Mastectomy - Male Subcutaneous :
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Male Chest Reconstruction usually precedes below the waist surgery for FTM patients as protruding breast contours are a sin quo non of the female presentation.
While for very small breasts a peri-areolar skin excision can be performed, the problem of maintaining an adequate pedicle to support the nipple areolar complex without protrusion of the pedicle through the skin becomes challenging. Bringing skin into the borders of a contracted areola will cause puckering which hopefully with time will smooth out. A permanent fixation suture is often required to prevent tension on the suture line from causing a slowly expanding scar.
A transverse inframammary incision with free nipple areolar grafts is my preferred approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T).
The areola is trimmed to a pre agreed upon diameter and the nipple sectioned with a pie shaped excision and reconstituted.
Although the patient must be cautioned there may be varying sensory loss because of nerve disruption, our limited experience has been favorable in this regard as distal nerves are known to regenerate.
Nipple areolar grafts must be kept wet with saline soaked gauze re-moistened every 3 hours for at least 5 days to maintain tissue viability until capillary buds grow into the graft.
Plan on having a roommate or spouse do this for you throughout the night.
Some crusting of the grafts is not unusual and will usually shed by the 3 or 4th week. By all means do not lift or pick them off as the adherence of the graft may be very tenuous and its viability very fragile.
After tissue settling some revision surgery may be required and is usually done for a nominal fee relating only to use of the facility and anesthetic services if required (as opposed to being done under local).
You will have a general anaesthetic, and will be asleep for the whole operation. The surgeon normally makes a cut around part of the nipple. He takes out the breast tissue. The overlying skin and nipple stay there. The cut is stitched up. Afterwards the chest looks pretty normal for a male. The operation can either be done as a day case, which means that you come into hospital on the day of the operation and go home the same day, or as an in-patient case, which means spending one or two nights in hospital. Your surgeon will have discussed with you which operation you will be having.
Before the operation
Stop smoking and try to get your weight down if you are overweight. If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check you have a relative or friend who can come with you to hospital, take you home, and look after you for the first week after the operation. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to hospital with you.
On the ward, you may be checked for past illnesses and may have special tests, ready for the operation. Please tell the nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Many hospitals now run special pre-admission clinics, where you visit for an hour or two, a week or so before the operation for these checks.
Complications are minimal and seldom serious. If you think that all is not well, please ask the nurses or doctors. Bruising may be troublesome. Occasionally some old blood collects under the wound, but this can easily be removed. Occasionally the wound edge and nipple do not heal well in places. This always settles down but may take 2 or 3 weeks to do so. Infection is a rare problem and settles down with antibiotics in a week or two. There may be some numbness around the nipple. This gets better over a month or more.There may be some flatness of the chest, but this improves over 6 months or so.
Will it hurt?
There is some discomfort on moving rather than severe pain. You will be given injections or tablets to control this as required. Ask for more if the pain is still unpleasant.
You will be expected to get out of bed the day after operation despite the discomfort. You will not do the wound any harm, and the exercise is very helpful for you.
The second day after operation you should be able to spend most of the your time out of bed and in reasonable comfort. You should be able to walk slowly along the corridor.
Recovery after a Mastectomy
After a mastectomy, an oxygen mask may be given to those with a history of chest problems and a drip tube is often fixed to the arm vein. The drain is removed after one to three days, but until then, the wound is dressed regularly to keep it clean. Purple and yellow bruising around the wound is common but should fade away after a few weeks. Similarly, swelling around the skin may occur and again this is only temporary. In both cases you should contact the doctor if these side effects persist. The wound itself takes three months to completely heal and complications are rare. However if you find after this period that there is a collection of old blood under the wound, bruising, slow healing and numbness of the wound edge and nipple, infections, and flatness of the chest, again contact your doctor. Antibiotics or additional treatments are usually in order.
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