What is top surgery?

Top surgery is surgery that removes or augments breast tissue and reshapes the nipples and chest to create a more masculine or feminine appearance for transgender and nonbinary people.

Types of top surgery include:

• Chest Masculinization
• Chest Feminization

Who may benefit from top surgery?

Transgender and nonbinary people may choose top surgery as part of their gender affirmation treatment. Top surgery can be part of a person’s affirmation surgery plan to address gender dysphoria, which occurs when gender identity does not correspond to sex assigned at birth.

Gender affirmation surgery, including chest masculinization or chest feminization procedures, can improve well-being in patients who:

• Have ongoing and documented gender dysphoria.
• Have the legal and mental ability to make responsible medical decisions for themselves.
• Are successfully addressing other mental and physical health concerns.

Chest Masculinization

Chest masculinization uses one of several surgical approaches to remove breast tissue, and in some cases reshape and reposition the nipples for an affirming look.

Types of Top Surgery for Chest Masculinization

Depending on your goals, the surgeon may recommend several different approaches for top surgery. You and your surgeon will discuss the best choice for you, based on your body type, health and other factors.

Double Incision Mastectomy

This is the most common procedure for top surgery and can remove moderate to large amounts of breast tissue. The surgeon makes two horizontal incisions (cuts) across the left and right side of the chest, which accentuate the natural contours of the pectoral muscles. The greater the amount of tissue present before the surgery, the longer the incisions.

The incisions are kept separate where possible but may meet in the midline of your body. For larger patients, residual tissue along the side of the chest may occur. If this is a concern, it can be addressed with another surgery later.

The nipples and areolas are removed, reshaped, and then replaced (if desired) to achieve a more masculine appearance. The nipples will not have sensation immediately after surgery. Patients may regain some nipple sensation after six to 12 months, but they may be less sensitive than before.

Pros

• This approach is ideal for patients with larger breasts and excess skin
• The technique allows for a very flat chest contour
• The surgeons have some flexibility in nipple relocation or repositioning

Cons

• Drains are put in place after the surgery.
• Long incisions and resulting scarring may be visible along the base of the chest.
• Diminished nipple sensation may be temporary or permanent.
• Nipple care after surgery is more involved than after other procedures.
• There is a rare possibility of partial or complete nipple loss.

Keyhole Top Surgery for Chest Masculinization (Periareolar)

For people with very small breast tissue and no excess skin, the surgeon can make a cut along the lower half of the areola and extract breast tissue through this opening. The areola and nipple may be made slightly smaller before closing the incision.

This approach is used less often because it may not be successful when used for patients with large, drooping, or sagging breasts. For example, if a person can tuck a pencil horizontally between the underside of the breast and their torso and not have it fall to the ground (the “pencil test”), the keyhole procedure is unlikely to produce good results.

Pros

• The surgery leaves a less obvious scar along the border of the areola (the area of darker skin around the nipple)
• The procedure results in a very flat chest contour

Cons

• Drains are placed after surgery
• You may experience diminished or absent nipple sensation
• Inability for surgeon to reposition nipples or reduce the size of the areolas significantly

Buttonhole Technique for Chest Masculinization

This approach is for people who wish for a more masculine chest contour while preserving nipple sensation. In this surgery, the nipple and areola are kept on a stalk of tissue that includes and preserves the nerves.

Because this stalk of tissue remains in the chest, this technique will leave a small amount of bulk in the breast area and may not be the best option for those seeking a completely flat chest.

However, patients with some extra weight may find the results of this approach satisfactory, since some extra tissue in the breast area can look natural in people who carry some body fat.

Pros

• This approach gives patients the best chance of preserving sensation in the nipple, although results can vary.
• It is possible to make the areola smaller.
• The procedure can create an acceptable anatomic contour for heavier people.
• There is minimal nipple care necessary after surgery.

Cons

• The incisions are long horizontal lines across the base of the chest, like those used with the double incision approach.
• Some tissue bulk is left in the chest.
• Drains are placed after surgery.

Gender-Affirming Breast Reduction

Patients who desire a small, slightly feminine chest contour may benefit from this option. Like the buttonhole approach described above, gender affirming breast reduction removes tissue through a long incision like the one used in the double incision surgery. The nipple and its nerves are preserved on a stalk of tissue to preserve as much sensation as possible.

The surgeon shapes the chest into a rounder profile with a vertical incision, so the final scar will have an anchor shape.

Pros

• No drains are necessary.

Cons

• It requires a longer incision and scar like that of double incision surgery.

Breast Cancer Risk

Removal of breast tissue does not eliminate the risk of breast cancer developing in the area. If you are at risk for inherited breast cancer, be sure to inform your surgeon. Some care providers recommend a baseline mammogram before your top surgery procedures. You will still need to perform self exams of the chest and continue monitoring for breast cancer even after removing breast tissue.

Chest Feminization

A breast augmentation procedure may be part of a gender-affirming surgical plan, and can create a more feminine chest appearance. Breast augmentation involves a surgeon inserting a gel or liquid-filled implant into a pocket formed behind the breast tissue or under the pectoral muscle and centering each implant beneath the two nipples.

Those on estrogen therapy may experience breast growth as a result. Some surgeons and insurance companies will request one year of estrogen therapy to maximize natural breast growth before authorizing implant placement.

Estrogen can increase breast cancer risk. Some physicians or care providers may recommend a baseline mammogram before chest feminization and continuing breast cancer monitoring after the procedure. 

Top Surgery: What Happens

There are some similarities between chest masculinization and chest feminization procedures. For either surgery:

• Your procedure will typically take two to three hours.
• Top surgery procedures are performed as outpatient surgery. This means that most patients will not be admitted to the hospital.
• The surgeon will mark the area for surgery on your chest while you are sitting upright. The marks help ensure your surgery results are as symmetrical and natural looking as possible.
• You will be given anesthesia through an IV to help you sleep through the procedure.
• You will be positioned on your back on a table with padding around your arms to ensure you stay still and comfortable.
• You will wake up from the procedure with stitches and dressings on your chest, as well as a compression garment to protect against bleeding and fluid accumulation in the surgical areas.

Recovering from Top Surgery

It is very important to follow all the instructions your surgery team gives you when you go home from the hospital. For several weeks after surgery, you should not lift your arms greater than 90 degrees away from your body or over your head. You should also not push, pull or lift anything greater than five pounds during these four weeks. This ensures your scars will heal well and not stretch and become larger.

Compression garment. After top surgery, a compression garment will be placed on your body in the operating room. It is important to keep it on at all times to prevent postoperative bleeding and fluid collections.

• For chest masculinization surgery, you will wear a compression vest.
• For chest feminization surgery, you will wear a surgical bra.

Pain. You may experience some discomfort for a few days after surgery, but generally after four to five days your pain will ease and can be managed with over-the-counter acetaminophen and ibuprofen.

Dressings and drains. You will have dressings and possibly drains in place when you leave the hospital to help prevent fluid collecting in the surgical area. Do not remove them until you see your doctor after surgery. If you have drains, your doctor’s office will give you instructions on how to empty them and record the amount of fluid coming out of the drains. These drains will usually be removed at your first appointment after surgery.

Bathing and showering. Until you see the doctor, you may shower your lower body if you can do so without getting the bandages and dressings wet. Clean the top of your body with a sponge only until your doctor gives you the go-ahead for showering and bathing.

Risks, Complications and Side Effects of Top Surgery

• Top surgery scars: It can take up to 18 months for scars to resolve, and some people elect to have further surgery to minimize them. Avoid sun exposure, which can darken scars and make them more obvious.
  • For chest masculinization procedures, scars may appear as horizontal lines across the chest, or circles around the areolas.
  • For chest feminization procedures, the scars will be located underneath the breasts.
• Hematoma: Blood can gather in the tissues after surgery and form a clot, with symptoms such as pain, swelling and discoloration as well as an increased risk for infection. Hematomas form in about 1% to 2% of top surgeries.
• Seroma: Fluid can collect under the skin. Small seromas may not need any treatment and go away on their own. Seromas in top surgery can be prevented by drains in the surgical area and wearing your compression vest consistently after your procedure.
• Infection: This is a rare complication of top surgery but can happen. Cellulitis in the surgical area may require treatment with oral antibiotics and drainage.
• Breakdown of nipple graft: If nipples are moved and replaced, some skin sloughing is no cause for concern. But deeper tissue death (necrosis) can indicate that the graft is not successful, and more surgery may be necessary.
• Reduced nipple sensitivity: Numbness or tingling can happen if a nerve is disrupted or damaged during surgery. Nipple numbness may improve over time, but full restoration of sensation is not guaranteed.