Nao: My experience of Top Surgery
Leading gender affirmation surgeon, Ioannis Ntanos (he/him), chats to Nao (they/them) about their personal journey to top surgery. From overcoming medical mistrust to fears of general anaesthesia, this episode explores how medical teams can work with trans patients to develop confidence and affirm their identity.
Find Ioannis Ntanos on LinkedIn, Instagram and Threads.
To find out more about top surgery, visit https://www.ioannisntanos.com/
Welcome to the Top Surgery podcast. My name is Ioannis Ntanos. I'm a specialist top surgeon, working with trans-masculine, non-binary, and gender non-conforming individuals. I'm also an ethicist and a trans ally. In this podcast, I will be discussing gender affirming care with a range of guests from those who have experienced top surgery firsthand to experts and ethicists with an interest in the challenges posed by this underserved area of medicine. I hope you will join me in learning more about this fascinating topic.
In this episode of the Top Surgery Podcast, Mr. Ntanos chats to a former patient about their firsthand experiences and the impact which the surgery has had on their life.
I'm Ioannis Ntanos. My pronouns are he/him. I'm a consultant surgeon and I specialise in offering top surgery on gender diverse individuals, specifically trans-masculine, non-binary ones.
Hello, I am Naomi. I work as a digital recruiter and I have recently had top surgery with Ioannis. I use pronouns they/them.
Naomi, can you talk us through your journey to choosing to have top surgery?
I never really felt comfortable identifying strictly as female or male. I tended to dress in typically baggy masculine clothing. This has almost always helped me manage my feelings of gender dysphoria. Recently I was trying on a tux from my wedding and just hated the way it pulled across my chest. And the more I thought about this feeling, the more I wanted to make a change. I've always been afraid of doctors, literally anything medical my whole life. And I've avoided getting medical support, due to pretty much lack of trust. So I thought I would never choose to have a surgery. Looking into top surgery and hormone therapy, I was pretty nervous about the process, and I wasn't sure I was gonna be able to go through with it. It's easy to think you've had this feeling your whole life, so maybe you can just make do, but I am really glad I did make the decision to have surgery.
I found an online transgender healthcare provider, and they gave me an appointment pretty quickly. They supported me, chatted me through the process, gave me a gender dysphoria diagnosis, and I worked with a counsellor. She basically directed me to a really great podcast, which Ioannis was featured in. He immediately came across as somebody who cared about trans-masculine people and had chosen to be a specialist in top surgery. He was so friendly and approachable, and his tone of voice just put me at ease in the podcast. Ioannis mentioned every patient he talks to has a say in their procedure and the option for a discussion, and this was so different from the experience I'd had with healthcare before, where basically they give you one option and there isn't really a discussion, right? It is just that, or nothing. Hearing about the wait list time for surgeons in London being up to a year just to get a consult, I was so happy when I could contact Ioannis directly through his website and set up our first chat pretty much within a month.
Ioannis, is fear a major factor that comes up when you interact with patients?
Yes, and it's not uncommon, not only on top surgery for general adverse individuals, but for surgery in general. Especially for someone that didn't have a general anaesthetic before, it can be a rather fearful process and it's up to the surgeon to try and mitigate those fears. We never met before the first consultation. First consultation usually lasts between 45 and 60 minutes. And on that time, we have to know each other. It is equally essential for me as a surgeon to find out about you as a patient, as I guess it is for you as a patient to find out about me. If a proper relationship is not built between the service user and the service provider in the field that I'm specialising in, in offering surgery, things can go horribly wrong. I mean, things can go horribly wrong anyway. It is a stressful situation if there isn't a relationship between the doctor and the patient is not good for either party.
Ioannis, what is the aim of the consultation?
Well, to me first of all is an opportunity for the patient to find out who I am as well. So, I will allow enough time for everyone to express their desires, their expectations, to give me a small bit of the journey so far, who they are, how they got to up to here, how they came across myself, and then focusing on the bits that are “technical” about the operation itself. So, first of all allow time, and secondly try to be as authentic as you can.
Nao, how difficult was it for you to find a surgeon that could give you what you needed?
It can be really tough in the UK at the moment. Obviously some of the very well known ones have wait lists of basically a year or more just to have a chat with them. And obviously if you don't have that chat, like Ioannis said, you don't really have that personal connection, and you don't know if you're gonna feel comfortable with that person or not. So, you usually want to maybe speak to a few people so you can gauge who would be the best fit for you. Some other doctors as well don't consider gender dysphoria assessments unless they've been given by the NHS, and the NHS also has a really long wait list for this, so you're also kind of, they're dictating how you go through the process. I still really don't understand why they make it so complicated for transgender people. Other elective surgeries do not have these requirements, and as it is an elected, I chose surgery that you choose yourself, I still don't understand why they make it so complicated for us. And I hope that can change in the future.
Nao, how important is chemistry between a patient and a surgeon?
I find a friend in Ioannis, and I don't think I would've been able to go through the process without that feeling of a relationship trust, an emotional connection. So obviously I was super grateful to find him. Yeah, I met two other surgeons, and both of them I'm sure could have done a great job. But really both of them left me feeling very similar feelings to how I would with other, medical experiences I've had of non-personal, quite distant, very clinical, all things that made me feel incredibly anxious about going through a process like this. So to me, a huge difference.
Ioannis, why do you feel it's so important to build trust and chemistry going into this surgery?
I recognize the difficulties that gender diverse individuals have in accessing healthcare in the first place. So I totally recognize that there will be some discomfort on discussing with the medical professional to begin with. Some thoughts of holding back of maybe not being open enough because anything could derail the discussion. Someone can always say no to your request, and no one wants to offer an excuse like this. And that's totally wrong. If we are planning a meaningful relationship and good outcome operation, we need to have as much information as possible. So, we cannot allow that bond between the clinician and the patient to erupt. Otherwise, we will not have the ideal result for neither of us. So it's definitely worth it exploring more the relationship with someone who, keep in mind, is letting themselves completely to your own hands and the general anaesthetic with you holding a knife. I mean, the thought of it can be really scary.
Ioannis, if someone was coming in for top surgery, how many steps are there in the process?
That there is definitely one consultation, and that, as I said, can last for from 45 to 60 minutes. But there is no exhaustive consultation. There is no consultation where we can say, that's it. Now the next step is already set and not allow if more questions come up, if more queries come up, if anything need to be discussed more, not allow for further consultations. And I understand it can be difficult in someone's timeframe to arrange for all this, but we need to allow enough time and we need to allow ourselves to be available to our patients if they need us. We need our patients, especially in what I do to be a hundred percent committed and to be fully aware, first of all, of the potential risk and complications, secondly of the expected outcomes. Okay? And thirdly of the irreversibility of what we are planning to do,
Ioannis, how would someone communicate with you if they had questions after the consultation?
Yeah, so they then access me through my website, through my email address. And if I think that the question is pretty simple to answer, I'll respond with a couple of lines. If I think the question needs a further assessment, maybe the question derails from what was discussed in the consultation, or maybe we missed something completely and we need to revisit again, then we'll arrange for a further consultation and at least in my practice, any additional consultation for the first one, for which obviously there is a fee, any additional one is free of charge.
Nao, can you talk us through the referral process?
Well, after I had the meeting with the counsellor at the online health provider, they basically provide you with a mental health and gender dysphoria document, and that's what you give to your surgeons. So I provided that Ntanos, and we discuss my background, the feelings around gender dysphoria, what I hoped to gain from having the operation, what the ideal would look like, you know, I guess it's kind of core motivations, isn't it? Why do you want to do it, and like I said, you know, talks about the risks so I could have a good think about those. And then we went pretty much straight into, well had that think and then went to booking a date, which was great.
Cause I think when you are nervous about having surgery or something in the future, it's better to kind of get it locked in so then you can kind of commit to it and kind of get yourself in a good head space to build up the confidence and the energy to go through it all. So yeah, I think having Ioannis there to send a quick email to or talk to in between, or explore kind of any lack of confidences around things or questions. I was worried about my skin because I have very sensitive skin. I was worried about the afterwards, the tape that we would use to hold the incision together might give me a reaction, but Ioannis kind of shared with me what he would use, and kind of made me feel pretty confident and comfortable. That it would be fine, and it was, say, just being able to have that back and forth about something quite simple, that's an immediate put your mind at ease, you know, he's connecting with you. He's thinking about these things with you as well, and I know, again, that's something that you don't often get. So for me, yeah it was hugely beneficial.
Nao. What made you choose Mr. Ntanos for your surgery?
It really was mostly the connection from the first consult that we had. I felt relaxed and confident and comfortable that he was really gonna give me that support and give me care about what I was looking for in terms of a result. I also obviously looked online and saw that he had been kind of specialised in transgender issues and looking into modern top surgery procedures. I'd seen in America that a lot of the surgeons out there were not using drains and were using procedures which did not require them. That's something that Ioannis had basically said he could do. And again, he was the only one of the surgeons who could do that and gave me as an option, which I was really happy about.
Cause I knew that I'd have to, travel to Manchester and it would be difficult for me to have them removed. So, if it was something we could do, I was a hundred percent on board to do that with him. So, I went from feeling really petrified about ever having a surgery to feeling like I'd spoken to somebody who had my back, and was going to listen to me and care about what I wanted from it. Which, like I said, I just didn't think it was a possibility when I started thinking about the whole thing.
Ioannis, can you talk us through the use of drains in top surgery?
Well, the use of drains is not the only thing that historically has no actual scientific ground. There are a few things in surgery that we kind of inherited them our teachers, and we carried on doing them. And, and there is some research in the last years on whether you actually need to use drains or not. In my head, the default position should be no use of the drains. There is a place for the use of drains if surgical indicated, I use them myself as well, especially if the dissection area is too large. But only then if I don't feel that they're clinical indicated, I will never use them. And it does make a difference on the postoperative experience of any patient. They don't come free of other things that we need to use.
So, whenever I don't use drains, a compression vest needs to be used for 10 to 15 days. Some individuals will find it nothing to wear. Others will not like it because it does resemble the use of a binder. However, you don't have to carry around this awkward plastic tubes with two bags for an undisclosed number of days. In my practice when I use the drains you only keep them for two days, but I know there are surgeons around that can use them for up to seven or 10 days and can be a total nuisance. So, used only if required by default, no drains for everyone.
Nao, can you talk a bit about your surgery experience?
Sure. So, I commuted from London to Manchester the day before, and I had the first surgery on a Saturday morning. So, I was welcomed by the nurses at The Pines in Manchester, and they made me feel really welcome. I knew that they'd been working with a number of transgender patients, and obviously felt completely comfortable with them, and they made sure, you know, that I felt the same. I arrived, had a shower, I got into my medical gown. Ioannis came and checked I was feeling okay. He chatted with me about what to expect. He marked where he was going to do the incisions and double checked we were all agreed on the procedure. I meant the need notice and made sure we were all set with them as well.
And it all ran super smoothly. We were on time, and I was in recovery I think after about three and a bit hours, if that's right. Obviously, I don’t know exactly, but I think it was around that. Obviously, the biggest fear was going under, but like I said, the nurses, the anaesthetist, Ioannis, everyone just put me at ease. I did have a little bit of nausea afterwards, but it was totally fine. It was none of the things I was really worried about, it being highly clinical or everyone being quite stern and unaffectionate, and everyone was very sweet and soft and kind, so yeah, not what you imagine, I guess, in a hospital. So, they gave me something to eat and obviously you spend the time after your surgery making sure that you can have something to eat, go to the bathroom and basically stand up again.
Ioannis came back in, and he checked with me and made sure that I was well, and then I was pretty much ready to go home shortly afterwards. So, in and out in pretty much less than a working day, and was back to work, I think pretty much in a week. And then able to exercise, getting better mobility and everything back to normal one a few weeks. So, I was obviously very lucky. No issues, no problems, and no real pain. So, my experience was very good.
Ioannis, when people come in for top surgery, what would you say are their main concerns?
I think that, yeah, being put under is a major issue, especially if someone didn't have a general anaesthetic before. However, the process generally, as Naomi described it, is a lot of people trying to make you as comfortable as possible. Everyone in the field is aware of how stressful that situation can be. So, if occasionally we've put someone's favourite song on the radio while they're being put under, so that's the last thing they hear before they're put to sleep. Everyone wakes up in recovery, which is a calm environment, and they are allowed enough time to be fully alert there before they are transferred back on their, on their bed on the ward. But there are, I believe, I had a couple of general anaesthetics myself, that the most scary thing must be the fear of the unknown.
All these people that you've never felt before, which you don't necessarily know exactly how, what they will be doing when you, you don't supervise them. So, it's important that these operations take place in an environment with everyone is familiar with what we are doing as far as our cohort of patients, but also as far as surgery in general. And the more experienced the staff is, the more smooth the process is, things can still go wrong. Okay? And everyone, every individual has an individual experience when it comes to all this, but certain guidelines should be in place for everyone to make that process as streamlined as possible.
Ioannis, how many top surgeries have you performed?
Up to today? I have performed 445.
Nao, does it make a difference knowing that Mr. Ntanos is an active ally to the community?
A hundred percent, yeah. I followed Ioannis and he’s completed his MBA, and has been working towards improving top surgery provisions in the UK. And just somebody who's looking to push the bracket and make sure that other non-binary trans people are getting the support and surgery that they're looking for means a lot, especially to somebody who hasn't had trust in healthcare providers in the past. Yeah, I think you can feel obviously his passion and how much he cares about the space, just the moment you speak to him. And you don't always get that with people that do any trade, to be honest. You know, people go into a business sometimes, you know, profession for money or for whatever reason they do, but it doesn't necessarily mean they care about the people or the thing they're doing like he does. So for me, like I said, it was everything and towards my journey and actually getting a procedure that has made a big difference to me.
Ioannis, what is it that fuels your passion for helping the trans community?
Well, we will need a lot of time if I'm to expand on this. But the main reason is similar to why I decided to become a doctor in the first place. And it's about offering care. It's about caring about other people. It's about engaging, about allowing people to fully expand their potential to be themselves. And you can do that in medicine from different fields. I chose to do it from this one. And my engagement with trans healthcare can be considered “accidental” because there is no formal training when it comes to who can perform these operations, not only in the UK but worldwide as well. The reason that I stayed in this service is because I want to empower people to be themselves. I want to help them fulfil their potential. And I understand what the obstacles they have to face, not only in healthcare, but in life in general, to, to me, my patients are an aspiration. It takes, so much bravery to be trans, I just want to be there and help.
Ioannis. Do you have any plans to deliver formal training in top surgery at any stage?
Yes. I mean, my experience in trans healthcare goes beyond the number of operations I have performed. So, I'm regularly attending national and international conferences. I have completely the full cycle of the training, from offered by the World Professional Association of Transgender Healthcare from wpath. I spend a lot of personal time reading about trans healthcare. I am in the process of trying to develop a formal or informal fellowship, a program that will allow other surgeons to train on what I do. My dream would be to structure a training process that will go beyond surgery as well. So, someone who is doing this operation should be exposed not only on the technical skills, but also on how to be an active ally, or how to be an empathetic person on how to know about the inequalities about health disparities that exist for gender diverse individuals. This way you can understand better your patient's needs and hopefully better understanding leads to better results, better experiences for everyone.
Naomi, what has having top surgery meant to you for your day-to-day quality of life?
I think the biggest moment for me so far was obviously putting on my tux for my wedding and not feeling self-conscious. The thought of previously wearing anything tight across my chest, like a shirt or a jacket, literally always would've made me feel uncomfortable or, you know, not right? So to be able to do that and feel like I wanted to was incredible. I've definitely spent more time at the gym. Caring for my body now is possible, to feel like I have a body I can connect with. I think you don't necessarily recognise how uncomfortable you are until you make a change, and then you make that change and you can feel much more yourself at ease, and able to do other things that will help you be a better you in the future. So, I'd say it's improved every part of my life because I'm comfortable. I'm more comfortable being this me.
Now, what advice would you give somebody considering top surgery?
It's daunting, super daunting. And if you're scared of doctors like me, you might, you know, think is not a possibility. But I would highly recommend speaking to surgeons, as you might find a connection with one. Obviously needing to have an assessment, like I mentioned before, just to be comfortable in your own skin, I find unfair. But if you are worried about NHS wait times and you have a little money to go private, obviously I recommend there are online providers, there are private surgeons like Ioannis who you can get an appointment with, who you can speak to in person who you can plan your surgery with. And it can be a personalised thing. Obviously like we talked about before, it is irreversible, so it's not something you need to rush into, like, you know, take your time.
You want to feel fit; you want to feel like your head is in the right place. It is gonna be at least a week of feeling like you need to be supported by somebody else. And you need time to just mend. So being able to take time out, being active, but then knowing that during that recovery period it's gonna be tough, but at the other side of it, it is gonna be a huge reward. You're gonna get to the other side of that process and feel, you know, hopefully a hundred percent better. So yeah, take your time and hopefully have the opportunity to choose the right person for you and, you know, give a surgeon the opportunity to make a connection with you. Cause it makes a big difference.
Ioannis, what advice would you give to somebody considering top surgery?
Think about it. Do your research. Don't think that there is only one way to get where you need to be. Feel free to express yourself to the surgeon. If at any point you are free and the person across the table doesn't agree with you being free, then it's probably the wrong person. Okay? Feel free to express your desires, your expectations, what you want to get out of it, and you eventually get up, get a connection with the right person that will help you in that pathway. It's not easy. It's one of the things that being trans is not easy. Surgery is not easy to begin with. I would advise everyone to do as much research as they could, preferably through first person reporting rather than Dr. Googling who knows what. Okay there is a lot of, and I'm sorry for using the word, rubbish online, and a lot of legends and nuisance. It's always better in the community to discuss. And if you, personally, I'm happy to give advice to anyone regarding the surgery, and this is what we're doing this today. Outside a personal consultation, we need as surgeons to go out and allow everyone to have access to our knowledge in advance. This is how we'll empower our patients to make the right choices and have a better experience overall.
Ioannis, when it comes to top surgery, are there many different surgical techniques?
There, there are different surgical techniques. If that's the major question and for some individuals that will be important, it will be the minimum scarring versus the long scars, which are extremely visible, but I don't think that's the important bit. I think first of all, a surgeon should be able to offer the entire range of procedures. If the surgeon can offer only one, of course, everyone in their cohort will be suitable for that operation. So first of all, being allowed to offer everything. Secondly, even if I know in advance, based on someone's body habitus that there is only one option when it comes to surgery, I'm still going to explore everything. I'm still going to let them know why this is necessary, why we cannot do the minimum invasive surgery. I'm still going to match that as much as I can to their desires and expectations. And most of all, I will allow them time to speak. I have patients who come to me from the beginning and tell me, I know I need a double incision, this is what I'm going to have, we don't need the consultation. Yes, we do need a consultation. We do need one. We do need to learn about each other. I need you to know if that's the ultimate outcome, how we get there.
Ioannis, what is the recommended approach when the operation doesn't go according to plan?
First of all, we need to make sure that everyone knows exactly the risks and complications. Because even with the best of intentions, things will go quoted wrong sometimes. And if that happens, if someone is informed about what could go wrong, then it'll be fine. The problem starts when something completely unexpected appears, and this is when you're trying to explain, and you end up discussing, why didn't you tell me that instead of what you can do about it? So, you end up in a retrospective discussion that should have taken place in the first meeting. When something goes wrong, it's important to make sure that that connection we discussed before is actually there. And in that case, if the trust is there, the surgeon will be there as well to deal with it.
It could be something minimum, like some more pain, for example. And okay, we'll prescribe some more painkillers. It could be something significant, some asymmetry on that chest after surgery that wasn't expected, and now come on the long run. That wasn't ideal in that case. First of all, someone should have the skills to correct it if possible. If not, he should have made sure that this possibility was discussed in advance. What I don't like is patients that come to me and tell me, I'll leave it to you, do whatever you want. You are the expert. No, okay, I'm the expert only when it comes to offer you all the information so that you can make a properly informed decision. And then I will offer you my sales skills as well, but I'm not an expert on what you need, on what you want or how you will respond if you have a postoperative hematoma or if you have a dog year after surgery that require a second operation that may come or not with potential more financial implications. So once everything is clear from both sides, what could go wrong and what does that mean in recovery time, in finances, in going back to work. Yes. Then yes. Okay. Feel free to discuss anything with myself.
Naomi, what advice would you give to somebody undergoing top surgery?
I think some of the things that, you know, are minor that are going to happen, like some small bleeding and some, some necrosis of the nipple as is healing so that kind of black and nipple that may stay blackened for a little bit longer than you expect it to. And sometimes when you are, getting back into mobility and you kind of maybe stretch a bit too far and you extend that scar line out a little bit. I think obviously having a conversation around all these things, so it's not a surprise, and having a little bit of thought around, you know, surgery can't be perfect, whatever we do to our bodies, there isn't any sense of absolutely perfect.
So going into it there, something like this with the headset of, something might be slightly different than I expected, but I'm going to be comfortable with that. I remember we definitely had a conversation about that, and I think having maybe some images that read it is full of some great before and after images. I think that was a big resource for me and, and people sharing kind of timelines and stories, so you get a sense of, you know, one week after surgery it is not gonna look like maybe what some other person's has looked like six months after surgery, you know? And everyone's healing is completely different. So, don't set yourself up to compare yourself necessarily, but be prepared that you might have a small infection afterwards or you might require more time bandaged up or have a hard time maybe with some of your skyline stretching. And I think if you go into the journey knowing that all of these things are a possibility, just like anything, we are not all gonna have the same journey or result then, I think that's a really safe place to be.
I hope you enjoyed this episode of The Top Surgery Podcast. Please subscribe and leave us a rating in the review. You can connect with me on LinkedIn and Instagram at Ioannis Ntanos. To find out more about top surgery, visit Ioannisntanos.com.