# Top Surgery Last updated February 19, 2026 > [!important] This page is for educational purposes only and should not be considered medical advice. > [!NOTE] Looking for the complete deep-dive? > This page is a free educational overview. For insurance strategies, WPATH letter templates, and step-by-step surgical preparation, see **[[Becoming Yourself - The Complete Guide to Gender Affirming Surgery|Becoming Yourself]]** — the 1,093-page patient-written guide to gender-affirming surgery. > **[Get the book on Gumroad →](https://borgpup.gumroad.com/l/tyslr)** - [[#Introduction]] - [[#Goals and Outcomes Across the Spectrum]] - [[#Chest Masculinization Techniques]] - [[#Double Incision with Free Nipple Grafts]] - [[#Periareolar and Keyhole]] - [[#Inverted-T (Anchor)]] - [[#Technique Comparison]] - [[#Chest Feminization (Breast Augmentation)]] - [[#Hormonal Breast Development]] - [[#Augmentation Techniques and Anatomy]] - [[#Nonbinary and Gender-Expansive Options]] - [[#Candidacy and Preparation]] - [[#Health Requirements]] - [[#BMI Considerations]] - [[#Smoking and Healing]] - [[#Mental Health Assessment]] - [[#Physical Preparation and Binding]] - [[#Recovery and Healing]] - [[#First 48 Hours]] - [[#Weeks 1–6]] - [[#Months 2–12]] - [[#Nipple and Sensation Considerations]] - [[#Common Complications]] - [[#Scar Management]] - [[#Long-Term Outcomes and Satisfaction]] - [[#Insurance and Access]] - [[#Choosing a Surgeon]] ## Introduction Top surgery is one of the most common gender-affirming procedures, yet conversations about it often default to a single narrative: trans men getting mastectomies. The reality is far more expansive. Top surgery serves trans men and transmasculine individuals seeking chest masculinization, trans women and transfeminine individuals pursuing breast augmentation, nonbinary and gender-expansive people exploring the full spectrum of chest modifications, and anyone whose relationship with their chest causes distress or disconnection. The evidence is clear: top surgery achieves a pooled satisfaction rate of 92% across studies, with regret rates below 1% — making it one of the most successful surgical interventions in medicine (Bustos et al., 2021). Whether someone seeks a completely flat chest, augmented breasts, or something deliberately in between, the goal remains the same: a body that feels like home. --- ## Goals and Outcomes Across the Spectrum ### Different Goals for Different People **Masculinization** creates a flat, typically male-appearing chest contour through breast tissue removal, nipple repositioning, and contouring to emphasize pectoral definition. The goal is often not just flatness but a specifically masculine aesthetic that looks natural in fitted shirts, at the beach, and in intimate moments. **Feminization** creates or enhances breast tissue, typically through augmentation with implants. Research shows that less than half of transgender women develop even the smallest cup size with hormones alone, making augmentation a common and valid choice. **Androgynous or nonbinary outcomes** deliberately avoid binary endpoints. A 2024 study found that 40.6% of patients undergoing chest surgery identified as nonbinary, with outcomes comparable to binary patients across psychosocial measures (Roblee et al., 2024). This isn't a niche population — it's nearly half of all chest surgery patients. ### Beyond Appearance Top surgery also addresses functional concerns. Chest binding carries real risks: skin irritation, breathing restriction, rib pain, and in some cases rib fractures with prolonged use. For many, surgery eliminates not just dysphoria but the daily health burden of compression. Chest dysphoria affects what people wear, where they go, who they're intimate with, whether they exercise, whether they swim. Surgery doesn't just change the body — it changes what becomes possible in daily life. --- ## Chest Masculinization Techniques The choice of technique depends primarily on chest size, skin elasticity, and aesthetic goals. No single technique is universally "best." ### Double Incision with Free Nipple Grafts The most commonly performed technique, used in 80–90% of chest masculinization cases (Wilson et al., 2018). Two horizontal incisions along the inferior pectoralis border allow complete removal of breast tissue and excess skin. The nipple-areola complex is removed, resized to masculine proportions (typically 20–22mm), and repositioned as a free graft. **Best for:** B cup or larger, significant ptosis, excess skin, priority on maximal flatness. **Operating time:** 2–4 hours under general anesthesia. **Tradeoff:** Bilateral chest scars and significant or complete loss of nipple sensation. Scars fade substantially over 12–18 months, but sensation loss is often permanent. ### Periareolar and Keyhole These pedicle-preserving techniques keep the nipple attached to its blood and nerve supply. **Keyhole** involves a small incision at the areola border for liposuction and direct excision. Requires an A cup or smaller with excellent skin elasticity — a narrow candidacy window. **Periareolar** uses a donut-shaped incision around the areola, allowing more tissue removal and some skin tightening. Extends candidacy to A–small B cup with good elasticity. Pedicle techniques offer approximately 85% sensation retention, but when performed on patients outside candidacy criteria, revision rates climb to 55% (versus 8.8% for double incision). If a surgeon says you're a candidate for keyhole when you wear a C cup, seek a second opinion. ### Inverted-T (Anchor) Preserves the nipple-areola complex on an inferior pedicle while allowing extensive tissue and skin removal. Offers 60–80% pre-existing nipple sensation retention while accommodating larger chest sizes (Gender Confirmation Center, 2024). Particularly suits patients prioritizing sensation, plus-sized patients, and those seeking nonbinary outcomes with some volume maintained. The tradeoff is more extensive scarring with an additional vertical scar. ### Technique Comparison | Technique | Best For | Sensation | Revision Rate | Scar Pattern | |-----------|----------|-----------|---------------|--------------| | Double incision (FNG) | B+ cup, excess skin, flatness priority | Lowest (0–30%) | 8.8% | Bilateral horizontal | | Keyhole | A cup or smaller, excellent elasticity | Highest | Variable | Minimal (areola only) | | Periareolar | A–small B cup, good elasticity | ~85% retain some | Up to 55% | Around areola | | Inverted-T | Larger chests, sensation priority | 60–80% retained | Moderate | Anchor pattern | --- ## Chest Feminization (Breast Augmentation) ### Hormonal Breast Development Hormone therapy alone produces limited breast development for most individuals. Less than 50% achieve the smallest cup size (AAA) with hormones alone, and only 3.6% achieve greater than A cup after one year (de Blok et al., 2018). A prospective study found 71% achieved less than A cup after three years, leading approximately two-thirds of transgender women to pursue augmentation (Vuurman et al., 2021). WPATH SOC 8 recommends a minimum of 12 months of feminizing hormones before augmentation, though 2–3 years more realistically maximizes hormonal development and allows the skin envelope to stretch for better outcomes (Coleman et al., 2022). ### Augmentation Techniques and Anatomy **Implant selection:** Silicone implants are strongly preferred due to natural feel and lower rippling — critical given limited overlying breast tissue. Failure rates are approximately 0.5% per year versus 2% for saline (Patel et al., 2021). **Placement:** Typically submuscular (subpectoral) for better concealment, reduced rippling, and lower capsular contracture rates. **Incision:** Most commonly inframammary, allowing the surgeon to release and reposition the typically high natal male inframammary fold. Transgender women present distinct anatomical features: broader chest, widely spaced nipples, smaller areolas, limited skin envelope, and higher inframammary fold. Ask specifically about transgender patient volume during consultations — a surgeon who excels with cisgender augmentation may produce mediocre results without understanding these differences. **Fat grafting** is increasingly used as an adjunct or standalone procedure but has 30–50% fat resorption rates, making it best for refinement rather than primary augmentation. --- ## Nonbinary and Gender-Expansive Options Formal literature remains limited, but clinical practice has advanced significantly. Research confirms comparable outcomes for binary and nonbinary patients (Roblee et al., 2024). **Radical reduction** creates a significantly smaller, flatter chest while deliberately retaining some tissue — distinct from complete masculinization or standard cosmetic reduction. **Customization** includes larger NAC (25–30mm vs. masculine standard 20–22mm), positioning closer to chest meridian, controlled tissue retention creating small "mounds," and even foregoing NAC reconstruction entirely — 21.9% of nonbinary patients choose no nipples versus 3.6% of binary trans men. Surgeons recognized for nonbinary expertise include Dr. Scott Mosser (San Francisco), Dr. Charles Garramone (Florida), and Dr. Sidhbh Gallagher (Miami). > [!tip] Consultation tip > Ask: "Have you performed non-standard chest surgery before? Can you show me photos of non-flat results?" A surgeon who responds with confusion probably isn't the right fit. --- ## Candidacy and Preparation ### Health Requirements Most surgeons require stable or well-managed mental health, medical clearance, realistic expectations, capacity to consent, and a support system for recovery. Having depression doesn't disqualify you — being in active crisis might mean delaying until you're stable enough to recover well. ### BMI Considerations Many surgeons historically imposed BMI cutoffs of 30 or 35. A Johns Hopkins 2023 study of 2,317 patients found BMI is a "poor metric" for determining candidacy, with current evidence calling cutoffs "not empirically based" and noting they "disparately impact TGNC and racial/ethnic minority communities" (Rothenberg et al., 2021). Seek surgeons who evaluate candidacy individually. ### Smoking and Healing Smoking is the most important modifiable risk factor. Nicotine constricts blood vessels, increasing revision rates (OR=1.73), dramatically increasing nipple graft failure risk, and delaying wound healing. Complete cessation for a minimum of 4 weeks before surgery is required — including vaping, patches, and nicotine gum (Sørensen, 2012). ### Mental Health Assessment WPATH SOC 8 requires one letter from a qualified mental health professional. Importantly, **hormone therapy is not required before chest surgery** — a key distinction from many bottom surgery requirements. ### Physical Preparation and Binding In the weeks before surgery: complete pre-op testing, fill prescriptions in advance, prepare your recovery space, arrange a caregiver for at least the first week, practice sleeping on your back, and stop NSAIDs (1–2 weeks), herbal supplements affecting bleeding (2 weeks), nicotine (4+ weeks), and alcohol (48–72 hours). Those who bind should stop 2–4 weeks before surgery to allow skin recovery. This period can be psychologically difficult — plan loose, layered clothing and limit social situations requiring presentation. --- ## Recovery and Healing ### First 48 Hours Expect chest numbness from local anesthetic, moderate pain, grogginess, significant swelling, drains in place (for masculinizing surgery), and tight compression. Sleep elevated at 45 degrees, keep arms at your sides, and take short walks for circulation. A caregiver is essential. ### Weeks 1–6 **Week 1:** No lifting over 5 pounds, back sleeping only, short walks. Drains removed when output falls below 30 mL/day (typically 5–10 days). First post-op appointment at 7 days for dressing removal. **Weeks 2–3:** Light desk work may resume. Driving cleared at 2–3 weeks. Begin scar care once incisions are fully closed (~3 weeks). **Weeks 4–6:** Lifting limit increases to 25 pounds. Physical labor typically cleared at 4–6 weeks. Most discontinue compression at 6 weeks. > [!note] Post-surgical depression is common and normal during this period — contributed to by anesthesia effects, pain medication, and limited mobility. Most patients find mood stabilizes as physical recovery progresses. ### Months 2–12 Swelling continues decreasing over 4–6 months. Scars are most raised/pigmented at ~3 months, then begin softening. Full exercise typically cleared at 6 weeks, swimming at 4–6 weeks, contact sports at 3 months. Final results assessment is appropriate at 12 months. Sensation that has not returned by 18–24 months is likely permanent. --- ## Nipple and Sensation Considerations **Free nipple grafts** (double incision): Approximately 98% complete graft survival at experienced centers. Up to 100% initial loss of erotic sensation; about 48.3% experience permanent complete sensation loss. Protective sensation (pressure, temperature) returns in the majority over 6–24 months (Bustos et al., 2021). **Pedicle-preserving techniques:** Approximately 85% retain some sensation, with better preservation of both protective and erotic sensation. **Targeted nerve reinnervation (TNR)** is an emerging technique that reconnects severed nerves to the nipple graft. Early research shows promising restoration of sensation at 12 months (Rochlin et al., 2024). Not yet widely available. **Options after nipple loss or for those choosing no grafts:** Surgical reconstruction using local flaps, 3D nipple tattooing (highly realistic with skilled artists), or no reconstruction — which research associates with higher satisfaction scores among nonbinary patients (Roblee et al., 2024). --- ## Common Complications | Complication | Rate | Key Points | |-------------|------|------------| | **Hematoma** | 5.4–21% | Most common immediate complication; watch for rapid unilateral swelling | | **Seroma** | 0.7–36.4% | Fluid collection; small ones reabsorb, larger ones aspirated in clinic | | **Infection** | 0–4.8% | Increasing redness, warmth, fever; treated with antibiotics | | **Nipple necrosis** | Complete: 0.6–5.6%; Partial: 0–11.1% | Smoking is biggest modifiable risk factor | | **Dog ears** | 15–20% | Excess tissue at incision ends; minor revision after 12+ months | | **Capsular contracture** (augmentation) | 3–3.62% | Scar tissue tightens around implant; may require revision | | **Implant malposition** (augmentation) | 4.51% | Higher than cisgender rates, likely due to anatomical differences | | **Wound dehiscence** | Variable | More common at tension points; managed with wound care | Most revisions are minor procedures addressing aesthetic concerns rather than serious complications. --- ## Scar Management Scars evolve predictably: most red and raised at 1–3 months, gradually softening through 6–12 months, with final appearance at 12–18 months. Patience is essential — scars at 3 months often look dramatically better at 12. **Silicone sheeting or gel** — first-line treatment. Begin when wounds are fully closed (~2–4 weeks). Wear 12–24 hours daily for 2–6 months. **Scar massage** — begin at ~3 weeks. Use circular motions and perpendicular friction with moderate pressure, 5 minutes per session, 2–3 times daily for the first 3 months. **Sun protection** — strict SPF 30+ for at least 12 months. UV exposure can permanently darken healing scars. **Scar tattooing** — medical tattooing can blend scars with skin tone (wait for maturity at 12–18 months). Many individuals also incorporate scars into decorative tattoo designs. **Revision surgery** should wait until 12–18 months post-surgery. Immature scars continue to change; premature revision may produce suboptimal results. --- ## Long-Term Outcomes and Satisfaction The evidence is remarkably positive. Satisfaction reaches 92% (95% CI 88–96%) across transmasculine patients and 75–100% for augmentation, with 100% reporting quality-of-life improvement (Bustos et al., 2021; Hager et al., 2022). Mental health outcomes include lower psychological distress (aOR=0.58) and lower suicidal ideation (aOR=0.56) (Bränström & Pachankis, 2020). Regret rates are among the lowest in medicine: less than 1% for chest masculinization versus 14–21% for the average surgical intervention — making gender-affirming surgery regret 7–14 times lower than average (Bustos et al., 2021). Beyond statistics, patients describe: moving through the world without constant chest awareness, eliminating binding discomfort, comfort with intimacy previously avoided, and simple pleasures like swimming shirtless, wearing fitted clothing, and looking in a mirror. For many, top surgery represents the single most impactful step in their transition. --- ## Insurance and Access Virtually all major insurance companies now recognize transgender-related care as medically necessary. 96% of surveyed insurers cover masculinizing chest surgery, though only 68% cover feminizing augmentation due to "cosmetic" classification challenges. Twenty-four states plus DC prohibit transgender exclusions in health insurance. **Coverage requirements:** One mental health letter, documented gender dysphoria, capacity to consent. Hormone therapy is not required before chest surgery. **Prior authorization** typically takes 15–30 business days. Common denial reasons include missing documentation, "cosmetic" classification, and out-of-network providers. **Appeals work.** Gender Confirmation Center reports 90% success in securing approval through appeal. Don't accept an initial denial as final. **Self-pay costs (2024–2025):** Double incision $14,000–$17,000; periareolar/keyhole $8,000–$12,000; feminizing augmentation $8,000–$15,000. Additional costs include pathology, prescriptions, compression garments, scar care products, travel, and lost wages. Organizations like Point of Pride offer grants for top surgery. --- ## Choosing a Surgeon **Board certification** by the American Board of Plastic Surgery (ABPS) is the gold standard. "Cosmetic surgeon" does not equal board-certified plastic surgeon — verify credentials at plasticsurgery.org. **Experience matters.** Ask: How many of this specific procedure have you performed? What are your complication and revision rates? Request before/after photos of patients with similar body types at 1 year, not just early post-op. **During consultation, consider:** Does the surgeon listen to your specific goals? Are they comfortable with nonbinary outcomes if relevant? What is their approach to nipple sizing and placement? What is their revision policy? > [!warning] Red flags > Lack of board certification, surgery in non-accredited facilities, high-pressure sales tactics, claims of zero risk, immediate availability (experienced surgeons book 3+ months out), no portfolio, consultation only by assistants, persistent wrong pronouns, and dismissiveness about your goals. --- > [!tip] Related Pages > - [[Phalloplasty]] — masculinizing genital construction using tissue flaps > - [[Metoidioplasty]] — masculinizing genital construction using testosterone-enlarged clitoris > - [[Vaginoplasty (PIV, PPT, Colo)|Vaginoplasty]] — penile inversion, peritoneal, or colovaginoplasty > - [[How to Prepare for Gender Affirming Surgery]] — practical pre-op checklist > - [[Bottom Surgery Aftercare Shopping List]] — community-built recovery supplies list > - [[A Comprehensive Resource on Adult Hormone Replacement Therapy|HRT Guide]] — testosterone, estrogen, and intersex-specific HRT > - [[Global Resource Directory]] — providers, funding, and information across 10+ countries --- ### References 1. Bränström, R., & Pachankis, J. E. (2020). Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries. *American Journal of Psychiatry*, 177(8), 727–734. [https://doi.org/10.1176/appi.ajp.2019.19010080](https://doi.org/10.1176/appi.ajp.2019.19010080) 2. Bustos, V. P., et al. (2021). Regret after gender-affirmation surgery: A systematic review and meta-analysis. *Plastic and Reconstructive Surgery Global Open*, 9(3), e3477. [https://doi.org/10.1097/GOX.0000000000003477](https://doi.org/10.1097/GOX.0000000000003477) 3. Coleman, E., et al. (2022). Standards of care for the health of transgender and gender diverse people, version 8. *International Journal of Transgender Health*, 23(Suppl 1), S1–S259. [https://doi.org/10.1080/26895269.2022.2100644](https://doi.org/10.1080/26895269.2022.2100644) 4. de Blok, C. J. M., et al. (2018). Breast development in transwomen after 1 year of cross-sex hormone therapy. *The Journal of Clinical Endocrinology & Metabolism*, 103(2), 532–538. [https://doi.org/10.1210/jc.2017-01927](https://doi.org/10.1210/jc.2017-01927) 5. Gender Confirmation Center. (2024). Periareolar top surgery and inverted T top surgery guides. [https://www.genderconfirmation.com](https://www.genderconfirmation.com) 6. Hager, S., et al. (2022). Complications and satisfaction in transwomen receiving breast augmentation. *Archives of Gynecology and Obstetrics*, 306(6), 2155–2162. [https://doi.org/10.1007/s00404-022-06603-3](https://doi.org/10.1007/s00404-022-06603-3) 7. Patel, H., et al. (2021). Chest feminization in male-to-female transgender patients: A review. *Transgender Health*, 6(5), 244–255. [https://doi.org/10.1089/trgh.2020.0057](https://doi.org/10.1089/trgh.2020.0057) 8. Roblee, C. V., et al. (2024). Patient-reported outcomes following gender-affirming chest surgery: Binary vs. nonbinary. *Plastic and Reconstructive Surgery Global Open*, 12(11), e6297. [https://doi.org/10.1097/GOX.0000000000006297](https://doi.org/10.1097/GOX.0000000000006297) 9. Rochlin, D. H., et al. (2024). Targeted reinnervation during gender-affirming mastectomy and restoration of sensation. *JAMA Surgery*, 159(12), 1388–1395. [https://doi.org/10.1001/jamasurg.2024.4121](https://doi.org/10.1001/jamasurg.2024.4121) 10. Rothenberg, S. S., et al. (2021). Body mass index requirements for gender-affirming surgeries are not empirically based. *Transgender Health*, 6(3), 129–133. [https://doi.org/10.1089/trgh.2020.0068](https://doi.org/10.1089/trgh.2020.0068) 11. Sørensen, L. T. (2012). Wound healing and infection in surgery: The impact of smoking. *Annals of Surgery*, 255(6), 1069–1079. [https://doi.org/10.1097/SLA.0b013e31824f632d](https://doi.org/10.1097/SLA.0b013e31824f632d) 12. Vuurman, M. A., et al. (2021). Long-term follow-up and trends in breast augmentation in 527 transgender women: A 30-year experience. *Journal of Plastic, Reconstructive & Aesthetic Surgery*, 74(9), 2096–2102. [https://doi.org/10.1016/j.bjps.2021.02.012](https://doi.org/10.1016/j.bjps.2021.02.012) 13. Wilson, S. C., et al. (2018). Masculinizing top surgery: A systematic review of techniques and outcomes. *Annals of Plastic Surgery*, 80(6), 679–683. [https://doi.org/10.1097/SAP.0000000000001354](https://doi.org/10.1097/SAP.0000000000001354)