I want top surgery, but I want to keep my feeling in my nipples and don'tt want pancake nipples . What do I do?

"Top surgery" is the common lay term for transgender mastectomies in which female breasts are removed ("mastectomy" as a term means breast removal) and a masculine chest created.Breast tissue removal can, of course, be incomplete, but then again, how much "residual female breast" tissue do you want to keep? "Just enough, and not a bit more, to allow nipple sensation to remain." Because you want a masculine chest, not a "mostly masculine" or "partly feminine" pair of breasts to remain, even if nipple sensation is your almost favorite nerve, or right up there with number one!As I read my colleagues' answers, I am struck by how often the reply includes the caution to select a surgeon "experienced" in top surgery, but how few of these respondents tell the honest truth that nipple sensation is almost always lost with properly-performed transgender mastectomies. As in well over 97%!This makes me suspect that at least some of these respondents are themselves inexperienced in transgender mastectomies, and are simply performing Wise-pattern breast reductions (anchor incisions) and incomplete breast tissue removal as their version of true transgender mastectomies and chest masculinization.I say this not to be critical of these colleagues, or their esteemed plastic surgical professors, but the rather unfortunate truth is that the vast majority of properly and fully-trained plastic surgeons received little to NO instruction or experience in transgender patients (but of course lots of breast reductions, breast lifts, gynecomastia operations, and if general surgery tracked into plastics fellowship--mastectomies for cancer). That's what they know, that's what they were taught, so that's what they do now when confronted by this "new" class of transgender patients who want their female breasts transformed into as masculine a chest as possible.So, when faced with the potential of treating transmen who want their female breasts removed (NOT reduced, lifted, or operated-on anything like a female-type outcome), these plastic surgeons rely on their female breast reduction patterns and training, and simply apply that to transmen. We all know that a well-performed breast reduction (that preserves SOME breast tissue) will preserve nipple sensation about 85 to perhaps 90% of the time. But do you, as a transman, want an anchor pattern with centrally-placed areolas that are still too large and have a distinctly non-masculine large protruding (usually) papilla (the actual nipple in the center of the areola)? Or do you want a convincing chest masculinization? (Even if the sensation is lost.)Sensation is good, even great, but not at the expense of a feminine scar pattern, residual breast fullness, non-masculine nipple/areola aesthetics (size, protrusion, and position), and basically a very non-male appearance. IMHO, of course!Even keyhole mastectomies for transmen with small female breasts, elastic skin, and already-small nipple/areola complexes will require the removal of 99% of the actual gland, leaving only a small disc of breast tissue beneath the nipple/areola complex (NAC) for blood supply and to prevent abnormal and disfiguring adherence to the underlying pec musculature. When cis-males have breast gland beneath their chest skin and fat, they call this gynecomastia, and often request surgery to remove (even the small amounts of)breast tissue to leave a flat, masculine chest. Gynecomastia patients usually lose their nipple sensation (but it's not usually a man's favorite nerve), as do transmen undergoing keyhole top surgery. The more breast tissue that is allowed to remain, potentially the more likelihood that the sensory nerve (lateral 4th intercostal, plus sometimes branches of the 3rd and 5th) to the nipple/areola is preserved . . . and the less masculine the resultant chest is!Skin reducing mastectomies require removal of the nipple areola complex, papilla (nipple) reduction is some (many) cases, areola reduction to a masculine size, and after mastectomy skin flaps are closed to mimic a lower pec fold (NOT a female breast reduction, breast lift, or cancer mastectomy), grafting of the reduced-size and reduced-papilla NAC as a free skin graft to the appropriate masculine position. This yields complete numbness in 99+% of cases. Unless, of course, the surgeon is doing some sort of female-pattern, tissue-preserving, not very masculine top surgery. NOT proper "top surgery," IMHO.Sure, a FEW of my dozens and dozens of top surgery patients over the past two and a half decades have noted "some" return of sensation, but it's not "the good kind" that you are asking about and hoping for.Frankly, I think it's a disservice to imply that doing some sort of "special technique" by a self-proclaimed "experienced in this type of surgery" plastic surgeon will preserve anything approaching normal or erotic sensation. That's just wrong and disingenuous. Or, misinformed as to what proper incision patterns and chest-masculinizing top surgery can achieve. Click on the web reference link below for examples (a cross-section over many years, not all "perfect outcomes," but a true representation of what I have achieved with widely-varying anatomies) of my own top surgery patients. None of them retained nipple sensation, BTW. Best wishes! Dr. Tholen

There are several methods used which depend upon the patient’s breast or chest #size before surgery. Considerations on the surgical technique to be applied 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. It's best to consult with your board-certified plastic surgeon about your concerns and to confirm if FTM Top is in your best interests. With any surgical procedure, there are some risks which your doctor will discuss with you during your consultation.

Depending upon the size and shape of your breasts, it may be necessary to perform a nipple-areola graft in order to achieve a flat, masculine chest.  If grafting is done, the nipples will become numb.  However, not all patients require grafting.  In order to get a qualified, ethical, and expert opinion on your surgical options and expectations, schedule an in-person office consultation with a plastic surgeon certified by the American Board of Plastic Surgery.
Best of luck,Keith M. Blechman, MDNew York, NY

I appreciate your question.The 2 major methods are double incision mastectomy with nipple grafting and keyhole.It depends on the size of your breasts as to which method would be best for you and the ability to maintain nipple sensationThe 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

Hello Ashtonftm,Thank you for your question.  There are options available in order to preserve nipple sensation in FTM top surgery.  However, this completely depends on your current breast size and skin laxity.  Larger breasts are very difficult to completely reduce and give a fully masculine contour while keeping the nipple sensation intact.  However, smaller breasts are much more amenable to nipple sensation preservation techniques and a masculine contour can be achieved much more consistently.  I would recommend meeting with a plastic surgeon with experience with this type of surgery so you can be examined and discuss your goals so you can work together to come up with a plan.Best of Luck!Dr. Rednam

Thanks for your question.  Preserving nipple sensation with FTM top surgery is possible, but it greatly depends on your initial breast size, distance of the nipples from the crease, as well as your overall body size and desires.  In general, trying to preserve sensation will not allow as aggressive of a flattening to be performed.  Also, even with maintaining the blood supply to the nipple, sensation can still be affected. In my experience, most trans men prefer to loss sensation to have a flatter, more masculine chest, although that is a completely individual choice. I suggest that you meet with a board certified plastic surgeon who has experience in transgender surgery fro an evaluation and discussion of options. Best of luck!

There are two main techniques for performing top surgery.  You may expect to have some degree of loss of nipple sensation after surgery.  In some cases the feeling in the nipple may return.  A consultation with a board certified plastic surgeon who performs top surgery can help you to understand what your options are.  

If your top surgery is done correctly you should still have sensation in your nipples.  Its important to choose a surgeon who performs these procedures regularly and someone who is a board certified plastic surgeon. 

I'll assume that you need a double incision technique, since there are no photos. Keeping the nipple/areola on a pedicle rather than a free graft will help preserve sensation (also will help minimize pigment loss and complete nipple volume loss).  However, you may have some contour fullness of the pedicle.  This however can be improved with a minor second procedure later to debulk the pedicle.

Hi AshtonFtm,Thanks for the post. There are two main surgeries for FTM top surgery: Double incision and Periareolar. Which technique to be used is based primarily on breast size, nipple position, and skin tone and skin excess. For those with larger breasts, looser or excessive skin, and low nipple positions, they will require the double incision technique with free nipple grafts. In these cases sensation will likely be permanently lost but the chest contour will be the most masculine. Again, the type of surgery will depend on the starting point of your breasts.Sincerely,Dr. Dadvand