Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people.

What is top surgery?

Top surgery is another name for chest masculinization or feminization. Using one of several surgical approaches, surgeons augment or remove breast tissue, and in some cases reshape and reposition the nipples for an affirming look.

Who may benefit from top surgery?

Transgender and nonbinary people may choose top surgery as part of their gender affirmation treatment. Gender affirmation surgery can address gender dysphoria, which occurs when gender identity does not correspond to sex assigned at birth.

Gender affirmation surgery can improve well-being in patients who:

• Have ongoing and documented gender dysphoria.
• Have the legal and mental ability to make responsible medical decisions for themselves.
• Are successfully addressing other mental and physical health concerns.

While testosterone therapy is not required for chest masculinization surgery, some surgeons and insurance companies will request one year of estrogen therapy to maximize natural breast growth prior to implant placement.

Types of Top Surgery

Depending on the patient’s goals, the surgeon may recommend several different approaches for top surgery:

For chest feminization:

• Breast augmentation with implants.
• Breast augmentation with fat grafting.
• Breast augmentation with implants and fat grafting.

For chest masculinization:

• Remove breast tissue and overlying skin.
• Eliminate the crease along the bottom of the breast (the inframammary crease).
• Contour the chest and emphasize the pectoral muscles.
• Make the nipples and areolas smaller and reposition them (nipple grafts).
• Remove the nipples entirely depending on patient preferences.

You and your surgeon will discuss the best choice for you, based on your body type, health, goals and other factors.

Breast Cancer Risk

Removal of breast tissue does not completely eliminate the risk of breast cancer developing in the area. If you are at risk for inherited breast cancer, be sure to inform your surgeon. Some care providers recommend a baseline mammogram before your top surgery procedures. You will still require monitoring for breast cancer even after removing breast tissue.

Estrogen can increase breast cancer risk. Those on estrogen therapy may experience breast growth as a result. Some physicians or care providers may also recommend a baseline mammogram prior to chest feminization and breast cancer monitoring after chest feminization.

Double Incision Approach for Chest Masculinization

This is the most common procedure for top surgery, and can remove moderate to large amounts of breast tissue. Two incisions are made horizontally, across the left and right side of your chest, which accentuate the natural contours of the pectoral muscles. The greater the amount of tissue present before the surgery, the larger the incisions. Your nipples and areolas are removed, resized, reshaped, and then replaced (if desired) to achieve a more masculine appearance.

Keyhole Top Surgery for Chest Masculinization

For people with very small amounts of breast tissue and firm skin, the surgeon can make a cut along the lower half of the areola and extract breast tissue through this opening. The areola and nipple may be decreased in size before closing the incision.

Top Surgery: What Happens

• Your procedure will typically take three to five hours.
• Top surgery procedures are performed as outpatient surgery. This means that most patients will not be admitted to the hospital.
• The surgeon will mark the area for surgery on your chest while you are sitting upright. The marks help ensure your surgery results are as symmetrical and natural looking as possible.
• You will be given anesthesia through an IV to help you sleep through the procedure.
• You will be positioned on your back on a table with padding around your arms to ensure you stay still and comfortable.
• You will wake up from the procedure with stitches and dressings on your chest. If you received chest masculinization, you will also have a chest binder. If you received chest feminization, you will also have a surgical bra.

Recovering from Top Surgery

It is very important to follow all the instructions your surgery team gives you when you go home from the hospital. For several weeks after surgery you should not lift your arms greater than 90 degrees away from your body or over your head. You should also not push, pull or lift anything greater than five pounds during these four weeks. This ensures your scar will heal well and not stretch and become larger.

Pain. You may experience some discomfort for a few days after surgery, but generally after four to five days your pain will ease and can be managed with over-the-counter acetaminophen and ibuprofen.

Dressings and drains. You will have dressings and possibly drains in place when you leave the hospital. Do not remove them until you see your doctor after surgery. If you have drains, your doctor’s office will give you instructions on how to empty them. These drains help prevent fluid from collecting in the chest or breast. Please record the amount of fluid coming out of the drains. Your drains will usually be removed at your first appointment after surgery.

Bathing and showering. Until you see the doctor, you may shower your lower body if you can do so without getting the bandages and dressings wet. Clean the top of your body with a sponge only until your doctor gives you the go-ahead for showering and bathing.

Compression garment. After chest masculinization surgery, you will wear a compression vest. This vest is placed on your body in the operating room after surgery. It is very important to wear the vest at all times to prevent post-operative bleeding and fluid collections.

Surgical bra. After chest feminization surgery you will wear a surgical bra. This is a special bra placed on your body in the operating room after surgery. It is very important to wear the bra at all times to prevent postoperative bleeding and fluid collections.

Risks, Complications and Side Effects of Top Surgery

• Top surgery scars: For chest masculinization procedures, scars may appear as horizontal lines across the chest, or circles around the areolas. For chest feminization procedures, the scars will be located underneath the breasts. It can take up to 18 months for scars to resolve, and some people elect to have further surgery to minimize them. It is important to avoid sun exposure, which can darken scars and make them more obvious.
• Hematoma: Blood can gather in the tissues after surgery and form a clot, with symptoms such as pain, swelling and discoloration as well as an increased risk for infection. Hematomas form in about 1% to 2% of top surgeries.
• Seroma: Fluid can collect under the skin. Small seromas may not need any treatment and go away on their own. Seromas in top surgery can be prevented by drains in the surgical area and wearing your compression vest consistently after your procedure.
• Infection: This is a rare complication of top surgery, but can happen. Cellulitis in the surgical area may require treatment with oral antibiotics and drainage.
• Breakdown of nipple graft: While some skin sloughing is no cause for concern, deeper tissue death (necrosis) can indicate that the graft is not successful and more surgery may be necessary.
• Reduced nipple sensitivity: Numbness or tingling can happen if a nerve is disrupted or damaged during surgery. The double incision approach for chest masculinization involves removing and repositioning the nipple, which calls for cutting the nerves. Nipple numbness may improve over time, but full restoration of sensation is unlikely.
• Irregular contours: Additional surgery to address chest contour may be called for in up to 32% of top procedures.