Top surgery for transgender men and nonbinary people is a procedure to remove breast or chest tissue (subcutaneous mastectomy). If your chest size is small, you might be able to have surgery that spares your skin, nipple and areola.
Top surgery, or male chest reconstruction, involves the surgical removal of breast tissue and tailoring of the remaining chest skin, when needed, to generate a masculine chest contour. Usually, the surgery involves reducing the size of the areola, the darker skin surrounding the nipple. The procedure is also called transgender mastectomy.
Top surgery is usually carried out after individuals have begun taking testosterone and after they have been presenting themselves socially as males for some time. The physicians at UI Hospitals & Clinics follow the World Professional Association for Transgender Health (WPATH) standards of care that require one letter assuring readiness for surgery from a mental health provider. Though most individuals undergoing top surgery are 18 or older, younger individuals may be considered for the procedure if the patient, their legal guardians, and their mental health professional are in agreement that top surgery is appropriate. The best candidates for top surgery are those who are mature enough to fully understand the procedure and have realistic expectations about the results. Male chest reconstruction is not recommended for transmasculine persons who intend to breast-feed.
Top surgery is not a simple operation, but it’s normally safe when performed by a qualified plastic surgeon. Nevertheless, as with any surgery, there is always a possibility of complications, including bleeding, infection, or reaction to the anesthesia. You can reduce your risks by closely following your physician’s advice both before and after surgery.
The procedure does leave noticeable, permanent scars. The scars fade with time, but never disappear completely. Poor healing and less favorable scars are more common in smokers. Though efforts are made to make the two sides of your chest as symmetric as possible, the procedure also can leave you with slightly mismatched chest walls or unevenly positioned nipples. Most patients experience a permanent change in feeling in their nipples and chest wall.
In your initial consultation, it’s important to discuss your expectations frankly with your surgeon. The contour that can be achieved with top surgery varies with each individual’s particular size and shape, and it is important that you have a realistic understanding of the results your surgeon can achieve.
The surgeon will examine your chest, and will probably photograph it for reference before and after surgery. (The photographs also may be used in the processing of your insurance coverage.) He or she will discuss the variables that may affect the procedure—such as your age, the size and shape of your chest and body overall, and the condition of your skin.
Your surgeon will describe the procedure in detail, explaining its risks and limitations and making sure you understand the scarring that will result. Your surgeon also will try to get insurance coverage for the procedure if you have insurance and your policy covers gender affirming surgery. You will be given information about the cost of the procedure if insurance coverage is not available to you.
Your surgeon may require you to have a mammogram (breast x-ray) before surgery. You’ll also get specific instructions on how to prepare for surgery, including guidelines on eating and drinking, avoiding smoking, and taking or avoiding certain vitamins and medications.
While you’re making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days if needed.
Techniques for male chest reconstruction vary, but the most common procedure is the ‘double incision’ approach. This involves a somewhat elliptically shaped incision with the lower part just below the breast and the upper part above the nipple. The breast tissue and the excess skin are removed using these incisions. The central portion of the nipple and areola is usually taken off the breast and then replaced at a somewhat higher position on the chest as a skin graft at the end of the procedure. In most cases, the size of the areola is made smaller so that it will appear more masculine. The ultimate scar that results from the procedure runs from near the lower portion of the breastbone toward the armpit.
Occasionally, when there is not a great deal of extra skin, the breast tissue can be removed through a more limited incision around the areola. An additional incision is often made near the armpit for liposuction.
After surgery, you’ll be wrapped in an elastic bandage over gauze dressings. A small tube will be placed on each side of the chest wall to drain off blood and fluids for the first week or two.
You may feel some pain for the first couple of days—especially when you move around or cough—and some discomfort for a week or more. Your surgeon will prescribe medication to lessen the pain.
The bandages will be removed a week or two after surgery during your first postoperative visit. Your drains will most likely be removed at that time as well. If your nipples were replaced as grafts, the dressings also will be removed from them. You will generally need to apply antibacterial ointment to the nipple grafts twice a day for two to three weeks after this visit to help them heal more completely.
You may experience random, shooting pains for a few months after your surgery. You can expect some loss of feeling in your nipples and chest wall skin. This usually improves over the next six months or so, but sensation may never be normal.
Although you may be up and about in a day or two, your chest wall may still ache occasionally for a couple of weeks. You should avoid lifting or pushing anything heavy for three or four weeks.
Your surgeon will give you detailed instructions for resuming your normal activities. Most people can return to work (if it’s not too strenuous) and social activities in a week or two. It may take longer to get back to more physical occupations and activities.
A small amount of fluid draining from your surgical wound or some crusting in the early postoperative period is normal. If you have any unusual symptoms, such as bleeding or severe pain, don’t hesitate to call your doctor.
Although much of the swelling and bruising will disappear in the first few weeks, it may be six months to a year before your chest wall settles into its new shape. Even then, the shape will fluctuate in response to weight changes.
Your surgeon will make every effort to make your scars as inconspicuous as possible. Still, it’s important to remember that male chest reconstruction scars are extensive and permanent. They often remain lumpy and red for months, and then gradually become less obvious.
Of all gender affirming procedures, male chest reconstruction results in the quickest body-image changes. Like all gender affirming treatment, the goal is to treat gender dysphoria and improve overall quality of life.
However, as much as you may have desired these changes, you’ll need time to adjust to your new image—as will your family and friends. Be patient with yourself, and with them. Keep in mind why you had this surgery and chances are that, like most transmasculine people, you’ll be pleased with the results.