple grafts have healed. So during your first post-up visit, we'll open the vest. Maybe we'll take out the drains if they're ready to come out. There'll be something called the bolster, which is put on during surgery. It's a dressing that's sewn to the chest wall that keeps the nipples in place for the first few days. So we remove that at just a few stitches to take out. You'll see that there's some tape glue to your incisions. That'll stay on. We'll put the vest back on. And then after this first visit, you'll be able to take a shower. Normal shower, soap and water. Let soapy water run over everything. Just no swimming, no soaking in the bathtub. Second post-up visit will be pretty similar. Usually by the second post-up visit, which is another like two weeks after surgery, we can take your drains out. It depends on how much is coming out of them. But that's why it's really important that you bring that log with you so we know when you're ready. Usually about that time, we'll remove the tape that's covering your incisions so you can see what they really look like. And if there's any stitches left over, they'll come out at that time. So things to look out for after surgery. And if you see any of these things, you should call me or go to the emergency room. So fever over 101, pain that's getting worse instead of better. Every day, it should be getting a little bit better. If it's getting worse, that's a sign of a problem. Any bleeding, redness in the skin of the chest, swelling on one side that you don't have in the other, especially if it's significant. Or if the drain on one side is filling really, really quickly, or not at all, those are things to let me know about. And then some long-term considerations. So all surgery leaves scars. Scarring is that it's worse after around six weeks. So that means the scars are going to be thick and raised and pink and sometimes itchy. So that that gets worse for the first six weeks. And then over the next six months, two years, the scars will settle down. I recommend that patients use silicone tape, which you can buy on Amazon or in the drug store, starting at one month. It comes in a roll. You cut a little piece. You put it on the scar and you wear it like eight or 10 hours a night or even all the time if you can tolerate it. And then you can reuse each piece a few times until it loses the stickiness. After top surgery, one of the good parts is that you never have to have a mammogram again. You still though have to have breast cancer screening every year after the age of 40. But for you, that would be a really good physical exam by your primary care doctor or some doctor that you see regularly, just to feel for any lumps or bumps. If you need a revision that's usually apparent by like six to 12 months, we want to give your scars enough time to settle down until we know what they're really going to look like. And then if you need any fine tuning, then we can do it at that time. If it's something small, we can do it in the office just with some local anesthesia, some numbing medicine. If it's something big, we would do it in the operating room. One question that I get a lot is, are revisions going to be covered by my insurance? And I would say there's no guarantees in life. Insurance companies can be unpredictable, but I've never had a revision not be covered. So I would be very optimistic about that. And then over time, you'll regain sensation in the skin in the chest and hopefully someone in the nipples, but it may not ever be as much sensation as you had before. Okay. So one quick word about body contouring or a few quick words. This is a little, I know it's not chest massization, but I think it is important to talk about. Because of the shape of our skeleton and the distribution of fat, people assign male birth and people assign female birth to have different contours or different shapes of the trunk and the hips. So there's things that we can do to address this if we're trying to make the torso have a more masculine silhouette. And what that is, it's called body contouring. So body contouring is sculpting the shape of the body so that it's more in line with the gender identity. So for masculinizing body contouring, we do liposuction. We do liposuction to remove fat from the flanks, the hips, the side of the chest and the thighs. And that's a really nice compliment to top surgery. Insurance will sometimes cover it. It really depends on the insurance plan. And we can usually do it at the same time as top surgery so that you just have one surgery. It adds about 30 minutes to an hour to the surgery. But it's definitely an option to talk about it. That's something that's interesting to you. And that's all I have. So thank you for listening. And I would be happy to take any questions that you have. And again, here is my contact information, our phone number. And then thank you for tuning in tonight on a Tuesday night. Do we have any Q&A? Let's take a look. Not at this time. So thank you very much. And I hope that everybody has a good night. Oh, we have one question before we sign off. How do we do this? Answer live? What do we look for in the letter? Okay, that's a great question. So I've answered live again. I hope that this is still going through. Okay. So thank you for asking that. That's a great question. There are some specific phrases in the letter. And it basically has to do with does a patient meet those WPATH criteria for gender dysphoria, meet those criteria for surgery. So it has to include how long you've known the patient and in what capacity you have to discuss that their gender dysphoria has been occurring over a long period of time and it has been stable, that they have the capacity to make their own medical decisions, that you believe that the surgery is going to be helpful to them in addressing their gender dysphoria. And I think I might be forgetting, but they're all listed in that WPATH standards of care, the components of the letter. That's a great question. What technically, sorry, what technically is the best screening method for breast cancer after top surgery? So physical exam is the best way. A really good physical exam filling for lumps and bumps. There's no way to do a mammogram, but if there is anything suspicious after physical exam, the next options would be ultrasound or MRI, but those are not for screening processes. And then the last, we have another question. Do we have permission to use screenshots to be getting their presentation for educational purposes? I think that's fine. I would not use screenshots of the patient photographs, but of any of the texts that I wrote, that's absolutely fine. Any other questions? Okay. Thank you very much. I hope everyone has a good night.