“There are a few options for gender-affirming mastectomy procedures, depending on your current anatomy and your goals for the procedure,” explains Dr. Patricia McGuire, a plastic surgeon in St. Louis. You can expect repositioning, reshaping, and possibly liposuction to help create your new contours.Â
"The creation of a proper masculine appearance for transmen involves much more than 'standard' mastectomies (as for cancer patients), breast reductions (which reduce the size of the breasts), or even male breast reduction surgery (aka gynecomastia surgery)," explains Dr. Tholen.
For instance, typically, the higher, more centrally placed female nipple areola position doesn't align with the traditional masculine aesthetic, which requires lower, more lateral placement.
Your natural breast size will play a role in your surgeon's technique: people with naturally small breasts usually need little to no skin removed during their surgery, while those with larger or more drooping breasts usually require removal of excess skin and fat.
The procedure typically takes 3–4 hours and is performed under general anesthesia, so you'll be asleep during the procedure. Surgical options include:Â
- Double incision: This is one of the more common top surgery techniques. “In this procedure, the breast [tissue] is removed and the nipple and areola, which are usually removed and reduced in size to give a male appearance, are then reattached as a skin graft,” says Dr. McGuire. With such free nipple grafts, you may have limited sensation in your nipples after you’ve healed. Â
- Keyhole procedure: The nipples and areolas remain attached to the underlying tissue to maintain the blood supply, which leaves sensation intact. This technique is limited to patients with small breasts and minimal sagging. Â
- Periareolar procedure: Your surgeon will make an incision around the border of each areola, then create another larger circular incision, through which a ring of skin and the breast tissue will be removed. Nipple sensation remains. This technique is also limited to smaller-chested patients with good skin elasticity.Â
- Inverted T: This technique is similar to the double incision and works well for medium to large breasts. The skin on the chest is opened along two horizontal incisions, at the top and bottom of the pectoral muscle. (The muscle itself is not touched.) The skin is pulled back, and breast tissue is removed. Additional liposuction may be performed to adjust chest contouring. Â
- Minimal scar: This procedure involves small incisions on the sides of the chest and partly around the areolas. Recommended for small chests, it leaves nearly invisible scars and retains sensation in the nipple.Â
- Buttonhole: This technique removes larger amounts of breast tissue and skin than the keyhole and periareolar methods, meaning it’s a good choice for medium and large chests. Nipples are resized and repositioned without additional incisions, so it preserves pigment and sensitivity.Â
If you’re BRCA positive, it's safest to have all of your breast tissue removed, to significantly reduce your risk of developing breast cancer. (If the disease runs in your family and you haven’t yet been tested for the BRCA gene, your doctor may recommend doing this before your surgery.)
When it comes to choosing a surgical technique, Dr. Tholen says it's important to understand how your own anatomy comes into play. Every patients wants the fewest incisions and least noticeable scars, but "double-incision top surgery is always required with breasts above a certain size, and these sizes will differ with age, skin thickness, skin elasticity, and healing," he says. He cautions that undergoing the wrong type of surgical procedure could end with you asking, "how can this be fixed?"
RealSelf Tip: While it’s not required to undergo hormone therapy before top surgery, many transgender individuals do. Recent studies also say it’s OK to continue hormone therapies during surgery. Talk with your health care team about what's best for you.
