This article was reviewed by Nathan Levitt FNP-BC
For this article, we are going to be using anatomical language to refer to body parts, but we celebrate any words you use to self-identify. The language we use for our bodies matters, just like how we ask others to touch and experience our bodies, and respecting this is a part of healthy and active consent.
Top surgery is one of the most common gender-affirming surgeries for transmasculine people, transgender men, and non-binary people. Top surgery is a procedure that involves removing the breasts (commonly known in the cis community as a bi-lateral mastectomy) and may also include chest contouring, nipple grafts, or nipple and areola resizing and repositioning to achieve a flatter, or, what should might call a more “masculine” looking, chest.
Gender-affirming surgeries such as top surgery can improve quality of life for transgender people and help resolve some of the more debilitating effects of gender dysphoria. Studies consistently show that most transmasculine people are satisfied with their results after surgery.
Before we deep dive into all things top surgery, it’s important to know that not all transgender people choose to get surgery. Whether or not you want top surgery has no bearing on the authenticity or validity of your gender identity. While top surgery can alleviate feelings of gender dysphoria for some, many people other than may choose to get it for a variety of reasons. Just know that your gender journey is entirely up to you and there is no one way to medically transition. You are trans enough no matter what aspects of your body you do or don't change.
What is top surgery?
Top surgery (or gender-affirming chest reconstruction) is a surgical procedure in which the breast/chest tissue is removed to create a flatter, more “masculinized” chest. Some surgeons might refer to top surgery as “ftm chest masculinization.” While anyone of any gender can get top surgery, usually, trans men, transmasculine people, and other gender-expansive or non-binary people opt to get it. It’s important to note that while some people might resonate with the “masculinizing” language, other people’s top surgery journeys have nothing to do with masculinity.
There are several different types of procedures that people opt for depending on their personal preferences, breast size, and goals.
It’s important to know that top surgery is not an elective or cosmetic procedure, but a medically necessary and often life-saving surgery that allows trans people to live their lives fully.
Top surgery as a term is typically used to refer to the transmasculine surgical procedure of breast removal, although some transgender women who increase the size of their breasts via breast augmentation might also refer to this as top surgery. In this article, note that we are referring to top surgery in the transmasculine context.
How do I know if top surgery is right for me?
If you’ve ever experienced discomfort with your chest or an uneasy relationship with that part of your body, top surgery might be right for you. You might have a dysphoric relationship with your breasts due to an internal feeling of gender dysphoria or due to external experiences of being frequently misgendered. Perhaps this is a relatively new feeling after coming to terms with your gender identity or starting testosterone HRT, and you’ve developed a different relationship with your body. Or maybe, as a trans man, you’ve always experienced gender dysphoria for most of your life and have always known that top surgery is for you. You also might not experience dysphoria at all, but want to change your chest or body for other reasons.
The point is that people have different reasons for wanting to get top surgery and there is no right or wrong way to arrive at the decision. Remember to take it one step at a time. The process of coming to terms with the fact that top surgery might be for you can be an emotional, exciting, and overwhelming experience. Due to the anti-trans sentiment in many of our upbringings, there is a lot of fear attached to the process of medical transition.
While some people have experienced chest dysphoria from an early age, a lot of people live in more of a gray area regarding whether or not top surgery is the right decision for them. Just know that you are not alone— there are lots of other people out there going through the same thing you are. Don’t rush yourself to make any decisions or beat yourself up during the process, make sure to hold space and be compassionate with yourself.
What are the different types of top surgery procedures?
When considering top surgery, there are a few different options to choose from depending on your breast size, desired physical outcomes, and health history. A reminder that here at FOLX, we believe in Health At Every Size (HAES). We know that weight by no means equals health, but unfortunately, the fatphobia in the medical community still results in some folks being told by surgeons that they should lose weight before top surgery or that they are not appropriate candidates for certain procedures. While results may vary, the size of someone’s chest is a bigger consideration than the size of their body when it comes to getting top surgery.
Below are some descriptions of the different types of procedures so you can learn which might be right for you. This is not an extensive list of all procedures as the field of gender-affirming surgery is expanding every day, but here are some of the most common ones.
Double incision (DI) with or without nipple grafts
Double incision (otherwise known as a subcutaneous bilateral mastectomy) is one of the most widely-used top surgery techniques and is ideal for people who are B-sized and larger. During this procedure, two horizontal incisions are made along the pectoral lines and the breast tissue is removed to create a flat chest. Additional liposuction may be performed to help prevent “Dog Ears” or to provide a flatter contour. The nipples are removed and then typically resized and then grafted back onto the chest. This can result in limited sensation throughout the nipple/areola area, as well as other areas of the chest.
Some trans masc or nonbinary people might opt out of the grafts and instead choose a chest without nipples or get nipples tattooed on later. If this is something that you’re interested in, you can talk to your surgeon during your consult as to whether or not they offer this procedure. Just know that the decision of what you want your body to look like is yours alone and you know what is best for you. This surgery type is suitable for people of all chest sizes. However, typically people with medium or larger-sized breasts for whom retaining sensation is not a top concern might choose double incision.
Inverted T or T-anchor
Inverted T or T-anchor is a technique that is ideal for people who want to retain as much sensation as possible in the nipple/areola area and are typically B-sized or larger. The T-anchor technique keeps the nipple and areola attached to native body tissue, avoiding the need for a free nipple graft. During this procedure, two horizontal incisions are made along the pectoral muscle and an extra vertical incision is made—thus the name inverted T.
This technique requires more tissue to be left behind to supply blood to the nipple area, as the nipples remain attached. For those who are wanting the flattest possible chest, T-anchor might not be the best option for you as more tissue needs to be preserved to keep the nipple and areola alive. However, if retaining nipple sensation and having nipples, areolas, and chest that can be more full in appearance works for you, then T-anchor might be a good option.
Note that nipple sensation can be affected during any top surgery procedure and might be diminished as a result or will need recovery from being numb. Some patients report gaining back full sensation while others describe a duller feeling of sensation that returns. Inverted-T top surgery also has the potential for fewer complications compared to Double Incision because there are no nipple grafts (which do have some risk of infection and loss). A note that not all surgeons offer this procedure, so make sure to talk to your surgeon during your consultation about what they offer.
The Buttonhole technique is similar to the Inverted-T technique in many ways, except that there is no need for a vertical incision, therefore the nipple and areola don’t need to be placed as a free nipple graft. Because of this, it is possible that more density in the chest might remain to preserve sensation, resulting in a more full-appearing chest.
Buttonhole allows for more breast tissue to be removed through one incision than the keyhole or peri-areolar methods and works to preserve nipple placement, pigmentation, and sensation; however, the surgeon might have less control over the placement of the nipple as with the Double Incision procedure. Buttonhole is a good choice for patients with less chest tissue (so require less skin excision) who don’t care as much about complete flatness in their chest, but who want more control over their results than Keyhole or peri-areolar can provide.
The Keyhole technique is usually a good option for people who are small chested (A-sized and smaller). Not many people qualify as a candidate for this procedure given the requirements of needing a very small chest and tighter chest skin. This procedure involves minimal scarring as a small incision is made along the areola border through which the breast tissue is removed.
With the Keyhole procedure, the nipple stalk is usually left intact, although some surgeons will choose to resize the nipple itself. The areola is not resized and nerve sensation can remain intact after numbness fades. As with all top surgeries, complete and total regaining of nipple sensation is not always guaranteed. It is also important to note that the precision of nipple placement can be harder to control with Keyhole, given that the results depend highly on the original placement of your nipples. Some transgender people prefer this method since there are no large incisions made, therefore, no scarring. While other people might choose different procedures because they want top surgery scars or don’t mind them.
Peri-areolar (otherwise known as Peri or the ‘donut’ or ‘circumareolar’ technique) is best for people with good skin elasticity (this is decided by a surgeon during consultation) and usually B-sized or smaller chests. The Peri-areolar procedure involves one incision made all around the border of the areola, and a second larger concentric circle incision made to create a donut shape through which tissue is removed. The Peri top surgery procedure is somewhere between the Keyhole technique and other surgeries that may require more skin removal. The nipple stalk is usually left intact, though some surgeons will resize the nipple itself, and therefore sensation is often maintained.
A "drawstring" or “purse-string” technique is used to bring the skin together and connect it to the edges of the areola, which may be downsized. This can sometimes create a ripple pattern or pleating effect around the area due to a mismatch of the circle sizes, but most of the time these ripples disappear or diminish during the recovery process. Note that the Peri-areolar procedure can have a higher revision rate due to the challenge of the technique.
Fishmouth or “Batwing” Incision Surgery
Last but not least, there is the Fishmouth top surgery procedure which creates scars that radiate out from the nipple to create a non-anatomical layout of scars. Much like the Inverted-T or Buttonhole, there is a better chance of maintaining increased sensation, but more ability to obtain the flatness and tightness to the chest than with the Inverted-T approach.
Because the scars are not placed along the pectoral line, but often appear as horizontal lines inward and outward from the areola itself, this is a good option for many non-binary or other gender-expansive people. This can be a great option for patients who are more gender non-conforming and therefore do not wish to have what is typically called either a “male” or a “female” appearing chest.
What do you need to get top surgery?
If you ask the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) criteria—which most doctors who offer top surgery use—you will typically need one referral letter from a healthcare provider or mental health provider that indicates:
- Persistent well-documented gender dysphoria
- Capacity to make a fully informed decision and to consent to treatment
- Age of majority in given country (otherwise follow SOC for children and adolescents)
- If significant medical or mental health concerns are present, they must be reasonably well-controlled
Most surgeons these days use the informed consent model, however, to get surgeries covered by most insurance companies, WPATH standards must be followed which includes a referral level from a medical or mental health provider. If you are paying out of pocket for top surgery, you may not need to provide a referral letter, so long as you sign a legal release that confirms your understanding of both the methodology, duration, potential risks, aftercare, or the procedure as well as the permanent nature of the surgery, and that they are undergoing top surgery at your own responsibility. However, some surgeons might require a letter on file to protect themselves legally.
It’s important to know that in the United States, hormone therapy is not a prerequisite for top surgery. Although some surgeons will recommend being on testosterone HRT to help build muscle in that area if that type of aesthetic look is important to you.
How much does top surgery cost?
Unfortunately, not everyone has equal access to top surgery. If top surgery is not covered by your current health insurance, or if you are uninsured, the average out of pocket cost is between $3,000 and 10,000, which may or may not include other fees such as costs for consultations, general anesthesia, other medication, or aftercare items such as compression garments. If needed, you can find a great breakdown of ranging costs per surgeon here. Additionally, you may have to consider travel-related costs if you’re traveling out of your area to seek surgery, and some surgeons may want you to stay locally for one to two weeks post-surgery.
As far as getting top surgery covered by insurance, more insurance companies are accepting the medical necessity of transgender healthcare and gender-affirming surgeries. The American Medical Association, American Psychiatric Association, and World Professional Organization for Transgender Health all agree that top surgery is a medically necessary procedure. However, coverage will vary between health insurance companies, states, and individual plans.
Some state Medicaid plans include gender-affirming surgeries for transgender people and others purposefully exclude such care. For an up-to-date list on state-by-state transgender coverage, see movement advancement project (MAP)’s resource here. Make sure to read your policy fully and pay special attention to the exclusions and limitations section. You can also call your insurance company’s member services number and ask about coverage for transition-related services, surgeons included in your health plan, whether your plan has out-of-network benefits, and how much your deductible is.
Is top surgery safe?
The short answer is yes. Top surgery with an experienced and skilled surgeon is a very safe and low-risk procedure, although it’s important to know that with any surgery comes some degree of risk. However, the idea that transgender surgeries are any more dangerous than common cisgender surgeries—including mastectomies and breast augmentations to name a few—is misguided, often due to a lack of informed education and training, as well as anti-trans bias. It’s important to discuss with your surgeon any previous reaction to anesthesia that you may know of, what medications you are currently on, your medical history, and family history including history of cancer.
It’s also important to understand the risks of infection, blood clots, loss of sensation, seroma (fluid buildup), complications with drains (depending on which surgery you have), bruising, bleeding, and scarring. It’s also important that you discuss any current use of tobacco, as this can potentially affect your healing and some surgeons may require that you quit smoking cigarettes weeks before you get top surgery.
For more information on top surgery check out Trans Healthcare’s directory for gender-affirming surgeons in the United States or Callen Lorde’s Gender Conforming Surgeon List & Resources for NY-specific surgeons and some national. QueerDoc also provides referrals for gender-affirming surgeries. Transbucket is also a great community resource for before and after photos of all different types of gender-affirming surgeries (note: you have to identify as transgender and/or nonbinary to access the site). You can also check out the MTF Surgery and FTM surgery websites for a list of gender-affirming surgeons.
Know that FOLX clinicians can help write letters of recommendation from a hormone provider, as needed for WPATH standards, and our member support can provide surgery referrals if needed. If this is something you are interested in, please do not hesitate to get in touch with your clinician. If you are interested in scheduling a virtual consultation with an affirming clinician here at FOLX, you can do so here. If you are interested in getting started on a testosterone membership, that process begins here.