Episode 50: Thursday July 21
How important is gender affirming surgery? Gender affirming surgery is on the rise, with patient demand expected to grow from a market value of $300 million in 2019 to potentially $1.5 billion by 2026. Despite the ongoing political conflict over gender rights and care, gender affirming surgery is now an important aspect of comprehensive plastic surgery care.
Drs. Salvatore Pacella @sandiegoplasticsurgeon, Sam Jejurikar @samjejurikar, and Sam Rhee @bergencosmetic welcome guest @drmanishchampaneria Dr. Manish Champaneria. We talk to Dr. Champaneria about his expertise regarding gender affirming (transgender) surgery, specifically top procedures. If you are interested in gender affirming care, this episode is a this episode is a MUST - find out more at https://3plasticsurgerypodcast.com/
#podcast #plasticsurgery #cosmeticsurgery #boardcertified #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone #bestplasticsurgeon #beforeafter #aesthetic #aesthetics #realpatientrealresult #transformation #transgender #genderaffirming #trans #lgbt #nonbinary #mtf #ftm #gender
S03E50 GENDER AFFIRMING TOP SURGERY WITH GUEST DR. MANISH CHAMPANERIA
[00:00:00] Dr. Salvatore Pacella: Well, welcome everybody. Uh, we're back again. Uh, Dr. Sal Pacella here from San Diego joined by Dr. Sam Rhee from Paramus New Jersey and Dr. Samir Jejurikar from Dallas, Texas. We've been off on a little hiatus and this is, uh, uh, three plastic surgeons in a microphone. How are you guys? We're all doing great.
How are you? Good, good, good. Hanging in there. So, uh, excited to get started again today we have, uh, exceptionally special guest, my good friend and my partner, Dr. Manish champion area. Um, he's one of our attending surgeons at Scripps clinic Scripps MD Anderson cancer center. And today he's going to talk about some of the awesome work that he does, uh, within our group.
But first, before we do that, we're gonna ask it over to Sammy J who's gonna give us our little disclaimer.
[00:00:57] Dr. Sam Jejurikar: This is always the fun part of the show. Uh, just a little bit of legal advice. This show or not, the show is not a substitute for professional medical advice, diagnosis or treatment. This show is for informational purposes, only treatment and results may vary.
Based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified providers with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something you may see in this show.
[00:01:27] Dr. Salvatore Pacella: All right. Fantastic. Well, so I'd like to introduce, uh, Manish champion area once again. So, uh, Manish did his residency at Loma Linda university in Southern California here and then followed by a, uh, fellowship in microsurgery at the university of Washington. And Manish has a, a, a great interest in breast reconstruction, surgery, um, free flaps doing lymphedema surgery and general reconstructive surgery, uh, within our group, but also has a very special, unique niche interest in transgender surgery or what we call gender affirming surgery.
So Manish welcome. Join us. How are you?
[00:02:05] Dr. Manish Champaneria: Thanks. Thanks guys. I'm I'm doing great. Thanks Sal for having me on. And thanks Sam, number one and Sam number two.
[00:02:12] Dr. Salvatore Pacella: wonderful. Um, so Manish, maybe you wanna tell us a little bit about, um, first of all, I wanna just make sure I'm getting nomenclature. Correct. Is it transgender surgery or gender affirming surgery?
Maybe discuss a little bit about kind of the history of this discipline and, and sort of the, the naming conventions, perhaps
[00:02:31] Dr. Manish Champaneria: if you could. Yeah. That's a great question. Sal, I think transgender surgery was the older nomenclature. It's kind of an archaic term now, previously it was known as that. And that's because I don't think there was a space for these different genders that are now, um, being recognized in the, in the society.
Now, there is a space now for patients who may not be transgender, but who are still seeking different types of these surgeries. And so the proper terminology is gender affirming care, gender affirming surgery. and that's because we have patients who now identify as non-binary or gender queer or by gender.
So there's a lot of different terminology, different genders under the gender umbrella. And the one term that is cohesive is gender affirming surgery. So that's the right term to use. Okay,
[00:03:15] Dr. Salvatore Pacella: great. Um, and tell us a little bit about how you got into this discipl.
[00:03:21] Dr. Manish Champaneria: You know, it, it's very interesting. I went to a 70 Adventist institution and I had literally no, no surgeries done in residency, um, for gender affirming care.
And I think that this has become a little bit more of a hot topic in the past 10 to 15 years, but I really had very, very little exposure, um, in my fellowship at the university of Washington under. Some giants like Peter Negan and other people. They actually had experience of doing gender affirming care of doing top surgery and some bottom surgery.
And so that was really my first exposure to the field. Um, and from there, when I started practice in the Pacific Northwest, um, I actually had to kind of learn on my own in a way I had to do a lot of research, speak to different professionals and different leaders in the field. Um, I worked at. At an institution that accepted Medicaid.
And I was one of two or three providers in the whole state of Washington that, that, that took that insurance. So I had a whole slew of patients who were looking for this type of surgery. So that's kind of how it started for me. That's great.
[00:04:20] Dr. Salvatore Pacella: Um, and you know, maybe you could tell us a little bit about the, the sort of nomenclature of cuz, you know, obviously it can get very confusing for the, for the uninitiated.
Um, so maybe you could talk a little bit about, um, the difference between cysts and trans and. You know, kind of that nomenclature, if you would.
[00:04:39] Dr. Manish Champaneria: Yeah. Yeah, definitely. So if you're a cisgender male, that means you are born a male and you identify as the male gender. So CIS means same. Whereas transgender means you may have been born.
A gender that you don't identify with later on in life, let let's say you're a transgender male. So that means that you were, um, born a female genetically, but you identify as a male. So you're transitioning to become a male. So you're transgender male when it comes to that. And then. There's non-binary patients as well.
Those people don't identify as male or female, or they have traits of both. Um, and if you do a quick Google search of gender umbrella, there is terminology that is really quite expansive. There's different terms for almost everyone. And so I think the goal of the, of the, of the community is to try to be as inclusive as possible.
So,
[00:05:33] Dr. Salvatore Pacella: so this is a very interesting topic. So you, you trained with, uh, Peter Negan and one of, uh, Peter's proteges at the university of Michigan is a, uh, a surgeon who is very close to us. Dr. Bill Kuan. Uh, yeah. Okay. waiting for, uh, we, I know I had to work in a, a bill Kuzon reference in here somewhere. So, um, so the three of us actually, um, did, uh, a bit of work, I think in residency with, um, some of the gender affirming surgeries, particularly with bottom surgery, which was just an absolute, fascinating discipline, um, you know, long, long cases and just, um, really kind of extensive anatomy.
Um, You, and I have obviously worked, uh, on caring for some patients together. I, I obviously don't do any, uh, major, uh, gender affirming surgery, but I will do some rhinoplasty for, for some of these patients. Mm-hmm . Um, so maybe, maybe you can kind of tell us a little bit about what your interests are and then kind of maybe, uh, talk a little bit about the, the timing associated with this.
Um, so if, if someone sort of is interested in, in this surgery, kind of what what's. What's the process for getting to where they're going.
[00:06:48] Dr. Manish Champaneria: Yeah, definitely. That's a great, that's a great question. So some of my interests, my, the, the, the part of my practice, that's the. Large and the most growing is top surgery.
So when we talk about top surgery, that basically means top versus bottom. And literally it means top meaning chest surgery versus bottom, meaning your genital surgery. So I do a lot of, um, gender, gender affirming, top surgery. So usually it's female to male. They want their. Breasts removed and they want a masculine chest appearance.
And so that's, um, FTM top surgery basically. Um, it can also be termed as a non-binary top surgery, which is essentially similar. There's some different nuances. Um, And so I do that, um, in addition to male, to female, top surgery as well, that's either fat transfer or breast OGs with breast implant as well.
Um, the other aspect that I'm interested in is facial surgery as well. So, um, making the face more. Feminine. So typically that means a, for a forehead reduction, uh, a brow lift, um, we can shave down the Mandal. Um, we can do tracheal shaves as well. The one area that I, that I don't do, and that's where we work together, cell is rhinoplasty.
And so whenever someone needs a nose that needs to be feminized, we do work together on that. So. Um, those are kind of my interests, um, and
[00:08:08] Dr. Salvatore Pacella: be before, before we jump in there. So tell me a little bit about the percentages. What, um, what percentage would you say is top surgery? Female to male versus male to female.
[00:08:19] Dr. Manish Champaneria: Yeah, that's a great question. Um, I don't have the exact numbers, but I will say that, um, the overwhelming majority, I would say, I would say about 80 to 85% of my patients are female to male. And that's because it's challenging to get rid of your breast. You know, a lot of these patients will bind or they tape, um, or they wear substances like binders that can kind of compress their breast down, which is challeng.
I mean on a hot summer day, it's really hard to do that. Or it's just challenging when you go to work and you have very large breasts, how do you fit in, how do you pass for the gender that you wanna be in? So, um, the, the, the most patients that I have are female to male, and that being said, there are patients who are male to female, but what they can do is they can put on a bra, they can stuff their bra, or when they're on hormones, they're actually forming breast.
And so, um, . Yeah, so the, the most patients are female to male.
[00:09:11] Dr. Salvatore Pacella: So, so what's, what's the process of sort of getting to that point of, of choosing gender affirming surgery. And, and maybe you can maybe comment a little bit about, um, kind of what you see as far as the aging and sort of patients under 18. Um, and maybe a little bit about if there's some general medical recommendations.
Uh, obviously there's a very controversial topic. There's some parents, I know that. Have kind of been hesitant or supportive of, of their children, uh, in this regard. So how, how do you navigate that? What what's what do you usually see? Yeah,
[00:09:47] Dr. Manish Champaneria: that's a great question. So again, um, so whenever I see a patient for gender firming care, The one document.
The one guideline that I follow is the WPATH. So that's the world professional association of transgender health. Um, and that is an international organization that has surgeons, psychiatrists, mental health professionals, endocrinologists, a whole slew of different professionals within the field, trying to standardize care for transgender and non-binary patients.
So I think it's important to follow those guidelines and recommendations in every. Every 10 years, those guidelines get, um, reviewed and things get changed as necessary. And so, um, that's the most important part of this is whenever a patient comes in. I, I try to follow those criteria. So typically for top surgery, um, The recommendation is to be living in your gender of choice for at least one year.
And the reason for that is they wanna make sure that you are happy, that you've made the right choice, because a lot of these surgeries are, are irreversible. If you're having a mastectomy, we can't give you back that anatomy. Um, and so, uh, we just wanna make sure. You are indeed living in your gender of choice and you're happy with that choice.
Um, hormones are not necessary, um, for anyone over the age of 18, the, the, the WPATH requirements basically say you don't need to be on hormones. Um, and those are the only two, uh, things medically. And then the third aspect of that is getting a letter from a psychiatrist, a mental health professional, uh, a licensed care social worker, someone to verify that you are making a sound decision for yourself.
Um, and once you have that, then typically that's kind of. The entry point into seeing a physician and getting gender affirming care. Now that being said, the majority of patients that I see, there's a large age range and it's become a little bit more disparate. Now, when I first started doing this, I would see patients in their twenties, thirties, and forties.
Um, and the overwhelming majority of patients are within their twenties. Right. They're they've just come out of adolescence. They're, they're trying to build their life. Um, and they, and they are out in the world and they're, and they're, and they're figuring out who they. But I've recently been seeing a lot more younger patients recently in the past three or four years, patients as young as 13 and 14, who are, um, questioning their gender and wanting to pursue this, this route.
So, so it makes it a little bit challenging and there's a gray area within the WPATH requirements that basically they say, you know what, if you're under the age of 18, you should really be on hormones for a year. But then the gray area says. Well, but there are extenuating circumstances that, um, if you're not on hormones and the surgery would be beneficial, the surgeon is able to, to do it.
So it is quite controversial. As you said,
[00:12:35] Dr. Salvatore Pacella: you, you know, it's interesting. Uh, when and Sammy, uh, both double Sammy's, um, uh, Refresh my memory. If, if you don't remember, if I don't remember, um, correctly when we were at Michigan and we would do these types of surgeries, I, I seem to recall that, um, there was a, a much more extended period of time that, um, the patients had to live as a male or a female.
And I believe that a requirement was they had to be under the care of an endocrinologist on hormone therapy. Is that, is that correct? Do you guys remember?
[00:13:10] Dr. Sam Jejurikar: Yeah, I think it was the Harry Benjamin. It was the Harry Benjamin society, um, criteria. And it was either a year or two that they had to live as an opposite, a member of the, of the, their preferred gender.
And then, yeah, they need letter. I thought they need letters from therapists, psychiatrist. It was this whole criteria.
[00:13:29] Dr. Salvatore Pacella: It was much more stringent from what I recall.
[00:13:32] Dr. Sam Jejurikar: Yes. It definitely definitely was back
[00:13:34] Dr. Salvatore Pacella: then,
[00:13:34] Dr. Manish Champaneria: but
[00:13:35] Dr. Sam Rhee: that was for bottom surgery in specifically. Um, yeah, I think I see. And that's obviously a bigger commitment, um, than say top surgery
[00:13:43] Dr. Manish Champaneria: would be great.
Yeah. For bottom surgery. I think we need two separate letters, one from an endocrinologist as well as one from a mental health professional. And I think that timeframe is a little bit longer than a year as well. It might be even two years. Um, and again, that is a bigger is, is a bigger commitment for. So,
[00:14:00] Dr. Sam Rhee: what is the insurance, uh, situation like in California for you in terms of gen, uh, gender affirming surgeries?
[00:14:08] Dr. Manish Champaneria: It's actually quite favorable. We have the majority of insurance companies, um, are supportive. Um, most of the patients come in with a navigator from the insurance to help, um, to help guide them through the process. Um, so I would say the majority of insurances are, are great to work with. Yeah. Um,
[00:14:26] Dr. Salvatore Pacella: so Manish, um, You know, we're seeing obviously, um, you know, in the, in the world, uh, a much more, um, popularity of these types of surgeries.
Yeah. Um, and we're also seeing, you know, a little bit more, um, Uh, acceptance of, of children, young children having, you know, kind of a living a different gender. So, um, what, what do you think is responsible for that? Have we, have we been off the mark as physicians for many years and not, not seeing this? Or is there some sort of popularity coming about, I mean, what, what are your thoughts on that?
I mean, when a, when a family, a family comes to see you. Maybe with a child who's five or six or 10. Um, pre-pubescent what, what are your thoughts on that kind of, what, how do you navigate that process?
[00:15:15] Dr. Manish Champaneria: So I think that it's been around for quite some time, but I think that what's, what's really changed is, is, uh, society in general.
I think that we have become more of an accepting society. And so I think
When people say transgender and and gender affirming care has become more trendy or more popular. And I think that is a true statement, but I think that it's something that was always there, but as a society, we didn't really recognize it.
I think now I think we have advanced socially such that now we accept gay marriage. We are more open to lifestyles that are not consistent with maybe your own. And so I think that has changed the landscape for where we can offer plastic surgery for transgender and non-binary patients.
And while we're doing this, there's also the opposite as well. There's a lot of states that are trying to limit the amount of care that can be given as well. So as more and more people identify and question their gender, you're gonna see a shift, right? There's gonna be a subset of people who are accepting and then a subset of people who are not accepting. So it's gonna be even more challenging to navigate in the future.
[00:16:19] Dr. Salvatore Pacella: Okay, great. Um, so why don't we, uh, jump into some cases here, Manish. So would you like to, uh, maybe share your screen here and we can
[00:16:27] Dr. Manish Champaneria: a little, yeah, totally. You got it me one second.
Okay. Are, do you like see the first patient? . Yes. Yes. Okay, perfect. So, um, this is a 25 year old transgender male. So born Fe born female transitioning to become a, a male. Um, and this is a type of top surgery called a keyhole top surgery, um, which is, uh, a really favorable type of surgery for patients who are small chested.
So typically these are patients who are a cup or bup breast, um, very small chested, and we're able to basically put the incision at the. Nipple border. So typically from three o'clock to nine o'clock along the nipple, and we're able to perform the mastectomy, keeping all of the skin and the nipple intact.
The before pictures, you'll see this patient's quite small chested. They're basically an ACU breast. They don't have a lot of sagginess or excess skin. And so with that, um, the incision is based at the nipple. We're able to remove the breast tissue, um, and they're left with, um, a result that really, um, with time and with minimal scarring, um, may not be able to be so, um, The scars won't, won't be quite prominent.
Now the problem with the surgery is that I, I think the healing time is a little bit longer. You're doing a whole surgery from a very small incision. So access is a little challenging. Um, and the second issue is that you don't really have control over the size of the nipple or the placement of the nipples.
So oftentimes the nipple can be a little bit lower than expected. Or the nipple is quite prominent. And so in these cases, what I sometimes will do is do a, a secondary procedure in the office where I can reduce the nipple size or lift the nipple by a centimeter or so if the patient desires, this patient was happy with their result and didn't want a secondary procedure.
[00:18:28] Dr. Salvatore Pacella: So, so, uh, this is really a kind of a half circle type of per alar access. Is that?
[00:18:34] Dr. Manish Champaneria: Yeah, definitely. Yeah. And so, um, We're really not changing, um, too much of the skin. Um, we're just take, we're just taking out the, the inside breast tissue. So,
[00:18:47] Dr. Salvatore Pacella: and that, and that does that, uh, displacement of the nipple that you're talking about.
Some sometimes I imagine that could probably be more beneficial too, right? Because the male nipple is oftentimes offset a bit laterally and a bit lower than in the female nipple, obviously. Right.
[00:19:03] Dr. Manish Champaneria: Definitely. Yes, definitely. So for this patient, you'll see that, um, the nipple is right at the inferior aspect of the pecs muscle.
There's a little bit of a shading. So for this patient, it worked out really well. And in general it typically works out well. Um, but there are some patients who just have, you know, a longer torso, a longer chest. And so that can be a problem. If that's the case, you can also perform a par Ola top surgery, which is basically this exact surgery, but instead of doing an incision, just.
The circle underneath the nipple, you're making the circle all the way around the nipple as well. So the only caution with that surgery is that there's a high, there's a hybrid vision rate, almost 70%. So I tend to use that sparingly if possible. Very
[00:19:46] Dr. Salvatore Pacella: good result. So very good
[00:19:48] Dr. Manish Champaneria: result. Cool. Thank you. Yes.
Excellent. So our second patient, um, is a double incision top surgery, a 32 year old trans male. Um, and you'll see, on the, before pictures, they have a BCU breast. They do have a defined INFR fold. They have larger nipples with aerial complexes that are, that are. Wider. And so for this type of surgery, we're basically amputating the breast.
We're removing breast tissue as well as skin. And what we do is we remove the nipple completely as a free nipple graft. So we use different sizers, um, and, and different shapes. Uh, typically we use an 18 to 20 to 22 nipple size to remove the nipple completely. Then we prepare the nip. Um, and then we sew it in place over the chest, um, in the correct anatomy.
Um, the goal for this surgery is to place the incision closer to the inferior border of the Peck muscle. Um, and I think that's really key in order to get a nice natural result. Um, another key is to not have access tissue in the lateral chest. So it's, it's what patients call a dog ear and what we call dog ears as well.
We try to just tailor that lateral. Um, when I do the surgery, I typically bolster the nipple. So that means I make a little gauze dressing and so that over the nipple, so that there's good contact and that stays in for about a week and then it comes off at a week. Um, and so for this patient, you'll see that the scars are, are, um, gently curving up in the middle, which is, uh, quite standard, uh, a, a little bit more straight towards the midline towards the mid of the chest.
And then. Laterally, it does have to rise up and that's because of the shape and the anatomy of the breast. Do, do you
[00:21:33] Dr. Salvatore Pacella: put any, um, any, uh, sort of application sutures or anchoring sutures to secure it to the lower border of the chest? Like a three point suture. .
[00:21:45] Dr. Manish Champaneria: Yeah. Um, I actually don't do that, but what I do do is I put, um, a couple layers of sutures.
So what I do is to the Peck fascia at, at the bottom, I, I do suture it there and it's not a three point, but it is a more of a, a tacking suture so that, um, it doesn't move and it stays in place.
[00:22:04] Dr. Salvatore Pacella: And, and you know, a little bit for our viewers, um, a lot of these surgeries, um, they've been kind of adapted from a lot of gynecomastia surgeries that we've done in the past.
Um, prior to gender affirming surgery, being so popular and, uh, very similar concept for small gyne AMA patients, you can oftentimes do a per Ariola incision for larger patients with a lot of skin burden. Um, it's very similar to this. Yeah, definitely. Um, and, and Manish, tell us a little bit about, um, you know, the, the nipple appearance after something like this.
So, um, you know, in, in my experience many times, if I have a really, really large breast reduction, um, we have to do free nipple grafts for that. And particularly in patients with a lot of pigment in their skin, Asian, African American, et cetera, oftentimes, you know, The, uh, the grafting does not come out really all that.
Well, it's oftentimes hypopigmented. So what's your experience with the, the graphs in this, in this scenario?
[00:23:08] Dr. Manish Champaneria: Yeah, definitely. I, um, whenever I see a patient of color, a black person, a Hispanic person, anyone who is, who has a little bit more of a, a darker skin tone, I tell them about 90 to 95% of my. We'll all have nipples that are not as dark as they once were.
And there's areas that'll become lighter over time that does improve. And what I tell patients is, is if it doesn't improve, then it's a quick fix. It's a nipple tattoo. And we do have an artist here who, who actually goes up to San Francisco. Who's based here in San Diego. Um, but that's a very good point about the nipple.
And then. Another Pearl for me is there's a lot of complications with nipple grafts. You know, you're putting a devascularized, which means poorly blood supply skin graft, over skin that's already been revitalized. And so there's a high rate of failure. And so what I do in order to maximize success is I really thin out that nipple graft.
Um, I make it as thin as possible. And so you do lose some projection of the nipple, but the majority of patients that I. Have spoken to don't mind that they actually don't want a prominent nipple. And so the rate of success is a little bit better. Um, and so, and then what I do too for patients is I have them tell me what size nipple they want.
You know, there's such variation in patients these days, um, anywhere between 1820 and 22 millimeters is usually a sufficient size and that's, and that coincides with, uh, cisgender male nipple size as well. So, okay.
Um, our next patient, a 39 year old transgender male, um, again had a very similar surgery to the previous one, but in this one I added liposuction. And so, um, The patient, as you can see is extremely large tested. They have a higher BMI. And so the complication risk profile is a little bit more elevated.
There's a higher risk of bleeding, higher risk of, um, the nipples not taking, um, higher risk of infection as well. And so, um, the surgery was done in a similar fashion. We try to place the incision, um, at the chest fold, which aligns with their Peck muscle. Uh, again, nipple graphs that are bolstered in place.
The one difference here. in the preoperative photographs, you'll see that the breasts connect in the center. So whenever there's a lack of space, um, that means that you should really ideally connect the incisions together. Um, if you don't, um, you will have excess tissue, a small breast in the center of their chest, over their sternum.
And the patients really hate that. Um, and then I also counsel patients like this is, you might have a dog ear, you might have excess tissue laterally, um, that we, that we can tailor with liposuction. We can reduce more skin, um, and that the incision will be longer. Um, and so I think part of this process is meeting the patient's goals, but also advising them about what you can do and what you can't do in a safe fashion.
And do you use drains for your procedure such as. Yes, every single one of my mastectomies gets a drain. Um, I believe that, um, a drain can be challenging for patients initially, but I think it really can help reduce the fluids and, uh, prevent seroma in the long run.
[00:26:19] Dr. Salvatore Pacella: And ish. Do you, um, is it standard, uh, standard of care to send all of this tissue for path?
[00:26:29] Dr. Manish Champaneria: Yeah, it is absolutely standard of care. If you look at most hospital pathology departments, they actually man mandate any breast tissue that is removed from, from a patient either if it's insurance or cosmetic must be sent to pathology so that they can review the breast specimen. And I, I think that's
[00:26:44] Dr. Salvatore Pacella: a very, very important, uh, point for our viewers.
Um, you know, if you're, if you're having these types of surgeries in an outside facility or in an office operating room or something, You know, I think it's really critical to understand that those, that tissue should be sent off to pathology. That may be an excess cost, but it it's something that's very, very important.
Have you ever seen a, um, in one of your, uh, gender affirming cases, anything come back as, uh, as a breast cancer ever.
[00:27:16] Dr. Manish Champaneria: I've actually had one patient and the margins were clear. Yeah. So it's very, it's very, very rare, but it was, uh, a duct carcinoma inside you. And that was, um, yeah, that was removed entirely.
But what we also did was then sent the patient to an oncologist and, and they got the proper care, which ended up being nothing else beyond the mastectomy, but wow. Yeah. Very important. I mean it can, yeah, it, it very well can happen. So, and then I'd also like to add if you're a patient over the age of 40, I typically recommend a mammogram or some breast imaging as well.
And I know that can be quite dysphoric, um, being a transgender male with breast, trying to ha have a mammogram, but I think it's really important to make sure that you are clear of any suspicious lesions or diseases within the breast prior to having this type of surgery.
[00:28:06] Dr. Salvatore Pacella: Do you have any, oh, sorry. Go.
[00:28:08] Dr. Sam Jejurikar: No.
I was just curious what your recommendations were for patients regarding BMI requirements. I know if I'm doing a, just a, a, a CIS, um, gender, female, and I'm doing a breast reduction. Mm-hmm I typically find 'em, it's really hard to get a good result if their BMI is above a certain amount. And I have to imagine you face the same issues in this patient population as well.
[00:28:30] Dr. Manish Champaneria: Yeah, definitely. Um, I don't have a BMI cutoff and most, uh, gender firming care surgeons don't have BMI cutoffs. One of the things is, um, a lot of the patients and the community will cite you as being restrictive and not offering care to everyone. So I try to be as inclusive as possible, but what I do is I counsel them and I say, Hey, if your BMI is over 40, your complication for infection for the NPP.
Not taking for bleeding for D V T are quite high. And I just counsel them and say, Hey, we can do the surgery, but your result may not be the one that you want. And they understand that. Um, and there are, there are patients who are over, you know, BMI 40, who do well. And there are some that don't, I just did a patient who had a BMI of 44, very small chested, but they had a postoperative hematoma.
And so, um, these things happen. Um, and it's challenging of
[00:29:23] Dr. Salvatore Pacella: course. And Benish tell us,
[00:29:25] Dr. Manish Champaneria: are you doing all
[00:29:25] Dr. Sam Rhee: of these surgeries at your hospital or are you doing them in an outpatient facility? Like what, what type of setting are you performing
[00:29:32] Dr. Manish Champaneria: these surger? Um, I do them at both. And so I do them both at a surgery center, as well as a hospital.
Um, prior to the pandemic, I would keep the patients overnight in the hospital for postoperative pain control. So I can visit with them the next day, make sure they don't have a hematoma. And then when COVID hit, we kind of changed our practice pattern. Um, so all of these patients go home unless they have a request to stay in the hospital.
And I found that, um, I would say the majority of patients do really, really well. their pain is under control. The family's there to help them with their drains and, and, and there's no issue with them. So, yeah.
[00:30:11] Dr. Salvatore Pacella: Manish one, one question. Uh, we, we probably got time for one more question or comment. Um, tell us a little bit about the scar burden here.
Um, obviously, you know, with gyne Masia patients and gender affirming, uh, mastectomies, you know, this is a massive scar, huge scar, um, patients absolutely have to take the time to get used to that scar. Um, what do you do for scar treatment? What's the concern for patients? Are they. Um, is there any buyers remorse with say, Hey, I, you know, I love the result, but this scar is just huge.
Uh, how do you treat that secondarily?
[00:30:47] Dr. Manish Champaneria: Yeah. Um, scarring is quite, quite extensive. Um, unless you're having a keyhole surgery, any person who has a double incision top surgery will have an extensive scar burden. And if the incisions connect in the center, you're at higher risk for OID. What I found in these patient population is that they are okay with scars as long as the, the breasts are removed.
And even if the scar turns into a keyloid, they're still happy with that. They've undergone surgery. But that being said, I try to give them the best scar possible. I also counsel them that the majority of the scar that occurs is something that is genetic and that if you're prone to kilos, you might have a kilo.
If you're prone to thickened white and darker scars, that might happen again. And so I often employ, um, scar massage. I have them use silicone scar gel. I have, um, some patients also purchase silicone scar strips. And then there are patients who also, I prefer over to our dermatologist for laser therapy. Um, and I think that helps as well.
So, but in the end they all know they're gonna get a scar and their scar can vary. So great. Uh,
[00:31:52] Dr. Sam Rhee: one, one last question for me. I, um, yeah, I had a medical school classmate who, um, his name is Jess ting and he was running the Mount Sinai, um, gender center for a while and they did a. A documentary called born to be a couple years ago, which mm-hmm, the biggest insight I got into it about gender affirming surgery was just how difficult a lot of the patient's lives were, uh, in terms of.
You know, discrimination, um, a lot of, uh, psychological issues based on, uh, a lot of the difficulties they faced in terms of their gender experience. Um, what do you do in your center and in your care to make sure that patients can get a very positive gender experience when they go through this? Because obviously this is something that is growing and is very important, but is not necessarily
[00:32:44] Dr. Manish Champaneria: yeah.
Uh, sort of. I don't think everyone is open as
[00:32:49] Dr. Sam Rhee: open-minded, as, uh, others are. And so how do you ensure that everything goes well in terms of your patient's experience? .
[00:32:58] Dr. Manish Champaneria: Yeah. So I think having an open anonymous conversation with your staff and letting them know that, Hey, we're gonna have patients of different lifestyles of different genders.
And so, um, I, I think that starts with, um, being on the phone, on the telephone from our patient service representative at the front, um, keeping, um, a very, you know, and, and informal, very open, honest, Friendly type of demeanor. Um, we have flags throughout our office as well. I think that's important to show that there's visibility and that we're quite accepting.
Um, a lot of my nurses in the hospital, as well as within the clinic, as well as the front desk girls also ask, Hey, what are your pronouns? What is, uh, how do you identify? And I think that's often a difficult question to pose when you're first starting to do this. But if you don't know, you just ask and I think that's quite important.
Um, and then I think also I'm a member of the LGBT community too. I'm out and proud as well. And so I think they, they like that in the sense that if a surgeon can be comfortable practicing in this clinic, in this hospital, well, then it's gonna be okay for me too, if I undergo this type of procedure. So, and I think that's, what's helped my practice grow as.
That's great.
[00:34:14] Dr. Salvatore Pacella: Well, Manish. Um, we're just about out of time, but I wanted to thank you for joining us. This is obviously, uh, um, a new and rapidly changing discipline in plastic surgery. And we're happy to have you on board at Scripps. And, um, thank you so much for coming on the podcast and, and shown us the nuances.
[00:34:34] Dr. Manish Champaneria: Thank you for having me guys. This is great.
