"T" and Surgery

	I have had several inquiries recently regarding testosterone and its effect on the breast, how it may affect top surgery, and whether or not it is necessary to be on "T" prior to undergoing top surgery. Testosterone treatment may affect the breast tissue by causing some atrophy (decrease or weakening) of the glandular portion of the breast, causing it to become softer and perhaps creating some sagging of the tissue and skin. It will probably not significantly affect the breast size, except in unusual cases, though the breasts may appear smaller due to ptosis (sagging). Testosterone may increase muscle mass, making the pectoral muscles more prominent. This effect does not influence the surgical procedure, as the operation is designed to remove breast tissue and excess skin, and to reconstruct a natural male appearing areola and nipple. It does not involve any surgery of muscle. There is no absolute requirement that a patient be on "T" prior to undergoing surgery. There are several situations where patients would benefit from not being on hormones prior to undergoing breast reconstruction (top surgery). One would be a medical contraindication to hormone therapy because of underlying disease or organ dysfunction. Another would be in a large breasted individual where the effect of "t" would be to masculinize other secondary sexual characters such as facial hair, voice, possibly a receding hairline, and muscle development, etc. making "passing" difficult due to the difficulty in concealing breast size and probably creating more emotional distress rather than alleviating it. Also, if a patient's therapist felt that hormones were not an essential part of a patient's transition or goal, surgery could proceed without it. Another situation where testosterone would not be a prerequisite to surgery is in those cases where an individual has been living successfully in the male role for an extended period of time, at work, socially, and perhaps in an ongoing relationship. Some patients feel that hormone effect allows better contouring of the chest during surgery. This is not necessarily the case. The goal is to create a natural male appearing chest, not to contour a "body builder" physique. That must be left to exercise and body building strength training. Surgery removes unwanted breast tissue, excess skin, and creates a properly positioned and proportioned nipple and areola. The tissue left behind must try to match the basic body morphology of the individual. Sufficient fatty tissue must be left behind to match the surrounding fatty tissue so as not to create a sunken appearance to the chest. Leaving too much fatty tissue would create the appearance of small breasts remaining. No attempt should be made to leave breast tissue in such a manner as to simulate enlarged pectoral muscles. This leaves tissue which does not have the feel of muscle, but rather the feel of breast tissue. Also, the effect of hormones on this remaining tissue may not remain stable over long periods of time and, if hormones need to be discontinued at some later date for medical reasons there is no way to determine what will happen to the remaining breast tissue. It could, for example, increase in size distorting the appearance of the chest wall.