Surgery Types

At The Garramone Center, Dr. Garramone performs two types of chest masculinization surgery (FTM Top Surgery & FTN Top Surgery Procedure) for his FTM (female to male) transgender, trans-masculine, trans-male, non-binary, gender neutral, gender variant, lesbian, pan-gender, and female identifying patients:

• FTM Top Surgery & FTN Top Surgery Procedure Double Incision Method
• FTM Top Surgery & FTN Top Surgery Procedure Peri-areolar or Keyhole Method

FTM Top Surgery & FTN Top Surgery Procedure Double Incision Method: Transgender Surgery FTM Top Surgery & FTN Top Surgery Procedure Double incision Method can be performed on FTM patients presenting with pendulous sagging breasts. This usually requires a scar extending from underneath the existing breast fold to the lateral outside of the chest. The nipple and areola are removed, resized, and replaced as a “free nipple grafts” in a new position to give a “male” appearance to the chest. The scars are permanent, but most scars will fade and many patients are very happy with their new chest appearance.

FTM Top Surgery & FTN Top Surgery Procedure Peri-areolar or Keyhole Method: Transgender Surgery FTM Top Surgery & FTN Top Surgery Procedure Peri-areolar or Keyhole Method is usually reserved for FTM patients with very small breasts who have little breast tissue, breast skin that does not sag, or breast skin that is too tight to perform a double incision method. Dr. Garramone may recommend liposuction of the chest first to remove as much breast tissue as possible and then perform an incision along the lower border of the nipple-areolor complex. Through this incision the remaining breast tissue can be removed.

Most patients usually know if they are a candidate for the Double Incision Method. This would include breasts larger than an “A-cup”, sagging breast skin, or personal preference. We receive a lot of inquiries from patients about the “Keyhole” or “Purse String” procedure, and whether this is the right surgery for them. There are a few things that these smaller scar procedures cannot accomplish.

• First, nipple position cannot be controlled with the “Keyhole procedure. It is not uncommon for the nipple areolar complex to actually become lower on the chest once the breast tissue is removed. The nipple should be placed in the lower outer portion of the pectoralis major muscle to give the most convincing “Male” aesthetic chest, and this is unpredictable with the “Keyhole” procedure.
• Second, the size of the nipple areolar complex cannot be safely resized without potentially causing the blood supply to the nipple to become compromised leading to “death” of the nipple. Most female areolas are much larger than a biological males, and resizing the areola is a major consideration to be made for proper surgical results to occur.
• Third, even the slightest bit of excess breast skin below the nipple position can cause contour irregularities of the lower chest. Your skin contracts after surgery only to a certain extent, and the contraction is unpredictable. This leaves little control on how your final chest contour will appear. Also, the final chest contour may not be noticeable until several months after the initial “Keyhole” surgery, where as the chest contour for the “Double Incision Method” is more readily noticeable immediately after surgery.All of these issues occur with the “Keyhole” or the “Purse String” surgery, and not with the “Double Incision Method”. While some patients are good candidates for the “Keyhole” surgery, they may want to consider these few uncontrollable resulting outcomes and decide whether this is something they can find acceptable. Otherwise, the “Double Incision Method” may be the best option for them, as this is the only surgery that accurately addresses the nipple position, areolar size, lower chest contour, most immediate appreciation of the final chest contour, and most aesthetically pleasing “Biological Male” outcome.

Many people contact our office regarding Breast Reduction surgery for Gender Confirming Care. Most of these patients do not want the traditional Double Incision Method Chest Surgery, and would prefer a reduction in the size of their breasts to something more congruent with their Gender Identity. There are two main types of Breast Reduction Surgery that can be performed, and this is dependant on the patient’s breast size and requested new breast size:

• Traditional Breast Reduction
• Breast Reduction with Free Nipple Grafts (most commonly performed for Gender Confirmation)

The options for Breast Reduction can be discussed during your phone call with Dr. Charles Garramone. He will discuss the expected results and scar placements required. Most of the postoperative care is similar to traditional chest masculinization.

Transgender Surgery ManSculpture® Body Masculinization is commonly performed at the same time as the FTM & FTN Top Surgery Procedure. This consists of shaping the body to a more “masculine” form with the use of Power Assisted Liposuction techniques. By lipocontouring the abdomen (stomach), love handles (flanks), and the “saddle bag” area of the outside hips or thighs with ManSculpting, Dr. Garramone can give your body a more streamlined and masculine appearance. By performing ManSculpture® at the same time as the FTM & FTN Top Surgery Procedure, you can save money on the overall operating costs, as performing both procedures separately at different times will be considerably more costly. This is why Dr. Garramone recommends this procedure to be performed safely and concurrently with your chest surgery.

ManSculpture® or MaleSculpture® are names Dr. Garramone created to refer to use of liposuction to perform Body Masculinization. Dr. Garramone has specific techiniques and protocols to performing ManSculpture®, which no other surgeon can claim to be able to perform ManSculpture® or MaleSculpture® specifically. Dr. Garramone has performed thousands of ManSculpture® procedures, and is the only Plastic Surgeon in the World who can perform the ManSculpture® or MaleSculpture® procedure. If you are seeking Transgender Body Masculinization, then Dr. Garramone’s procedure ManSculpture® is the “gold standard” procedure and most recognized procedure for achieving this goal.

Remember, “No other surgeon in the World can say they will perform ManSculpture® or MaleSculpture®  for body masculinization, as Dr. Garramone is the only Plastic Surgeon in the World who can offer this procedure.”

Most common areas requested are the Flanks (love-handles), Outside Thighs, Abdomen (stomach), Inside Thighs. Look at the image to the right—–>

We receive a lot of questions regarding scars with the FTM Top Surgery & FTN Top Surgery Procedure.Many questions ask about the length of the scar, the shape of the scar (straight or curved), widening of the scar, and color of the scar. You must remember, every patient is different and every patient requires a different scar and scar placement. How your scar heals depends a lot on your genetic makeup and inherent ability to heal. Dr. Garramone will discuss the potential appearance your scar and scar placement during your visit with him.We also recommend the use of silicone based scar products for after surgery and have them available for purchase in our office.

Most patients will undergo only one FTM Top Surgery procedure to obtain their desired chest or breast shape. Some patients may still require additional procedures to correct excess skin issues, an asymmetry or a complication from the surgery. If a patient is over their ideal body weight, then there is an icreased chance a future revision surgery will be required. Patients who are overweight or have a lot of excess skin, may require additional surgery for contouring which is not part of their initial chest surgery. Dr. Garramone always explains this in great detail when consulting and seeing his patients preoperatively. Transgender Surgery has no guarantees and can be very challenging. The Transgender Patient must be well informed and willing to accept the possibility of future Transgender Surgery to achieve their desired goal. Dr. Garramone charges a nominal fee for revision surgery of his prior patients within the first year after surgery, but keep in mind, this fee may be higher if revisions are required to be performed in a surgical center or hospital. The Operating Room, materials, and Anesthesia Fees cannot be waived and are the responsibility of the patient.

At least once a week we receive an email or phone call requesting this “New” procedure, and whether Dr. Garramone will start offering this as a choice for chest surgery. The simple answer is “No, not unless there is an absolute indication for it, which is true of all chest procedures.”

The Buttonhole technique has lately been touted as a “New” procedure unlike anything else, and superior to many other choices including the Double Incision Method, because it allows preservation of nipple sensation. But, it shares the common technique of making the exact same incisions as the Double Incision Method, but leaving the nipple attached to underlying breast tissue and then creating a new incision or “buttonhole” to bring the nipple out through, thus the “Buttonhole” technique. Very simply, it is the exact same procedure as the “Inverted-T” procedure, but without the small vertical scar. Sadly, both the Inverted-T and Buttonhole techniques promise maintaining nipple sensation, which is rarely true. They also require leaving behind a fair amount of breast tissue to maintain the nipple sensation, thus running into the same problems of giving the appearance of excessive breast tissue. Basically, it looks like the Patient still has breasts and fullness in the lower portion of the chest and therefore prevents them from attaining the “Ideal Aesthetic Male Chest” they are looking for. Photographs or diagrams on a Plastic Surgeon’s website can show you a great result for any procedure ever described. Why? Because they are taken with proper forward lighting and with the Patient in a neutral position, thus hiding any shadows or appearance of chest fullness. Dr. Garramone has performed many consultations for Revisions of the Inverted-T and Buttonhole technique, and it almost always requires converting the procedure to a Traditional Double Incision method just to remove the excessive amount of breast tissue that was voluntarily left behind by the previous surgeon. “Is it indicated for all Patients?” No, it may be indicated for some very rare specific cases, but should never be considered as a first option for the general population seeking chest surgery. The same way the “Keyhole” technique is not indicated for Patients with D-cup breasts.

Finally, the “NEW” Buttonhole Technique for FTM & FTN Top Surgery is not really a “New” procedure by any means, and was first described in 1925 by Dr. R. Passot and has been performed in all types of Breast Reduction and Mastectomy Surgery for over 90 years (if not longer) in the specialty of Plastic Surgery. Labeling something as “New” does not make it revolutionary, nor does it make it “New”.

Roughly 20% of the phone calls performed by Dr. Garramone each year, involve discussions with many patients who have already had FTM Top Surgery & FTN Top Surgery performed by a different doctor. Some patients have minor concerns they would like fixed, but many have major deformities from their prior surgery performed by other doctors. Dr. Garramone has become a specialist in fixing these deformities caused by other doctors, and can discuss these options with you if you have had a less than ideal result from another surgeon.

Yes, but Dr. Garramone does not recommend it. There are risks to not having drains placed after surgery including excessive swelling, increased pain, seroma (fluid pocket) formation, contour irregularities from a seroma, delayed healing from a seroma, etc. If you are willing to accept these risks then you can request not to have any drains placed during your surgery.

Yes, many patients are opting to NOT have any Nipple Graft Reconstruction done during their chest surgery. Most of these patients want to have the nipples Tattooed onto their chest at a later date, but some patients just do not want to have Nipples. This is your choice, and if you do not want Nipple Grafts then let us know during your phone call or in-person consultation with Dr. Garramone.

Dr. Charles Garramone performs most FTM Top Surgery procedures in less than two hours. If having ManSculpture®, this may add an additional 1-2 hours of operating time.

FTM Top Surgery is best performed on patients over the age of 18 years. This allows for the procedure to be completed on a fully grown adult individual who will likely not grow in skeletal size any further. Performing surgery on younger individuals under 18 years is not ideal, as the person is still growing into their adult body. If performed too early, their results cannot be guaranteed to remain aestheitically ideal and they could have potential issues with normal skeletal and muscular growth if their healing causes scar contracture and deformity.

FTM Top Surgery, when performed by an experienced Plastic Surgeon like Dr. Charles Garramone, carries a low risk potential and a low revision rate.

Most patients should have a full 6 to 8 weeks off from a labor job after FTM Top Surgery. If you have a desk job you may be able to return to work within a few weeks.