Top Surgery: Types, Prerequisites, Cost, Recovery, And More

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Medical News TodaySubscribeWhat to know about top surgery

Medically reviewed by Catherine Hannan, M.D. — Written by Beth Sissons on April 25, 2022

Purpose
Requirements
Consultation
Transmasculine top surgery
Transfeminine top surgery
Preparation
Recovery
Risks
Cost
Choosing a surgeon
Doctors and support
FAQs
Summary

Some transgender or nonbinary people have top surgery to alter the appearance of their chest to align with their gender identity.

Transgender men and nonbinary people may have transmasculine top surgery. This removes breast or chest tissue to give the chest a masculine or nonbinary appearance.

A medical name for this procedure is a “subcutaneous mastectomy.”

Transgender women and nonbinary people may have a procedure to increase the size and shape of their breasts with implants or lipofilling. A medical name for this procedure is breast augmentation.

This article looks at top surgery in more detail, including who might have it and what it may involve.

What is the purpose?

A transgender man after top surgery. — Adam Gray/Future Publishing via Getty Images

Top surgery can alter the appearance of the chest to align with a person’s gender identity.

People may have top surgery to help treat gender dysphoria. Gender dysphoria is a psychological condition. People with this condition experience distress due to the difference between their sex assigned at birth and their gender identity.

Transgender men or nonbinary people may have top surgery to remove breast tissue.

Transgender women or nonbinary people may have top surgery to increase the size of the breasts and otherwise alter their shape.

Requirements for top surgery

The World Professional Association for Transgender Health (WPATH) Standards of Care outline certain criteria for top surgery. They say this is to help protect the health and well-being of potential candidates.

For people to undergo top surgery, according to WPATH, they must meet these criteria:

The person has persistent gender dysphoria that has been well-documented by a qualified mental health professional.
They are able to make a fully informed decision and provide their consent for the treatment.
They are the age of majority in their country — otherwise the standards of care for children and adolescents apply.
Any preexisting, significant medical or mental health conditions are under reasonable control.

Hormone therapy is not a prerequisite for top surgery to remove breast tissue.

For people undergoing transfeminine top surgery, WPATH recommends having feminizing hormone therapy, or estrogen hormone therapy, for at least 1 year before the surgery, though this is not a set criteria. The aim is to help promote breast growth, and it may lead to better outcomes.

John Hopkins Medicine advises people who are considering top surgery to read through the WPATH Standards of Care and look for healthcare facilities that reference those standards.

A person may have an initial interview with a clinical specialist to discuss their medical history and any requirements. The next step may be a discussion with the surgeon to talk through the specifics of the procedure.

What to expect at a consultation

Before top surgery, a person has a consultation with their surgeon. The surgeon explains the procedures available and the advantages and disadvantages of different techniques, including the risks.

During the consultation, a person can expect to discuss:

their transition process
their surgical goals
any medical conditions, including drug allergies
any current medications or other treatments
any previous surgeries

The surgeon:

evaluates the person’s general health
examines their chest and breasts, taking measurements and examining the skin
takes photographs
discusses surgical options and outcomes

At a future consultation, a person can discuss their before and after photos with the surgeon.

People may find it helpful to speak with others who have undergone top surgery or to read firsthand accounts.

Transmasculine or female-to-nonbinary top surgery

The American Society of Plastic Surgeons (ASPS) explains that transmasculine, or female-to-nonbinary, top surgery may involve these steps:

The person receives a general anesthetic or intravenous sedative.
The surgeon removes breast tissue and sometimes excess skin from the chest.
They reposition any remaining tissue to create a masculine shape to the chest.
In some cases, the surgeon may reposition or reduce the size of the nipple and areola.

There are different techniques, and the surgeon discusses each in detail with the person beforehand.

The chosen approach may depend on:

the amount of breast or chest tissue
the person’s desire for nipple sensation
the amount of excess skin

Different techniques include:

Surgery type	Definition
Keyhole	This involves making a small incision around the nipples to remove excess tissue and reduce the nipples’ size.
Peri-areolar	Peri-areolar top surgery may be suitable for people with smaller chests. A surgeon makes two circular incisions around the areolas to remove breast tissue, before resizing and replacing the areolas.
Minimal scar	This less invasive technique may suit people who require minimal breast tissue removal. A surgeon makes a small incision at the side of the chest, and around part of each areola. They may then use liposuction to remove fat from the chest.
Double incision	This involves removing tissue from two incisions across the left and right sides of the chest. The incisions highlight the natural pectoral muscles.
Inverted T	This method is similar to the double incision technique, but the surgeon makes an additional incision from the bottom of the areola to the incision along the pectoral muscle. This allows the surgeon to reduce each nipple’s size and reposition it without severing the nipple stalk. In this case, the person still has nipple sensation.
Buttonhole technique	This involves making two incisions beneath the breasts and one around each areola. This allows the surgeon to remove breast tissue and excess skin.On each side, the surgeon then makes a circular incision for the new placement of the areola. They then move the nipple and areola into the new opening and secure them in place.

Transfeminine or male-to-nonbinary top surgery

Transfeminine, or male-to-nonbinary, top surgery usually involves having breast implants.

The procedure may involve these steps:

The person receives an intravenous sedative or a general anesthetic.
The surgeon makes the incisions and places the implants in the chest.
They close the incisions, and the person later recovers consciousness.

At an earlier consultation, the person and their surgeon discuss which type of implants are most suitable.

Alternately, the surgeon may use a technique called lipofilling. This involves having liposuction. Then, the surgeon moves the fat from elsewhere in the body into into the breasts to increase their size and otherwise change their shape.

Preparation for surgery

To prepare for the surgery, a person needs to:

have a letter of recommendation from their therapist
stop smoking, if this applies
avoid aspirin, herbal supplements, and anti-inflammatory drugs
undergo testing and medical evaluations

Recovery and aftercare

It is important to follow the surgeon’s aftercare instructions.

For transmasculine top surgery, this may include:

wearing support bandages around the chest to help reduce swelling and support the chest
having a temporary tube attached to the chest to drain excess fluid
attending any follow-up appointments, as necessary

It may take several weeks for the swelling to reduce and the chest to be the person’s desired shape.

For transfeminine top surgery, aftercare may include:

wearing bandages or a support bra to reduce swelling and support healing
attending any follow-up appointments, as necessary

It may take several weeks for the swelling to reduce and the breasts to reach the person’s desired shape.

Risks

The surgeon and other healthcare professionals should describe the risks of top surgery, which can include:

bleeding
bruising
infection
loss of nipple sensation
poor wound healing

Transmasculine surgery can also lead to the loss of the nipple and areola.

Additional risks of transfeminine surgery can include:

an implant leak
capsular contracture, the formation of scar tissue around an implant
the need to replace or remove the implants in the future
anaplastic large cell lymphoma, a rare type of non-Hodgkin lymphoma

Cost and financial aid

The cost of top surgery may vary, depending on the facility, its location, and the experience of the surgeon.

Other factors that affect the cost include:

the surgeon’s fee
the anesthesia fees
post-surgery garments
tests and X-rays
prescriptions

Some insurance providers may cover some of the costs of transmasculine top surgery and some of the costs of transfeminine top surgery.

People in the United States can learn about what to look for in insurance coverage here.

Choosing a plastic surgeon

People can find plastic surgeons who are board-certified members of the ASPS here.

Also, some surgeons are members of WPATH. This often means that they have undergone additional training in transgender medical care. A person can find surgeons who are members of WPATH here.

Transgender-friendly doctors and support

Organizations offering services, support, and resources for transgender and nonbinary people include:

John Hopkins Medicine Center for Transgender Health
University of California, San Francisco Transgender Care
National Center for Transgender Equality
Transgender Health Resources from the American Academy of Family Physicians
Transbucket, which provides information about surgical transitions
The Trevor Project, which offers an online support network for young LGBTQIA+ people
the Trans Lifeline resource page

Frequently asked questions

Below are answers to common questions about top surgery.

Is top surgery painful?

People may experience discomfort in the first few days after the surgery. People may be able to return to regular activities within 4–5 days.

However, it may be necessary to limit some physical activities to allow for optimal healing.

Is top surgery permanent?

As WPATH notes, top surgeries are irreversible. Full consent and understanding of the procedure is crucial.

How will top surgery change nipple sensation?

With the removal of breast tissue, people may lose some sensation in their chest. Over time, some nipple and chest sensation may return.

Loss of nipple sensation with breast implants is less common.

Summary

Some people have top surgery to alter the appearance of their chest so that it aligns with their gender identity.

Transfeminine, or male-to-nonbinary, top surgery involves changing the shape of the breasts with implants or lipofilling.

Transmasculine, or female-to-nonbinary, surgery involves removing breast or chest tissue.

Before a person has top surgery, they need to meet a set of requirements, such as having well-documented and persistent gender dysphoria.

People can consult transgender-friendly healthcare professionals to discuss surgery options and the desired outcomes.

LGBTQIA+ resources

To discover more evidence-based health information and resources for LGBTQIA+ individuals, visit our dedicated hub.

Surgery
Cosmetic Medicine / Plastic Surgery
LGBTQIA+

How we reviewed this article:

SourcesMedical News Today has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical journals and associations. We only use quality, credible sources to ensure content accuracy and integrity. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

FAQ: Chest masculinization. (n.d.).https://www.hopkinsmedicine.org/center-transgender-health/services-appointments/faq/top-surgery
Is there a loss of nipple sensation if you get implants? (n.d.).https://www1.plasticsurgery.org/psconnect/askasurgeon/detail.aspx?thread=843
Preparing for gender affirmation surgery: Ask the experts. (n.d.).https://www.hopkinsmedicine.org/health/wellness-and-prevention/preparing-for-gender-affirmation-surgery-ask-the-experts
Standards of care for the health of transsexual, transgender, and gender-nonconforming people. (2012).https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English2012.pdf?_t=1613669341
Top surgery. (n.d.).https://www.transhub.org.au/top-surgery
Transfeminine top surgery. (n.d.).https://www.plasticsurgery.org/reconstructive-procedures/transfeminine-top-surgery
Transmasculine top surgery. (n.d.). https://www.plasticsurgery.org/reconstructive-procedures/transmasculine-top-surgery
What is gender dysphoria? (2020).https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

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Medically reviewed by Catherine Hannan, M.D. — Written by Beth Sissons on April 25, 2022

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