Mastectomy and the transgender patient

A Cleveland plastic surgeon who’s performed more than 850 double mastectomies for transgender men says respect and openness are among the keys to success. Surgeons must be willing to undergo public scrutiny, he says, and they must treat patients with the proper gravitas as they undergo what may be the most important procedure of their lives.

The mastectomy procedures themselves are typically quick and well-tolerated operations, says Daniel Medalie, M.D., a plastic surgeon with Metrohealth Medical Center of Cleveland and assistant professor at Case Western Reserve University. “It’s not any harder than a breast reduction or other procedures that plastic surgeons do,” he says.

But does Dr. Medalie’s own extraordinary workload — he performed double mastectomies on some 850 patients from 2006 to 2015 — suggest that many of his colleagues may not be as willing to work with transgender patients who want to transition from female to male? “People shouldn’t be coming from all over the country and world to see Daniel Medalie in Cleveland, Ohio,” he says.

Dr. Medalie reports on his experiences in a report that was released in poster form at The Aesthetic Meeting in April. He spoke with Cosmetic Surgery Times about his continuing commitment to transgender patients, and he provided advice for surgeons who wish to follow in his footsteps.

He first encountered transgender surgeries, mostly male to female, while training at the University of Pittsburgh. After graduating in 1999, he worked at the University of Kentucky.

Like his colleagues who perform breast augmentation surgeries, he began to be approached by transgender patients seeking breast surgery. “The difference between me and them was that I’d say, ‘Sure, no problem.’ Any plastic surgeon can do this kind of surgery, but there has to be a willingness to do it.”

He performed more double mastectomy procedures after moving to Cleveland in 2002, and his presence on the Internet sparked intense interest from transgender patients. His YouTube videos of two types of procedures have attracted more than 500,000 hits, he says.

“A vast majority of patients come from out of town and other countries,” he says. “Many people come from England because it’s more expensive to have it done there than to come to Cleveland and stay for a week.”

In This Article

Surgical Stats

Unique Challenges

NEXT: Surgical Stats

Surgical Stats

According to his report, Dr. Medalie has provided successful double mastectomies for 850 patients with high satisfaction and an aesthetic revision rate of less than 10%.

He groups patients into three groups based on pre-operative photos:

1. A double mastectomy with free nipple graft
2. A subcutaneous mastectomy with partial areolar incision
3. A subcutaneous mastectomy with a circumareolar incision and “purse-string” closure.

The procedures take 1.5 to 2 hours, he says. Hematoma accounted for almost all early complications, leading to re-operation rates of 1% within the first five days after surgery. Two patients had late hematoma infections that required IV antibiotics. No patients reported complete loss of nipple graft.

Future research, he says, will use questionnaires to focus on issues after surgery like satisfaction with results and quality of scars.

NEXT: Unique Challenges

Unique Challenges

These procedures do pose unique challenges for plastic surgeons, but not in the realm of the operations themselves.

For one, “you have to play a little bit of psychiatrist,” Dr. Medalie says, and make sure patients are confident in their decisions to undergo double mastectomies. “Sometimes I’ll meet the patient in holding area and they seem nervous, they don’t seem masculine, and they’re young.” Not only does he require a therapist’s letter, he also uses his own powers of judgment to decide who should go under the knife.

It’s also crucial to understand that these patients aren’t like others, he says. “You’re changing this person’s life in a dramatic way. This is the most important day of their life. For me, it’s one of four procedures I do that day. I have to keep reminding myself about how important this is for the patient.”

Openness to the outside world is also vital. “You can’t hide bad results. In the age of the Internet, you’re wide open,” he says. “If you’re treating it like another liposuction surgery, if you don’t get the pronouns right or find out the name they like to be called, they’ll post about you on the Internet right away.”

So why perform these procedures at all? Dr. Medalie says they’ve “really been a positive experience” for him, and his other patients haven’t reacted negatively. Insurers cover about 20% of the procedures, which cost about $6,700 in his clinic, and laws in some states make insurance coverage mandatory.

“It’s possible to do this in a safe fashion, and there’s good patient satisfaction,” he says. “We’re plastic surgeons, and we should be doing this.”

Disclosures

Dr. Medalie reports no relevant disclosures.