Top surgery, commonly known as gender-affirming chest surgery, involves procedures designed to remove or reshape breast tissue to create a chest contour that aligns with a person’s gender identity. For transmasculine and non-binary individuals, this typically involves a bilateral subcutaneous mastectomy to achieve a flatter, masculine-appearing chest. This surgical intervention is widely recognized as a medically necessary component of comprehensive gender-affirming care, primarily aimed at alleviating chest-related gender dysphoria. The specific technique used is determined by the patient’s existing chest anatomy, including tissue amount and skin elasticity, as well as the desired aesthetic outcome.
Common Surgical Techniques
The choice of surgical approach depends primarily on the patient’s chest size and the elasticity of the skin. For individuals with larger chests or significant skin laxity, the double incision mastectomy with free nipple grafts is the most frequently performed technique. This method involves two horizontal incisions, one above and one below where the pectoral muscle will be contoured, allowing for maximal tissue removal and the excision of excess skin. The nipple-areola complex is completely removed, resized, shaped, and then reattached as a skin graft in a position appropriate for a masculine chest contour.
For those with smaller chests and good skin elasticity, a keyhole or periareolar technique may be an option. The keyhole procedure uses a small incision along the bottom edge of the areola to remove the breast tissue. The periareolar technique involves a circular incision around the perimeter of the areola, with a second, larger circle of skin removed to tighten the skin envelope. These minimal-scarring methods often preserve more nerve connections, offering a greater chance of retaining sensation in the nipple-areola complex.
The buttonhole or inverted-T methods are designed to remove significant tissue and excess skin while keeping the nipple and areola attached to an underlying stalk of tissue. This attachment maintains the blood supply and nerve connections, increasing the likelihood of sensation preservation, but it may compromise the final degree of chest flatness. The surgeon will discuss the pros and cons of each technique, balancing the desired final contour against factors like scar placement and nipple sensation.
Eligibility and Preparation Requirements
Undergoing top surgery requires meeting certain medical and psychological prerequisites established by professional bodies like the World Professional Association for Transgender Health (WPATH). These guidelines, known as the Standards of Care, ensure that the procedure is appropriate and safe for the patient. A diagnosis of persistent, well-documented gender dysphoria is a core requirement for nearly all patients seeking the procedure.
The process mandates an evaluation by a qualified mental health professional who must provide a letter of readiness for surgery. This letter confirms that the patient has the capacity to give fully informed consent, that any significant mental health concerns are reasonably well-controlled, and that the patient understands the permanence of the surgery. Insurance providers commonly require one such letter for chest procedures, though some policies may ask for two.
Although hormone therapy is often part of a gender transition, being on testosterone is generally not a strict prerequisite for chest masculinization surgery. The decision to pursue hormone therapy is separate from surgical qualification, though some surgeons may recommend it to increase muscle definition, enhancing the final aesthetic result. Before the surgery date, the surgeon will require medical clearances, including standard blood tests and often a smoking cessation period of several weeks to months to reduce the risk of wound healing complications.
Immediate Post-Surgical Care
The immediate period following top surgery is focused on managing swelling, pain, and preventing fluid accumulation. Patients wake up wearing a compression garment, or binder, which is applied directly after the procedure to minimize post-operative swelling and encourage the newly contoured skin to adhere smoothly to the chest wall. This garment is typically worn continuously for the first four to six weeks, only being removed for showering.
Surgical drains, usually small, flexible tubes called Jackson-Pratt drains, are often placed under the skin to remove excess fluid that naturally collects in the surgical space. These drains prevent the formation of seromas (fluid pockets) or hematomas (blood clots), which can complicate healing and affect the final outcome. The drains are generally removed by the surgeon in the first week or two post-operation, once the fluid output drops consistently below a specific volume, often less than 30 cubic centimeters per 24 hours.
Pain following the procedure is typically managed with prescribed medications for the first week, after which many patients transition to over-the-counter pain relievers. Activity restrictions are significant in the first six weeks, requiring patients to avoid lifting their arms above shoulder height, carrying objects heavier than five to ten pounds, and engaging in strenuous exercise. Most individuals can return to desk work or light activities within one to two weeks, but full physical activity is usually restricted until at least six weeks, allowing the internal surgical sites to fully heal.