Female To Male Gender Affirmation Top Surgery

Female to male chest reconstruction is a surgery that provides the opportunity for an individual to feel
like their most authentic self. The surgery, also referred to as “top surgery,” provides transgender and
non-binary individuals with the chance to reconstruct the chest for a more masculine appearance—thus
allowing an individual to express his/their sense of self through physical attributes. Making the decision
to undergo this surgery can often feel overwhelming due to the combination of personal sentiments and
outside factors that may shape if and when the surgery can be completed. It is our job to make all
parties involved comfortable during this transition by having an open stream of communication
regarding the procedure, surgical techniques utilized, and recovery.

What is chest masculinization surgery?

The main goal of the surgery is to help provide confidence and increase self esteem in our patients by
further aligning their physical characteristics with their truest sense of self. The surgery involves
removing unwanted breast tissue and repositioning/resizing the nipple in order to create a more
masculinized chest. The two techniques we utilize most frequently are the “double incision” and the
“buttonhole”.

Double Incision Technique:

The double incision technique is the most common technique utilized for this surgery
due to its popularity and effectiveness to achieve a flat and tight chest. This technique
also allows for the personalization of areola size and position based on patient
preference. This technique involves two incisions, as the name entails: one incision is
along the inframammary fold of the breast, which enables the surgeon to remove
excess skin and breast tissue. The second incision is around the areola to remove the
nipple-areolar complex. This enables the surgeon to create a free nipple graft, which can
be resized and grafted into a more lateral position, creating the appearance of a
masculine chest. A patient has the option to customize this surgery by determining to
have anatomically feminine or masculine nipple size and position, or in some instances
no nipple and areola at all.

  • Benefits: flatter and tighter chest, useful in individuals with larger breasts or excess skin
  • Risks: Complete loss of sensation in the nipple, loss of the free nipple graft or delayed wound healing, discoloration of the areola
  • Surgery: About 2 hours, outpatient procedure. Patient will most commonly have drains on either side for 7-10 days following the surgery. Patient will also have a bolster dressing in place if nipple grafts are utilized to help the graft adhere. These will be removed about 1 week after surgery at the first post-op visit.
  • Recovery: Following this procedure, a patient will normally have pain in the chest area for a day or two and be sore for a week or two. After about two weeks, a patient may resume light exercise and activity, while still avoiding rigorous exercise such as running and jumping. The tissues will take about 6-8 weeks of healing time to reach full strength following the operation. After that time, the patient his little to no restrictions. It can however, take months to determine how much sensation was maintained in the nipples during the surgery.

Buttonhole Incision Technique

Unlike the double incision technique, the buttonhole technique does not create a free
nipple graft. This technique instead utilizes a “inferior pedicle” approach, which means
that the neurovascular supply to the nipple should remain intact. This provides a higher
likelihood of maintaining sensation to the nipple.

  • Benefits: Useful in individuals with smaller breasts, higher chance of maintaining nipple
    sensation
  • Risks: Delayed wound healing, residual breast tissue noted after the surgery, lack of
    customization of nipple size and positioning
  • Surgery: About 2 hours, outpatient procedure. Patient will most commonly have drains
    on either side for 7-10 days following the surgery.
  • Recovery: Following this procedure, a patient will normally have pain in the chest area
    for a day or two and be sore for a week or two. After about two weeks, a patient may
    resume light exercise and activity, while still avoiding rigorous exercise such as running
    and jumping. The tissues will take about 6-8 weeks of healing time to reach full strength
    after the operation. After that time, the patient has little to no restrictions.

Will I still need Mammograms after my Surgery?

The mastectomy to remove your breast tissue as part of transgender surgery is different from a mastectomy for breast cancer. We are not removing all of your breast tissue as part of an oncologic resection. Breast cancer risk may be reduced because the volume of breast tissue is much smaller but you should discuss appropriate breast cancer screening with your primary care provider. Self exams, mammography, ultrasound, or MRI may all still be indicated to screen for breast cancer in transgender patients.