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Surgeon, Ioannis Ntanos, returns for a second episode of the GenderGP podcast in which he tackles some of the key questions guys should be asking when considering top surgery. This episode of the podcast seeks to educate and empower the individual so that they can get the most out of their experience.

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Links:

GenderGP Blog Post – Top Surgery for Trans Guys

 

The GenderGP Podcast

Top Surgery: what to ask, with Ioannis Ntanos

 

Hello, this is Dr Helen Webberley. Welcome to our GenderGP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.

 

Dr Helen Webberley:
I’m delighted to be back again with Marianne and myself and back with Dr. Ioannis. He is, we have had Dr. Ioannis as our guest before. He’s a surgeon who specializes in chest and top surgery for transmasculine people. So really delighted to have you back again, Ioannis. And I want to learn so much more than I learned last time, even though last time you filled my boots with learning. So lovely to have you on. And I hope that your spring weather is the same as ours is here.

Dr Ioannis Ntanos:
Thank you very much for inviting me back. And it was a blast the last time, and it is a pleasure again, it’s very nice to be here with both of you. Thank you.

Marianne Oakes:
You’re welcome.

Dr Helen Webberley:
So, Ioannis, we’ve got lots of questions to ask you. We want to know it all, because I tell you a secret, I’ve never had top surgery. I don’t think Marianne’s ever had top surgery. And so we speak from a position of ignorance sometimes. You, I don’t know whether you’ve had top surgery or not. I’m not going to ask you, but I think you might’ve done that surgery in your time. And I’d be really grateful if you could just give us some nuggets. What do people ask you? What do people want to know? What should we be telling people? Because it’s really hard in this area of healthcare. The education is very little for doctors, the education is very little for those who support people, and the education is very little for patients. So I’d love to use this opportunity to really, I don’t know, share the myths, share the truths, debunk the lies and teach people what they want to know. So over to you, Ioannis. Tell me, tell me everything, you know,

Dr Ioannis Ntanos:
I’ll try my best, Helen. Thank you very much. So, so let’s start with the basics. I don’t know if we covered that last time. Top surgery is a stop, is a part of someone’s transition, but it’s not necessarily a part for everyone. So top surgery includes chest surgery, in forms of mastectomies and chest wall for reconstruction from transmasculine individuals, or a BA, a breast augmentation for transfeminine. But it’s not, it’s not there for everyone. Okay. But it is a choice for, for some or some of those individuals. And you’re right. I haven’t had top surgery myself, but I have done a few. Okay. So, so I’m conducting these consultations regularly every week and some of them appear to be more meaningful than others. And this is, it comes, essentially comes down to how prepared someone is to come and have the discussion with myself. And I, I enjoy more that guys that are more informed that come to me with specific questions that come to me, knowing what they want in their head. And then we’ll explore whether these expectations can be actually met or not. And it’s a limited time that you have to go through through everything. So the more prepared someone is, the more this consultation will actually be beneficial for both parties. I can focus on anything you want. If you have a question or I can start by saying the basics that would be, I would love everyone to know in advance before going and seeing any surgeon.

Dr Helen Webberley:
I think that would really be useful. So if we could share this bit of knowledge, say right, if you’re going to go and see Dr. Ioannis, then here, listen to this first, because this answers the basic questions. And then you can go hard hitting with the questions that really are specific to you and your personal outcome that you’re wanting. So that would be really, really good.

Dr Ioannis Ntanos:
Yeah. So, so I don’t think what I’m going to today is specific. I think all surgeons would like to have to have knowledgeable and prepared patients, individuals to speak to. So first of all, lifestyle is important if you’re planning to having top surgery, okay, consider quit smoking. It’s simple as that. Okay. It’s an operation that can take place at any point. Why not be prepared? It’s a big operation. It takes three or more than three hours. It’s done under general anesthetic. We are not negotiating on whether if you are stopped smoking or not, we will not do the operation or not. You will have your operation anyway, why not get yourself in that position to have the optimum outcome from a general anesthetic point of view and from wound healing and scarring point of view that could be affected as well. Okay. So please just stop smoking.

Dr Helen Webberley:
That’s good advice. Isn’t it? Because I mean, yes, anybody who is having a general anesthetic and it’s going to, there’s going to be impacts, there’s going to be lung involvement, so stop smoking. But also that the thing that people don’t always know about it is that wound healing. And healing and the outcome, and the scars are really important. You know, Marianne was saying earlier that, you know, people want the aesthetic look. They want to be able to run into the sea with their chest. And that scar healing is really important and smoking does matter. So I don’t want to lecture everyone on smoking, but we do think it matters.

Marianne Oakes:
Can I just stop there? And if you really are struggling to quit smoking, we do offer hypnotherapy now, which can help. So yeah, I should put that in there.

Dr Helen Webberley:
Absolutely.

Dr Ioannis Ntanos:
I mean, it might be difficult for someone okay. To consider quit smoking, but, but this, this is a huge step on someone’s transition. Okay. And I think they should invest at least some some time to consider that this will improve cosmetics, will improve the scar and will improve the quick healing of the skin, making anyone’s surgeon’s life much easier. Okay. So, so that’s, that’s one thing and the close to that close to smoking take care of your skin. Okay. Acne can be a problem with, with some individuals who are on testosterone. So specific treatment of the skin might require prior to any surgical consideration, to bring the skin situation that will minimize the risk of postoperative infection. So keep your skin moisturized, keep acne out of the way, don’t shave your chest. Okay. Prior to any operation, because that includes the risk of infection too.

Marianne Oakes:
Can I ask, is binding likely to damage the skin? I was just thinking of sweating and that kind of thing.

Dr Ioannis Ntanos:
No, certainly. Sweating is not the problem. It will stretch the skin. So if someone is binding and maybe before binding oeriareolar or circumareolar mastectomy was possible. This is the technique that gives us the less, the least expected scarring. With prolonged binding, this might not even possible anymore. If the skin stretches too much, we have to remove part of the skin during the operation. So for those individuals that are borderline, yes, maybe (unclear 7:20) might take away that chance. I’m not a very big fan of binders either. And going back to smoking, prolonged binding affects the breathing as well. So I always advise my guys to quit binding altogether if they can at least two to three weeks in advance before the procedure. So, these are the basics to focus on the area we’re going to perform an operation. But it’s not only that, okay, someone needs to do some research, someone needs before coming, seeing myself or any other surgeon, they have to have at least a basic knowledge of what we’re going to discuss. So there are different surgical techniques and the decision of which one we should choose is a combination of two things of what the surgeon can offer based on their skills and the relative size of the chest. And also what the individual is expecting, what their expectations are, what they want to achieve. It’s not always, you know, black and white. We sometimes we both compromise both ways, trying to achieve an agreement. But my understanding is I try to get informed as much as I can regarding the individual I have in front of me. They should try also get as much information they can from what we do in order to have a meaningful discussion.

Dr Helen Webberley:
So basically what you’re saying is peopla can come with some basic knowledge and understanding, then you, then you’ve got more time in your consultation to talk about the bit specific to them. It’s kind of do your homework first. Isn’t it really?

Dr Ioannis Ntanos:
Absolutely. I always start my consultations with the single question. Okay. How much research have you done? What do you know so far? So that builds on the foundation of what we are going to discuss further, and see if that is actually the truth. It’s different discussing with someone, what is surgery? What is top surgery? Why we do top surgery and different to focusing on the different techniques on how we can not see them on a why I was able to offer something to a friend of yours and not yourself because these are the differences. And in the information era, the information is out there. If someone looks for it, they will find. They will find videos online. They will find forums where they can discuss. There are different websites with a lot of information. In that sense, they can pick up the information that feels important for them, and they can feed it to myself or any other surgeon. And we can use that as a base to discuss further. So one of the questions I always get for example is I was told that you can only offer a single type of operation, a single, a single technique, that’s it. You do not offer anything else. And this is a myth. Usually, the technique we are offering either myself or anyone else is what we know to do and what is available in that specific (unclear 10:36) of a specific individual and the five field, but the technique would be suitable for someone. And for any reason, I cannot offer it myself, I should always, and I do consider referring them to, for a second opinion. Guys should have that in mind as well. If they want something specific and have done their research and the surgeon is not willing to offer it to them, it’s not a taboo issue to request for a second opinion, discuss with someone else. See if that’s actually the truth.

Dr Helen Webberley:
It’s tricky though, isn’t it? I mean, I hear what you’re saying from a medical point of view, but I think sometimes in trans healthcare, people are so desperate. They’ve waited such a long time. They’ve had to kind of beg and plead and burrow all the way along. And so I think sometimes people are scared to kind of put up their hand and say, excuse me, I don’t know. I’m not sure about that. Can I get a different opinion? Could we try something different to what you’re suggesting? It’s sometimes feels a bit cap in hand, doesn’t it? You know? Yes, sir. No, sir. That’ll be fine sir, thank you.

Dr Ioannis Ntanos:
I totally understand that. I agree with you all. And it all comes down to health care services, not being open and honest with trans individuals, and then they, they feel left outside. And I’m sure you have yourself cases that someone is so scared of the healthcare system. Now they don’t even go to approach it for any other medical region. What I’m saying is that individuals like myself are involved in this service are open for discussion, are open to refer for a second opinion, to listen to concerns, to consider different things that might appear strange to someone who is not involved in this service.

Marianne Oakes:
I’ll tell you what’s coming to my mind here is that we, the health service and clinics focus a lot on, are you trans? Can you prove you’re trans? And all the effort is making sure this person knows they are trans and not on what does that mean to what would help you? What would be the best outcome? And this isn’t just about top surgery, it’s about any surgery. It’s about, it’s about the the medications we give as well. Isn’t it Helen? That they come in and they so, what do you call it, they’re almost paralyzed because they just, you know, that we’re just going to ask about their gender and not ask about what they want. And I just think this is really interesting that, you know, they’ll, they’ll get as far as surgery and still almost choking to say, I just want a masculine chest. And I need advice on how to, what is best for that? Because people might invalidate their gender. Why is that important? You know, am I making sense there?

Dr Ioannis Ntanos:
I think you are, Marianne. And let me just say two things about this one. When someone approaches a surgeon to discuss top surgery. Why is someone feeling that way? And what (unclear 13:40) is or not is completely irrelevant. This, this, this has been explored by other professionals where they receive referrals to discuss surgery, and we are here to discuss surgery. I will, myself also, touch base with a few things just to make sure that what I can read on a referral is still valid because sometimes it takes a long time from the initial referral to actually see someone, okay? But that will be the end of it. The rest I should be focusing on surgery. And the questions, the research, should be of the guys should be on surgery as well. So for example, someone should be prepared that I will ask them, or any other surgeon will ask them questions. How do you feel about nipple sensation? Do you want it retained? And in some of them yes or no, that’s fine. But once someone answers to me, you know, I’ve never thought about it, then it’s an, it’s a whole different discussion that we’ll have to get into about using nipples for sexual pleasure about losing the ability to respond to hot or cold stimuli. It’s a much wider discuss that cannot always be covered on the consultation to just discuss surgery.

Dr Helen Webberley:
But does that depend on the technique that’s used, Ioannis, the nipple sensation? How is it affected? Tell us a bit more about that.

Dr Ioannis Ntanos:
So, yeah, I mean, there are techniques like the circumareolar technique where, where the nipple sensation will be preserved in 75 to 85% of cases. And even if it’s not entirely, it will be for most of the nipple. There are (unclear 15:22) flap techniques for accessed reconstruction where slightly less sensitive will preserve roughly around 75%. And there are techniques like double incision and free nipple graft reconstruction, where the sensation is completely lost.

Dr Helen Webberley:
So basically if it’s important, if nipple sensations and important parts of that person’s life, whether it’s their daily life or their sex life or whatever, life, then it’s important to bring up and mention. And that’s what you’re saying really, isn’t it?

Dr Ioannis Ntanos:
Yes. Then we’ll come to balance, then we’ll have the surgeon needs to discuss with them. Okay. How important is it? Is it important so much to risk the risk of a revision? To risk the risk of a second operation to try to achieve a flat and male test? If yes, then we can negotiate. Say if we are willing to take that risk. There are certain techniques. If nipple sensation is important and there are certain use cases, for example, the smoking we mentioned earlier, okay. Some of the techniques like the dermal flaps will have a worst outcome in smokers. So if you want to retain nipple sensation, okay, let’s wait six months for you to stop smoking. And then we can go ahead with that technique. So it all comes down on knowing exactly what top surgery is, what we’re going to discuss in certain terms of technique. And another thing would be different techniques have a different risk for the need of revision. So, so generally speaking, all individuals are warned that if symmetrisation is not achieved, if there is any excess of skin on one side, we might need to visit again, to have a second operation and perform a corrective procedure. However, let’s say that we have an individual who is a high risk for general anesthetic. I would probably choose a technique that will have the least risk of revision, trying to avoid going back to theater again, to correct anything. So that’s another thing that we might take in consideration. Even if the suitable, technique is available, the chest is suitable. If we want to avoid the risk of reoperation, we might say, okay, let’s forget about all this. This is a health issue. Let’s focus on offering you what will be suitable with a single procedure.

Dr Helen Webberley:
Yes, there’s lots to think about, isn’t there?

Dr Ioannis Ntanos:
Yes.

Dr Helen Webberley:
More than I thought. Marianne, are these the kinds of things that you do get asked about? Because you do get consultations, you do the kind of pre-surgery referrals. What kinds of things come up? Do these?

Marianne Oakes:
I do. And I must admit the one question I always, well, that everybody stutters on is when I say, what’s your goal for surgery? What are you hoping it will achieve? And they all–like I say, the most I will get is to just want a flat chest. You know what I mean? Some people will say, I just want to be able to put a t-shirt on, you know, without having to bind. I want to be liberated from the binder. It’s one that always (unclear 18:37) because I think it’s, I think they believe that it’s just, you know, it’s just an operation and it’s the same outcome and what you’re saying, Ioannis, is says, actually, you’ve got choices to make. Or there’s a potential of having choices. And it’s really important that you research them choices. So, you know, anybody else I talk to now, they’re going to get a small lecture. Not that I’m going to answer these for them, but I do believe–what I was going to ask as well is, are there any links that we could be put, putting to go along with? Well, to actually just go on our website where people could get some of this information?

Dr Ioannis Ntanos:
I’m pretty sure there is. I mean, I know there is a lot of information on there. Most of it is from websites for individual surgeons around the world, but WPATH has a lot of information as well there, okay? And most of it is about logistics about how referrals are going through and what the surgeon should do. Okay. But, but there are, there are a few–I would be happy to work with you and we can create a list and maybe put it on your website.

Marianne Oakes:
Yeah.

Dr Ioannis Ntanos:
You were saying something, Marianne, and then you’re actually saying two questions. So one question is, what are your expectations after surgery in your eyes? The answer is most of the times I just want a flat chest. So what I’ve done in the last year is I’ve changed my question. And my question now is what do you want to be able to do after surgery that you cannot do now? And then the guys starting, revealing, what are their feelings, what exactly the feelings are? I want to be topless on my holiday in Spain. Okay. I want to be able to exercise because, because I’m afraid to go to the gym. I want to be able to go swimming. I want to build up the confidence, the sexual confidence with my partner. I want different things in life. And these are the important things because yeah, I mean, we can always achieve a flat chest. We should be exploring more than that, that’s what I’m saying.

Marianne Oakes:
I asked that question in conversation later on, interestingly enough, one of the main, yeah, they would love to go swimming and I always include it in my reflection at the end, these three things actually go swimming, go on a family holiday to the beach, and actually to be able to plan the life so that they’re not having to think I’m at work all day I’ve got my binder on. I’m not going to be able to go to that function tonight. Do you know they’re missing out on social events? Because they’re having to plan when they can wear the binder and they’re the three key areas that I always try to reflect, and I just find it so sad. I’ll be honest with you that your life is so restricted. So yeah, I do ask that question. What, not, not with the goals, but I always do it in the reflection afterwards.

Dr Helen Webberley:
It’s interesting, Marianne. It reminds me of that gender dysphoria noise that to Aiden Olson-Kennedy talks about. And I can just imagine that guy at work thinking, is it visible, is my binder visible is anything sticking out the side? I wonder when I’m going to get top surgery. Oh god, have I got time to change before I go home? Will this shirt look like or will this tshirt or will that thing that I’m going to wear the same thing, is it going to look okay as this? WIll I be too hot if I have to put that overcoat thing on? They can just hear that noise. How can they concentrate when they are at work or school when they they’ve got all that noise going on?

Marianne Oakes:
Interestingly enough, university, sorry Ioannis. At university where I’d have to go in in the morning and then the mayor, you know, lectures going on into the afternoon. And then all the mates are going straight to the, you know, the student union bar afterwards. And they’re thinking, oh, well, if I wear a binder and if I could just go and hide somewhere for a couple of hours and he’s out and then put it back, and then you find that the forgotten the sports bra, which they might wear while they’re just do, you know, it’s just, did you just want to pick the bag up, go to the lessons and go and enjoy themselves? It’s crazy.

Dr Ioannis Ntanos:
That’s important stuff here which I don’t think we can cover in this discussion. But this is the discussion we’ve had last November in one of the WPATH workshops where different surgeon was saying about we should, we should be aiming to offering the procedure in younger ages. So, so there are milestones in the person’s life. If someone is attending to go to the university, why not allow them to go to the university with their desired chest? Why should they transition surgically the second year after having struggled the first years and then having to start all over again? So these milestones, if we can try to respect them and give them the, the initiative these individuals want, it will be brilliant. Unfortunately, the system doesn’t always work like that.

Dr Helen Webberley:
It’s so interesting. You talk about it with, with gender affirming hormones in young people and puberty blockers. And it’s about stages, not ages, you know, at age 18 to get referred and therefore not have operations or something till 19 20, or whenever the waiting list, you know, I know it’s difficult to make these things fit with people’s lives and we can’t always get it right, but it’s, these milestones are really, really important, aren’t they? And people, young people, all people just want to fit in with the rest of the crowd. That’s what human nature is, is like, we want to fit in with the crowd. You know, whether you’re a young kid wanting to start puberty, or whether you’re an older university student, just wanting to go down the bar with all the others, because that’s what the crowd do. That’s the future. We talked about that before.

Dr Ioannis Ntanos:
Can I switch the discussion to something else which has been increasingly visible to me. I see more guys of rather more advanced age being referred for top surgery. And there are different discussion why this is happening, but there are different considerations for them. So if someone is above the age of 40, for example, and they will require some imaging investigations to make sure that the chest is tissues. Okay. So they, they will, they will require to have a mammogram and they should be aware of that in advance because it might be a situation which they’ve never expected that we’ll have to go through. So that’s one thing. Secondly, with advanced stage, we’ll have more potential medical comorbidities, which goes back to what we said that maybe some options will not be available. Not from a sense, not from a technical point of view, but because we want to decrease the risk of, of going back for a revision. And of course these individuals have a different, usually we have a higher BMI, which means that we might have to make some compromises when it comes to the lateral sides, for example, of the chest wall and then the famous dog ears. Okay. But it does matter the age on its own for offering the procedure. Okay. And very, very recently I had a consultation with an individual who was 72 years old, and I was happy to offer them the procedure. And it was a brilliant consultation. So what I want to say is don’t feel discouraged by your age if you want to pursue surgical transitioning.

Dr Helen Webberley:
That’s a lovely thought. I love the thought of older people saying it’s not too late. I am going to be my authentic self. I learned those words from Marianne and I love them. So I love the thought that actually, no, it’s not too old, but of course, as you say, there are, there are medical considerations. We’re not as fit as we get older. We don’t heal as well. We don’t, you know, general anesthetic brings another level of risk to that. And also, yeah, I’ve never thought about that. You know, what, if there is an underlying cancer or something that hasn’t been seen, you know, we do need to make sure we’re not cutting into something like that when we’re doing stuff.

Dr Ioannis Ntanos:
Sometimes, Helen, it’s not even an underlying cancer. I have last year, I had a couple of cases with strong family history of breast cancer. And we had to choose that technique. That would be, that would feel more safe to perform safe in the long run, safe from an oncological point of view, just because of the family history. And we did, I did discuss the case with colleagues who are specifically involved in cancer surgery with (unclear 27:36) to see what will be the best technique in that case. So that’s another thing to consider. If there is a need for consulting with a different surgeon, for different reasons, that should be available. And adaptations will always be made to be able to offer you a statistically, what is best for the individual, but also from an oncological point of view, more safe.

Dr Helen Webberley:
And again, you know, this, you speak so much sense and so much wisdom, and it’s almost like that again with peeking into the future where the standards of care for trans medics and trans surgery and trans therapy support are the same as others areas of healthcare, because this is exactly what we would have and expect and expect no less in other areas of healthcare. And it fits still feeling a little bit futuristic, but this is absolutely what we’ve got to aim for. Isn’t it?

Marianne Oakes:
I was just going to say, I’m just loving the conversation here. I wrote the piece for the newsletter for Abby yesterday and spoke about spring and how, you know, the changing of the seasons, how our hope’s coming back. And I’m just listening to this conversation. Yeah. It might be the future, but at least these conversations are being heard. One point, I just really, you know, just to summarize what I’m hearing, we talk about regret a lot with transition and regret isn’t about that. You know, I shouldn’t have transitioned. Regret sometime is just taking top surgery from the first surgeon that will chop them off. And then the regret is that they didn’t have sensitive nipples. They didn’t get what they wanted from the surgery. And I think, you know, everything we’re talking about here is about reducing the chances of regret and actually giving people body autonomy, giving them the body that they want, or at least as closely as we can to give them what they need given the right information, which I think is really important.

Dr Ioannis Ntanos:
I would never–Thank you, Marianne. I would never use expression like, you know, the first surgeon to chop something off, but we’ve discussed this before, okay, is a need for establishing who should be performing their operations, how many they should be performing every year to retain the ability to do them. We need guidelines. We need NICE guidelines. We need college guidelines. We need a university curriculums to go through transgender special in surgery. Let’s do it.

Marianne Oakes:
Would it be possible, and if I’m going off way off here, just bring me back. But when I hear about guidelines, my heart sinks, when it comes to transgender health care, because the guidelines, I know that I’ve got the same hormonal makeup as Vicki, my wife, but I know what she can do compared to me because I’ve got that little trans prefix and the guidelines for me are so difficult to navigate, but for her, the doctor, oh yeah, you want to increase your dosage, you know? So if the guidelines are about informing about the surgery. And the surgery, as they would, anybody else that actually this surgery is as important to a trans guy as it is to any guy who needs chest surgery. So yeah, that’s, that’s what I would like to, to see.

Dr Ioannis Ntanos:
Guidelines are there to protect, they are there to promote, they are not there to gatekeepe. So we just need to sit down all of us, we are involved in this services and say, who is doing that? How are they trained? How do they keep up with those skills? What are the skills apart technically performing the procedures you need to be aware of, of different things as well. And you need to be dedicated on what you do. It’s not that I’m doing something else 99% of the time. And yeah, let’s, let’s put that in because I have a free list on Saturday. Let’s let, let’s do a top surgery as well.

Dr Helen Webberley:
If I think of the guidelines that I’ve read, I mean I haven’t read how to do operations. But I’ve read guidelines on surgery for trans people. And again, a lot of it is focused on how many referral letters you need, what are the minimal criteria that you’d have to fulfill in order to get referred? And I can see those pages, you know, there’s so many pages of those, but then these questions that we ask, but I’ve never seen them. I’ve never seen them. I’ve never seen them talked about, I’ve never seen them written. And it’s like, you know, we need to just address that balance, don’t we?

Marianne Oakes:
Can we start today? Can we come out and write these? I’m excited to get a list of questions that could put us at the fall from the referrals.

Dr Helen Webberley:
I texted Abby in the beginning of this conversation and I said, Abby, start writing these questions down. We’re going to make these by the end of this, we’ll have it. You talked about dog ears and we’ve talked about a flat chest. So if that’s what people are wanting, we don’t want dog ears. And we do want flat chests. Is that possible for everybody? Is that just too have one way to stick it? What happens if you’re big chested to begin with? Tell us about that.

Dr Ioannis Ntanos:
So, so there is, there is no contraindication when it comes to how large the chest is. It can be as large as you want, but you will have some limitations on the technique you can use. The larger a chest is, the more likely it is to require a free nipple graft reconstruction, because you will need to reposition the nipple in an ideal situation in a masculine chest. Now, when it comes to BMI, we should always keep in mind that the high BMI, if a large test goes with a high BMI means a higher risk for all types of complications from general anesthetic, from wound healing from post-operative complications of all types, generally speaking, we would prefer any BMI below 39. I have done exceptions myself, which I didn’t regret. So when I saw a guy who is six foot three, and he’s been on a diet for three years and he comes to you and tells you, you know what, that’s my BMI, what can I do? Okay. Get rid of, help me with my chest. If you will help me with my dysphoria, I would go to the gym and I’ll come back in a year and go see my BMI. And I will agree to that. So exceptions can always be made. What is important to BMI and guys should know about it is that we plan in operation with how the BMI, how the body is at the time of the procedure. If your body habitus changes in the future, the aesthetic outcome might be compromised. So I’d see if your ideal BMI and then approach a surgical procedure. Okay. I don’t want to perform an operation for how count someone start is today. Then they gained 20 pounds and then it looks horrible. And the vice versa includes also individuals who have a very low BMI. So I will be very reluctant to perform the procedure in some of the BMI, less than 18, for example, or 19, because they will gain weight in the future. And in any case, if that is associated with any type of mental health issue, this should be addressed first.

Dr Helen Webberley:
I think what can be addressed, Ioannis, and, you know, we do understand that there are some people who use weight as a way of masking that the body shape that causes a lot of dysphoria. But if we can get the medical treatment right, first, if we can prepare that body medically. So they’ve got the right hormone balance for the right amount of time and get that bit sorted so that nobody needs to either put on weight or lose weight artificially in order to mask a bits of their body, then we’ve got a much better chance of then handing over to you for the surgical bit, with someone who’s balanced in their hormones, ready, and a body ready. That’s not being restricted or artificially competent any way to hide bits. Do you know what I mean? And I think the medical bit is so important. Isn’t it?

Dr Ioannis Ntanos:
You are absolutely right. This is why I don’t consider that someone is handing me someone to perform the operation, need them a multidisciplinary team approach. So, a multidisciplinary team approach would mean, if you are starting a discussion about someone transition medically, why note involve the surgeon from the beginning. They might require to discuss surgery down the line. Why not have that discussion from the beginning, not to push anyone to have surgery, just to explore what might be improved, if we get to that situation.

Marianne Oakes:
If you give people clear guidance, they will be empowered by it. I think this notion that well, we’ll deal with this first and then we’ll look at the next bit, it just doesn’t, it doesn’t fit right with me. I’m just listening now. And I’m just thinking how much therapists could learn from talking to the surgeons, not about the techniques, but how they could help their clients to prepare for the journey and, and plan their pathway and realize that actually, yeah, I do need a good BMI. I do need to not be small. I need to get my mental health, right? Because actually I’m going to get a far better outcome. I can aspire to the closest to perfection that is possible and not just have this, I don’t know, rambling, you know, we’ll decide when we get there approach. So yeah, I think therapists, you know, I’m a therapist, but I could learn so much by talking to surgeons to be able to prepare. I didn’t know any of this. I’m not gonna lie to you. And I’ve gone through the system. Nobody has ever spoke to me about, you know, if you want surgeries, this would be a good idea for you. All they’ve ever asked me is to tell my story three times.

Dr Helen Webberley:
I mean, that multi or interdisciplinary approach is so important. I mean, it’s no secret, but I’m going through a GMC process at the moment. And one of the allegations against me is that I didn’t use an MDT approach enough and I’m thinking to myself, so, and what they mean by that is Dr. Webberley, where was the multitude of psychologists and counselors and social workers and therapists, making sure that this person was trans. But it’s making me smile that if I said, well, actually my MDT included surgeons because I want as well as gender affirming hormones, I want to prepare this young person for surgery in the future. I think they would just look at me as if I was a complete and utter zombie, you know, but it’s so right. You know, this multidisciplinary approach isn’t intended to validate gender. It’s there to support the patients. So, Marianne, I’ll get you in when I need you to help this person in their journey and how they’re gonna navigate the rest of their life. Yes, and let’s get Ioannis in early so that we can work out the best way together. And let’s not, let’s not say right, you’ve got to give up smoking and you’ve gotta be, you gotta be a BMI of 29 before I’m gonna cut you open. It’s actually about, listen, if you were to give up smoking, or if you were to just say, stabilize your BMI, it would be safer for you. We’d get better wound healing. Actually your scars are going to heal great. And they’re not going to stretch if you, if you pumped up at the gym in the next six months. And so why aren’t we having that conversation that is futuristic? And that’s my, that’s my rant over.

Dr Ioannis Ntanos:
You’re right. And Marianne, I’m flattered that you feel that you’re learning things from a surgeon. I’m learning things from counselors and therapists all the time. And I think surgeons should have an interest in what therapists and counselors do before considering doing these operations. This is not just the technical skill you need to acquire. You need to be aware of the individuals you’re treating.

Marianne Oakes:
Yes.

Dr Ioannis Ntanos:
Can we go back on, on a couple of practicalities that I wish the guys would know before going to see a surgeon.

Dr Helen Webberley:
Yes, definitely.

Dr Ioannis Ntanos:
Okay. So, so they will be asked about personal history regarding their chest and about family history regarding the chest. And sometimes the answer is, I don’t know, I’m not in contact with my family, or I don’t know, I had a lump at some point, but I don’t remember what it was.

Dr Helen Webberley:
So actually, I imagine that actually, that someone’s chest is a part of their life that they would rather forget. So if they had a lump in the future, or if aunt Gladys had had an operation, they don’t wanna talk about breasts. They don’t want to talk about that. They don’t want to think about that. So actually they just want to consider the future of their chest, but these questions are important. If you did have a lump before or a biopsy or something, or scan anything, just, can you get the details? And if aunt Gladys did have an operation, it would be actually quite useful to know what it was. Can you ask them, can you ask aunt Gladys? And again, this just, why isn’t it, why do we need to answer those questions? It’s not because we’re nosy because actually it’s important for us to understand that.

Marianne Oakes:
I think it would be good to frame it slightly differently. Do you know? If you’re going to think less about your chest, if we have this information, you’re going to get a better outcome. You’ll never need to think about it ever again, but if you don’t, then we’re going to have to have more in-depth conversations, which are going to be more painful. So preparation is the thing. That’s the theme today, isn’t it? Preparation is everything.

Dr Ioannis Ntanos:
And then if I may, one last thing that keeps coming back on that these discussions. Most of the guys will have an individual that they know that is some (unclear 42:07) journey considering operation. They might have had it in the past. They have a friend that the operation in the past, I think it’s important to realize that individual experiences do not account for everyone. Someone may have a terrible experience. Okay. And they communicate that to you. It doesn’t mean that you will end up in the same situation. So I would prefer guys to go speak with the surgeon with an open mind, okay? I think we are here to help. And this would be the only focus of the discussion. There are horrible stories online. We shouldn’t be discussing them, but extraordinary stories don’t account for what most surgeons are trying to do.

Dr Helen Webberley:
Yeah. And of course the stories online, the ones that get the most attention are the most graphic. They are the most disturbing. They are the most horrific and that’s why they get the most shares. Some guy taking his top off at the beach isn’t going to be the best story.

Dr Ioannis Ntanos:
I was just going to say one last thing that anyone should be prepared for is that the operation can not take place the next day. We don’t, we need, we call it, it’s not right. But anyway, we use the term cooling off. Okay. So, so after we discuss and we are agreeing to an operation, we need to offer some time, the length of the time differs. It differs from the individual, it differs with practices from surgeons availability. Okay. But there is a need for some time, because questions might arise after the discussion. And if questions arise, guys, please discuss them, send an email, pick up the phone. Don’t consider that I cannot. Okay. We agreed on operation. Now. I cannot have any more questions because of my job, the discussion, it doesn’t work like this. Okay. You should contact your surgeon at any point if you feel that something more needs to be addressed.

Marianne Oakes:
Can I just reframe that rather than cooling off period? Cause I would recoil a bit. You know, I might get, well, I would say is a processing period where people go in and have a think, you know. It’s about taking the information, but cause I would say this at the end of counseling, you know, when, when you’ve had a really heavy session where lots of themes have come up and you can see it’s got, you know, just take some time, just, don’t try to address everything in one go, just go away, process it, what come up and then contact us again. If you feel you need to. We will readdress that at a later today. So yeah, processing period.

Dr Ioannis Ntanos:
I will use that term from now on, Marianne.

Dr Helen Webberley:
Ioannis, can I ask a question that I would like to know the answer to and that’s about the scarring. So what can we do after the op to make sure that we get the best scarring? What about tattoos and things like that? When can we, can we have tattoos to hide any scars, that kind of thing?

Dr Ioannis Ntanos:
Well, the scar healing and the skin healing differs from individual to individual. Generally speaking, tattoos are safe to be done after six months. What someone can do to improve scarring is that there are a lot of things, a lot of information online, again, different guys that use different things. There is not consensus in the science and the one on whether one ointment works better than another one type of oil, better than something else. Two things are important. If you look after your scars, they will look better. Even if you just use a moisturizing and massaging of the area. Secondly, try to avoid sun exposure for at least six months. If you want to enjoy your flat chest in the summer somewhere, use sun protection, the same amount of use for your face. So protect your scar as much as you can and they will be fine. But tattoos. Yeah. After six months, it should be safe to do anything. I’m always happy to discuss anything, to educate our guys, anything at all.

Dr Helen Webberley:
Brilliant. Thank you so much, both of you for doing this again today, I’m really excited to get this one published and to have the FAQ’s alongside it and to prepare these guys for the best results and the best outcome possible.

 

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