pre-op

Waiting to go back to surgery…

As with any other part of transition, chest surgery is a personal decision, and not all folks who transition F to M choose to have or are able to have chest surgery. For me, it was the most important and even urgent part of my transition. I knew that I wanted to have chest surgery even before I knew that I am transgender. I had hated my breasts since they began to grow during puberty. Once I decided to transition, chest surgery felt even more important and quickly became an urgent need. Thanks to my beautiful wife and a group of amazing, compassionate friends, family, and even strangers, I was able to get the money for chest surgery, which was completed on January 23, 2013 by Dr. Kathy Rumer in Ardmore, PA, which is a suburb of Philadelphia. I am incredibly pleased with my decision to have Dr. Rumer perform my chest surgery, and I only wish more people seeking this type of surgery knew about her practice.

I acquired the money I needed for surgery mid-December 2012, and immediately booked the surgery. I had my consultation with Dr. Rumer a few weeks prior to booking surgery, which she did via Skype. After I paid my surgery deposit and booked the date, Dr. Rumer’s office mailed me a packet, which included all the orders for my pre-op bloodwork, physical to be completed by my primary care doctor clearing me for surgery, and my prescriptions for pain medication and antibiotics which would be taken post-operatively. She prescribed Percocet 5/325 for pain, and Keflex 500mg 3x daily for an antibiotic.

I was required to stop taking testosterone two weeks before and 1-2 weeks after my surgery, and I also was required to stop taking any NSAID pain relievers 2 weeks before and 2 weeks after. Both the T and NSAIDs are to be discontinued because of their effect on blood clotting. In addition to these two things, Dr. Rumer also sent a list of over-the-counter and prescription medications that needed to be discontinued, as well as a list of food and beverages that could affect clotting and healing that should be avoided leading up to and directly following surgery. In addition to all of these things – one of the most important things was that smoking drastically changes your ability to heal, and it is imperative that you discontinue smoking cigarettes before and after surgery.

Because of my chest size, I only had one option for what type of procedure I wanted, which was a double incision subcutaneous bilateral mastectomy. I’m not totally sure what chest size I was before surgery since I hadn’t owned or worn a bra in years, but I believe it was somewhere in the 46DD range.

Choosing a surgeon

I initially assumed that I would go to Dr. Garramone in Sunrise, FL, but I was really concerned about traveling from New York to Florida just a week after a double mastectomy. I wanted a surgeon that was experienced in trans surgery specifically, but I didn’t want to have to fly. I looked into several surgeons: Dr. McGinn in New Hope, PA, Dr. Johnson in Springfield, MA, Dr. Weiss in NYC, Dr. Fischer in Baltimore, MD, Dr. Medalie in Cleveland, OH, Dr. Bartlett in Brookline, MA, Dr. Costas in Concord, MA, and Dr. O’Sullivan in Wellesley, MA.

I ended up choosing Dr. Rumer for a number of reasons:

  • Her commitment to and involvement in the transgender community 
  • She trained in the same programs as Dr. Leis and Dr. Garramone
  • She was very accommodating to my needs and really personalized the surgery process for me
  • She has recovery suites available in her office for $50/night that includes post-operative care

I really don’t have enough good things to say about Dr. Rumer. She used to be an engineer, and she went to medical school to become a surgeon. She is incredibly down to earth, and doesn’t have that “God” complex that I’ve experienced with many other surgeons. She answered all my questions personally, and always returned my phone calls in a timely manner. She also has the world’s cutest dog, who is a Puli named Calypso. To top it off, her office is this gorgeous three-story house with the office on the first floor, she and her husband’s apartment is on the second floor, and the recovery apartments are on the third floor – she came to see me one night after midnight when I had an emergency situation with one of my drains. My wife just went down and knocked on the door, and she was taking a look at me just a few minutes later. I ended up turning green and starting to pass out, and she stayed so calm and collected the entire time. She is also just a real person. Her huband, Kerry, was such an amazing host and made sure that we had everything we needed, including picking us up a brand new coffee maker when the one in the kitchen was broken. It was the perfect situation for the money and convenience.

The surgery experience

My surgery was on Wednesday, January 23, and we left for Philly on Monday and stayed with friends Monday night. We headed over to Dr. Rumer’s office on Tuesday afternoon around 2 p.m., where we got checked into the apartment, went grocery shopping, had a nice early dinner, and got settled and into bed early. I had been having some serious anxiety the week leading up to surgery, which exacerbated my chronic pain, so my primary care doctor had prescribed me some Xanax just for the week leading up to surgery, which I took the night before surgery. I had already had my pre-op bloodwork and testing done – I had to have my physical completed and faxed to Rumer’s office by January 9. I also had to have my letter from my therapist on original letterhead and signed, which also had to be mailed in three weeks before surgery. I faxed both my physical from my doctor and my therapist letter ahead of time, and then sent the orignal copies of those two items together via FedEx.

I already had my prescriptions filled before arriving in Philly, so that was one thing we didn’t have to worry about. I was pretty nervous, and my wife really wanted to sightsee and plan all kinds of activities for Tuesday, but I really just wanted to get settled and relax. It was about -10˚ – too cold to live – so we ended up doing some light sightseeing Tuesday morning (Independence Hall, the Liberty Bell and the Betsy Ross House) and then having lunch with my college friend, Mel, and her adorable 4 month old baby, Estelle, before heading to check into the apartment and get settled. We went to Trader Joes, which was just a few blocks down the street from Dr. Rumer’s office, to get some groceries and stuff that I could eat while recovering. We didn’t want to order food for every meal… that could get expensive quickly. After grocery shopping, we headed out to dinner at a little Irish pub.

I had received a call Tuesday letting me know that my surgery was scheduled for 7:30 a.m. on Wednesday, and so I needed to be at the surgery center at 6:30 a.m. Not surprisingly, I couldn’t sleep at ALL, so I was up and ready to go by 6. When we arrived at the surgery center, I received a phone call from the center – literally as I was walking out of the elevator onto their floor – asking if I had a place to hang around and wait because they wanted to move my surgery to 9:30, as one of the anesthesiologists called out. I almost had a heart attack – it just felt so bad to wait that long (years) for this surgery only to have it moved back several hours on the morning of. I’m sure I would have dealt with it if I had to, but I basically told the lady that I was already there, and if they could find someone, they needed to. Lo and behold, an amazing anesthesiologist named Glenn was able to come in on short notice, so my surgery was only 30 minutes behind schedule.

The nurses at the surgery center were absolutely amazing. It was so obvious that they have worked with a lot of trans people – it was clear that they understood the magnitude of this day for me. They made sure I was comfortable, they made sure that the person starting my IV got it on the first stick, they made sure I had plenty of warm blankets and that my privacy was protected, and they especially made sure that my wife was taken care of, as I’m sure she was incredibly nervous. They updated her every step of the way and went above and beyond to make sure our experience was a good one. I don’t remember all of their names, but there was one named Paula, and my recovery room nurse’s name was Chris, and she was incredible.

recovery-roomDr. Rumer came over around 8 to mark me up, and went over any questions I had. It was only a few minutes later, and Glenn came over to give me some kind of happy juice – I remember being wheeled back and saying, “Well, it’s 5 o’clock somewhere!” That was just about the last thing I remember well – I don’t really remember too much of the operating room. I vaguely remember waking up – Chris had a Percocet down my throat before I could even open my eyes. Also before I could open my eyes, I apparently was overcome with emotion over the reality that the surgery had finally happened, and was just sobbing fairly uncontrollably. They brought Crystal back so she could be with me, and then they made her leave for a little so I could rest, although i just couldn’t. I was feeling pretty okay – they gave me a double whammy of Fentanyl, and then let me go home.

I decided on the way home that it would be a great idea for me to get a burger from Five Guys. Absolutely drugged out of my mind, I hopped out of the car before Crystal could stop me and went in to order a burger, but as soon as I got there realized that was a bad, bad idea, so I went right back to the car and passed out. We got home, and she set up a recliner chair for me in front of the TV, where I probably passed out and slept for hours. When I woke up, I tried to take a bite of my burger, but I was pretty nauseous and ended up throwing that bite up. I didn’t eat much that day – I mostly slept and drank gatorade and a Pepsi here and there.

That night, I got up to use the restroom and empty my drains, and suddenly, my drains began to fill up at an alarming rate. They should fill up about 30-50% every couple of hours, and they filled up 100% twice in a row in less than 5 minutes. Dr. Rumer came right up to the apartment, and determined that my bandages, which were tight, were cutting off the drain because of the way I had been sitting in one place all day long. When I changed positions and got up to walk, they were able to drain. She ended up going ahead and changing the bandages out and then I was okay. During that process of changing the bandages, I saw my chest for the first time, and I think it was overwhelming, as well as seeing all the stitches and just feeling nauseous and lightheaded. Because of all that, I ended up passing out. It was fine, though, and Dr. Rumer handled the situation with a cool, calm head.

We stayed one week in the apartment, and I think my wife was going stir crazy. I watched several seasons of Glee, as well as finished watching a season of Parks and Rec, along with doing a lot of sleeping. The day after surgery, we were able to take a trip out and eat breakfast at Cracker Barrel, as well as purchase an AppleTV which allowed us to watch all those great shows easily.

rumer-drains-out

Dr. Rumer taking out my drains and nipple sponges

Tuesday was supposed to be our last night, but Dr. Rumer came up and asked if I wanted to get my drains out then because she had a really early surgery come up the next morning. I couldn’t jump on that opportunity fast enough – she came right up to the apartment, removed my drains, and then we jumped on the road so that we could get home as soon as possible. Getting the drains out felt really, really weird. It didn’t hurt at all – it just felt weird. But, it was over in a second, and then I was able to put on a regular shirt! I only had to wear a small ace bandage to help keep compression so the swelling would go down. It was really a pain, and I found it hard to do all the time. I did the best I could, and my results are really fantastic.

One of the things I like about Dr. Rumer is that her surgery technique doesn’t leave those straight-across scars with super, super flat chests like I’ve seen. Not saying that those techniques are wrong – I personally just like her technique better for my own chest. My incisions are absolutely flawless – it is obvious they were done by someone who is an amazingly talented surgeon. I haven’t even needed to use anything on my scars like Scarguard or Scar Away. At four months post-op, they are barely visible in some parts. This is partly due to the fact that I don’t scar badly, but it can also be attributed to the skill and finesse of Dr. Rumer.

Recovery beyond week one

I was instructed to wait 6 weeks before swimming, and I had to keep a thin coating of antibacterial ointment over the nipple grafts, along with Telfa pads (non-stick gauze pads) to cover the grafts. Dr. Rumer said that I was allowed to drive as soon as I felt well enough and able to, but just not to reach too high and suddenly up on the wheel. I had heard that I wouldn’t be able to raise my arms or even pick up a glass and drink from it for several weeks. Personally, this was not my experience. I actually drove most of the way home from Philly one week after surgery – it was super, super foggy, and I’m just the driver in our relationship, so I was really happy to be able to drive. I started driving one week out, although I avoided driving if I didn’t really need to go somewhere, whereas usually I run errands just for the fun of it and because I enjoy the freedom of driving around.

My incisions looked really, really good from the start. My nipple grafts took 100%, which was a relief. The biggest thing that I wasn’t ready for in terms of what to expect after surgery was the complete loss of sensation in your chest. I literally could not feel my chest – at all. It was not a pleasant feeling, either. It is a combination of the severing of nerves, and I believe that they also inject lidocaine all into your chest at the beginning of the surgery, and I’m not sure how long that lasts, but I wonder if it may have had some residual effects. I would say that the kind of numbness I experienced directly after getting my drains out was rather uncomfortable, and it was really, really numb. It was a strange feeling, and I immediately started worrying that it would always be like that. Luckily, I began to regain some sensation over the following week, and then also beyond that. My right side under my armpit was the first to regain sensation. My left side regained some, but the right side seemed to be healing more quickly – for a little while, anyway. The nipple color also started coming back more quickly in the right side. For a while, they looked like they were almost the same color as my skin, which was strange.

chest-post-op

My chest at 6 days post-op

I would not suggest doing this, but I had just gotten a job teaching swimming lessons the week before my surgery, and told them it would be 5-6 weeks before I could get in the water. Eager to be able to do my part, I ended up getting in the water almost a week before I should have. I started in the water on March 4, and my surgery was January 23. I was pretty much healed, with the exception of a few small places, although the incisions were closed. I was also starting to swim some laps – 2-4 laps a couple of times per week, just to start getting my arms and body moving again. In retrospect, this was a really bad idea, and please please please learn from my mistakes on this one and follow your surgeon’s instructions!

About 7-9 weeks after surgery – so a few weeks after starting swimming lessons – I began to really have pain in my right incision under my armpit. I knew it felt weaker than my left side, and the incision was kind of red and inflamed and not healing terribly well. I had had a doctor look at it at another unrelated appointment, who said that it shouldn’t be that red at that stage in my recovery, but that it wasn’t infected. That was on February 20, I believe, when the doctor said that – a few weeks before the complication arose.

Post-Op infection

It was a Wednesday night, and I was in the pool with my students, when one of my children with disabilities who would get really, really excited to be in the pool (she was so awesome – she LOVED swimming!) got a little too excited, and straight up kicked me in the right pec. My chest was already hurting, and it immediately made my entire right side of my chest super red and inflamed. When it was still red and inflamed over an hour later, I realized that it was a cellulitis, and I believe that the impact of the kick spread whatever infection was already brewing in there and made it worse. I immediately notified my supervisor and asked to teach from the deck for the rest of the night.

When I got home, I was really in a lot of pain and was very concerned about the redness, so we went to the ER, where they gave me a prescription for oral antibiotics and told me to come back if it got any worse. I started the antibiotics right away – they prescribed Bactrim and Keflex, I believe. By Friday morning around 3 a.m., the infection had spread, and I was in more pain, so we went back to the ER. They started me on a couple of IV antibiotics immediately, and the attending doctor on the floor who was assigned to me was the most amazing, kind, compassionate, and excellent doctor I have ever seen while hospitalized. His name was Dr. Dhamoon, and he was this jolly, soft, gentle man with a turban. He was so incredibly respectful of my gender identity, and even though my name change hadn’t gone through and my gender marker hadn’t been changed, he never once slipped up on pronouns and made sure that all the nurses were aware of how they should address me, and we never had to explain our situation more than once. I cannot say enough nice things about this wonderful doctor.

Right before they transferred me up to the floor, which was some sort of ICU step-down unit since I had a post-op infection, they gave me a bolus of Vancomycin. When I got up to my room, I suddenly realized that I was itching my scalp and neck and back way more than is normal. I quickly Googled “vancomycin itching”, and sure enough, Vancomycin causes something called “red man syndrome” in some patients who receive it. Of course, since I tend to get any complications possible, I got red man syndrome. I buzzed the nurse and asked if I could have some Benadryl, thinking they’d bring me a tablet or two of diphenhydramine, or maybe even a liquid dose. Instead, they brought in IV Benadryl, and didn’t warn me of the side effects of receiving it IV as opposed to orally. The nurse pushed it super quick because I had been waiting almost an hour, and all of a sudden, I felt weird. I honestly felt like I had just shot up heroin, or at least how I imagine that to feel. It almost felt like I wasn’t in my body – I didn’t have control over my speech, and I literally just had to pass out and go to sleep, which I then did for a solid five hours.

The next day, a surgical resident came in and re-opened the incision, drained it, and packed it. A few hours later, I was discharged and sent home. I was given another round of oral antibiotics, though I can’t remember which ones.

After being released from the hospital with the infection, the incision began to heal very quickly, and I was able to swim again about two weeks later.

Healing post-infection

As of June 2013, I am completely healed from surgery, and my nipples are starting to look much more normal. The color is starting to come back in the areolas, although the centers of both nipples are still a work in progress as far as the color goes. I do not have sensation in the left nipple, but I have sensation in the right nipple. I have sensation back in pretty much the entire right side of my chest, except for one very small area, but I don’t even notice it. My left side seems to be slowly regaining sensation, both under my armpit, and all across the pec.

About two months ago, I had some puckering in the right incision where it began at my sternum. It was because when I had the infection, there was some barbed suture exposed at the drain hole, and I accidentally pulled on it, not realizing it was barbed suture. When I pulled, it created tension, almost like a purse-string, and wouldn’t release. One night, I thought I had a little suture or something sticking out of the incision start at the sternum where the puckering was, and I went to squeeze it to see if I could pull it out, and all of a sudden there was this loud, hard POP. It was the barbed suture that was all puckered severing/breaking. It immediately felt better, and unpuckered instantly. I was really glad this happened, because I was worried that I would need a revision for the puckering.