What is top surgery? A guide to the reconstructive chest procedure for transmasculine individuals

• Top surgery is a procedure that reshapes the chest and removes breast tissue.
• This procedure is typically done by transgender men or non-binary individuals who need a more traditionally masculine appearance to match their gender identity.
• If you are interested in top surgery, it's important to speak with a doctor about which type is right for you, how much it costs, how you should prepare, what you can expect, and how to recover.
• This article was medically reviewed by Zil Goldstein, the associate medical director of Transgender and Gender Non-Binary Health at Callen-Lorde Community Health Center in New York.

Top surgery is a procedure that shapes breast tissue into a more traditionally masculine chest. It is often done by transmasculine individuals, such as transgender men or some non-binary people who, through puberty, had developed breast tissue.

In fact, top surgery is sometimes the only gender-affirming surgery that transmasculine individuals undergo, says Edward Ray, MD, a plastic surgeon who specializes in transgender surgery at Cedars-Sinai Medical Center.

"It's a very visible part of the body, the shape of the chest is important to patients, so it has an effect on how patients see themselves and their gender identity," Ray says.

What is top surgery?

"Generally speaking, when people refer to top surgery, they're referring to a mastectomy," says Loren Schechter, MD, a plastic surgeon who specializes in gender confirmation surgery at Rush University Medical Center.

A mastectomy is the medical term for when breast tissue is removed, which is sometimes necessary for people with breast cancer. However, Schechter notes that transmasculine top surgeries are different from mastectomies for breast cancer.

Mastectomies for breast cancer often remove breast tissue, nipples, lymph nodes, and can leave more prominent scars on the chest. Transmasculine top surgeries typically remove less breast tissue than a full mastectomy, are less invasive, and the patient can choose to reposition their nipples to create a chest that appears more masculine.

There are six types of transmasculine top surgeries:

• Periareolar
• Double incision
• Buttonhole
• Keyhole
• Minimal scar
• Inverted-T

The most common type of top surgery is double incision, says Schechter, as they give patients the best control of how their chest will look. Periaereolar surgery is also common, as it causes less scarring than a double incision surgery.

Here's what you need to know about these two common types, as well as how to prepare and recover from a top surgery procedure.

Periareolar top surgery

Periareolar top surgery involves removing fat and skin without repositioning the nipple. The nipple isn't removed, keeping it where it naturally is and retaining more nipple sensation after surgery.

Schechter says periareolar surgeries best suit individuals with smaller chest sizes, ranging from an A or B cup, who have good skin elasticity. Though this is influenced by genetic factors, you may have good skin elasticity if you:

• Don't smoke
• Haven't experienced extreme weight loss after having been at a heavier weight

Double incision top surgery

Double incision is a bit more invasive. Skin is removed in addition to breast tissue in this type of surgery. The surgeon removes the nipple from the body, cuts it to a smaller size, and reattaches it to create a more masculine chest. While Rays says it's a more involved surgery, patients will have more control over the appearance of their chest.

These surgeries can also include liposuction and chest contouring to create a more masculine appearance. Both types produce a flatter, more masculine appearing chest.

Schechter says that though these are the most common types of top surgeries, some non-binary or gender diverse individuals may elect to not do some parts of them for personal aesthetic reasons.

Questions to ask your doctor about top surgery

If you're considering top surgery, first ask your surgeon about the following:

• Can I see pictures of your previous work? Doing so gives you a sense of how your own chest will look after surgery.
• Have you worked with trans individuals before? Schechter says this is important because top surgery for trans individuals differs from traditional mastectomies, and so it's important for the surgeon to understand why transmasculine individuals want top surgery and the type of result they're looking for.
• Are you a member of WPATH? This stands for World Professional Association for Transgender Health. WPATH keeps medical practitioners up-to-date on the latest transgender health news, discourse, and surgery techniques. The organization's guidelines are designed to improve the health and wellbeing of trans individuals, and most surgeons who do top surgery end up joining WPATH, Ray says.
• What are the health risks I should consider for this procedure? Top surgery risks include bleeding, poor healing of the incision area, infection, loss of nipple sensation, and anesthesia complications. You could experience more risks based on your current and past health history, so discuss what risks could occur with your doctor.
• How much will the procedure cost? This can vary depending on your surgeon and insurance coverage. Read on to learn more about average costs.

How much top surgery costs

Schechter says the typical cost of top surgery is about $6,000 to $12,000, though it can be as low as $3,500. According to Ray, this can depend on:

• Whether it's covered by insurance
• Which surgeon you are using
• The location of the surgery
• The type of top surgery you are having

For example, periareolar tends to cost less than double incision, since the former is less invasive.

Health insurance increasingly covers top surgery, Ray says, estimating that they're now 90% covered by insurance. Top surgery is considered a reconstructive surgery — like with plastic surgery — and should thus be covered by your insurance.

You can see whether private or state health insurance either explicitly does, doesn't, or has no policy regarding transgender healthcare services on LGBT Map. The Human Rights Campaign also has a list of major private insurance companies that offer transition-related coverage.

You should call a surgeon's office to see if they accept your insurance, as it varies from surgeon to surgeon. For more information on organizations that help fund top surgery, visit the California-based Trans Health Consulting website.

How to prepare for top surgery

If you decide to undergo top surgery, you should make sure you take care of several steps in the weeks leading up to the procedure:

• Don't smoke. Schechter says to stop smoking at least six weeks before top surgery, because if you smoke, it can lengthen the healing process. He says the same is true for secondhand smoke. "If you live with someone who's a heavy smoker, tell them to smoke outside the house," Schechter says.
• Avoid taking medication that thins the blood. Aspirin and other blood thinners increase the risk of excessive blood loss during surgery.
• Plan to take time away from school or work. Students or those with a desk job need about one to two weeks to heal from their surgery. People with more physically intensive jobs, or jobs that require you to hold heavy items, may need four to six weeks off.
• Secure lodging and assistance immediately after the surgery. You'll have limited mobility after surgery. Having someone assist you with eating food, changing clothes, and addressing your surgery wounds can help make for a smooth recovery.
• Set up your recovery area. You want to take it easy in the first few days after surgery. If you're mostly going to stay in bed, place your electronics and chargers on a nearby table, along with bottles of water and books. Have some pillows to place under your back, too, as you can't sleep on your side or stomach for a few weeks after surgery.
• Stock up on food or medication you may need. You can't drive for at least two days after surgery, so be sure to have everything you need where you're recovering.

How to recover from top surgery

After top surgery, your torso will be wrapped in a compression binder. The garment prevents bruising, swelling, and fluid accumulation at the surgery site, which can impact the chest contouring. It's typically worn for three to six weeks after surgery.

The surgeon will also install drainage tubes (colloquially called "drains") for those who had double incision or periareolar surgery, as they'll remove any excess fluid accumulating at the surgery site. Not everyone who has top surgery will have drains for surgery — it's up to the surgeon's discretion.

You can only move your arms at the elbow post-op, as moving your arms too much can cause fluid to accumulate in the surgery area, Schechter says. Someone should help change your bandages and apply antibiotics around the incision in the days after surgery.

Don't smoke for the first three weeks after surgery, as smoking shrinks your capillaries and could slow down the healing process. Avoid drinking alcohol, too, as it can also hinder the healing process.

If your nipples were grafted, meaning they were removed then sutured onto chest skin, it's common for them to become scabbed or flaky after surgery, Schechter says. Your chest, and especially nipples, will lose sensation after surgery, and it could take years for the sensation to return. If sensation does return, it will feel more like a light touch comparable to stroking the back of your hand, Schechter says. The nipple also won't get hard.

For about six months after the surgery, both Schechter and Ray say to avoid exposing your chest to direct sunlight. The sun can darken any scars. Your skin is also more prone to sunburns since it's lost sensation and you can't feel if it's burning or not.

Potential side effects to watch out for

You should call your doctor if you experience any of the following symptoms after surgery, particularly in the chest area:

• Excessive swelling
• Pain
• Redness
• Infection or pus
• Bleeding
• Fever

The probability of experiencing a serious complication from top surgery is less than half of 1%, according to the Gender Confirmation Center. But if you experience any of the following symptoms above, it could be the sign of infection at the incision site. Bleeding can stem from a broken blood vessel leaking blood into the incision area — which can cause asymmetry or infection. But the risk of infection is below 1%, as well.

Scarring is normal after this type of surgery, Ray says, but your surgeon can give you silicone strips to place over the incision area to reduce scarring.

Ray also notes that your chest may be slightly uneven after surgery. "Making one side of the chest be a mirror image of the other can be very challenging," he says. Sometimes, revision surgeries to address asymmetry may be necessary.

Takeaways

Both Ray and Schechter say top surgery is a safe and effective procedure for properly selected individuals. WPATH recommends people who wish to undergo top surgery:

• Live in their preferred gender for a year before undergoing surgery.
• Have persistent, well-documented gender dysphoria. This can be noted in a letter from a mental health professional acknowledging your gender dysphoria.
• Be old enough to legally obtain the surgery in your country.

With the various ways people experience gender, though, not all of these criteria are always necessary. Overall, the best way to achieve the right outcome for you is to find a medical professional you trust, and discuss what you're hoping to gain from top surgery and how you want to go about it.

Related articles from Health Reference:

• Hormone microdosing is an option for trans people who want slower, gradual change to their bodies — here's how it works and the risks involved
• How to bind your chest safely, according to experts
• The best gender-inclusive clothing
• How to reduce swelling after liposuction and speed up recovery
• Should I get liposuction? Here's how to know if its right for you