MASCULINIZING TOP SURGERY

Pros

• Top surgery can help align your body with your gender identity and expression. 
• An impressive 98% of RealSelf members who reviewed their procedure say it was Worth It. Many reviewers report improved quality of life and a feeling of liberation afterward. 
• No more chest binding! Chest binding can irritate the skin, damage blood vessels, and cause back pain, so permanent removal of breast tissue means you’ll be free of those issues. 
• The procedure can reduce the risk of breast cancer.

Cons

• Masculinizing top surgery techniques are still not taught in most plastic surgery programs, so it can be difficult to find an experienced surgeon unless you're willing to travel (which can increase your costs). The procedure isn't the same as bilateral mastectomy procedures taught in general surgery programs for cancer patients, nor is it a "mega" breast reduction, says Dr. Richard Tholen, a plastic surgeon in Minneapolis, who has been performing top surgery for more than 25 years. Choosing a surgeon who has years (or ideally decades) of experience performing this procedure on nonbinary or transgender people is vital to a good result.
• If your surgeon doesn't offer sensation-sparing mastectomy surgery (a relatively new, advanced technique) or you're not a candidate for it, you may lose feeling or experience diminished sensation in your chest and nipples. While it may come back as nerves regrow, it may not return as an erogenous sensation.    

RealSelf Tip: Removing breast tissue is irreversible, so results are permanent. That's usually a good thing, but it also makes it even more important to choose an experienced surgeon who has the skill to create a result that aligns with your aesthetic goals, while reducing the potential for complications or a poor outcome.

• Average Cost:
• $8,403

• Range:
• $1,300 - $17,340

This cost typically includes the consultation, surgeon's fee, facility fee, anesthesia fee, and follow-up care. It may also include a compression garment. Ask for a detailed cost estimate during your initial consultation with your surgeon, so you understand what's covered in your cost prior to your surgery. 

Your cost will depend on your provider’s level of experience, their practice location, and the details of your procedure.

For instance, keyhole and periareolar top surgery procedures are typically less expensive than the double incision method by as much as $2,000, according to Dr. Jed Horowitz, a plastic surgeon in Newport Beach, California. 

Top surgery may be covered by your health insurance plan, depending on the laws in your state. Unfortunately, insurance coverage for top surgery for either transmen or women is less likely to be available than coverage for facial masculinization or feminization. 

If your chosen surgeon regularly offers gender-affirming surgery, their staff will likely be able to guide you through the process of requesting insurance coverage.

You can finance your treatment with CareCredit.

The masculinizing top surgery photos in our gallery have been shared by the provider who performed the procedure, with the patient's consent.

“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. 

"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: 

• 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.  
• 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.  
• 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. 
• 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.  
• 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. 
• 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. 

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.

Most people are able to return to a desk job within two weeks after top surgery. If you have a job that requires you to lift heavy objects or move frequently, you may need to be out for up to six weeks before safely returning to those duties. 

Strenuous exercise or lifting more than 10 pounds can usually be resumed after six to eight weeks, but check with your doctor before doing any chest-focused weight lifting.

Here's what will happen in between your surgery and when you head back to work:

• Immediately after your procedure, you’ll be wheeled into a recovery room to be monitored for any complications or blood clots. 
• You’ll be able to go home the same day, once you're alert and stable.
• If you traveled for the procedure, you can stay in a hotel, with a trusted friend, or in a post-op facility, like a recovery house. You won’t be able to drive yourself and should not stay alone, just in case there's a complication. 
• Swelling is normal after surgery. It usually peaks within 48 hours, and it takes anywhere from a few weeks to a few months for it to fully resolve, depending on the details of your procedure and how your body responds.
• You’ll most likely have surgical drains on either side of your chest for a week or more, to prevent fluid build-up.
• Your doctor will advise you on when you can shower or bathe, and they may provide you with a medical soap and other supplies to keep you incisions clean (and help avoid infection).
• Many surgeons also have patients wear a compression binder after surgery, for anywhere from one to six weeks. This helps prevent fluid build up, aids the skin in adhering back to the chest wall, and also helps minimize scars. 
• If your nipples were reduced and repositioned, you'll have a special dressing called a bolster, to keep them in their new position as they heal. Bolsters are removed after about a week. 

Related: How to Stay Safe When Traveling After Surgery

It typically takes three to six months for the swelling to resolve, so you can see the final results of your flatter or more masculine chest.

Performing weight-training exercises to build muscle mass both before surgery and after recovery can enhance your results.

If you want a stronger look, pectoral implants made of silicone gel or solid silicone can be surgically inserted, to create the appearance of highly developed chest muscles.

Top surgery results are considered permanent and aren't reversible. Patients who've undergone the procedure often worry that their breasts might "grow back" if they gain weight, but because it removes the breast tissue (not just fat tissue), you'd have to gain a substantial volume of weight before your chest looked feminine again.

One goal surgery is to minimize the appearance of scars and optimize their placement. Not surprisingly, removing larger breasts leaves larger scars.

A well-performed double incision surgery leaves scars on each side of the chest, but skillful incision placement can position the final faded scar along the lower edge of the pectoral muscles, following the natural contour. "This simulates normal male anatomic features, while making the scars less apparent," says Dr. Tholen. 

For transmen who are on testosterone hormone therapy, new hair growth further conceals scars. 

Proper wound healing, such as protecting the incision area from excessive activity for a few weeks, will help reduce bleeding, bruising, and the formation of seromas that can make scarring worse. Avoiding sun exposure during the period when scars are still pink and susceptible to hyperpigmentation also helps.

Scars are permanent but will fade over the course of a year. You can help this process along with scar treatments, including silicone sheets or scar gel, beginning two weeks after surgery. Your surgeon can advise you on which brands and size to purchase. Some even offer complimentary laser scar removal. 

RealSelf Tip: Plastic surgeons who use "standard" bilateral mastectomy or breast reduction techniques will leave scars that are both unnecessary and unsatisfactory, says Dr. Tholen. "Careful measurement and precise skin closure in layers avoids the vertical scar patterns of female breast reduction operations," he says. 

To avoid poor scarring, ask the plastic surgeons you consult with to show you before and after photos of their trans patients.

Masculinizing top surgery is considered safe and effective when it's performed by an experienced, board-certified plastic surgeon. 

In follow-up studies, transgender men who have undergone the procedure report very low rates of complications and high rates of satisfaction. Scarring is generally within expected limits, and necrosis (tissue death) of nipple grafts is rare. 

One report of 220 subcutaneous mastectomies in 110 transmasculine patients found that the overall mean aesthetic score was 4.07 of 5. For the 12 (11%) patients who underwent revisions, the aesthetic score increased from 1.88 following the first operation to 4.11 following the second operation.

In a study that compared transmen undergoing top surgery with cisgender male and female counterparts undergoing mastectomy for other indications, transgender males were not at an increased risk of adverse outcomes—including postoperative complications and readmissions.

"These favorable results should encourage surgeons to expand their offerings to transgender patients and reassure them as to the safety of chest masculinization as a component of gender affirmation," researchers concluded.

That said, any surgical procedure comes with potential complications, including bruising, swelling, nausea and vomiting, blood clots, infection, seroma (fluid build-up), and poor reaction to general anesthesia. 

It's common to experience diminished chest or nipple sensation after the surgery, but patients usually retain some sensation. Most patients actually report increased sexual satisfaction following their procedure, likely due to enhanced body confidence. 

Quality of life is also significantly higher among transgender men who've undergone chest reconstruction, compared to those who haven't. In combination with hormone therapy, the procedure is also more effective in alleviating gender dysphoria than hormones alone.

Agarwal, Cari A, et al. "Quality of life improvement after chest wall masculinization in female-to-male transgender patients: A prospective study using the BREAST-Q and Body Uneasiness Test." J Plast Reconstr Aesthet Surg. 2018 May;71(5):651-657.

Centers for Medicare and Medicaid. "Summary of clinical evidence for gender reassignment surgeries." 

Cregten-Escobar, Patricia. "Subcutaneous mastectomy in female-to-male transsexuals: a retrospective cohort-analysis of 202 patients." J Sex Med. 2012 Dec;9(12):3148-53.

Cuccolo, Nicholas G, et al. "Mastectomy in Transgender and Cisgender Patients: A Comparative Analysis of Epidemiology and Postoperative Outcomes" Plast Reconstr Surg Glob Open. 2019 Jun; 7(6): e2316.

The International Center for Transgender Care. Transgender Mastectomy Surgery.