A guide for foreigners for getting top-surgery in the

U.S/Canada.
Seven steps and you're there

If the individual steps are manageable, than so is the whole

24-04-17

For comments, suggestions or questions

Contact: r.esperoza@hotmail.com
About the author & this guide
Hello there. Since you are reading this I expect you are either considering getting top surgery
yourself or somebody else you know is. If so, you have come to the right place. I will do my
best to break down the process of getting surgery into seven manageable steps. As for your
author; my partner underwent the surgery and I did most of the research needed. While
doing this I noticed there was a lot of information ' out there' , but that it was a bit difficult
as where to start. Also most guides assumed people were from the US or Canada, which is
obviously not applicable to all people who get surgery there. Therefore this guide aims to be
a roadmap for people who have to travel to get their surgery. If you like this guide, feel free
to spread it. Detect mistakes, have useful tips & tricks, or have questions please feel free to
leave messages or e-mail me. Furthermore I wish to explicitly state I do not receive any
money from organisations, surgeons or websites. It is possible for people to leave a donation
if they want to.
For who is this guide?
Any person who wants to find practical information on how to get a FtM top-surgery in the
U.S. or Canada. I use ‘FtM’ here solely to refer to the type of surgery because it is the most
common search term for this procedure. I am aware that there are various people who wish
this procedure but who do not identify with the label 'FtM'. If you are one of them: this
guide is also for you. Unfortunately, this guide is also only for people who have money to
spend. In case of FtM top-surgery the total cost of your travel is likely somewhere between
$10.000 and $20.000. If you do not have this amount of money there might be payment
schemes, loans or insurances available.
Why this guide?
Personally it was not possible for us to get a letter of recommendation from an expert, as
many surgeons require. We weren't able to get surgery in the EU, so had to look for
alternatives. You can ask your local transgender organisations whether alternatives exist
first. Many transgender people face hurdles in their health care. Some of you might have
anxiety attacks and not be able to see a psychologist who is going to dig in your past. For
others the professionals will not believe you need the surgery, or put up barriers like you
first have to be “mentally stable”, “take hormones” or whatever they can come up with. I
wish not to say psychologists are often incompetent, not because it is untrue but because
this would be beside the point. For some people the system simply does not work and they
need an alternative. For these people the model of informed consent, in which the patient is
assumed to be capable of determining what medical care they need, is an alternative.
Whatever experiences drove you to this guide, know that you are not alone.
Curse, it fucking helps
A month prior to the trip me and my partner undertook I would have sacrificed a limb to
know everything would be fine. Seriously. At surgery day I felt the weight of the world lifted
from my shoulders. Worry all you have to, but keep taking small steps at the time to bring
your dreams a bit closer. If need be, do sports, fucking curse like a freaking sailor, curse some
more, make art, do whatever helps.
The steps:
Laying foundations

Step 1: Investigating procedures

Step 2: Selecting surgeons

Step 3: make a schedule

Planning

Step 4: contact a surgeon

Step 5: Preparing to travel

The surgery

Step 6: final consult

Step 7: Surgery day and post-op

For travel companions

Final remarks

Step 1: Investigating procedures

You are unhappy with your chest. It ought to be flat. Fair enough, but you'll need to define
what you want a bit more precise. There are various procedures with different results and
outcomes. This step is designed to help you think about these and finding out what is best
suited for you. This is a back and forth process. Although knowing the pros and cons of
different procedures is required for knowing which of these you think is best for you, it is
equally true that if you do not know what you prioritise you cannot select a procedure.
I suggest you start by reading up on the various procedures for FtM top-surgery and focus on
their different pros and cons (when I wrote this guide the best information was on:
http://www.topsurgery.net/procedures/). Generally speaking, three types are available:
Keyhole/ Peri areolar: These procedures are generally considered favourable because
they leave very small scars and limit nerve damage. The pitfalls are that it can only be
performed on people who are relatively ‘small’, also the nipples tend to end up a bit low on
the chest. Revision is more often required compared to other procedures.
Double incision with grafts: This procedure is popular. It can be performed also on
patients who cannot get keyhole. Most surgeons place the incisions above the nipples.
Nipple sensation often gets lost.
Double incision without grafts (inverted-t, buttonhole): Inverted-T should preserve
nipple sensation and is hence quite popular. It does leave an additional scar compared to
double incision with grafts. The buttonhole procedure is a relative new technique only
available at five surgeons (one of which uses informed consent). Like inverted-t it should
preserve nipple sensation but does not create an additional scar.
Which procedure is best suited for you is mainly dependent on the size of your breasts, their
angle as well as skin elasticity. For determining which method is best for you, you can use a
method called the Mosser method (see: http://www.trans-health.com/2014/mosser-
method-ftm-top-surgery/ ).
To get an idea of how the results of various procedures look you can visit
http://www.transbucket.com and filter for a specific procedure. Only look at photos at least
3 months post-op, since before that too much wound healing is going on to see the results
properly.
Some people find it easier to select a procedure than others. Ultimately I suggest you discuss
this with your surgeon during your first consult (step 4). If you decide which procedure is
best for you, great. Else, don’t fret too much about it. For now, make sure you are familiar
with the various procedures and the (dis)advantages of all of them. In step 4 you have the
chance to discuss your considerations with your surgeon.
Step 2: Selecting surgeons
This step is by far the most challenging of them all. How the fuck is anybody supposed to
know what surgeon to entrust their lives to? In the end it will always remain a bit of a
gamble but there are some things that might help you decide.
If you have a referral letter of a psychologist most surgeons will accept you. In this case trim
down the list and limit it to about five to ten surgeons to avoid complete confusion.
If you don’t have such a letter; no problem choose one who works with a model of informed
consent (http://www.topsurgery.net/surgeons/informed-consent.htm). Although the list is
not terribly long (it had 11 surgeons when I last looked) it still provides you with ample
choice.
Make a table with four columns. Put the names of the surgeons in the first column.
Find their websites and put them in the second column. If no site exists; remove their
row entirely.
Go to each website. If you don’t like the website because it is not clear, looks shady
or because it seems that FtM top-surgery is something they hardly ever do, remove their
name of the list. If one surgeon is massively more expensive than several others; delete.
Write all the procedures they perform in the third column. Count keyhole/ peri-
areolar as a single category and be aware that buttonhole is similar to inverted-t, except for
having an incision less. Delete the row of any surgeon that does not preform all procedures
you are interested in.
At this stage I eliminated about halve the surgeons and was left with six possible candidates.
Now it is time to do some deeper research. Only trust people who have actual experience
with the surgeon. I have come across a blog that slurred a surgeon simply for performing the
procedure. These are just attempts to discourage you from getting surgery at all, just ignore
them. Where to find these reviews? Anywhere you can. Transbucket, google reviews, Susan’s
place and YouTube are your best bet, but any information is valuable. (Note: I have been
informed that it is possible for companies to remove google reviews to their liking. Hence
their information might be influenced).
How exactly you select them is up to you. It really depends on what you value most
(experience, flexibility, price, location, bedside manners (as you can find out via reviews) and
so on). In the end I eliminated one because he didn't use proper pronouns according to
several people, one because I couldn't find any photos and another because I taught the
results didn't look as good as those of some other surgeons. I presented these three options
to my partner. He picked Dr. Hope Sherie, mainly because we wanted to hear more about
the buttonhole procedure. I can fully recommend her since our experiences with her clinic
have only been great, however I read several great reviews about other surgeons as well and
think it is important you pick the surgeon that suits you best.
Step 3: Making a schedule
With this I do not ask you to pick any particular date as of yet, but just consider in what
period you could go. Keep in mind the following:
 Medically, due to pressure on the incisions, it should be safe to fly back one week
after surgery. I strongly recommend to fly only two weeks post-op, preferably three.
 In case you have somebody to travel with you; ask for their availability. A person you
can trust and who can look after you is of great value.
 If you don’t have somebody to travel with you, don’t despair. Make sure to book a
caregiver for the first 24 hours (ask your surgeon). Also make sure you have either a
hotel with room service or an Airbnb with people who are willing to help. You will be
less flexible compared to people who do have a travel companion, but combine
goodwill and financial incentives in equal proportions and you’ll be fine.
Congratulations, you levelled up from level A to B. The foundations are laid, let’s get to the
actual planning.
Step 4: contacting a surgeon
At this time you should have a fairly good idea of what you want and have selected at least
one surgeon who you think is competent. I suggest contacting this surgeon now. Explain in
an e-mail you are not from around, but that you are considering travelling to the US/Canada
for the surgery. Ask for a Skype (or phone) consult to discuss details. For most surgeons this
is either free, or the fee will be deducible from your surgery fees. If you have to pay some
money ($100), so be it. From this point onwards the clinic you contacted should be able to
give instructions. If the clinic remains vague, hesitant or you do not like the way they treat
you. Leave, go to the next.
If everything goes well the clinic should be friendly and plan an e-consult. This opportunity
allows you to ask any question you might have. Make sure to make a list beforehand and
never hesitate to ask a question you have, it is literally their job to answer these. Make at
least sure that in the end of the conversation:
- You are well informed about the different procedures. The provided information
should be sufficient to make your choice (even though the final decision might be
as late as the day before surgery)
- You do know about cost. If unclear from their website ask whether essentials (like
post-op garments, narcotics, post-op appointment) are included in the price. It is
normal to still have to pay for additional garments, silicone cream and
medication. Whatever the case, make sure you are informed and know what you
get for your money.
- Both parties agree on the financial arrangements. If you need to pay in
instalments, discuss this. Also make sure you are aware of their cancellation
policies.
- It is clear how to go on from here, i.e. both parties know what to expect from
each other and who will take the next step.
Honestly, I kind of enjoyed the e-consult. If the conversation went well, decide to stick with
this surgeon, if they weren’t nice to you or were unable to answer your questions, perhaps
you should look for another surgeon.
Step 5: preparing to travel
Up until now the only thing that cost money was the consult with the surgeon. This step will
cost a considerable amount of money. How difficult it is to prepare yourself mostly depends
on your travel experience. There are numerous good resources on travelling in general, in
this guide I will only elaborate on this which are special to travelling for FtM Top-Surgery.
Think about:
Planning:
The dates which are alright for your clinic.
You will want at least a full day to settle when you arrive. It gives you some time to recover
from a jet-lag, get acclimatised and if anything goes amiss (your connecting flight is delayed)
you will still be fine. You do not want any unnecessary extra stress.
You have at the very least one week after surgery before going back. This is not optional. But
honestly, the more time you have the better. Personally, I favour flying after three weeks,
although you should be alright two weeks post-op.
Border regulations; make sure you are allowed in the country, that your visa/ESTA is in order,
that your passport is not about to expire ect…
Hotel:
Make sure you are in a calm environment. You will want to rest a lot after the surgery
(hostels are problematic due to noise, as well as difficulties with shared bathroom usage).
Also, if travelling to a hot climate check for A/C.
Pick an hotel or Airbnb close to your clinic. You do not want to travel far on your first day. If
this is really expensive, book it for a 1-2 days and move to a cheaper hotel/Airbnb later.
To my surprise you can walk ordinary stairs after surgery. No need to worry about ground-
floor only.
Make sure there is a way for you to get food/drinks or other items you might need. This is
especially important if you are travelling on your own (check for delivery/room services is
so).
Money:
Get a credit card, in the U.S. they use this excessively (compared to many other places where
debit cards are much more popular). If this is impossible for you, use cash.
Paying for the surgery can often be done with a simple bank transfer, this prevents troubles
with spending limit or having to travelling with a lot of cash.
Safety:
Assholes are everywhere, and you will be particularly vulnerable. You do not have to be
open. Saying “I will have surgery but wish not to disclose why” is legitimate.
To pack or not to pack?
You won’t be able to carry luggage. Seriously even a small backpack (or trolley) is impossible.
If you are travelling alone, travel extremely lightly and ask for help everywhere.
Bring one or two things that might relax you (your favourite stuffed animal) and leave things
which cause you stress (work, ect.) This is good life advice in general, but especially so for
recovering patients.
You will need a binder/compression vest after surgery. Most surgeons will provide you with
one of these, but a second one is useful. You won’t be able to reach your arms above your
shoulders, so it must be a binder that closes using velcro. Look online or ask if your surgeon
sells any.
Button-up shirts will be necessary, since you won’t be able to wear anything that requires
you lifting your arms.
You might have a bit of bleeding and/or drainage post-op. To prevent stress about bedsheets
getting dirty, bring something to protect them.
A straw
A thermometer
Misc.
Generally, in the better shape your body is, the better you will heal & recover. A healthy diet
is important. Smoking isn’t a brilliant idea, be careful with drinking 1-2 weeks prior to your
surgery. Furthermore, I can recommend yoga since it is both good for your body and helps
reducing stress (Tara Stiles has great tutorials on YouTube).
Everybody reacts differently to surgery. Some people are fine and hardly feel any pain,
others experience a lot of pain and discomfort. You can read blogs or watch YouTube videos
about this.
If travelling with someone, make sure they read the section “for travel companions” in this
guide.
Don’t book buses after your surgery, because of shaking and general discomfort. Trains are
okay.
Costs
In general, the costs of this trip will depend mostly on price of surgery, accommodation and
travelling. Since the cost of surgery cannot be helped, focus only at accommodation and
travel if you have a limited budget. Think critically about what you need. For instance, 1-2
weeks post-op you will not want to stay in a hostel, but having a house mate who works full-
time might be fine (Airbnb). We also manage to save $300 by booking flights tickets to D.C.
and taking a bus to Charlotte (and train back). Below is an estimate of our travel expanses to
give you a clue about what to expect. Mind that we are experienced budget-travellers. We
spend for two people in total about €12.150 ($13.500).
Travel
Amsterdam- Charlotte (2-way) 2250
Accommodation
Charlotte (2 weeks) 1000
D.C. (1 week) 1000
Money spend misc. (mostly groceries & uber) 1000
Surgery 6700
Medication 200
Total €12.150 ($13.500)
Step 7: final consult & post-op
A dream becomes a reality. After travelling there are just a few more things to do,
and then you will be alright.
First of all at this stage your clinic will provide you with all the information you need
and will be able to answer all your questions. Equally important; make sure that the surgeon
knows exactly what you (procedure, straight/curved scars, nipple reconstruction or not,
whether you want a ‘muscular shape’ or as much tissue removed as possible). Make sure
you have a contact number in case of emergencies.
Make sure you have a phone that works. Mine (European) worked fine, but if not buy
one. You will want to be able to contact people in case emergencies (unlikely).
The day(s) before surgery you will want to consume extra protein. This gives your
body the building blocks for wound healing.
You will need to pick up pre-scripted medication.
Get some super-light food for after surgery.
Make sure you are in possession of a thermometer.
Rest well, eat well, follow any instructions provided by your surgeon and good luck.
If travelling with somebody you are comfortable with and who can do post-lymphatic
massages (does not have to be a professional): ask for a massage before surgery. It helps you
relax and boosts your immune system.
Post-op
It might be unbelievable at first, the realisation that you have a flat chest. Or perhaps
you are more surprised it once wasn't flat. Congratulations.
Somebody needs to be with you nonstop for the first 24 hours post-op. No
exceptions. Your body will be drugged up and will remain so for some time. All you need to
do on the day of the surgery is nothing at all. People will take care of you and make sure you
end up safely in a bed. Later you will want to eat some light food.
Let’s focus on your recovery. There are a few things to consider:
- Use common sense. There will be instructions that are logically incompatible (‘look
whether the incisions look fine’, and ‘keep the binder on’). In general; don’t worry
too much as long as you don’t have a fever, don’t smell foul (infected) or feel weird
pains at a specific spot.
- Make sure you take your temperature regularly, especially during the first 24 hours.
Unless your caregiver notices your body is particular warm there is no need to
sacrifice rest for this. But when awake, take your temperature every two hours.
 - Sleep as much as you can. You need to rest and be stress-free. Block any contact with
people you don’t want to contact. Set an auto-reply on your e-mail if required.
- When it comes to movement you will be severely limited. Obviously don’t lift heavy
things and don’t stretch. After one day recovering, also move about a bit in the
room, maybe you can walk a block outside.
- The binder should be tight, but you do want to be able to breath
- Nutrition: protein, zinc and healthy food
- Massages: lymphatic- drainage, if travelling with somebody you are comfortable with
or if you have the money to go to a professional.
- Questions? Worries? Ask your surgeon.
- Walk small bits outside if possible
- You need to wear your binder for 2-6 weeks post-op.
- Personally I felt various websites optimistic about the recovery time. In one week
time you will be able to walk again, but for instance you are still unable to open
heavy doors. After the second week you will feel fitter, but you are still rather weak.
Apart from that there is mental recovery. You managed to get your surgery, will
probably feel relieve and want to hold on to the feeling of bliss without directly
falling back into daily routine. If at all possible, avoid going full-time to work as long
as you can. Physical work can, in my opinion, only be resumed after two-three
months.
- When the incisions are closed (1 week post-op) you can apply silicone cream to
minimize scarring, if desired.

For travel companions

The person you are travelling with will be vulnerable and is entrusting you with care.
The most important thing is to listen carefully what they want and respond to that. However
there are some things I can say on the matter:
- Keep the person as stress free as possible. All they need to know is that they are very
brave having taken all these steps and that they will be fine. Let them rest.
- If you want somebody to contact, arrange this. Discuss any matters that might cause
stress with them, rather than with the patient.
- Restrain the person from doing stupid things. For instance, it is all nice and well that
they want to carry their own bag, but they are simply not allowed. Do not leave the
hotel/Airbnb until they agree you carry all the bags.
 - Make sure they take the appropriate medication at the appropriate time. This
doesn’t come down to a minute or two, but especially anti-biotics have to be taken
as prescribed.
- If foul smelling or fever arise. Don’t hesitate and contact the surgeon. Do so calmly.
This is not up to debate.
- Don’t be over-caring; it is good for the patient after the first day to move about a bit.
You want water? What a splendid exercise, go get it yourself. Walk along if necessary,
don’t overburden them.
- Gather information so you know what to expect, there are many youtube videos on
this topic. Read up on wound-healing, diet and anything you might need to know. For
instance, think of meals with lots of protein. Is your patient a vegan? An excellent
challenge to try out vegan recipes with protein.
- Anything in your life is for a week less important that the health of the patient. They
entrusted you with the care, it is an honour.
If both of you are okay you might want to learn lymphatic drainage massage. It is relaxing
and good for the immune system. Generally, with massages; be careful and don’t apply too
much pressure, ask “does this feels nice” regularly. Obviously, massages are quite intimate.
Thanks
Thank you for reading this guide. I sincerely hope this guide may be useful to you in keeping
track of your planning. Comments, suggestions or additions are welcomed and can be send
to r.esperoza@hotmail.com . Best luck to you all.