Top surgery is not considered a high-risk procedure. It carries complication rates similar to other common chest surgeries like breast reduction, with an overall complication rate around 12% and most of those complications being minor and treatable. Serious events like blood clots occur in less than 1% of patients. That said, every surgery carries some degree of risk, and understanding the specific ones for this procedure helps you make an informed decision.
Overall Complication Rates
The most comprehensive data on masculinizing chest surgery shows an overall complication rate of about 12%. The majority of these are issues that resolve on their own or with minor treatment. Between 4% and 9% of patients need a return to the operating room shortly after the initial procedure, usually to drain a blood collection or treat an infection. For context, these numbers are comparable to those seen in cosmetic breast reduction, which is one of the most commonly performed chest surgeries.
Life-threatening complications are rare. In a study of over 1,700 patients who underwent gender-affirming surgeries, blood clots (deep vein thrombosis or pulmonary embolism) occurred in just 0.7% of those who had masculinizing procedures within 90 days of surgery. Fatal outcomes from top surgery specifically are not tracked in large enough numbers to produce a reliable mortality rate, which itself reflects how uncommon death is from this procedure.
The Most Common Complications
Hematoma, a pocket of blood that collects under the skin, is the complication surgeons deal with most often. It occurs in roughly 1 to 2% of cases in the general population undergoing similar surgeries, though rates as high as 5 to 11% have been reported in certain subgroups of transgender patients. Hematomas are typically drained in a brief follow-up procedure and rarely cause lasting problems.
Other common but minor complications from a large 15-year surgical review of 679 patients include:
- Seroma (fluid buildup under the skin): 6.5%
- Infection: 3.7%
- Hypertrophic scarring (raised, thickened scars): 2.8%
- Wound separation: 0.4%
Most of these are managed with drainage, antibiotics, or scar treatment. They’re uncomfortable and can slow recovery, but they don’t typically affect the final result in a significant way.
Nipple Graft Outcomes
If your surgery involves a free nipple graft (the double incision technique), one natural concern is whether the grafted nipple will survive. The data here is reassuring. In the same 679-patient study, partial nipple tissue loss occurred in only 0.5% of free nipple graft cases. Total nipple loss did not occur in a single patient. Keyhole procedures, which don’t detach the nipple, had zero cases of any nipple complications.
Sensation is a different story. Loss of nipple feeling is extremely common after double incision surgery. One study of 95 patients found that 100% reported loss of nipple sensation following the procedure. Some feeling may return over months or years, but significant permanent numbness is typical with this technique. Newer approaches involving nerve reconnection during surgery are being explored, but reduced chest sensation is something to expect and plan for emotionally.
Anesthesia and Hormone-Related Risks
Top surgery is performed under general anesthesia, which carries its own small set of risks. For transgender patients, a few specific considerations come into play. Hormone therapy can increase blood’s tendency to clot, which raises the baseline risk of clots, stroke, or heart-related events slightly. This is one reason many surgeons ask patients to pause hormones for a period before surgery.
Patients on hormone therapy also experience higher rates of nausea after anesthesia. If you’ve used a chest binder for an extended time, your lung function may be mildly restricted, which your anesthesiologist should know about. These aren’t dealbreakers, but they’re reasons your surgical team will ask detailed questions about your medical history beforehand.
Factors That Increase Your Risk
Smoking is the single most impactful modifiable risk factor. Current smokers have significantly higher rates of wound separation, infection, and tissue death compared to non-smokers, and smoking independently predicts complications even after accounting for other factors like weight and diabetes. Most surgeons require you to quit smoking at least several weeks before surgery, and this is one requirement worth taking seriously.
Body weight also plays a role. Many surgical programs set BMI thresholds, commonly requiring a BMI below 30, 33, or 35 depending on the program, or evaluating patients with higher BMIs on a case-by-case basis. Higher BMI is associated with more difficult wound healing and greater surgical complexity, though the evidence for specific cutoff numbers is debated in the medical literature.
Surgeon experience matters too. A study on revision rates in cosmetic plastic surgery found that patients whose initial surgery involved a resident (a surgeon in training) were over seven times more likely to need a revision compared to those operated on exclusively by an attending surgeon. The revision rate was 3.6% for attending-only cases versus 22.2% when residents were involved. Choosing an experienced surgeon with a strong track record in this specific procedure can meaningfully reduce your chances of needing additional surgery.
Revisions and Long-Term Satisfaction
Some patients do need a second procedure to refine results. The most common reason for revision is scar management, not a medical complication. Scar revision accounted for over half of all revision procedures in one large study. This reflects the reality that scars from double incision surgery are visible and their final appearance depends on individual healing, skin type, and surgical technique. Some amount of scar treatment (silicone sheets, steroid injections, or minor scar revision) is a normal part of the process for many patients.
Despite these physical trade-offs, long-term psychological outcomes are overwhelmingly positive. A meta-analysis pooling nearly 8,000 transgender patients who underwent gender-affirming surgeries found that the overall regret rate was just 1%. For transmasculine surgeries specifically, regret was less than 1%. This makes top surgery one of the lowest-regret surgical procedures in all of medicine, comparable to or better than rates reported for common elective procedures like knee replacement or cosmetic surgery.