Gender - General Surgery
Gender Surgery Services – the Manchester Chest Wall Contouring Clinic
Welcome to the Manchester Chest wall contouring Clinic. We pride ourselves on being a non-judgemental, supportive team that provides high quality surgical assessment and care to all transgender and gender non-conforming people requesting chest wall surgery.
You can find information here on how to access the service, where and when the clinic is held as well as details about what surgical techniques we offer. We also explain what to expect throughout your journey before, during and after your surgery.
How to access the service
Following your assessment by a recognised Gender Identity Clinic (GIC), you can be referred to us to talk about chest surgery. The majority of patients attend after a direct referral from a gender clinic. GP referrals can only be accepted if there is detailed documentation of your assessment by a GIC and confirmation of NHS funding. We currently accept referrals from NHS Scotland as well as NHS England. Unfortunately, we are unable to accept self-referrals.
How long will I have to wait?
Our waiting times vary depending on the number of referrals.
Where and When are the clinics held?
Clinics are held at the Outpatients F department at North Manchester General Hospital, every Thursday afternoon 11am to 5pm. The department is in a separate building to the main hospital and the chest contouring clinic is dedicated only to look after patients requesting chest wall contouring surgery so you should feel at ease and welcome when you arrive.
Outpatients F is located next to Car Park 1, to the left of the main hospital entrance, up the hill.
How do I get there?
North Manchester General Hospital
By Public Transport
You can plan your journey from most major cities in the country using the Greater Manchester’s journey planning tool shown below:
The hospital has good bus service links, with over 30 buses an hour serving bus stops located at the hospital site during the day. The main bus services are the 42, 52, 53 and 118.
The North Manchester General Hospital is also a short walk or bus ride away from the Abraham Moss and Crumpsall tram stops on the Altrincham to Bury line.
The hospital is located off Delaunays Road, Crumpsall. Follow signs from A576 Middleton Road or travel along A664 Rochdale Road, turning onto Middleton Old Road, then onto Old Market Street, until it becomes Delaunays Road.
When you arrive
Our clinics are all held in Outpatients F, which is located next to Car Park 1, to the left of the main hospital entrance, up the hill. It stands as a separate building to the main hospital.
Car park 1 is directly outside and does offer parking areas for patients and visitors. Payments for parking are currently only possible via cash so please don’t forget your change! Please ensure you only park in the patient/visitor “green zones”.
Car Park Charges
- Up to 1 hour £1
- Up to 2 hours £2
- Up to 6 hours £3
- Up to 8 hours £4
Local Hotels & Accommodation
You may need to stay overnight to attend your appointment if you live out of area. Here we have suggested a few local hotels to consider:
Premier Inn, Heaton Park
Middleton Road, Crumpsall Manchester M8 4NB
Westlynne Hotel & Apartments
16 Middleton Road, Crumpsall, Manchester M8 5DS
Sovereign Serviced Apartments
23-25 Polygon Road, Manchester
Who will I meet?
We are a multidisciplinary team who all work to ensure you get the best care possible. Here is a list of the people you may meet at your appointment:
- Miss Grit Dabritz, Consultant Oncoplastic Breast Surgeon – who will discuss with you your medical history and wishes and expectations of surgical treatment
- Miss Kate Williams, Consultant Oncoplastic Breast Surgeon – who will discuss with you your medical history and wishes and expectations of surgical treatment
- The Pennine Breast Clinical Nurse Specialist Team – provide detailed advice and support regarding the type of operation choices and peri and post-operative care advice
- The Pennine Medical photography team – who, with your consent, will take chest wall photographs pre- and post-operatively
- The Pennine breast radiology team – who may be involved in taking mammograms (breast x-rays) for anybody over the age of 40 years and / or ultrasound examinations if needed
- Out-patient F administration, nursing and support workers – who will make you feel welcome and at ease during your visit as well as chaperone you through your examination and investigations
What to expect and what happens when I attend?
Your own individual treatment pathway can vary depending on your needs, but below is an outline of the minimum numbers of interactions needed between you and us as your surgical team. This pathway ensures you receive safe, high quality care that meets the standards of care for the health of transsexual, transgender and gender non-conforming people set out by the World Professional Association for Transgender Health.
First assessment visit
When you arrive for your first assessment visit, after booking in at reception, you will be asked to take a seat in the waiting room. One of our nursing staff will then ask you to fill in a questionnaire sheet (asking a little about your own personal medical history and family history if you know it) so that this information can be used during your appointment. One of the nurses will then check your height and weight. Once done, you will then be taken through to be seen by one of the surgical consultants in the clinic.
During this appointment a thorough medical history is taken as well as a frank and honest discussion about what your own ideas and desires are regarding your chest wall surgery. Once this information has been gathered, the surgeon will then examine your chest wall, taking a few important measurements at the same time to allow thorough and accurate surgical planning. If you are over the age of 40 years, you may be asked to undergo a mammogram prior to your surgery even if your examination is unremarkable (an xray test of your breasts). If on examination it is deemed necessary, whatever your age you may have to undergo an ultrasound scan of your breasts, although this is rarely indicated.
Once this examination has taken place, the surgeon will then go through with you the different surgical options that are available to you, taking into account both your medical history and your physical stature. The risks and benefits for each different technique will be explained and a provisional surgical plan made.
Once this provisional plan is agreed, you will be asked to consent to having pre-operative photographs of your chest wall for your medical records, so that surgical planning can occur without you being present in the hospital the day before surgery. These photos are taken in our medical photography department, which is easily within walking distance of the clinic and we are happy to direct you on the day. Once these photos are taken you are free to return home, with a planned second pre-operative appointment date booked and given to you before you leave.
Pre-operative follow up and consent process
The second appointment has three aspects to it and so you may be given three separate appointment times. We ask you to attend for your first appointment time and then after this point we endeavour to be flexible in trying to ensure you see all relevant people in a timely manner. It can be a long afternoon however so please be prepared for a bit of waiting in between appointments. All aspects of the consultation are important however to ensure you receive the best care. These are explained below:
- Meet with a Clinical Nurse Specialist
You will have the opportunity to discuss your chosen surgical technique in more detail, be able to look at example photographs of patients who have undergone chest wall surgery in our department and understand the risks involved. The practicalities of the time in and around your surgery date will also be explained. You will be informed of what to expect in the post-operative period including what activities you should and should not do, when and where surgical drains are to be removed and how to care for your dressings before they are removed in you post-operative follow up clinic appointment. You will have plenty of time to ask any questions you may have thought of since your last appointment.
- Undergo a pre-operative assessment
This ensures that you are well enough to undergo a general anaesthetic. For the majority of patients this questionnaire can be done via a telephone appointment before your consultation, sometimes it is done on the day, but whichever way it is done, you will have routine bloods and some swabs of your skin taken as part of this follow up appointment to ensure all necessary tests are carried out.
- Meet with your surgeon for consent
The final part of the appointment is where you meet with your surgeon once more to discuss any further questions and make a final surgical plan together. The majority of patients will be dated for their operation at this point, and the details of the future hospital admission should be explained. You will be asked to sign a consent form at this point to verify you have had the opportunity to ask all of your questions and that the procedure has been adequately explained.
Your admission time for surgery can vary, depending on factors such as where you live in relation to the hospital and what time your surgery is planned. The exact details will be explained to you in your 2nd pre-operative consultation and confirmed in a letter from the hospital prior to your surgery date however as a general rule, we may ask you to be local to the hospital the night before your operation (which can sometimes mean staying in a local hotel the night before surgery) so that you can attend the hospital early on the morning of your surgery at be safely admitted (sometime 07.30am, sometimes 11am). Please do not make any travel arrangements before you have received the confirmation letter from our booking office as things can change in due course.
The morning of surgery can be a little busy, as nursing staff have to go through paperwork with you, the anaesthetist needs to meet with you to explain the anaesthetic process to you and your surgeon needs to see you and mark your chest with a pen in preparation for surgery. Once you’re changed and ready for theatre you will be walked down to the operating theatre by a member of the nursing team and then will be met at reception by the theatre team, who will take you through to the anaesthetic room.
Your surgery can take anywhere between 2-5 hours to complete. Once your surgery is over, you are monitored in recovery for a time before being admitted onto a surgical ward. You will usually have a drain on each side of your chest, that stay in place for 2-3 days post-operatively.
Most patient stay in hospital for 1-2 nights and then are discharged home with painkillers to ensure you are comfortable. Patients who live out of the area will be asked to stay in a local hotel one further night before traveling the long-distance home the following day. Surgical drains are usually removed by our own team prior to you traveling home if you live out of the area or by out-patient appointment if you don’t have far to travel.
1st post-operative follow-up appointment
We ask for chest wall dressings to stay in place until we see you at this appointment, which can be two or three weeks after surgery depending on which technique has been used to contour your chest. Sometimes keeping the dressings in place can be tricky, but it’s usually possible to “patch” the dressings with medical tape until your appointment.
Once the dressings are removed in clinic, one of our clinic nursing staff will clean your wounds and you will be advised whether any further dressings are needed after this point. We often ask you to have post-operative chest wall photographs taken at this point so that we have a record of our operative outcomes and with your consent these can sometimes be used to show other future patients our surgical results.
At home, once the wounds are dry and healed, we ask you to massage the scars with moisturiser to encourage them to soften and become less sensitive. Silicone tape dressings can sometimes be helpful to try and encourage the wounds not to widen in the future, although this can be difficult to predict.
2nd post-operative follow-up clinic appointment
We ask to see you six months after your surgery to ensure that you are happy with your results and assess whether any revisional procedures are required. The majority of patients are more than happy with their result, however it is helpful for us as a team to assess you face to face in clinic so that we can address any issues and modify our practice accordingly in the future. We also ask you to have more chest photographs at this point.
Things you can do to help with your transition
A good long-term outcome from FtM chest wall contouring surgery or MtF augmentation mammoplasty relies on combined efforts from the patient and the surgical team. You can help yourself to gain the best results by taking note of the following points.
We ask all patients to ensure that their weight is such that their Body Mass Index (BMI) is £ 30 before we list you for surgery.
To calculate your BMI please visit: www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx
We know how difficult this can be to achieve sometimes and it seems unfair but there are several reasons for this requirement, explained below:
The risks to your health associated with a general anaesthetic are increased when your BMI is >30 – for example there is a higher risk of clots in the deep veins of the leg (DVT) which can sometimes break off and stick in the lungs, causing a serious medical condition called a pulmonary embolus (PE). There is also a higher risk of a post-operative pneumonia or heart complications with a higher BMI. We want to reduce these risks by asking you to drop your weight to a healthier level.
Your long-term aesthetic outcome can be affected by a higher BMI. Those with a BMI >30 have a higher incidence of wound infection and breakdown, an increased risk of excess skin folds at the edge of your chest wall (known as “dog ears”) and a higher likelihood of nipple loss. By reducing your weight prior to surgery, you are giving yourself the best chance of a good long-term cosmetic outcome.
We ask all patients to stop smoking at least 3 months prior to surgery, and preferably before you are listed for surgery. This includes stopping all nicotine replacements (including e-cigarettes). This is because the blood supply to your nipples and the other skin on your chest wall relies on tiny blood vessels that constrict (get smaller) in response to nicotine. When these blood vessels get smaller, the blood supply to the skin and nipples is reduced, meaning that they are more likely to lose their blood supply and thus there is an increased risk of nipple loss. There is also a higher risk of wound infection and wound breakdown as a consequence, all leading to a poorer cosmetic outcome long-term.
For anyone prescribed testosterone supplementation, testosterone can increase your risk of developing blood clots in your legs (DVT) or in your lungs (PE). You will be given compression stockings on the day of admission to wear during your hospital stay that are designed to reduce your clot risk. We encourage you to continue to wear them for a further two weeks after surgery, and to move around as much as possible at home whilst you are recovering from surgery. We will give you injections to slightly thin your blood to reduce the risk of these complications whilst you are in hospital. Some people require these injections for up to two weeks at home after the surgery. Testosterone can also increase your risk of bleeding. It is therefore important to let your testosterone levels drop a bit - and surgery is safer in the period of “washout”, or after being off testosterone for a number of weeks depending on what type of testosterone you are on. You can go straight back on your normal dose of testosterone the day after surgery. If you bring your testosterone with you, the nurse will administer it on the ward.
For anyone prescribed oestrogen supplementation, being on oestrogen therapy can also increase your risk of developing blood clots in your legs (DVT) or in your lungs (PE). You will be asked to stop your oestrogen 2 weeks prior to surgery. You will be given compression stockings on the day of admission to wear during your hospital stay that are designed to reduce your clot risk. We encourage you to continue to wear them for a further two weeks after surgery, and to move around as much as possible at home whilst you are recovering from surgery. We will give you injections to slightly thin your blood to reduce the risk of these complications whilst you are in hospital. Some people require these injections for up to two weeks at home after the surgery.
Prior to chest wall contouring surgery for FtM transitions, we ask you to exercise your chest muscles (“pecs”) prior to surgery to build muscle bulk and strength. Good musculature definition gives a better cosmetic outcome and can help contour your chest. It is important however to follow your surgeons’ advice regarding exercise after surgery; this will have to restricted whilst you heal in the immediate post-operative period, usually for 6-8 weeks.
What surgical techniques are available for FtM chest wall contouring surgery?
To protect patient confidentiality, we do not currently show clinical photographs on our website. You will however have the opportunity to look at some example clinical photographs during your initial consultation, prior to discussing things with your surgeon. Below, we have outlined the techniques we currently offer along with a description of who is most suitable for each technique.
We try as a surgical team to listen to your personal requirements and priorities from chest surgery before recommending a surgical technique that we feel is most suitable for your physical shape and requirements. Clinical experience sometimes means that we cannot recommend the technique you are hoping for prior to the consultation, and if this were the case, we would do our best to explain the clinical reasons why. The decision process regarding surgical technique can take as long as you personally require it to, but all patients are seen at least twice in Manchester before a final decision is made.
With all techniques, tiny surgical Titanium clips are left inside your body for ever – these are used to seal off blood vessels. They can show up on routine chest X-rays, and do not cause any long-term problems. In all cases, the stitches that are used to close the skin are dissolvable, and do not need to be removed. Paper stitches are used on the outside as well to try and produce a scar that is as flat as possible. In general, your dressings should not be removed until you see your surgeon for your post-operative visit. You may shower as normal, since your dressings will be waterproof.
Whatever type of operation you have, there will be drains in place post-operatively. These are small plastic tubes which sit under the skin and are connected to a bottle. This is to drain any fluid or blood away from the operation area. These drains may be left in from anything between 1 and 3 days. Don’t worry about the length of time they are in; they have a job to do. Removal of the drains is not a painful procedure and is usually done at the hospital prior to your discharge.
Rarely, there is hardly any breast tissue present at all, and if the skin is in really good shape – and is nice and springy, then it might be possible to suck out the fatty tissue in the breast area using a special needle. Once the fatty tissue is removed, the skin should then contract and flatten against the chest wall. The advantage of this procedure is that the scars are only around 5mm long, and can be away from the breast area on the side of the chest. The disadvantages are that it may need doing more than once to achieve the desired flatness, and also may leave lose skin so that a second surgical technique may be needed later on. There can sometimes be a lot of bruising, and also there is the potential to damage underlying structures such as the chest wall and the lungs.
- Extended peri-areolar with Gortex stitch
This is best for patients with small breasts, who have little or no breast droopiness. A small amount of skin is removed to try and shrink the breast skin, and a scar is placed all around the areola (the dark round area around the nipple). The areola can be made significantly smaller if desired. A permanent tiny Gortex suture is placed around the new sized areola to try and stop it from stretching again post-operatively. The Gortex stitch can remain inside your body forever without causing any side effects. The advantage of this technique is that it can be performed through a small scar, and has the potential for the scar to remain just around the edge of the areola. The disadvantage is that it can be difficult to reach the very edges of the breast tissue, and to separate the edge of the breast tissue from the chest wall. This can mean that there could be “ghosting” of the breast disc – the visual illusion that there is still a circular breast shape on the chest wall.
- Dermal flap (double incision)
This technique is good for patients with medium sized breasts who specifically want to try and keep the sensitivity of their nipples. It is an alternative to nipple grafting, and the scars are placed at the bottom of the breast area (sometimes also known as “double incision” – in fact dermal flap, nipple grafting and bi-pedicled techniques all use the “double incision” type of scar”). The dermal flap is the skin from the bottom area of the breast, which has its top layer removed, so that the nipple can be placed inside the chest area and re-positioned in a more male-like position, still connected to its blood supply. The advantages are that nipple sensation can be preserved in up to 70% of patients. Dis-advantages can be that the buried skin can lead to an increased 3% risk of infection. The scars are also larger than in the two techniques above.
- Bi-pedicled (double incision)
This can be used for larger breasts, when nipple sensation preservation is important, when otherwise a nipple grafting technique may be the only option. Occasionally it can be used for small breasts, which are unsuitable for peri-areolar or dermal flap techniques. The nipple is kept on 2 blood supplies, one from above and one from below. The nipple can only be placed in the centre of the scar, which although is a long scar, is placed higher up on the chest in a more horizontal position. The advantage is that nipple sensation can be preserved. The disadvantage is that the scar is higher and more visible across the chest. There is a slighter higher risk of leaving bulges at the middle and outer edges of the scar / chest area – this is often referred to as “dog ears”.
- Free nipple graft (double incision)
This technique is suitable for when a large amount of skin and tissue needs to be removed or when the patient does not mind losing sensation in the nipple area. Also for patients with lots of chest hair it is safer to use this technique in order to reduce the risk of hair continuing to grow underneath the skin causing cysts and infection. It is a quicker operation to do, and the complication rate tends to be lower. It often gives a flat chest area. However, the nipple usually loses sensation, and can lose its brown/pink colour as well. In 2% of cases, the nipple/areola can fall off completely, and in up to 10% of cases there can be some partial loss of areolar skin.
What surgical techniques are available for MtF augmentation mammoplasty?
To protect patient confidentiality, we do not currently show clinical photographs on our website. You will however have the opportunity to look at some example clinical photographs during your pre-operative follow up consultation, prior to discussing things for the second time with your surgeon.
Breast augmentation, or augmentation mammoplasty, is a procedure that uses breast implants to enhance the size and shape of your chest.
Most trans-women begin hormonal therapy and find the resulting physical changes positive however, some still desire larger breasts. These trans-women are referred to our surgical clinic, (usually by a gender clinic or their GP) for consideration of surgery.
Unfortunately, not all chest augmentation and reconstruction surgery is funded by the NHS and each case has to be individually assessed by a qualified surgeon and then considered by an independent funding review panel after the first surgical assessment. This decision is NOT made by the surgical team themselves. All the surgical team can do is assess each patient and recommend a surgical treatment option that they feel is appropriate for that patient and then apply for funding on the patient’s behalf. The process can be appealed by you should the outcome not be favourable, but the process can be time-consuming and frustrating.
The techniques used during MtF breast augmentation are the same as traditional aesthetic breast augmentation. The key to your surgical assessment however is deciding whether you have enough skin to stretch over the top of a correctly sized implant so that the procedure can be performed as a single stage, or whether the procedure should be done as a two-staged procedure to create the desired end result. Your current nipple position will also be taken into consideration. If these do not need to be moved far to reach an optimal position, a one-stage procedure will be acceptable. However, some women may need to have the nipple position moved to achieve an optimum cosmetic result, in which case a two-stage procedure is recommended.
A large number of patients have enough skin at assessment to allow for a single-stage procedure. This means that a permanent, silicone breast implant can be inserted underneath the breast tissue already present to enhance the size and shape and ensure that the resulting breast size is in keeping with your overall physical frame. If very minimal breast tissue has developed after hormonal therapy then the implants may need to be placed underneath chest wall muscle (pec muscle) as well as the breast tissue so that the implant is not as visible or easy to feel underneath the skin. Your surgeon will explain which surgical technique will be best for you and why at your consultation.
In patients where it is thought there is not enough skin at presentation to cover the size of implant needed to create the desired size and shape of breast, then a two-stage technique will be recommended. An initial procedure is performed to place expandable, temporary saline-filled implants underneath the breast and/or muscle (referred to as expanders). Initially these expanders can be placed into the chest wall reasonably flat yet once the surgical wounds have healed, they can be gradually expanded up to the desired breast volume. Once you and your surgeon are happy with the overall volume of the augmented breasts, you can then undergo a second procedure to replace the expandable, temporary implants with permanent silicone implants.
The two-stage approach can seem time consuming and frustrating but if recommended to you by your surgeon, it is done so to ensure that you benefit from a more aesthetically pleasing result in the long-term.
It must be remembered that breast implants are not without risk. In the short-term, there is a risk of breast implant loss due to infection, which would mean a second operation to take the implant out and leave your chest flat for a while again whilst you are treated with antibiotics and the infection settles. This risk of this is higher if you have other risk factors (such as a history of diabetes, obesity or smoking. Please see above section on “what can I do to help my transition” for more information). In the more long-term there is a risk of implant rotation (if anatomically-shaped implants rather than round ones are preferred), contracture (or scarring around the implant) leading to a poorer cosmetic outcome over time, or a very small, rare risk of implant-related lymphoma over a much longer period of time.
What surgical techniques are available for non-binary individuals?
Your specific requirements will be discussed at your two pre-operative appointments taking into account your general health, chest size and desires from surgery. You are welcome to discuss any specific issues different to those described in the MtF and FtM surgical technique sections, for example if you would like to keep your nipples and if so where would you like them to be positioned. Please refer to the techniques described in both of the FtM and MtF sections of this website to understand the different techniques available to you, depending on what chest appearance most suits your own gender identity.
It is not necessary for you to be on any hormones in order to have chest surgery but if you are planning on taking hormones at some point we would recommend that you start these before surgery to avoid the need for corrective surgery as your chest shape changes.
Our departmental secretary can be reached using the following information. Please do not hesitate to ask questions if we have not managed to answer them here.
Miss Dawn Yates, PA telephone 0161 720 2849
Fax: 0161 720 2228