What's my Best Surgical Option for Gynecomastia/FTM Top Surgery? (photo)

Thanks for including photos, as they are critical in giving you advice specific to your anatomy. Keyhole (periareolar) incisions leave nearly imperceptible scars, so of course every trans patient would prefer essentially "invisible" scar mastectomies. However, to create the most natural, normal male chest appearance requires the areolas be much smaller than your present areola size, the nipples themselves to be much smaller and less protruding, not to mention having the glandular tissue removed in a way that creates a masculine pec area without loose hanging skin.Even after weight loss, your breasts still have excess skin and significant ptosis (droop), which would be retained if only the gland were removed via keyhole incision, whether this was done with lasers or any other method. So you therefore require skin-reducing mastectomies, nipple reduction, areolar reduction, and placement of your appropriately-sized nipple areola complexes as full thickness skin grafts in the normal masculine position (lower and more lateral than central and higher female nipple position).This is a common F-M transgender operation that I have performed for over two decades, and would require about 4 hours of (outpatient) surgery, drains for a week to 10 days, skin graft dressings and care while the grafts become durable for about 3 weeks, and reduced strenuous activity for 3-4 weeks. Scars usually fade nicely after 6-12 months, and if situated correctly, simulate a natural Inferior pec line reasonably well. Someone your size may require touch-up surgery to minimize dog-ears laterally, but this is individual, and can usually be done (if needed) under a small local anesthesia office procedure.For examples of some of my top surgery results, both skin-reducing and keyhole, click on the web reference link below. Best wishes! Dr. Tholen

Thank you for sharing.
"Top surgery" is a broad term that can have varied meanings, especially when discussing gender-affirming surgery. Some individuals want a smaller breast mound, and some want a chest masculinizing procedure. Below, I will focus on a chest masculinizing procedure.
A key goal of chest masculinizing top surgery is to effectively remove excess skin and reshape the chest. Due to the presence of extra skin, a periareolar approach is not the ideal choice for best contour; this method is generally best suited for individuals with less skin excess and smaller breast volumes. Although some may desire minimal scarring and a quicker recovery, techniques like laser liposuction or the keyhole incision are not suitable for patients with significant breast tissue, drooping (ptosis), or enlarged areolas, as these options often result in suboptimal outcomes, such as residual tissue or poor chest contour.
In contrast, a double incision provides a more natural, masculine appearance, even with the trade-off of scars, which typically heal well over time. A chest masculinizing breast reduction ("top surgery") with double incision approach (and/or free nipple grafts and/or targeted nipple reinnervation for sensation) would be a more appropriate solution. This technique allows for the removal of a larger amount of skin and tissue, as well as better control over resizing and repositioning the areola. Liposuction should be combined with this procedure to achieve skin redraping and remove excess adipose, especially near the axillary area and lateral chest.
It is also important to consult with a qualified gender-affirming breast surgeon who can assess your goals and anatomy to determine the best technique for you.
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

Thank you for your question and for uploading your photos.   To give you correct answer you are not a candidate for laser lipo your result will be disastrous.   I understand you are desiring now down time and minimal  scarring.   But  the fact is that what you need is a mastectomy with nipple areola reduction and free graft and at the same time pectoral contouring with Vaser high def.   Most important make sure you do your research and that your Plastic Surgeon is Board Certified by the American Board Of Plastic Surgery.   Best of Luck

FTM Top Surgery can leave noticeable scars on the chest. Our office
specializes in Hidef Scar Protocols to help correct scars from FTM Top
Surgery; including Vbeam laser, fractional RF and Laser, scar modulation
RF, topical scar protocols that do not require surgery, and scar
subcision or excision. 
Best, 
Dr. Karamanoukian
Realself100 Surgeon

It's best to begin seeking a plastic surgeon with #board #certification and experience in this type of procedure. You should feel comfortable with your surgeon and his or her office staff. They should be open-minded regarding gender surgery. It’s important for your surgeon to have an aesthetic eye for body contouring, you should be comfortable with the surgical facility that your doctor uses and it should be certified. There are several methods used which depend upon the patient’s breast or chest #size before surgery. Considerations include the #laxity of skin, the #size of the #areola, the amount of #fat and recent weight #gain or weight #loss. The most common procedures which are described include the #periareola, #buttonhole, #double incision, and #anchor patterns. I often use #liposuction along with the double #incision for larger breasts, and, some variation for smaller breasts; depending upon the position of the areola. The female breast nipple and areola are often centered on the breast. However, the nipple and areola are lower and closer to the outside edge of the #pectoralis muscle in the male patient. Shaping the side of the chest may also be required and can be performed with #suctioning; along with contouring of the muscle, as noted above, to provide the best definition for the chest. Being each person varies, it’s important to be realistic about your goals and what is achievable. Your board-certified plastic surgeon will recommend the type best suited for you. The most important decision to be made before performing any surgical procedure is determining whether you are an ideal #candidate.

For FTM patients with larger breasts, the "double incision" is really the best option.  Anything else simply won't give you a masculine chest contour, and will likely either leave you with extra skin, residual breast tissue, or both.  Although the double incision leaves a scar, the trade-off is a much better contour and the freedom to do away with a binder.  In order to get a qualified, expert opinion on your surgical options and expectations visit a plastic surgeon certified by the American Board of Plastic Surgery.

Best of luck,Keith M. Blechman, MDNew York, NY

I appreciate your question.Given your size, you would probably need double incision mastectomy and nipple/areola grafting.Our office is set up to handle a lot of patients that travel in for surgery for our expertise.We can help set up recovery facilities, hotels and make the experience wonderful for you.Because of this you may even come by yourself.The best way to assess and give true advice would be an in-person exam.Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.best of luck!Dr Schwartz

The procedure of choice is definitely a Mastectomy with the free nipple graft technique. I suggest that you consult an experienced surgeon in this type of surgery. Results can be very satisfying and permanent. 

Although an exam would be needed your photos indicate that both skin reduction using a minimal scar technique and free nipple grafting is probably your best option. See below link on hint on selecting your surgeon

The best choice for FTM transition in this case would be double incision mastectomy with nipple graft.  You need to find a board certified plastic surgeon that specializes in the treatment of transgender patients to get the best results.