I Am a Ftm Transsexual Interested in Top Surgery but I Do Not Want my Nipples Changed?

Question

Is it possible to have top surgery without having the nipples removed, revised, or graphed on? I enjoy the sensation in my nipples and do not want to lose that. Or would a breast reduction be a better option? Basically I want a flat chest with my original nipples.

Paul M. Steinwald, MD · Answer

Yes, it is definitely possible to leave the nipples attached (as in a breast reduction, only a more "extreme" form of the same), in order to retain at least some sensation, especially if you are starting at a C/D-cup or smaller with a relatively minimal "drooping" effect. I agree that healing after full-thickness nipple grafting is often unpredictable, with high potential for partial nipple loss, thickened scars, pigmentation irregularities, etc., which is why this alternative "nipple-sparing" technique (with the incisions closed in an "anchor"-pattern) was developed and refined.

Jed H. Horowitz, MD, FACS · Answer

Yes, this is possible.  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.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.

Orna Fisher, MD · Answer

You do not show any of your pictures in order to determine which operation you are a candidate for.  In general though, you cannot leave your nipples (areolas) surgically unchanged and still have an acceptable cosmetic outcome. Either FTM top surgery or breast reduction would both alter the nipple areolar complex  although in different ways.  Also of note, a breast reduction is not top surgery  many reasons.
A skin sparing nipple sparing mastectomy, as done for some cases of breast cancer, can be done if you are an A cup or small B. In that case, there is also still no way to guarantee sparing of the nerves for nipple sensation.  If you are a large B cup or larger  and you did this, your remaining breast skin would be deflated and unpredictably wrinkled and indented to your chest wall. 
I'm sorry, but there is no magic. Top surgery is done how it is for very specific reasons. If we could spare the nipples completely  and still have the desired cosmetic outcome, we would all do that.

Rian A. Maercks, MD · Answer

In general I agree with the other doctors that have posted.  I have a frank conversation with each patient as to what is realistically attainable.  Depending on the patients anatomy and amount of skin below the nipple a non cumbersome pedicle and be developed and sculpted to appear as pectoral muscle bulk.  For patients that do not derive significant pleasure from their nipples this is a wasted venture and adds complexity.  For those that strongly desire nipple sensation it can be very advantageous and no vertical scar is necessary.  Healing is quicker and more reliable than with free nipple grafts.  The technique has to be tweaked for the individual's body, chest wall and skin excess. Not all patients are reasonable candidates for sensate nipple FTM chest masculinization.  I hope this helps!Rian A. Maercks M.D.

Russell Sassani, MD · Answer

Thank you for your question. In my experience, most trans men (like yourself) want as tight and flat a chest as possible with as much definition to the pectoralis muscle as possible. This would not be able to be achieved with a breast reduction alone as there will still be a "pedicle" of breast tissue beneath the skin flaps that is necessary to keep the nipple areola complex alive and sensate. The reason to do the breast reduction method then becomes solely to maintain as much nipple sensitivity as possible for those trans men that postop maintenance of erotic sensation of the nipples is important. Even with this technique there is no guarantee of maintenance of nipple sensation. With the standard double incision top surgery with free nipple grafts, the contour is usually superior, scar placement can be optimized into the inframammary crease only ( as opposed to the breast reduction anchor configuration which is periareolar, vertical AND inframammary), and nipple placement can be achieved into a more masculine position further lateral on the pectoralis muscle. I hope this helps and best of luck with your transition!!

Michael S. Beckenstein, MD · Answer

Any breast reduction technique whether the nipples are not relocated (rare) can alter sensation. No surgeon should promise the preservation of nipple sensation following breast surgery even if liposuction is the only approach used. You have to be willing to possibly diminish or lose sensation with Top surgery.

Richard H. Tholen, MD, FACS · Answer

I agree with Dr. Lawton's answer. Properly-performed transgender mastectomies would remove 99% of your breast tissue, along with the sensory nerves to your nipples. To imply that some surgeons or techniques can preserve or "spare" sensation in reliable or "guaranteed" fashion is truly false, and frankly, disingenuous.Breast reduction can preserve sensation in about 85% of patients, with more tissue removal reducing those odds. Breast reduction will NOT yield a "flat chest." Anchor-pattern breast reductions do NOT offer guaranteed sensory maintenance, and they do NOT yield a masculine-appearing chest (a "double whammy" IMHO).Total mastectomies, nipple reduction, areola reduction, and reconstruction of the nipple/areola complexes as full-thickness skin grafts will give you the most masculine results, but will usually result in numb nipples permanently. Some patients will recover some sensation in their grafted nipple/areola complexes, but this is neither normal nor erotic, but not totally numb either.However, to state or imply that properly-performed transgender mastectomies COULD yield sensate nipples that retain erotic sensation (if only you were to find that particular surgeon) is plainly a lie designed to fool prospective patients into seeking that particular surgeon or "special" technique. Don't "fall" for this deplorable lapse of ethics. Best wishes! Dr. Tholen

Jaime S. Schwartz, MD, FACS · Answer

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

Anthony Deboni, MD · Answer

Yes, this is possible, but it will limit the amount of flattening that you can get.  I have preserved nipples and sensation in some of my FTM transgender patients.  It tends to work better in patients who are on the heavier side, in whom a small amount of residual fullness is in line with the rest of their body dimensions.  Even with keeping the nipples vascularized, there is still a risk of sensation change.  Most of my FTM patients do opt for nipple grafting, however, as the goal of the flattest chest usually takes precedent over nipple sensation.Best Regards,Dr DeboniThe information above should not be considered a substitute for consultation with a board-certified plastic surgeon to address individual medical needs. Your particular facts and circumstances will determine the plastic surgery treatment which is most appropriate for you.

Gary Lawton, MD, FACS · Answer

A breast reduction with preservation of the nerves to the nipple will not result in the flat chest you are looking for.  The double incision mastectomy requires nipple grafting to ensure the flatness of the chest.  So you cannot unfortunately have both.