FAQs

If you are planning on using health insurance, documentation for hormonal therapy, as well as a letter from a mental health therapist confirming the diagnosis of gender dysphoria based on the (World Professional Association for Transgender Health) WPATH criteria is necessary. In certain cases, your insurance company may require letters from two separate mental health professionals.

Dr. Amirlak is a member of the WPATH and adheres to their guidelines with patient evaluation and surgeries. We strive to provide the best patient experience and the greatest aesthetic outcome. Dr. Amirlak has trained with renowned transgender and aesthetic facial surgeons and has mastered the art of top and facial feminization surgery in Dallas.

We have teamed up with adult and pediatric endocrinologists, gynecologists, and mental health therapists to provide the best comprehensive care for our patients

Male to female (MTF) or male to nonbinary (MTN) top surgery, also known as augmentation mammoplasty, involves placement of implants under the breast tissue or injection of fat into the breast tissue. MTF or MTN top surgery in combination with facial feminization surgery (FFS) may be the only surgical steps in one’s transition.

There are two techniques that are used for placement of implants. One technique involves placing the implant under the muscle (sub-pectoral breast augmentation) and the other involved placement of the implant over the muscle and under the breast tissue (sub-glandular breast augmentation). The decision on where to place the implant depends not only on the breast tissue and chest wall dimensions, but also the patient’s desire. Our preference for cisgender women, is to place the implant under the muscle so long as the patient does not have an extensive muscle mass with strong pectoralis muscles (typically seen in body builders). This provides a more natural upper pole of the chest. Although rarely bothersome, strong pectoralis muscles in muscular individuals could cause what is called “animation deformity”, which happens when the pectoralis muscle is flexed. Placement of implants over the muscle creates a sharper transition from the upper pole of the breast and cleavage to the chest wall, creating a more “done” look, however it avoids the potential animation deformity. In transwomen patients, we pay extra attention to such details and discuss them extensively with patients in advance.
The breast implant options are either saline filled implants or silicone implants. Saline implants are less expensive than silicone implants, but silicone implants feel more natural. When insurance covers the procedure, we prefer to use the newer generation silicone implants which have a cohesive gel and are much more resilient to rupture or long term problems.

Special techniques are used in cases where patients have minimal breast tissue and strong pectoralis muscle to provide the best and most natural outcomes in MTF Top surgery.

We utilize 3 dimensional imaging to assess the chest and various types of breast implant sizes in order to achieve the best results with each individual patient. Our patients can look at these images during their consultation and select the implant size and type that they prefer as long as there is adequate tissue to support the implant.

To see an example of a before and after result of a MTF surgery as well as a video of intraoperative details of the surgery, please visit www.amirlakplasticsurgery.com

Breast asymmetry is always a risk of any breast augmentation. Although we utilize the most advance technique in order to overcome breast asymmetry, there are often times when the pre-existing breast anatomy dictates the position of the augmented breast. Use of fat grafting has dramatically improved some of these issues, however this technique is rarely necessary.

Nipple sensation change or loss is rare, but is a potential risk in MTF top surgery.

Hematoma or bleeding under the breast tissue is a risk. This can be prevented by avoiding heavy lifting and increased physical activity after surgery, as well as avoiding all daily activities that increase blood pressure. Avoiding medications such as aspirin, ibuprofen (Motrin), fish oil, glucosamine, chondroitin, vitamin E, and Omega 3 for two weeks before surgery can decrease the incidence of unwanted bleeding during or after surgery. Please see the complete list of medications that are to be avoided at least two weeks before surgery
Breast pain following surgery could be a rare but potential risk.
Capsular contraction is also a potential risk following surgery- If severe, this issue would need to be addressed with an additional surgery.

Typically, it is not necessary to stop hormone treatments prior to MTF surgery.

Facial feminization surgery (FFS) includes multiple maneuvers which may include forehead reduction, rhinoplasty, upper lip lift, reduction or shaving of the chin, and electrolysis. Often the result of a well done natural facelift will increase the aesthetic goals.

Insurance does cover certain operations, though it can be more difficult to obtain approvals for FFS in comparison to top surgery. We have a dedicated team of insurance coordinators who will work on the patient’s behalf to obtain appropriate approvals from their insurance company.

Forehead reduction includes reducing the frontal bossing in order to create a more feminine look to the upper brow forehead area. This can be done through a traditional approach with a coronal or hairline incision and shaving the bone or doing a bone setback operation. Dr. Amirlak has been involved in research and the publication of the first ever operation for reduction of frontal bossing using a minimally invasive endoscopic approach. This is called endoscopic reduction of frontal bossing and is a great option in patients that do not want a coronal incision or hairline incision. The disadvantage of this procedure is that it can only be done in certain patients with specific thickness of the frontal bone. In order for us to assess the potential for this option, we obtain a CT scan with specific measurements.

To see an example of the before and after following FFS forehead reduction as well as an intraoperative video using minimally invasive endoscopic shaving of the frontal bossing, please visit: www.amirlakplasticsurgery.com.

Female-to-male (FTM) or female-to-nonbinary (FTN) top surgery is a gender affirming procedure performed for transgender men and non-binary individuals, in order to form a masculine chest. This surgery paired together with hormonal therapy maybe the only surgical steps that one takes for their transition.

This surgery generally involves removal of breast tissue resulting in a procedure that may not be reversible. For this reason, it is imperative that the WPATH guidelines are followed. The goal of the surgery is to provide the best outcome for the gender affirmation surgery. The standard is not only to achieve a flat chest, but also achieve a masculine chest where the pectoralis area and nipple are proportionate together.

Double incision top surgery with free nipple and areola grafts provides the best outcome for a flat and masculine chest. Adjunct high definition 3 dimensional liposuction is very important, especially in the areas of the lateral chest to define the pectoralis border as well as to avoid extra bunching of tissue after surgery (dog ears) and provides the best outcome for a masculine looking chest. Generally, nipple sensation will be decreased or will completely absent following this surgery.

In surgery, the nipple and areola are separated and grafted back on independently. This provides the most aesthetically pleasing nipple-areola complex that is similar to a male nipple and areola. The areola is also reduced in diameter to match the standard male areola size, which typically ranges from 22 mm to 28 mm in diameter.
This procedure is typically recommended for people with larger chest tissue and extra skin.

In certain skin types such as African American patients, the areola may have long term discoloration. In such cases, we recommend 3 dimensional tattoo to create the nipple areola complex. Although not routine, we offer this option which creates a relatively natural looking nipple-areola complex.

This procedure is usually an outpatient surgery that takes between 2-3 hours for the surgeon to perform. We use a special tape with a glue closure of the skin which provides the best long term outcomes for the scars.

To see an example of a before and after result of a double incision FTM surgery as well as a video of intraoperative details of the surgery please visit: www.amirlakplasticsurgery.com

This procedure is very similar to the double incision top surgery with nipple-areola grafts, the exception is that the nipple and areola are not placed back as free graft, but kept on a pedicle of tissue which can potentially preserve the sensation. This also may result in a more natural nipple areola complex. Regardless of these advantages, most patients prefer the previous option as it provides a more flattering masculine chest and avoids potential blood flow issues to the nipple.

If the patient has a small amount of chest tissue with minimal redundant skin, then the entire tissue can be removed through a small incision in the areola. We also use an endoscopic minimally invasive approach to make this operation easier on the patients’ recovery and improve the overall outcomes. With patients that present with large nipples, a staged nipple reduction is done in the office following the initial procedure.

To see an example of the before and after following transgender areolar minimally invasive FTM Surgery please visit: www.amirlakplasticsurgery.com

Infection or bleeding under the nipple could results in full or partial necrosis, as well as nipple areola loss. This is avoided by Using a compression garment and special topical compression foam for one week following the surgery.

Hematoma or bleeding under the mastectomy breast tissue is a potential risk following surgery. This can be prevented by avoiding heavy lifting and increased physical activity after surgery, as well as avoiding all daily activities that increase blood pressure. Avoiding medications such as aspirin, ibuprofen (Motrin), fish oil, glucosamine, chondroitin, vitamin E, and Omega 3 for two weeks before surgery can decrease the incidence of unwanted bleeding during or after surgery. Please see the complete list of medications that are to be avoided at least two weeks before surgery.

Additional revisionary surgery may be desired by a patient in order to address any extra tissue. This is done by excision at either end of the incision (dog ears), which may not be covered by insurance.

We generally recommend stopping the last dose of testosterone injections before FTM top surgery. Although some recent studies may suggest that the injection does not have to be stopped, we still recommend this until more conclusive data.

Facial masculinization includes several surgical options including rhinoplasty, chin augmentation with implants and widening the angles of the jaw, which can be done with fillers and fat injections.

You should avoid strenuous activity such as aerobic and weight lifting exercise for 2-3 weeks for both FTM and MTF top surgery. This includes swimming in pools, lakes, or hot tubes as well as refraining from any sexual activity. Following FTM surgery, you can wash your hair or the lower part of your body as long as you do not get the chest dressing wet. Following MTF surgery, you can shower the same day of your surgery.

Patients can return to work as soon as they feel well enough, with the restriction of limiting strenuous physical activity. Generally, patients will take one to two weeks off from work to allow time for proper healing. Although some surgeons may push earlier return to work, we would like to optimize our aesthetic outcomes and minimize complications. In standard MTF breast augmentation patients have less discomfort than FTM patients.

Most insurance companies are covering these surgeries. In case of denials or lack of insurance, the price ranges from $5,000 – $15,000, depending on the type and extent of the surgery. Keep in mind that each surgery is patient specific and these prices will vary from patient to patient.

We offer a comprehensive team approach for facial and top breast surgery for our transgender patients. We feel that gender affirmation bottom surgery should be done in center that has a dedicated microsurgery team with extensive training and experience in this area. Although we have world experts in each of these categories, we would like to develop a more comprehensive and cohesive approach before we offer these surgeries to our transgender patients.
At this time, we refer patients interested in bottom surgery to a specific center that we collaborate with and has a team who we feel provides the best care to our patients.

Nevertheless, the UT Southwestern team is in the process of developing the requirements to offer this surgery to our patients in the future.

We feel that the experience and expertise in top and facial surgery is at the highest level at UT Southwestern. We welcome patients to visit our clinic and we hope to achieve the best personal and aesthetic outcomes for our transgender patients.