I’m Ioannis Ntanos, a specialist in top surgery for trans masculine individuals. I am also an ethicist and active trans ally. Ask me Anything!

Do you ever introduce yourself at parties by saying you’re the top surgeon at your hospital?

:) pun intended? I am very boring at parties because universal healthcare, the fight for utopia and human rights are the things I want to talk about.
I usually introduce myself as Ioannis, I like poetry and the colour green.

Who's your favourite poet?

C.P. Kavafis

Ooh I’m reading Utopia for Realists right now. What’s your favorite nonfiction book about utopia?

Realist capitalism by Mark Fisher was the first in my mind.

I had surgery with you last Autumn and it was frickin fantastic. I way way over the typical BMI limits so my results are "as expected" but I couldn't be happier. Thanks for all you're doing with the community.

I don't really have a question but the sub requires it so how long would you say you have been specialising in this field in particular? Did you start in general medicine?

I am happy the operation had a positive impact in your life. I have been a consultant breast surgeon since 2011 and I have been committed exclusively to gender affirming care since 2017. Thank you

What distinguishes "top surgery" from mastectomy or breast enhancement/augmentation?

Top surgery is an umbrella term for gender affirming care in the chest area. For transmasculine it involves mastectomies and chest wall reconstruction; for transfeminine it involves breast augmentation +/- mastopexies (uplift).

Have any of your patients regretted their surgery?

I do not know. If they have they did not let me know. Regret is not exclusive to gender affirming surgery and there are interesting statistics about regret in a range of procedures. The risk of regret in gender affirming care is generally low.

I do not know.

If they have they did not let me know.

The risk of regret in gender affirming care is generally low.

Your first two sentences seem to contradict the last one.

There is no contradiction. Statistically the regret rate is low. I have had no experience of patients regretting top surgery personally.

What is something that you would you like anesthesiologists to know?

What a great question! I would like any doctor (and anaesthesiologists) to know about trans healthcare. The benefits of gender affirming surgery (GAS) and the beauty of the communities we serve. These operations aim to end suffering, to help people live their true lives. Apart from that it is an operation and small steps like pain control and antiemetics can go a long way. Some familiarity with the patients pronouns would be helpful too :)

I had surgery with you on November 22nd last year! I’m seriously indebted to you; completely changed my life😊

And my question is, did you always want to be a trans surgeon? If not, what was it that inspired you to focus on gender affirming care?

Hello, I have always wanted to offer help to fellow humans and that is why I got into medicine in the first place. I knew I wanted to dedicate myself to gender affirming after being exposed to it in 2017. The ability to help and the beauty of the communities made me stay.

How often do you get asked for top surgery to be done with no nips?! :)

Looks like you are on a roll! Well I get that request quite a lot, more frequently from NB/Genderqueer individuals. If everything has been considered and this is the patients wish, I am happy to accommodate it.

What's the required age to perform gender reaffirming surgery on someome?

The WPATH SoC7 states that they have to be of legal age of majority in the respective country, although some exceptions can be considered with long standing gender incongruence and parental consent.

I've recently read that cosmetic surgery's age of consent is 16 in Scotland, 17 in England and 18 in Wales, is this correct?

Hello, that is very interesting to mention. I do not believe that top surgery is purely cosmetic. It is life changing (if not life saving) and irreversible (for transmasculine). You are correct though, and I believe that WPATH will probably move towards that direction in the SoC8 that are expected to be published later this year. Whether that will result in any change in practice in the UK remains to be seen

To clarify, is elective FTM top surgery classed as cosmetic surgery? Is interesting what the governing bodies classify it as, due to so many legal barriers to under 18's in the UK. He could (theoritically) have a nose job, face lift etc with my permission at 16/17, but a "no" to top surgery? It's so frustrating

It is frustrating. Let's try and change it.

Have you ever done surgery when there are significant other health concerns?
(I have a well-managed congenital heart issue that I have always assumed would exclude me from seeking gender-related surgery, but these things advance all the time...)

Hello charlaine2124. This is not correct. Like with any other surgery you may require changing your blood thinners, but with good pre-operative assessment there should be no issue (as like with any other type of surgery).

One more - oops! What advice would you give for someone whose family member doesn't particularly like the idea of top surgery, who somewhat sees it as mutilation/damage, and who feels it'd be a source or future regret?

Hmmm, I am a surgeon and although I have educated myself a lot in healthcare, my position is not to give advise on family matters or acceptance. A counsellor or therapist is better positioned. I will see any patient in the presence of their family if they wish to.

what are your thoughts on traveling, maybe to Mexico, to get a more affordable procedure?

"Medical tourism" is not a contemporary issue and people fly from the UK to Turkey for cosmetic operations, from Italy to UK due to the procedure not being available there, from US to Cuba or Mexico for affordability. My thought is universal healthcare of high standards for everyone.

Globally speaking, how fast are medical/surgical techniques with regards to trans patients advancing? Any advances or new ideas pop out to you recently?

There is a lot of work going on globally with important research in different fields.

Surgery does not take leaps for any condition and I am unaware of any imminent breakthrough (at least for top surgery).

With greater understanding and acceptance more advances will develop. This should not hold back the treatments that can be offered today.

Do you do the version of top surgery where you pull the tissue out through the nipples? And if so, do you ever put the nipples back on upside down accidentally/can you tell which way they go?

(I know it sounds goofy but my trans friends and I were having an actual conversation about this recently lol)

Not sure what you mean by "through the nipples". Free nipple grafts are changing the appearance of the nipple significantly. The orientation of the nipple is preseved in the majority of cases :)

What's your opinion of the state of trans healthcare in the UK? And as a more direct question as a trans person who is looking into top surgery in the UK, what's your average waiting time for patients between referral and surgery if possible?

Trans healthcare needs to be improved. There are countries where some things work better and some things not. Education is really important.

Waiting times are varying a lot. Happy to be contacted by email and discuss any logistics of my practice.

I'm a doctor in the UK, currently an SHO in acute medicine but starting GP training next month. What in your opinion is the most important thing I can do in GP for my trans patients and helping them access the care they need? From my limited experience (in the North West, incidentally) it seems like it can be quite a battle to access care, especially for the younger trans people.

There's no LGBT+ without the 'T'!

There are a lot of resources online you can access from different websites (eg the LGBT foundation). There is the RCP course on gender incongruence and there are GP practices that are already embarking in shared care of the patients (eg Sefton care on Merseyside).

As a doctor who specialises with trans individuals how are you treated in the broader community? Do you still have the same respect in the community or have some groups unfairly targeted you for being a trans ally?

:) Are you referring to the broader medical community or the my personal life? I had experiences of targeting. Sometimes they get under my skin. most of them they don't. The people that matter in my life, family, close colleagues and most importantly the communities I serve give me enough support and respect to carry on.

I am wondering about both, but probably more towards your personal life, as I would imagine the medical community being professional enough to support you in your chosen field

The people in my personal life who are not happy with what I do, helping people live meaningful lives and alleviate suffering, should never been there in the first place.

What are some of the Risks of top surgery? I never hear people actual talk about that directly

Hi, there are risks related with any type of surgery (eg pain, infection, scarring, bleeding, venous thrombosis) and others that are specific to this type (nipple loss, asymmetry, "dog ears").

Edit: my apologies, I just realized I misread and that you specialize in transmasc surgeries, so I totally understand if this is not a question you are able to answer

Hi! This is a bit more of a personal question, but hopefully you can answer it. I’m a 32yo recently-out MTF trans individual planning on starting my transition next year. I was very overweight as a teenager and when I was 22, I had gynecomastia removal surgery as part of a larger set of post-weight loss cosmetic surgeries. My concern now is that there will be little to no breast growth, and/or that the surgery will make it more difficult to have a good outcome in the breast department if I get implants instead (provided there’s no natural growth). For context, I have incision scars running underneath each side of my pectorals, with inch-long scars from vertical incisions spanning from my nipples (which were relocated during skin removal) to said pectoral scars. I’ve also lost a good deal of sensation in my nipples that never returned, contrary to what my surgeon told me to expect after my surgery in 2013. I know “natural looking” breasts are probably not possible, but I’m hoping I can end up with at least a moderately-normal appearance.

I know it’s a bit niche, but have you ever encountered anyone in this situation, and if so, how did it turn out? Is that kind of scar tissue something that can be worked around or is it a major complication for that?

Hi there, You are correct that I do not regularly offer MtF top surgery. Previous surgery however will limit some options. As per the current WPATH guidance you will have to be on oestrogen for 12 months and then be considered for surgery (to check for any development of the remaining glandular tissue).

What happened in your personal development that led you to being such an advocate, ally, etc for the trans community?

"Happened" sounds like a misfortune (?!) which is not! Nothing happened and I am not the only one in this fight. If something can be counted was this:
"Question everything that you 've been told, dismiss what crushes your soul"
The ability to unlearn helped me but did not define who I am.

I think a better phrasing is "Was there an event that inspired you to advocate for this specific cause".

For me a lot of my passion for it was when a close friend came out to me, was anxious our friend group wouldn't accept her, and they did with open arms.

Then seeing how her father treated her and having to be there while her mother kicked him out because he would get physical and they didn't want to call the police.

A very formative series of events in my early 20s that shaped my views moving forward.

I cannot recall a "walk to Damascus" significant event in my life. I have a passion for universal healthcare and human rights from my early medical school years (studying in a country with bad record for both).

What do you do when someone regrets the surgery/surgeries, and they report this unhappiness to you?

Top surgery for transmasculine individuals is irreversible. If someone regrets the surgery all together I will try and make available to them any relevant support. If they regretted the aesthetic outcome of the procedure, I will discuss any revision options.

How does one “revise” this exact issue?

I was referring to the need for a more pleasing aesthetic outcome. A revisional operation sometimes may help. As before: the procedure is irreversible.

Hi, thanks for taking part in this AMA. How does gender affirming masculine top surgery differ from female mastectomy, in the technicalities and operative technique? I am a registrar about to start a breast job, but I don't think the unit has a GIC presence, so I am unlikely to be exposed to it, and therefore would like to learn.

Hello, it is great to see interest from fellow surgeons. The expectations are different compared to an oncological mastectomy and the surgical plane is different too. Some consideration is required to achieve a masculine (in most of cases) contouring on the chest, compared to a paper-thin like skin which is left behind after a mastectomy for a malignancy. Certain techniques like keyhole ones or with pedicled flaps require some plastic surgery knowledge as well.

How much psychological vetting and preparation do you require for a basically irreversible surgery? Do you follow up to find out how your patient is doing emotionally months later?

Hello, the suitability for surgery is defined by the referrer - a qualified professional - not the surgeon although I do take a detailed history myself too. I am not a psychologist. I do revisit my patients 6-12 months after surgery to find out how they are doing.

What would you say led you to specialising in top surgery, rather than anything else?

(Also, just wanted to say thanks for doing what you do. I had my top surgery with Mr Rubin in London last year and it's improved my life so much more than even I expected.)

Everything in life is 50% chance. My background in breast surgery led me to be employed in a hospital that was offering gender affirming surgery. The opportunity to offer my skills to the wonderful communities, to improve people's lives, to help alleviating suffering made me stay. My views in life are consistent with what I do and I have never felt any conflict.

Another question I forgot to ask - what would you say are some top tips for recovery after surgery? (Pun intended) 😄 Things like topical wound/scar care or anything else you recommend. Also what clothes do you suggest people come to surgery in? I've heard mixed answers of some surgeons allowing boxers to be worn for comfort vs others saying just the surgery gown. Hope that makes sense, and thanks for the insightful AMA I hope you had a good time! 🏳️‍⚧️

Go to surgery with anything that makes you comfortable. The provider should be able to accommodate anything else that might be required. Shorts are fine or follow the clinic's policy.
Everyone’s rate and quality of healing is different. If you had an operation before that resulted in poor healing, such as keloid formation or infection, please discuss this as part of your consultation. Healing is related not only to what you do after surgery, but also to what you do beforehand.
Please follow advice on smoking and maintain a healthy lifestyle. Look after the quality of your skin, including any acne. Make sure that any associated medical issues are well controlled (eg diabetes).
There are different oils/ creams that can be used to improve scarring with different anecdotal results. Silicone strips or ointment are proven to improve the appearance of scarring, however they should be used only after all the post-operative scabbing has naturally been removed. Avoid direct sun exposure for at least six months. If this cannot be avoided, use a high-factor sun protection (factor 50) and allow it to dry fully prior to sun exposure.

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There are a few medical aphorisms and "primum non nocere" is important. On one hand we do not harm when we care for others and offering them care that we have seen that it works in improving their wellbeing. On the other hand sometimes not doing anything is harmful.
Hippocratic aphorisms can (and do) have different interpretations. First do no harm means helping individuals be themselves because its harming if we do nothing while we know about care that helps.

How do you pronounce your last name? Does "Nt" sounds more like a "D"? I visited Greece last summer and I couldn't figure this rule out.

Nt=D in Greek indeed. It is a beautiful complicated language.

Hi Dr Ntanos! Thanks for this AMA! Do patients retain any nipple sensation after surgery? And I've always been curious what counseling or screening process prospective patients go through; does it differ from the process for more typical cosmetic and reconstructive surgeries?

The pathway differs from country to country. In the UK a referral from a qualified professional is required. Only few operations (keyhole or with pedicled dermal flaps will retain some of the sensation).

Have you ever not performed a surgery, for someone that you thought didn't really want it or was unable to really understand the full consequences of the surgery?

Yes. I have declined surgery in the past for different reasons, mostly when the individual did not appear committed or able to fully understand the consequences.

I had a hydrocelectomy performed 12 years ago and have constant chronic pain stemming from nerve entrapment in the inguinal canal.

I know it's our of the ordinary but every urologist and general surgeon over talked to is to afraid to go back in and try any surgical pain relief.

Do you think a specialist in your skills would have the confidence to remove a testical and the nerves up into the canal to help alleviate the physical jostling that exacerbates my pain without making the underlying scar tissue issues worse?

In my brain an expert of the plumbing and nerves of the groin is exactly who would be best suited to helping me. Any advice on who pr where to to go

No insight here I am afraid, as I am not involved in bottom surgery. It does not hurt to find a specialist bottom surgeon and explore that with them.

Do you have any experience / opinions on the current and future use of robotic surgical devices for these kind of procedures?

Hello, there has been no place in breast surgery for robotics yet. I have used robotics early in my career for lap surgery, but I am unaware of any significant attempts in the chest/breast. The future will tell.

How does one become an ethicist?

There are different routes. For example you earn a Master's degree in Health Care Ethics and the Law, you are a member of the Institute of Medical Ethics and you chair the clinical ethics committee of an acute tertiary hospital.

When there’s obvious mental disorder do you ever turn someone down or recommend therapy?

The WPATH guidance (correctly) states that existing mental health disorders should be well controlled before considering surgery. I have refused the operation to individuals when there were doubts about their mental health or their commitment to an irreversible procedure.

I'm curious! I'm a larger person - L/XL, BMI being 33. Are you able to angle incisions in a certain way or do you find that chest tissue size tends to determine options available? :)

Hello, A large BMI is no contraindication. All desires and expectations should be discussed. The result is usually a compromise for both parties. Long scars appearance is definitely something can be explored.

Hello, the mastectomy specimens are send to pathology to check for any occult malignancy and then disregarded according to biohazard protocols, like with any other surgical specimen.

What do you think of Jordan Peterson calling the surgeon that consensually operated on Elliott Paige a criminal, and comparing them to nazi doctors?

I think they are wrong.

Do you feel there’s an ethical conflict with trans healthcare in the uk? So many people end up needing to go private due to the long waiting lists. And they often see the same clinicians they would have seen on the NHS.

Many NHS providers are offering their services privately in all specialties. If there is a conflict for everyone I will happily accept it. If the argument is valid only due to the long waiting lists in the NHS then my answer is simple: We need to bring the waiting lists down in all steps of the NHS pathway. We need more qualified staff and commitment to all specialties.

If there is no waiting list, there is no need for private providers, if you accept that everything else is equal.
Right now the lists are long, and if someone can offer the service with high standards privately (as an alternative to the NHS pathway) then I see no conflict.

Beyond the reduced waiting list, the care needs to be on par with the care a cis person receives.

Yes, the waiting list for any kind of breast reduction must come down. But the waiting list for GIC care can be removed entirely. That's something I'd like to see more NHS doctors pushing for.

If you are considering the informed consent model I agree. There are however fights almost weekly to try and preserve even what there is available right now :(

Do you meet any kind of resistance or micro aggressions from medical colleagues when they find out you work with top surgery for trans individuals?

I do. All the time. I try to educate, I try to change preconceived ideas. Some times it works sometimes it doesn't.

Sorry if that question was already asked, but why did you choose that specific field of surgery ? Also, thank you for using your talent and knowledge for people who need it.

Sometimes you choose a career sometimes it chooses you. I have indeed answered the question earlier in the session :)

I had one last question about bathing post surgery. One of my biggest "nopes" is the idea I wouldn't be able to clean myself for several days post surgery

What would be your recommendations for post surgical care in that respect? Would shallow baths and flannel washes be acceptable so long as they avoided the surgical site?

Well in my personal practice the instruction is: no bathing until the dressings are removed and minor scabs have been naturally fallen out. Showering after dressing removal is fine.
If you can avoid the surgical site then do as you please :)

I always wanna ask people about their nipple choices!! Is it really so tough to move nipples? Do people have dysphoria about their nipples? What percentage of clients do you think chose no nipples, and is it primarily for aesthetics, or medical reasons?

Moving nipples (as free nipple grafts) is not technically difficult. A small minority will request no nipple reconstruction. Sometimes it is because they are afraid (stories of nipples "falling off"). Sometimes they aim for an elaborate tattoo and "they would be in the way", sometimes it is how the see themselves as. Dysphoria about nipples in my experience is limited to the size of the areola/nipple when it is inconsistent with the image they have for themselves.

Anything new researched on healing keloid scars? (I regret going back to work so soon after surgery and Im prone to keloids)

Hello, Nothing new I am afraid. Silicone gel and silicone strips may help.

Is there a certain age limit to who you will do surgery on? Like too young? Or even too old?

Edit: wording

Hi there,
No upper age limit as long as it is medically safe to have a long operation under general anaesthetic. I do not operate on individuals who are not of legal age of majority (18).

How hopeful are you regarding the future advances in your field? What more could be done from a scientific perspective to increase the success rates of such operations?

Κοιταζοντας τη χωρα μας δεν ξέρω αν πρέπει να νιώσω περηφάνια για το γεγονός ότι ένας Έλληνας κατάφερε να κατορθώσει κάτι τέτοιο, όσο και αν θα το ήθελα. Θα αρκεστώ στο να νιώσω περηφάνια ότι ένας συνάνθρωπος αφιέρωσε τη ζωή του σε κάτι τόσο ευγενικό. Σας ευχαριστώ για το έργο σας.

One can only be hopeful about anything in life. That is the only treatment I know against "the crippling terror of existence". What we can do is educate others, be vocal about the realities of peoples' lives, and in a scientific note, invest on research without compromising what we already know that works.

Προσπαθώ εδώ και χρόνια να δω αν μπορ΄ώ να μεταφέρω την εμπειρία μου στην Ελλάδα. Δυστυχώς δεν είναι εύκολο αλλα δεν το βαζω κάτω. Οι κατευθυντήριες οδηγιες του WPATH δεν ειναι καν μεταφρασμένες στα ελληνικά.

What are the chances that I’ll ever regain any nipple sensation? I had double incision a year ago and so far they’re still completely numb. 😕

The expectation with free nipple grafts is that the sensation will be completely lost. If some of the sensation returns is for reasons we do not fully understand.

How does one pronounce, "Ioannis"?

A short version is "Ya-nis" :)

What do you think of the age at which it would be ethical to let a transgender kid/teen decide over their own body and have HRT and surgery? Is there an age too young to let someone decide something so life changing, and if so, how do we ethically determine it? The ethics of denying treatment to someone sounds very hard.

It is not easy to have consistent arguments regarding topics like age limits. Adulthood is defined by different things and different ages historically and geographically (18? 21?). The Gillick competence in the UK provides a valuable framework for the capacity to consent.

Would the advancement of gender-abolitionist social theories hurt the profit margins of the American healthcare industry?

As a transwoman, I've spent a great deal of effort really stepping back and thinking about why I want to transition and I keep finding hat the main reasons for it stem from my own experiences of imposter syndrome, alienation, and generally just an overwhelming desire to conform to a gender norm that I never was allowed to do much self definition of... And after coming to the realisation that the biggest obstacle to me getting any form of transitional healthercare has always been financial barriers, lack of insurance coverage, and a fear of the very real dangers of life after transitioning I just came o the conclusion of "fuck the capitalist system, I'm a real woman if I transition and a real woman if I don't. Death to the corporate patriarchy, to hell with the christo fascists and may all the gender essentialists enjoy a very tall glass of shut the fuck up."

I know that may have been a little vulgar, but it just seems to me like people in the transosphere only get to exist as authentic "realtrans" if they shell out the cash to get passed (pun intended) the gatekeepers of just what defines which gender is what, so I just wanna know what a professional in actually providing the care thinks about all he hoops we have to jump through, the corporate greed that is fed by it and the financial and social gatekeeping behind it all. I mean, I get that your area of expertise is in the medical field, but I've never really had a chance to sit down with a healthcare provider who was allowed to speak off the cuff and honestly about the corruption that gets in the way.

Wow. That is a lot take in and limited time to reply. Apologies if I will be making only some bulleting points that come out of my experience with surgery, illness, bioethics and my life on this planet:

Capitalism is greedy. And healthcare is no exception, but I have worked in countries where universal healthcare is available to all.
If we accept everyone as they are outside "norms" and expectations then this will be a better place for all of us. I have been recently discussing the notion of "shame" opposed to what gender incongruence is (there is some published work from the university of Manchester).
I do not know how a world would look without gender stereotypes but I would welcome it.
Not everyone with gender incongruence need medical intervention. For those who need it, we should be able to provide it.

Thank you for taking the time to respond. I appreciate your varied background of experience and would like to know what you have developed out of you discussions on "shame" in opposition to the definition of gender incongruence. I mean, you should probably formulate a study or write a book around it with your peers. We would all definitely benefit from more literature on the subject in the book stores

My writing skills are not great I am afraid. There is a lot of useful literature around on trans issues. Some is included on the WPATH site, other you can find on different blogs.

i experience chest dysphoria but i don’t really identify as a trans man so i’d be curious to know about your non-binary patients. do you always aim for a typical male appearance, or do you ever get patients who want a more androgynous result?

i’ve considered getting a reduction rather than ‘full’ top surgery but it’s hard to know what would be best for me

A breast reduction (which is not regularly offered in the NHS) could be an option for an operation. The skills are available to any plastic or oncoplastic breast surgeon though and does not have to be through a gender affirming pathway.

While I've seen several of your answers about advocating for universal healthcare, it leaves me with the question - are you a part of the NHS or are you a private practitioner?

I am offering my service in the NHS as a specialist surgeon and I have a small private practice too.

What would you say to an unsure parent of a 15 year old trans child who wanted surgery?

Hi. Medical or surgical transition is not a panacea for everyone. Support by any means possible and seek help from a qualified inclusive professional. Explore the existing information together with them with an open mind and see where that will lead you.

I have heard that referring to any kind if gender affirmation surgery as "sex change" is considered offensive. I am puzzled by this, since gender and sex are not the same. Maybe "sex change" only makes sense for genitals, but do you know why it is in disuse as a term?

The majority of the medical community understands that transgenderism is present from very early on someone's life. Therefore the medical/surgical efforts are aiming to affirm that reality, not change something. A decision to transition is not easy, and it does not happen overnight. Words are important.

Had my top surgery Monday and feeling great, but the left side is a lot more sore and swollen, what could cause that? And is there anything else I should be doing other than using an ice pack?

Hello, if I was your surgeon you know how to contact me directly. If not please contact them as so close to surgery could be a sign of a collection.

Thanks - what do you mean by a collection? And it was like that the morning after and they advised the ice pack.

A seroma (collection of serous fluid) or small hematoma (collection of blood). It could just be expected post op swelling that will settle with time.

Do you have your ‘own’ anaesthetist who works with you at the different sites you operate from, or do you source from the hospital’s team please?

I am happy to work with any professional that are happy to work with me. No specific team, but I end up always with the same people :)

One of my trans friends is in the process of looking into top surgery and although his situation is different bc he's in a different country it got me wondering what the requirements would be for top surgery in the uk. Its my understanding that trans and nb people can get their breasts removed but could a cis woman too if she wanted?

I do not understand the logic behind the question I am afraid. What would be the reason for a ciswoman to have such a request? They would have to follow the same pathway as gender diverse individuals (a referral supportive by a qualified professional should be available).

Is nipple sparing possible (without grafting them) and if so, why is it not offered by more surgeons do you think?

Hi, do you mean a technique with the objective of retaining nipple sensation? This can be achieved with pedicled techniques (for example inferior dermal flaps) when certain conditions (like the size of the chest) are met. Every surgeon offers the range of the procedures that they are happy and familiar with.

yes. Numbness is something that people talk about but never really quantify. How common is it to have numb patches after typical DI with free grafts? And what is the size limitation for dermal flaps?

It feels like the UK is severely lagging behind in innovative procedures which is concerning. Do you think that's something liable to change in the future or are we stuck with only a couple of surgeons (like yourself) who actually want to step out of their comfort zone and come up with new ideas?

That is a great question with a lot to comment! Numbness is a symptom by definition subjective. With free nipple grafts, the sensation is expected to be completed lost, together with most of nipple projection. Some patients will claim that a part of the sensation returns with time (but I have no explanation for it).
The size limitation is rather technical to explain here, but it has to do with the nipple to inframammary fold distance, compared to the transverse width of the chest. Another was it to consider chest weight (<500g).
The more vocal we become and open about the benefits of top surgery, focus on education and leadership things will hopefully change in the UK too :)

Since 2003 the standards of care for transgender people have shifted away from mental care for, "gender dysphoria," and have shifted towards addressing the need for physical transition more and more. Now more than ever, transgender issues have become a political football in the U.S. Are you seeing the same correlation in the U.K. and do you believe that the attitude shift and revision of standard of care are in any way related, or is this simply coincidence?

Also, thank you so much for what you do. My son (F to M) had his too surgery last week. We, the family, are grateful beyond words to people like you who perform these gender affirming surgeries.

There is a race as we speak for the next conservative leader and PM in the UK. Among the living cost crisis, a war in Ukraine, the climate change and the normalization of the ever increasing financial gap between billionaires and the rest of us, the candidates where asked about "the trans issue". So yes it is happening in the UK too.

Some context, I'm a 17 yo transfem in the uk and recently referred to one of the uk gic pilots.

How do you feel about the state of trans healthcare in the uk? many of us have nothing but bad to say about the gics and we have some of the worst wait lists around. A lot of people are forced to seek private help amd a lot of the doctors involved with this are also nhs Dr's, I don't hold this against the doctors but the system as they are just doing what anyone would do in that position.

It is bad and it could be worse. It needs to be improved a lot in accordance with all the other targets that the NHS sets for all other patient pathways.

Why do you exclusively do top? Do trans have another surgeon for bottom?

I know very few surgeons who are familiar with the entire range of gender affirming surgery. Top surgery is offered by specialized breast and plastic surgeons, bottom surgery by specialized urologists and plastic surgeons.

Do you perform surgery for amab patients on hrt? If not, do you know any surgeons who do?

I do not perform regularly top surgery for transfeminine individuals although I do have the skills. It is not regularly funded in the NHS and there are lot of surgeons that are offering it privately (you will get a few results with minimum searching effort online).

Hi there! As someone getting DI with FNGs later on this year, what would you recommend to people who struggle visualising themselves with smaller nipples and can't decide on a size or placement? Is there a standard go-to that you work from or do you work out what will look best aesthetically on each unique body?

Also do surgeons usually provide post op binders or is that something patients have to buy themselves?

Thank you for all the wonderful work you do for our community! ❤🏳️‍⚧️

Hello, its been my pleasure and privilege to be involved with the communities and offering top surgery. I completely understand that visualizing post-op results can be tricky. I have had patients that took a picture of their chest and used a photo editor app to consider different things. Some of them show me the result of their editing and we have a conversation based on that. If someone is interested in a "sterotypically male appearance" then there are certain guidelines I use to reconstruct the chest.
I am not certain about other surgeons. When a compression vest is required post-op then I provide it myself.

How would you explain the benefits of gender affirming healthcare to a cis person? As a trans masc, I've had this conversation with my mom many times, but she has many misconceptions about it. I would figure it'd be better coming from an expert in this field.

Hello, It is not easy and I struggle to explain gender affirming care to people who are hold strong fixed ideas (not only in this subject but in others too). I think the best option is to try and make think about themselves. What would YOU consider if YOU were experiencing a dissociation between your AGAB and your gender identity. If they are cis ask them to consider how they would if someone was constantly misgendering you?
Some people however will be open and some will not.

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In all good faith,

https://www.who.int/standards/classifications/frequently-asked-questions/gender-incongruence-and-transgender-health-in-the-icd

Gender incongruence is not considered a mental health disorder by the WHO.

My son has been fully leading his best life for 4 years now, complete family support and permission etc and been on T for over a year. He turns 17 in May. Would this be a situation you'd be comfortable beginning consultancy privately for top surgery?

Hmmm, if my personal view was the only barrier then yes! But the NHS is following the SoC7 that states "legal age of majority". Private providers in the UK will not (in my experience) approve any operation that deviates from standard NHS practice. As I commented earlier, the WPATH SoC8 will probably address this and we will have to challenge current NHS practice to change.

Thank you for the good work you are doing!

How do you feel about media personalities like Jordan Peterson referring in general to someone like you as a "butcher" or "criminal"? Are you still able to have empathy for likes of them?

Well I am not a fan of any "theocratic fascist" or alt-right celebrity, but their choice of words say a lot about them and nothing about myself.
I do not tolerate someone preaching against tolerance.