Gender-affirming top surgery, medically known as a bilateral subcutaneous mastectomy, creates a more masculine chest contour. This procedure is a foundational step for many transmasculine and non-binary individuals, aligning their physical appearance with their gender identity. Top surgery involves the permanent removal of internal tissues, including the mammary glands, to achieve a flat aesthetic. The mammary glands are the main biological components that give the chest its shape and volume. This article explains precisely what tissues are removed, how surgical technique affects the extent of removal, and the long-term health implications.
The Anatomical Components Removed
Top surgery is fundamentally an excision procedure targeting the entire internal structure of the breast. The anatomical components removed include the glandular tissue, which is the network of ducts and lobules responsible for milk production. Surgeons aim for a near-complete removal of this parenchyma to ensure the resulting chest is flat and firm.
The procedure also removes a significant amount of surrounding adipose tissue, or fat, which contributes to the overall volume and shape of the chest. This comprehensive removal eliminates the projection associated with breast tissue and creates a masculine chest wall contour. For many patients, the removal of excess skin is also required so the remaining skin lies flat against the pectoral muscles.
The surgical specimen, consisting of glandular tissue, fat, and excess skin, is entirely removed during the operation. This process transforms the chest’s anatomy into a flatter, male-like chest wall. This is what distinguishes the procedure from a simple breast reduction, which leaves a larger portion of the glandular tissue intact. The ultimate goal is the creation of a definitive, masculine chest silhouette.
Surgical Techniques and Glandular Tissue Preservation
The extent of glandular tissue removal depends on the specific surgical technique employed, which is chosen based on the patient’s chest size and skin elasticity. For individuals with larger chests or significant skin laxity, the Double Incision (DI) mastectomy is the most common approach. This technique uses horizontal incisions, allowing the surgeon direct, wide access to the chest wall.
The DI method facilitates the most thorough excision of glandular and fatty tissue, resulting in a maximally flat chest contour. This technique allows for aggressive removal of the mammary gland and necessary excess skin. Complete removal of the tissue mass enables the creation of a defined, masculine chest crease below the pectoral muscles.
Alternatively, techniques like Keyhole or Peri-areolar surgery are reserved for patients with very small chests and excellent skin elasticity. These methods use a small incision around the areola to remove the glandular tissue. Although the goal is near-total removal, the limited visibility means the surgeon must tunnel and excise the tissue carefully.
Due to this constrained approach, smaller-incision techniques may sometimes leave a minimal amount of glandular tissue closer to the chest wall or under the areola. The surgeon must balance the goal of maximal flatness with preserving the skin and nipple stalk, which is necessary to avoid larger scars and maintain sensation. The choice of technique is a compromise between minimal scarring and the extent of tissue removal.
Long-Term Health Monitoring After Gland Removal
Despite the near-total removal of the mammary gland, a small amount of glandular tissue may remain along the chest wall or in the subcutaneous tissue surrounding the areola. This residual tissue is often necessary to ensure the viability and blood supply to the skin and the nipple-areola complex. Because some tissue remains, the risk of developing breast cancer is significantly reduced compared to pre-operative risk, but it is not entirely eliminated.
Top surgery reduces breast cancer risk by over 95%, bringing the risk profile closer to that of a cisgender male. Post-operative monitoring shifts away from routine screening procedures like mammograms, which are often no longer possible due to the lack of sufficient tissue. Patients are encouraged to perform regular self-examinations of the chest wall.
Any new lump, thickening, or change in the chest area should be promptly evaluated by a medical professional. For individuals with a strong family history of breast cancer or genetic risk factors, specialized screening protocols may be recommended. These protocols include targeted ultrasound or magnetic resonance imaging (MRI).