Gender-affirming FTM (Female-to-Male) Top Surgery, also known as a bilateral subcutaneous mastectomy, reconstructs the chest into a traditionally masculine contour. The primary goal is the removal of glandular and fatty tissue. For many individuals, this physical change is part of their journey to align their physical appearance with their gender identity. The resulting flatter chest shape significantly reduces gender dysphoria and eliminates the need for restrictive chest binding. This process involves careful planning and execution to achieve an aesthetically pleasing and natural result.
Primary Surgical Techniques
The choice of surgical technique depends heavily on the patient’s chest size, the amount of excess skin, and skin elasticity. Surgeons aim to remove tissue, sculpt the chest wall, and minimize scarring while achieving a masculine aesthetic. The two most common methods are the Double Incision Mastectomy and the Keyhole/Periareolar technique, each suited for different body types.
The Double Incision (DI) Mastectomy is the most frequently performed technique, particularly for individuals with medium to large chests or significant skin laxity. This method involves creating two horizontal incisions, typically placed along the bottom edge of the pectoral muscle. This allows for the removal of a large volume of tissue and excess skin to create a flat chest.
Double Incision Mastectomy
Because the nipple-areola complex (NAC) cannot be preserved when a large amount of skin is removed, the DI technique requires free nipple grafts. The surgeon removes the nipples and areolas entirely, reduces their size, and then reattaches them as skin grafts in a higher, masculine position on the chest. This approach offers the greatest flexibility in reshaping the chest. The resulting scars are permanent horizontal lines, often strategically placed to follow the contours of the pectoral muscles.
Keyhole and Periareolar Techniques
Alternatively, the Keyhole and Periareolar techniques are less invasive options reserved for individuals with small chest sizes and good skin elasticity. For the Keyhole procedure, the surgeon makes a single small incision along the lower border of the areola. Through this minimal opening, the underlying breast tissue is removed.
The Periareolar technique, sometimes called the “donut” incision, involves a circular incision around the entire areola. This allows for the removal of a slightly larger volume of tissue and permits the reduction of the areola’s diameter. A major advantage of both methods is that they often preserve the connection between the nipple and the underlying nerves and blood supply, potentially retaining more sensation. While scarring is generally limited to the areola border, these techniques are not suitable for patients needing significant skin removal or major nipple repositioning. Less common techniques, such as the Inverted-T or Fishmouth incision, may be used when a patient’s anatomy falls between the criteria for the primary methods.
Pre-Surgical Requirements and Consultation
The journey toward Top Surgery begins with a comprehensive consultation process that includes meeting specific medical and psychological preparedness standards. These requirements are often based on guidelines established by the World Professional Association for Transgender Health (WPATH) in their Standards of Care. The purpose of these prerequisites is to ensure the procedure is medically appropriate and that the patient is fully ready for this permanent step.
A foundational requirement is the submission of one or sometimes two letters from qualified mental health professionals. These letters must confirm a diagnosis of gender dysphoria and attest that the patient has the mental capacity to provide informed consent for the surgery. The mental health professional also assesses the patient’s psychosocial stability, ensuring any co-existing mental health concerns are well-managed before the operation.
The consultation with the plastic surgeon involves a detailed physical examination to determine which surgical technique is best suited for the patient’s anatomy and aesthetic goals. The surgeon evaluates chest size, skin elasticity, and discusses scar placement and final nipple positioning. The surgeon also reviews the patient’s general health history, including any medications or hormone therapy.
Hormone Therapy and Preparation
Patients on testosterone therapy are usually advised to continue their regimen, as this hormone can help increase chest muscle definition, contributing to a more masculine post-operative appearance. However, some surgeons may temporarily require the cessation of certain hormone medications before surgery to minimize the risk of blood clots. Routine pre-operative blood work is conducted to screen for any underlying health issues and confirm fitness for general anesthesia.
The Recovery Experience
The immediate post-operative period focuses on healing, pain control, and minimizing complications. Patients wake up wearing a compression garment, which reduces swelling and helps the skin adhere to the new chest contour. Pain is managed with prescribed medication, though many find over-the-counter relievers sufficient after the first few days.
Most surgical techniques require the temporary placement of small, flexible drains beneath the skin to collect excess fluid and blood, preventing seroma or hematoma. These drains are usually removed by the surgeon during the first post-operative appointment, typically within a week. Patients are restricted from raising their arms above shoulder level and from lifting anything heavier than ten pounds for the first few weeks to protect the incision lines.
The overall recovery time varies, but most patients can return to a desk job or light activities within two to three weeks. Strenuous exercise, heavy lifting, and activities that stress the chest muscles are generally restricted for six to eight weeks. Once the incisions are fully closed, usually around three weeks post-surgery, patients can begin scar management techniques. This often involves gently massaging the scars and applying silicone sheets or gel, which helps to flatten and fade the incision lines over the following months.