Mr Ivo Gwanmesia is a highly experienced London based Cosmetic Surgeon and Cranio-Facial specialist who performs female-to-male (FTM) TOP surgery as part of his broad portfolio of cosmetic procedures, which includes Facial Feminisation.
Mr Gwanmesia sees patients in his Harley Street clinic in central London and, when treating female to male transitioning individuals, adheres to the global ‘Standards of Care’ (SOC 8) established by the World Professional Association for Transgender Health (WPATH). A diagnosis of persistent gender dysphoria, documented by a qualified mental health professional, is required by Mr Gwanmesia before a consultation for TOP Surgery can proceed; read on to learn of our close association with expert transgender psychologist Dr Vickie Pasterski.
What is TOP Surgery?
TOP surgery, or chest masculinisation, is performed on female-to-male transitioning individuals who seek a natural-looking male chest. Called a Subcutaneous Mastectomy, this gender-affirming chest reconstruction removes breast or chest tissue and may be combined with a resizing of the areola and nipple, using keyhole surgery, to create a more masculine appearance.
Patients often present requesting removal of their breast tissue as the breast is a prominent female feature. They may be using binders to flatten their breasts, and a significant proportion of them may already be on masculinizing hormones.
We offer two types of chest masculinization surgeries in our practice, peri-areolar incision (keyhole surgery) and double incision mastectomy with free nipple grafts.
Scroll down to read our Top surgery FAQs
Peri-areolar Incision (Keyhole technique)
Individuals with smaller than average breasts and good skin elasticity or tone are often eligible for a Nipple-Sparing Subcutaneous Mastectomy using the Peri-Areolar skin excision technique or keyhole mastectomy. This less-invasive short-scar procedure can, in some cases, avoid additional nipple grafting. This technique is suitable for a minority of patients seeking FTM top surgery patients. Whilst having the advantage of having a small scar, it is worth noting that it carries a higher complication rate which includes seroma formation, nipple-areolar necrosis, hematoma formation requiring evacuation amongst others.
Double Incision Mastectomy with Free Nipple Grafts
Patients with larger breasts are more likely to require a Double Incision Mastectomy, which includes nipple grafting and resizing to achieve an optimally positioned nipple-areola complex. This is the most commonly employed technique for chest masculinization. It provides excellent exposure and the ability to precisely reposition the nipple areolar complex. Whilst having a lower revision rate and high satisfaction amongst this patient group, it has the disadvantage of a longer and more visible scar.
Consultation process and patient consent
A diagnosis of persistent gender dysphoria, documented by a qualified mental health professional, is required by Mr Gwanmesia before proceeding with a surgical consultation. We work with leading consultant transgender psychologist Vickie Pasterski of the Harley Street Gender Clinic, who can professionally assess patients and provide a clinical diagnosis of gender dysphoria before referring onwards to Mr Gwanmesia for a surgical consultation. Dr Vickie Pasterski is recognised as a Gender Specialist by the UK Ministry of Justice Gender Recognition Panel.
Preparation for surgery
At the consultation, a thorough medical history is obtained and a medical examination is performed by Mr Gwanmesia. This is to ensure that prospective patients are suitable for general anaesthesia. We recommend that patients undergoing surgery stop testosterone for at least a week prior to surgery. We also require that smoking is stopped for at least 4 weeks before surgery. A body mass index of least than 32 is preferable. Weight loss in overweight patients is associated with better surgical outcomes. The procedure of choice will depend on the degree of breast ptosis, breast volume, position of the nipple-areolar complex and elasticity of the skin.
Recovery
All of our procedures are performed under general anaesthesia. The patients go home the same day unless there are medical comorbidities that warrant a stay at the hospital. A drain is placed under each breast for 5 days. Patients are provided with a compression garment which is worn for 6 weeks. Follow up appointments at the office are at 1 week, 6 weeks, 3 months and 6 months. We usually recommend that patients take at least a week off work for recuperation.
Reasons for Top surgery
Chest reconstruction surgery is the most commonly requested procedure for FtM transgender patients and is a safe and effective treatment. The procedure can help transgender men and nonbinary people transition physically to their self-affirmed gender by re-contouring their breasts to help achieve a male-looking chest
Risks
The Standards of Care (SOC) published by the World Professional Association for Transgender Health (WPATH) are internationally accepted guidelines for the multidisciplinary care of transgender patients. The SOC rely on rigorous psychological evaluations by mental health professionals to prevent patient harm and ensure individuals meet referral criteria before surgical assessment.
At the consultation stage Mr Gwanmesia will assess any risks of Top Surgery in relation to the patient’s individual health and physiology. And he will explain, using diagrams and sometimes 3-D imaging, the procedure, recovery, aftercare and likely outcomes to expect.
What proportion of the population are affected by gender dysphoria?
The global prevalence of gender dysphoria is estimated at 0.5% of the total population, or approximately 25 million transgender people worldwide. Treatment of gender dysphoria is multidisciplinary, and may include psychotherapy and counselling, hormone therapy, and/or surgical intervention.
The Standards of Care (SOC) published by the World Professional Association for Transgender Health (WPATH) are internationally accepted guidelines for the multidisciplinary care of transgender patients. The SOC rely on rigorous psychological evaluations by mental health professionals to prevent patient harm and ensure individuals meet referral criteria before surgical assessment.
Schedule A Consultation
TOP Surgery for Female-to-Male (FTM) Chest Masculinisation FAQ
We charge a fee of £7500 which covers the hospital fee, the anaesthetist’s fee and the surgeon’s fee, as well as all post operative follow up visits
For those patients which long and large nipples, it is possible to reduce the size of the nipple at the same time as performing TOP surgery.
Most Top surgeries are done on an outpatient basis at our Harley Street ‘same-day’ surgical care clinic. You’ll be able to go home on the same day if you live locally, or back to your nearby hotel or arranged accommodation.
If an overnight stay is required for monitoring of the patient due to related health conditions such as propensity for blood clotting, then Mr Gwanmesia and his theatre team will perform the procedure in a nearby private hospital which provides private recovery rooms and 24/7 nursing and medical care.
For individuals diagnosed with Gender Dysphoria (GD) wishing to book and proceed with a gender-affirming surgical consultation, we will require one or more referral reports, including specialist assessment/recommendation by a gender specialist. We recommend Dr Vickie Pasterski of Harley Street Gender Clinic.
The number/nature of the report(s) depends on the surgical procedure sought. For example, Gender Confirming Genitoplasty (GCS) usually requires two letters of support from two different specialists, while Masculinising Chest Surgery, Breast Augmentation Surgery, or Facial Feminisation Surgery (FFS) usually requires only one.
Hormone therapy is not required under the WPATH Standards of Care, although testosterone can be useful. This is because the development of larger muscles in the chest area gives more scope for surgical options, offering greater chance of post-op patient satisfaction. Larger chest muscles can also be achieved through certain types of physical exercise, if the patient’s preference is to avoid testosterone therapy.
Patients will need to stop smoking for at least 4 weeks.
The effects of smoking can have implications for the use of anaesthesia during surgery and increase the likelihood of longer healing periods, and even of surgical procedures failing to properly take.
To mitigate against these risks, patients must have completely stopped smoking or using tobacco for at least four weeks prior to surgery taking place. Many also take advantage of this break to attempt to stop smoking permanently. This is a good source to help with stopping smoking.
Compression on the affected area is part of the healing process after chest masculinisation surgery, and a compression binder can sometimes be an important tool in achieving this. This is because compression can assist in reducing swelling, bruising or scarring, and also in helping to maintain the shape of the chest in the weeks following the operation. A binder can sometimes cause discomfort, but it is a valuable recovery garment, and should be worn, if recommended, for around 3-6 weeks post-op.
There are a number of methods that can be used to try to reduce the appearance of scarring after Top Surgery. Procedurally, these measures include the taping that will be applied to your chest in order to prevent damage or stretching to the affected are. The use of a compression binder can also assist in minimising scarring effects.
Behavioural factors can help reduce scarring too, such as avoiding unnecessary stretching or twisting in the weeks following surgery. It is also important to avoid exposure of scars to direct sunlight, or at least make use of high-factor sun protection, to avoid sustaining lasting damage.
Because Top Surgery primarily involves a significant reduction in the volume of breast tissue, there may be some corresponding reduction in the likelihood of developing breast cancer. However, the risk is not eliminated entirely, for a number of reasons:
- Since some breast tissue will remain after the operation, there is still the opportunity for cancer cells to develop
- The use of hormone replacement therapy (HRT) can also result in increases in estrogen, which can have implications for the likelihood of breast cancer
- As with all patients, factors such as family history of cancer, and behavioural patterns (eg smoking), can increase the chances of cancer developing
Learn about Mr Ivo Gwanmesia’s cosmetic surgery experience and professional credentials at his ‘about’ profile page.
