Top Surgery—A Comprehensive Guide for All Bodies#

Introduction: Who This Guide Is For#

Top surgery is one of the most common gender-affirming surgical procedures, yet conversations about it often default to a single narrative: trans men getting mastectomies. The reality is far more expansive. This guide 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 speaks clearly: top surgery achieves remarkably high satisfaction rates—92% pooled 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.

That phrase—a body that feels like home—appears throughout this book because it captures something that clinical language cannot. Gender-affirming surgery isn't about meeting external expectations or fitting into someone else's categories. It's about waking up in the morning and recognizing yourself. It's about moving through the world without the constant weight of your body betraying who you are. For many people, top surgery represents the single most impactful step in their transition—sometimes more so than any other intervention.

This chapter provides comprehensive, evidence-based information on all top surgery pathways. It covers surgical techniques in detail, honest complication rates, realistic recovery timelines, and practical guidance on access and surgeon selection. The information draws from peer-reviewed literature, WPATH Standards of Care Version 8 (Coleman et al., 2022), and clinical protocols from major surgical centers.

Understanding Top Surgery: Goals and Outcomes Across the Spectrum#

Different Goals for Different People#

Top surgery encompasses any surgical modification of the chest for gender-affirming purposes. The specific goals vary enormously, and understanding this variety matters—both for individuals trying to articulate what they want and for providers who need to listen beyond assumptions.

Masculinization creates a flat, typically male-appearing chest contour. This may include complete removal of breast tissue, repositioning of the nipple-areola complex to a masculine location, and contouring to emphasize pectoral definition. The goal is often not just flatness but a specifically masculine chest aesthetic—one that looks natural in fitted shirts, at the beach, in intimate moments.

Feminization creates or enhances breast tissue, typically through augmentation with implants. Goals often include achieving proportionate breast size, feminine breast shape, and natural-appearing cleavage. For transgender women, this surgery addresses what hormone therapy often cannot achieve on its own—research shows that less than half of transgender women develop even the smallest cup size with hormones alone.

Androgynous or nonbinary outcomes deliberately avoid binary endpoints. Someone might want a flatter chest without complete masculinization, smaller breasts without male-typical flatness, or an aesthetic that reads as deliberately ambiguous. A 2024 comprehensive 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 anymore—it's nearly half of all chest surgery patients.

The expanding understanding of who seeks top surgery reflects broader shifts in how gender is understood and expressed. Traditional gatekeeping assumed a linear narrative: assigned female at birth, identifies as male, seeks masculinization. But bodies and identities are more complex than that. Someone assigned male at birth might seek chest modifications that don't align with either "man" or "woman." Someone might want different things for their chest than for the rest of their body. The surgical community is slowly catching up to this reality—though as with so much in trans healthcare, patients often have to educate their providers.

Aesthetic Versus Functional Goals#

Beyond appearance, top surgery addresses functional concerns that non-trans people rarely consider. Chest binding—common among transmasculine and nonbinary individuals—carries real risks: skin irritation, breathing restriction, rib pain, and in some cases rib fractures with prolonged use. Many people bind for years before surgery becomes accessible. For them, surgery eliminates not just dysphoria but the daily health burden of compression.

Dysphoria relief remains the primary motivation for most patients. Research demonstrates that chest dysphoria specifically—rather than general body dissatisfaction—predicts surgical pursuit, and surgery effectively addresses this targeted distress (Donaldson et al., 2022). This distinction matters because it counters the narrative that gender-affirming surgery is about cosmetics or conformity. It's about addressing a specific, documented form of distress that other interventions cannot resolve.

The functional impact extends beyond physical health. 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.

Surgical Approaches for Chest Masculinization#

Chest masculinization surgery removes breast tissue to create a masculine or gender-neutral chest contour. The choice of technique depends primarily on chest size, skin elasticity, and aesthetic goals. No single technique is universally "best"—the right choice depends on the individual body and what outcomes matter most to that person.

Double Incision with Free Nipple Grafts#

The double incision with free nipple grafts (DI-FNG) is the most commonly performed technique, used in 80-90% of chest masculinization cases (Wilson et al., 2018). This approach involves two horizontal incisions along the inferior pectoralis border, complete removal of breast tissue and excess skin, and repositioning of the nipple-areola complex as a full-thickness graft.

This technique works well for those with medium-to-large chest size (typically B cup or larger), significant ptosis (Grade 2-3 breast sagging), excess skin requiring removal, poor skin elasticity, or priority on achieving maximally flat results. In practice, this describes most people seeking chest masculinization—which is why double incision dominates.

The surgical process typically takes 2-4 hours under general anesthesia. The surgeon makes bilateral incisions following the natural curve of the pectoral muscles, removes all breast tissue including the tissue extending toward the armpit (the axillary tail), and carefully contours the remaining tissue to create masculine chest definition. The nipples are removed as full-thickness grafts, resized to masculine proportions (typically 20-22mm diameter), and secured in their new position with bolster dressings.

Bilateral drains are placed and remain for approximately 5-10 days, removed when output falls below 30 mL per 24 hours. Post-operative compression is worn continuously for 4-6 weeks (UCSF Transgender Care, 2023).

Results are highly predictable with experienced surgeons. The technique accommodates virtually any chest size and achieves consistently flat outcomes. The tradeoff is bilateral chest scars and significant or complete loss of nipple sensation. That tradeoff deserves honest consideration—scars fade substantially over 12-18 months, but sensation loss is often permanent. For most patients, the relief of living in a flat chest far outweighs these concerns. But "most" isn't everyone, and those for whom sensation matters deeply should explore pedicle-preserving alternatives.

Periareolar and Keyhole Techniques#

Periareolar and keyhole techniques preserve significantly more sensation by keeping the nipple-areola complex attached to its blood and nerve supply rather than grafting it.

Keyhole surgery involves a small incision at the areola border through which breast tissue is removed via liposuction and direct excision. The technique requires an A cup or smaller chest size, excellent skin elasticity, minimal ptosis, and small areolas that do not require resizing. That's a narrow candidacy window—which is why keyhole represents a small minority of chest masculinization procedures.

Periareolar (circumareolar) surgery uses a donut-shaped incision around the areola, allowing removal of more tissue and some skin tightening through purse-string closure. Candidacy extends to A cup to small B cup with good skin elasticity, mild ptosis, and desire for areola resizing. This widens the eligible population somewhat, but still excludes most people seeking chest surgery.

These pedicle-preserving techniques cannot remove significant excess skin or dramatically reposition the nipples. When performed on patients outside candidacy criteria, they result in higher revision rates—up to 55% for periareolar versus 8.8% for double incision (Gender Confirmation Center, 2024). That's not a small difference. Surgeons who push pedicle techniques on patients with larger chests often do so because patients request it, hoping to avoid scars. The reality is that revision surgery creates its own scars—and the psychological toll of an unsatisfactory first result can be significant.

However, for appropriate candidates, pedicle techniques offer superior sensation preservation, with approximately 85% retaining some nipple sensation compared to much lower rates with free nipple grafts. The calculation is simple: if you're a strong candidate for keyhole or periareolar and sensation matters to you, these techniques are worth serious consideration. If you're borderline or outside candidacy, the higher revision risk usually makes double incision the wiser choice.

Inverted-T (Anchor) Technique#

The inverted-T technique preserves the nipple-areola complex on an inferior pedicle while still allowing extensive tissue and skin removal. The name refers to the scar pattern: a horizontal incision along the inframammary fold with a vertical incision extending upward to the areola.

This approach offers 60-80% pre-existing nipple sensation retention while accommodating larger chest sizes than periareolar techniques (Gender Confirmation Center, 2024). It particularly suits patients prioritizing sensation preservation, plus-sized patients with larger chests, those seeking nonbinary outcomes with some chest volume maintained, and individuals with significant ptosis who want to avoid free nipple grafts.

The tradeoff is more extensive scarring than double incision alone, with the additional vertical scar. For some, this is worth the sensation preservation. For others, the aesthetic impact of the anchor scar outweighs the sensation benefit. There's no universal answer—only the answer that fits each person's priorities.

Comparison: Helping You Choose#

Technique	Best For	Sensation	Revision Rate	Scar Pattern
Double incision with FNG	B+ cup, excess skin, priority on flatness	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

The consultation process should help clarify which technique fits your anatomy and goals. A good surgeon will be honest about candidacy rather than promising outcomes that your body can't deliver. If a surgeon says you're a candidate for keyhole when you wear a C cup, seek a second opinion.

Surgical Approaches for Chest Feminization#

The Reality of Hormonal Breast Development#

Breast augmentation for transgender women addresses a biological reality that can be deeply frustrating: hormone therapy alone produces limited breast development for most individuals. Research demonstrates that less than 50% of transgender women achieve even the smallest cup size (AAA) with hormone therapy alone, and only 3.6% achieve greater than A cup after one year of feminizing hormones (de Blok et al., 2018). A prospective study found 71% achieved less than A-cup after three years of hormone therapy, leading approximately two-thirds of transgender women to pursue augmentation (Vuurman et al., 2021).

This isn't a failure of patience or technique—it's biology. Estrogen-driven breast development depends on factors including genetics, age at hormone initiation, and individual hormone sensitivity. Some transgender women develop substantial breasts; most do not. Understanding this reality helps set appropriate expectations and validates the choice to pursue augmentation.

WPATH SOC8 does not set a universal 12-month feminizing-hormone requirement before breast augmentation. When hormones are desired and clinically appropriate, time for hormonal development can inform individualized planning, while surgeons and insurers may have their own requirements (Coleman et al., 2022). Two to three years may allow further hormonal development for some people, but it is not a SOC8 prerequisite or a guarantee of a particular surgical result.

Breast Augmentation Techniques#

Implant selection significantly affects outcomes. Silicone implants are strongly preferred for transgender breast augmentation due to their natural feel and lower rippling visibility—critical considerations given limited overlying breast tissue in most transgender women. Current silicone implants have failure rates of approximately 0.5% per year compared to 2% per year for saline (Patel et al., 2021).

Implant placement is typically submuscular (subpectoral) due to the paucity of glandular tissue in transgender women. This placement provides better implant concealment, reduced visible rippling, lower capsular contracture rates, and upper pole shaping from pectoralis major coverage. Essentially, when there's limited natural tissue to cover the implant, the muscle provides that coverage instead.

Incision approach is most commonly inframammary (in the fold beneath the breast). This approach allows the surgeon to release and reposition the typically high, ill-defined natal male inframammary fold—a critical step for achieving natural-appearing results. Other approaches (periareolar, transaxillary) are less commonly used in transgender augmentation because they provide less access for the fold repositioning that most transgender patients need.

Anatomical Considerations Unique to Transgender Women#

Transgender women present distinct anatomical features that experienced surgeons must address. The chest is typically broader with stronger pectoralis muscles. Nipple-areola complexes tend to be widely spaced and laterally positioned. Areolas are often smaller and more ovoid than the typical cisgender female presentation. The skin envelope is usually limited, constraining implant size options. And the inframammary fold sits higher and is less defined than in cisgender women.

Implant sizes have increased over time as surgical techniques have evolved—median 275cc in 1990-1999 to 375cc in 2010-2019 (Vuurman et al., 2021). However, insufficient skin envelope may limit options for some patients, making adequate time on hormone therapy before surgery particularly important. Rushing to surgery before the skin has stretched limits what's possible.

The surgeon's experience with transgender anatomy specifically matters here. Breast augmentation is common in plastic surgery, but transgender augmentation requires different considerations. A surgeon who performs excellent augmentation on cisgender women may produce mediocre results on transgender women if they don't understand these anatomical differences. Ask specifically about transgender patient volume during consultations.

Additional Feminizing Procedures#

Breast lift (mastopexy) may be combined with augmentation for patients with significant ptosis, though this is less common in transgender women given typically limited pre-existing breast tissue.

Nipple and areola feminization can include enlargement of the areola through grafting or tattooing, though many surgeons find that implant projection alone adequately feminizes the nipple-areola appearance. This may be worth discussing if your areolas are significantly smaller or differently shaped than desired.

Fat grafting is increasingly used as an adjunct to implant augmentation or as a standalone procedure. It can address contour irregularities, improve cleavage, and create more natural upper pole transition. However, fat resorption rates of 30-50% mean results are less predictable than with implants alone. Fat grafting works best for refinement rather than as a primary augmentation strategy.

Nonbinary and Gender-Expansive Top Surgery Options#

An Emerging Field#

The landscape of nonbinary chest surgery represents one of the most rapidly evolving areas in gender-affirming care. Formal literature remains limited—researchers and clinicians have historically assumed binary outcomes—but clinical practice has advanced significantly as more patients articulate goals that don't fit traditional categories.

Research comparing binary and nonbinary patients undergoing chest surgery found comparable outcomes across psychosocial measures, validating nonbinary surgical pathways (Roblee et al., 2024). This validation matters because it counters the concern that nonbinary patients might be "confused" or regret non-standard outcomes. The data shows they don't regret at higher rates than binary patients—they simply wanted something different, and they're satisfied when they get it.

The challenge is often finding surgeons willing and skilled enough to deliver non-standard results. Many surgeons have developed techniques optimized for binary outcomes—completely flat for transmasculine patients, fully augmented for transfeminine patients. Asking for something in between can be met with confusion, resistance, or simply lack of technique.

Partial Masculinization: Radical Reduction#

"Radical reduction" creates a significantly smaller, flatter chest—distinct from complete masculinization or standard cosmetic reduction. The goal is going from larger cup sizes to very small while deliberately retaining some tissue. This might be someone who doesn't identify as male but experiences dysphoria about their chest size—they want smaller, not flat. Or someone who wants an ambiguous chest that doesn't read as clearly male or female.

Techniques employed include modified Wise-pattern reduction preserving more tissue than typical masculinization, inverted-T with customized tissue retention, buttonhole techniques leaving "mounds" of breast tissue, and liposuction-only approaches for smaller chests seeking modest reduction. The technical details matter less than the principle: the surgeon works with the patient to define a specific outcome rather than assuming binary endpoints.

Customization Options#

Surgeons experienced with nonbinary patients offer extensive customization across multiple dimensions.

For the nipple-areola complex, options include larger and rounder NAC (25-30mm versus male standard 20-22mm), positioning closer to chest meridian rather than lateral masculine placement, or foregoing NAC reconstruction entirely. That last option—no nipples—might seem unusual, but 21.9% of nonbinary patients versus 3.6% of binary trans men choose it (Roblee et al., 2024). Some people simply don't want nipples. Their chest, their choice.

For contour, options include controlled tissue retention creating small "mounds," asymmetrical results for those who want them, and buttonhole or fishmouth techniques preserving some central fullness. The key is that these are deliberate outcomes, not surgical failures—the surgeon and patient agree in advance on what they're creating.

Interestingly, research found that absence of nipple-areola grafts was associated with higher chest satisfaction scores, validating this choice for those who prefer it (Roblee et al., 2024). This finding challenges assumptions about what bodies should look like.

Surgeons Specializing in Nonbinary Approaches#

Dr. Scott Mosser (Gender Confirmation Center, San Francisco), Dr. Charles Garramone (Florida), and Dr. Sidhbh Gallagher (Miami) are among surgeons recognized for nonbinary expertise. Dr. Garramone reports that 40-50% of current patients identify as nonbinary, reflecting broader demographic shifts in who seeks chest surgery.

Finding a surgeon who truly understands nonbinary goals requires specific questions during consultation: Have you performed non-standard chest surgery before? Can you show me photos of non-flat results? Are you comfortable with the specific outcome I'm describing? A surgeon who responds with confusion or tries to redirect you toward binary outcomes probably isn't the right fit.

Literature Gaps and Future Directions#

Significant gaps exist in formal research. No published studies address chest feminization or neutral chest options for assigned-male-at-birth nonbinary individuals—estimated to be one-third of the nonbinary population. Long-term outcomes beyond 1-2 years remain limited across all nonbinary procedures. No standardized nomenclature exists for "non-flat" techniques, making it difficult to compare outcomes across surgeons or research studies. Insurance coding and coverage for explicitly nonbinary procedures remains unclear.

These gaps don't mean nonbinary chest surgery is experimental or risky—it means the research community hasn't caught up with clinical practice. Surgeons are performing these procedures successfully; researchers just aren't studying them systematically yet.

Insurance Challenges for Nonbinary Patients#

Plans with transgender benefits often require binary gender identification in documentation. Therapists must sometimes navigate requirements using binary language for approval, even when patients identify otherwise. This creates an uncomfortable situation: using inaccurate language to access medically necessary care.

However, research found that self-identifying as genderqueer/nonbinary (versus transgender) was actually associated with lower likelihood of surgery denials, suggesting that nonbinary identity itself does not create additional insurance barriers when documentation is properly prepared. The challenge is more about binary-coded documentation requirements than explicit discrimination against nonbinary patients.

Working with a therapist experienced in insurance navigation—and a surgeon's office accustomed to prior authorization—can help bridge the gap between nonbinary identity and binary documentation requirements.

Candidacy and Preparation#

Health Requirements#

Most surgeons require stable mental health or well-managed mental health conditions, medical clearance addressing any chronic conditions, realistic expectations about outcomes, capacity to consent and understand risks, and a support system for the recovery period.

These requirements are generally reasonable—surgery requires the ability to participate in your own care and recover safely. The key word is "managed" rather than "absent": having depression doesn't disqualify you from surgery, but being in active crisis might mean delaying surgery until you're stable enough to recover well.

BMI Considerations and the Evidence Against Arbitrary Cutoffs#

Many surgeons historically imposed BMI cutoffs of 30 or 35 for top surgery candidacy. These cutoffs persist in some practices despite growing evidence against them.

A Johns Hopkins 2023 study of 2,317 patients found that "BMI is a poor metric for determining who should be approved for chest masculinization surgery," with slightly increased minor complications but very low serious complication rates across BMI ranges. Georgetown University research found acute complications comparable for patients with and without obesity (Rothenberg et al., 2021).

Current evidence suggests BMI cutoffs are "not empirically based" and "disparately impact TGNC and racial/ethnic minority communities who have higher average BMIs" (Rothenberg et al., 2021). This is a justice issue as much as a medical one—arbitrary cutoffs exclude people who could safely undergo surgery.

Patients facing BMI-based denials should consider seeking surgeons who evaluate candidacy individually rather than applying arbitrary cutoffs. Some surgeons will perform top surgery at any BMI with appropriate medical clearance; others maintain cutoffs regardless of evidence. Shopping around may be necessary.

Smoking and Healing#

Smoking represents the most important modifiable risk factor for top surgery complications. Nicotine constricts blood vessels, reducing oxygen delivery to healing tissues. This increases revision rates (OR=1.73, p=0.048), dramatically increases nipple graft failure risk, delays wound healing, and increases infection risk.

Cessation for a minimum of 4 weeks before surgery reduces wound-healing complications (RR 0.69); 8 or more weeks reduces respiratory complications (RR 0.53) (Sørensen, 2012). Most surgeons require complete nicotine cessation including vaping, patches, and nicotine gum—any form of nicotine causes vasoconstriction.

This requirement isn't arbitrary gatekeeping. Smoking genuinely increases the risk that your nipple grafts will fail, your incisions will dehisce, and your scars will heal poorly. If you smoke and want the best possible surgical outcome, quitting is the single most impactful thing you can do.

Mental Health Assessment#

WPATH SOC8 recommends assessment by a health-care professional competent in transgender health; it does not universally require one letter from a mental health professional for top surgery. If written documentation is required, SOC8 says one assessment letter from a competent health-care professional can be sufficient. A surgeon, program, or insurer may request different documentation, so confirm the requirements that apply to your care (Coleman et al., 2022).

Importantly, hormone therapy is not required before chest surgery—a key distinction from many bottom surgery requirements. You don't need to have taken testosterone to get chest masculinization, and you don't need to have taken estrogen to get breast augmentation (though adequate time on estrogen improves augmentation outcomes as discussed earlier).

The letter requirement is often experienced as gatekeeping, and there's legitimate debate about whether it should exist. But in the current system, it's required. Finding a therapist experienced with gender-affirming care can make this process feel supportive rather than adversarial.

Physical Preparation#

In the weeks before surgery, complete all required pre-operative testing (labs, EKG if indicated, chest imaging if requested). Fill prescriptions in advance—you won't want to visit a pharmacy the day after surgery. Prepare your recovery space with supplies within easy reach. Arrange caregiver coverage for minimum 24-48 hours, ideally the first week. Practice sleeping on your back if you're not accustomed to it—you won't be able to sleep on your side or stomach for weeks. Wash with antibacterial soap as directed.

Stop the following before surgery: blood thinners and NSAIDs (aspirin, ibuprofen, naproxen) typically 1-2 weeks before; herbal supplements that affect bleeding (fish oil, vitamin E, ginkgo, garlic) 2 weeks before; nicotine products minimum 4 weeks before (longer is better); alcohol 48-72 hours before.

Chest Binding Considerations#

Those who bind should stop binding for 2-4 weeks before surgery to allow skin to recover and reduce inflammation. This period can be psychologically difficult—you've been binding for a reason, and stopping before surgery feels like going backward. Planning loose, layered clothing and limiting social situations requiring presentation may help manage this transition period.

Long-term binding may affect skin elasticity, potentially influencing technique selection. Honest discussion with the surgeon about binding history ensures appropriate technique choice. If you've bound for years with tight binders, mention this—it may affect whether periareolar techniques are viable.

The Surgical Process: What Happens in the Operating Room#

Day of Surgery#

Patients arrive 1-2 hours before scheduled surgery time for check-in, verification, and pre-operative preparation. An IV is placed for fluids and medications. The surgical team confirms identity, procedure, and any final questions.

The anesthesiologist administers general anesthesia. For most top surgery procedures, patients are fully asleep throughout. The surgical team positions the patient, preps the surgical site with antiseptic solution, and drapes the chest.

The moment before going under can feel surreal—everything you've been working toward is about to happen. Some people feel calm; others feel terrified. Both are normal.

Double Incision Specifics#

Operating time: 2-4 hours

The surgeon marks incision lines following the inferior border of the pectoralis muscle, typically extending from near the sternum to the anterior axillary line. After making incisions, the surgeon creates skin flaps, carefully preserving the superficial vascular network. All breast tissue is removed including the axillary tail, and the tissue is sent to pathology. The surgeon achieves hemostasis (stops bleeding) meticulously—hematoma is the most common complication.

If performing free nipple grafts, the surgeon removes the nipple-areola complex, trims it to desired size (typically 20-22mm for masculine results), and secures it with bolster dressings. Bilateral drains are placed, typically Jackson-Pratt style. The surgeon closes incisions in layers and applies compression dressing or garment.

Periareolar and Keyhole Specifics#

Operating time: 1.5-3 hours

For keyhole, the surgeon makes a small incision at the inferior areola border, performs liposuction to remove fatty tissue, and directly excises glandular tissue through the limited incision. The nipple remains attached to its pedicle throughout.

For periareolar, the surgeon makes two concentric circular incisions around the areola, removes the donut-shaped segment of skin between them, excises breast tissue directly, and closes with a purse-string suture that tightens the skin around the (now smaller) areola opening.

Feminizing Augmentation Specifics#

Operating time: 1-2 hours

The surgeon makes the inframammary incision and creates the implant pocket, releasing the lower pole attachments to lower the inframammary fold to an appropriate feminine position. A partial release of the pectoralis major origin creates a dual-plane pocket. The surgeon irrigates the pocket with antibiotic solution, inserts sizers to confirm appropriate implant selection, places final implants using a no-touch technique to minimize contamination risk, closes in layers, and applies surgical bra or light compression.

Intraoperative Complications Managed#

Complications during surgery are uncommon with experienced surgeons but may include bleeding requiring additional hemostasis, unexpected tissue findings (rare tumors discovered incidentally), anesthesia-related issues (nausea, airway management), and positioning injuries (nerve compression, pressure injuries—prevented through careful padding and positioning).

Recovery and Healing#

Immediate Post-Operative Period (First 24-48 Hours)#

You will likely experience complete chest numbness from local anesthetic (which wears off over 12-24 hours), moderate pain most intense during this period, grogginess and possible nausea from anesthesia, significant swelling and early bruising, drains in place collecting fluid (for masculinizing surgery), and a tight compression garment or surgical bra.

Sleep on your back with head and chest elevated 45 degrees. Keep your arms at your sides—no lifting anything. Use the bathroom with assistance initially. Short walks around the house are encouraged for circulation and to prevent blood clots.

Pain management typically involves a multimodal approach: scheduled acetaminophen with prescribed opioids for breakthrough pain. Ice packs (with barrier to protect skin) may help swelling. Some surgeons use long-acting local anesthetic blocks that provide 48-72 hours of reduced sensation.

A caregiver is essential for minimum 24 hours, ideally through the first week. They assist with medication management, drain care and output recording, meals and hydration, bathroom assistance initially, and emotional support during vulnerable early recovery. If you don't have someone who can be there, discuss this with your surgeon's office before surgery—some areas have paid surgical companions available.

First Two Weeks#

Activity restrictions are significant: no lifting over 5 pounds, sleeping on back only (side sleeping typically permitted at 2 weeks with surgeon approval), short walks (under 15 minutes) encouraged with gradual increase, no raising arms above shoulder level, no driving until off pain medications and able to safely operate vehicle (typically 1-2 weeks), and no work for most patients (sedentary desk work may resume at 1-2 weeks with limitations).

For masculinizing procedures with drains, empty and record output twice daily. Strip drain tubing gently to maintain patency. Keep drain bulbs compressed to maintain suction. Watch for signs of infection at drain sites. Drains are removed when output falls below 30 mL per day for 1-2 consecutive days (typically 5-10 days).

Drain removal is quick and causes brief discomfort described as a "pulling" or "burning" sensation—uncomfortable but over in seconds. Some surgeons offer drain-free techniques using progressive tension sutures; these report comparable or lower seroma rates in experienced hands.

The first post-operative appointment is typically at 7 days for "the big reveal"—dressing removal and first look at surgical results. External sutures are often removed at this visit or at a follow-up between days 7-14. The surgeon assesses healing, checks for complications, and provides updated activity guidance.

That first look in the mirror can be overwhelming. Even through swelling and bruising and drain tubes, many people experience profound relief—this is what I've been waiting for. Others feel disoriented or uncertain. Both responses are normal. Your body has just undergone major surgery; give yourself time to adjust.

Weeks Three Through Six#

Gradual return to activities becomes possible. Light desk work is typically permitted from week 2 with limitations. Driving is usually cleared at 2-3 weeks. Physical labor and manual work typically wait until 4-6 weeks. Lifting limit increases to maximum 25 pounds. No upper body weight-bearing exercise (push-ups, lifting, etc.) yet.

Compression garment continues, with some surgeons allowing transition to a softer garment at week 3. Most discontinue compression at 6 weeks with surgeon clearance. Compression helps reduce swelling, supports healing tissues, and may improve scar appearance.

Scar care begins once incisions are fully closed (typically 3 weeks). Apply silicone sheeting or gel daily. Begin gentle scar massage (detailed in scar management section). Maintain strict sun protection.

Post-surgical depression is common and normal during this period. Contributing factors include anesthesia effects, pain medication, limited mobility, and the psychological weight of a major life event. Most patients find mood stabilizes as physical recovery progresses. If depression persists or intensifies, reach out to your mental health provider.

Months Two Through Six#

Continued healing occurs throughout this period. Swelling continues decreasing over 4-6 months; some subtle swelling may persist up to 1 year. Scars are most pigmented and raised at approximately 3 months, then begin softening. Sensation may begin returning, particularly for pedicle-preserving techniques.

Return to full activity becomes possible. Full exercise and gym activities are typically cleared at 6 weeks. Swimming may be permitted once incisions are fully healed (typically 4-6 weeks). Contact sports and activities with chest impact risk should wait until 3 months.

Continue scar massage 2-3 times weekly through this period. Consistent effort during the first 6 months yields the best long-term scar outcomes.

Six to Twelve Months and Beyond#

Complete scar maturation requires 12-18 months. During this time, scar color fades from red/pink to pale pink/white, scar texture flattens and softens, and scar width stabilizes.

Sensation that has not returned by 18-24 months is likely permanent. This timeline applies to both protective sensation (pressure, temperature) and erotic sensation.

Final results assessment is appropriate at 12 months. Revisions should generally not be performed until scar maturation is complete, as immature scars continue to change and premature revision may produce suboptimal results.

Nipple and Areola Considerations#

Nipple Grafting in Double Incision Surgery#

Free nipple grafts survive through a predictable biological process. During days 1-3 (plasmatic imbibition), the graft absorbs nutrients from wound fluid. During days 3-7 (inosculation and revascularization), new blood vessel connections form. During days 7-14, the graft stabilizes and bolster dressings are typically removed.

Complete graft survival reaches approximately 98% at experienced centers (Bustos et al., 2021). When complications occur, total nipple necrosis affects 0.6-5.6% and partial necrosis affects 0-11.1%.

Risk factors for graft failure include smoking (which dramatically increases risk), diabetes, autoimmune conditions, higher BMI, hematoma formation beneath the graft, and bolster dislodgement or inadequate immobilization.

If graft failure occurs, partial necrosis often heals with conservative wound care, leaving a smaller but viable nipple. Total necrosis may be addressed with healing by secondary intention (no nipple reconstruction), nipple reconstruction surgery at a later date, or 3D nipple tattooing for appearance without projection.

Sensation Outcomes#

Sensation outcomes differ substantially by technique.

With double incision and free nipple grafts, up to 100% initial loss of nipple erotic sensation occurs. About 48.3% experience permanent complete sensation loss (Bustos et al., 2021). Protective sensation (pressure, temperature) returns in the majority of patients over 6-24 months. Erotic sensation return is less predictable and often incomplete.

With pedicle-preserving techniques, approximately 85% retain some nipple sensation. Better preservation of both protective and erotic sensation occurs, though sensation may still be altered from pre-surgical baseline.

An emerging technique called targeted nerve reinnervation (TNR) reconnects severed intercostal nerves to the nipple graft and shows promising results. Early research reports that the majority of patients achieve complete restoration of nipple sensation, chest light touch, temperature sensation, and erogenous sensation at 12 months (Rochlin et al., 2024). This technique is not yet widely available but represents a significant advance for those prioritizing sensation.

Nipple Reconstruction Options#

For those who lose nipples to necrosis or choose not to have nipple grafts initially, several options exist.

Surgical reconstruction uses local flap techniques to create projection using surrounding chest skin. This is typically performed as an outpatient procedure under local anesthesia and may require tattooing afterward for color.

Tattooing for appearance creates realistic nipple appearance without projection through 3D nipple tattooing. This requires skilled tattoo artists specializing in paramedical work. Touch-ups may be needed over time as tattoo fades. Results can be highly realistic or deliberately stylized based on preference.

Deciding About Nipples#

Some individuals choose no nipple reconstruction, finding the flat chest aesthetic preferable or simply not prioritizing nipples in their embodiment. Research found that absence of nipple-areola grafts was associated with higher chest satisfaction scores among nonbinary patients, validating this choice (Roblee et al., 2024).

Questions to consider: How important is nipple appearance to my sense of embodiment? How important is nipple sensation? Would I be comfortable with no nipples if graft failure occurred? Do I want masculine-sized, feminine-sized, or differently sized nipples?

Sensation and Sexual Response#

Chest Sensation Changes#

Beyond nipple-specific sensation, the entire chest undergoes sensory changes after surgery.

After masculinizing surgery, the chest will be numb immediately. Protective sensation (awareness of pressure and temperature) typically returns over weeks to months, starting at the periphery and progressing toward the center and nipples. Areas of permanent numbness are common, particularly in the central chest and around incision lines.

After feminizing augmentation, temporary numbness around incisions and in the lower breast is common. Submuscular placement may cause temporary upper chest tightness. Most sensation returns within 3-6 months, though permanent subtle changes are possible.

Sexual Sensitivity#

The chest is an erogenous zone for many people, and changes to sexual sensitivity deserve honest discussion.

After masculinizing surgery with free nipple grafts, many patients experience significant or complete loss of erotic nipple sensation. This loss can be grieved even when surgery overall is affirming. Some find that sexual pleasure shifts to other areas of the body or that the psychological affirmation of a flat chest enhances sexual experience despite reduced physical sensation. The absence of dysphoria during intimacy may outweigh the loss of specific physical sensations.

After pedicle-preserving techniques, better preservation of erotic sensation typically occurs, though it may be altered from pre-surgical baseline.

After feminizing augmentation, most patients retain erotic sensation, though it may be temporarily diminished during healing. Some report enhanced sensation once healing is complete, possibly related to increased breast projection and skin stretch.

Timeline for Sensation Return#

Protective sensation begins returning within weeks and continues improving over 6-24 months. Erotic sensation, if it returns, typically follows protective sensation by several months. Sensation not present by 18-24 months is likely permanent.

Managing Sensation Loss#

For those who experience significant sensation loss, allow time to grieve if needed—this is a real loss even within an overall positive experience. Explore other erogenous zones that may become more prominent. Communicate with partners about changed sensation and what feels good now. Consider whether the psychological benefits of surgery outweigh the sensation changes (for most patients, they do).

Common Complications and Management#

Understanding complication rates enables informed decision-making and realistic expectations. Rates vary across studies due to differing definitions, follow-up periods, and patient populations.

Hematoma#

Hematoma is a collection of blood beneath the skin flaps, occurring when a blood vessel bleeds after closure. It affects 5.4-21% of masculinizing surgery patients across literature, making it the most common immediate complication and most frequent reason for unplanned return to operating room (Naides et al., 2022).

Risk factors include higher rates with limited/nipple-sparing incisions, possibly higher rates with testosterone use (though evidence is mixed), and blood pressure elevation in early post-operative period.

Signs and symptoms include rapid unilateral swelling (one side enlarging faster than the other), increasing pain on one side, tense firm feeling to the chest, and visible bruising spreading rapidly.

Small hematomas may be observed and will reabsorb over weeks. Surgical evacuation is indicated for significant swelling with increasing pain, expanding collections, compromise of skin flap viability, and potential risk to nipple graft survival.

Seroma#

Seroma is a collection of clear fluid (serum) in the surgical pocket. Incidence ranges from 0.7-36.4% depending on technique and whether drains are used.

Signs and symptoms include swelling that develops or persists after initial swelling resolves, a fluctuant (fluid-wave) feeling when palpated, and usually not painful unless very large.

Small seromas often reabsorb spontaneously over 2-4 weeks. Larger or symptomatic seromas are aspirated with a needle in clinic. Some may require multiple aspirations. Rarely, persistent seromas require drain placement.

Infection#

Infection affects 0-4.8% of masculinizing surgery cases. Risk factors include BMI (β=0.23, p=0.014), diabetes (OR=4.156, p=0.004), smoking, and poor wound care.

Signs and symptoms include increasing redness around incisions (beyond normal post-surgical pinkness), warmth, purulent (pus-like) drainage, fever, and worsening pain after initial improvement.

Minor infections are treated with oral antibiotics and close monitoring. Moderate infections may require IV antibiotics. Severe infections or abscess require surgical drainage, IV antibiotics, and possible hospital admission.

Nipple Necrosis#

Nipple necrosis is partial or complete death of the nipple graft due to inadequate blood supply. Complete loss affects 0.6-5.6%; partial necrosis affects 0-11.1% (Bustos et al., 2021).

Risk factors include smoking (most significant modifiable risk), diabetes, hematoma beneath the graft, bolster dislodgement, and excessive graft manipulation.

Signs to watch include color change (pale, dusky, or black), failure to pink up when bolster is removed, and separation of graft from wound bed.

Partial necrosis is managed with conservative wound care and often heals with smaller but viable nipple. Complete necrosis requires wound care until healed, with later reconstruction options if desired.

Wound Dehiscence#

Wound dehiscence is separation of the incision before complete healing. It's more common at points of tension (ends of incisions).

Risk factors include early excessive activity, poor nutrition, diabetes, smoking, and infection.

Minor dehiscence is managed with wound care and healing by secondary intention. Larger areas may require re-closure once infection is ruled out.

Dog Ears#

Dog ears are excess tissue creating bumps at the ends of incisions, typically near the armpits. They are the most common reason for revision after double incision, affecting up to 15-20% of patients.

Risk factors include larger tissue removal, higher BMI, and skin excess not addressed during primary surgery.

Dog ears can be revised in a minor outpatient procedure once scar maturation is complete (typically 12+ months). This is considered a revision rather than a complication per se—it's an expected possibility with certain body types.

Asymmetry#

Some degree of asymmetry is normal (human bodies are naturally asymmetric). Concerning asymmetry involves significant difference in nipple position or size, markedly uneven contour, or one side notably higher or lower than the other.

Revision may be considered for significant asymmetry after scar maturation is complete.

Complications of Feminizing Augmentation#

Capsular contracture occurs when the scar tissue capsule around the implant tightens abnormally. Incidence is 3-3.62% (Baker Grade III-IV) in transgender-specific studies, comparable to or lower than cisgender augmentation rates of 7.2% at 7 years (Hager et al., 2022). Management includes conservative approaches (massage, medication), capsulotomy, capsulectomy, or implant exchange.

Implant malposition/asymmetry has a pooled rate of 4.51% in transgender females—significantly higher than cisgender populations (p=0.004), likely related to anatomical differences (Hager et al., 2022). It may require revision surgery.

Implant rupture affects approximately 0.5% per year with modern silicone implants. It may be asymptomatic with silicone implants ("silent rupture"). It requires implant exchange.

Revision Rates Summary#

Overall revision rates provide context for expectations. Double incision has an 8.8% revision rate. Periareolar has up to 55% revision rate. Feminizing augmentation has approximately 16% secondary procedure rate over 30-year follow-up (Vuurman et al., 2021).

Most revisions are minor procedures addressing aesthetic concerns rather than serious complications.

Scar Management and Revision#

Understanding Scar Maturation#

Scars evolve predictably over time. During weeks 1-3, incisions heal, sutures are removed, and scar begins forming. During months 1-3, scars are most red, raised, and noticeable; they may feel firm or itchy. During months 3-6, gradual softening and fading begins. During months 6-12, continued improvement occurs. During months 12-18, scar maturation completes and final appearance is established.

This timeline means patience is essential. Scars that look concerning at 3 months often look dramatically better at 12 months. Avoid judging your results too early.

Silicone Sheeting#

Silicone sheeting represents the first-line, non-invasive gold standard recommended by plastic surgery societies (Jiang et al., 2021). Cochrane reviews find "weak evidence of benefit as prevention for abnormal scarring." Evidence is low-certainty but supports use.

Begin when wound is fully closed (typically 2-4 weeks post-op). Wear 12-24 hours daily. Continue for at least 2-3 months, up to 6 months. Adherence exceeding 16 hours/day correlates with better outcomes.

Silicone sheets (ScarAway, Mepiform, etc.) or silicone gel (applied daily) are equivalent in efficacy. Sheets are generally more effective for flat surfaces; gel works well for contoured areas.

Scar Massage#

Scar massage should begin approximately 3 weeks post-op, once incisions are fully closed (UCSF Transgender Care, 2023).

Use the pad of thumb or fingers directly on the scar. Apply pressure until skin blanches slightly. Use circular motions and perpendicular frictions. Move the tissue rather than sliding over it.

Perform 5 minutes per session, 2-3 times daily for the first 3 months. Continue 3-4 times weekly until scar matures.

Benefits include increased blood circulation to the area, breakdown of excess scar tissue, improved flexibility and reduced tightness, and possibly reduced chronic pain risk (Cambridge University Hospitals NHS, 2023).

Sun Protection#

Strict sun protection is critical for at least 12 months, preferably 18+ months. Healing scars are highly susceptible to hyperpigmentation; UV exposure can permanently darken them.

Apply SPF 30+ sunscreen to exposed scars. Reapply every 2 hours with sun exposure. Physical covering (clothing, tape) provides superior protection to sunscreen.

Scar Tattooing Options#

Medical/paramedical tattooing uses custom pigment matching to blend scar with surrounding skin tone. It requires skilled paramedical tattoo artists. Multiple sessions are typically needed. You must wait for scar maturity (12-18 months).

3D nipple/areola reconstruction creates realistic nipple appearance without projection. It's highly effective for those who lost nipples or chose no grafts. It's a specialized skill—seek artists with nipple reconstruction portfolios.

Decorative tattoos allow many individuals to incorporate chest scars into decorative tattoo designs. Scar tissue holds ink differently; experienced tattoo artists adjust technique. You may require more sessions and touch-ups than tattoos on non-scarred skin.

When Scar Revision Is Appropriate#

Surgical scar revision should generally wait until 12-18 months post-surgery, after scar maturation is complete (Thomas & Somenek, 2012). Immature scars (red, itchy, raised) should receive conservative treatment, not surgery.

Indications for revision include hypertrophic or keloid scarring not responding to conservative treatment, wide scars that would benefit from re-excision, dog ears or contour irregularities, and scar malposition affecting appearance.

Techniques include Z-plasty to reorient scars along relaxed skin tension lines, elliptical excision with meticulous closure, laser therapy, and intralesional steroids for hypertrophic/keloid scars.

Long-term Outcomes and Satisfaction#

What the Evidence Shows#

The evidence for top surgery outcomes is remarkably positive and consistent across studies.

Satisfaction rates are high. The pooled satisfaction rate is 92% (95% CI 88-96%) across 1,052 transmasculine patients (Bustos et al., 2021). Single-center studies report 90.5-99.7% satisfaction. Transgender breast augmentation shows 75-100% satisfaction, with 100% reporting quality of life improvement (Hager et al., 2022).

Quality of life improvements are documented through validated instruments. BODY-Q Chest Module mean satisfaction improved from 14.3 to 93.8 (p<0.001). Chest Dysphoria Measure improved 25.58 points. Transgender Congruence Scale improved 7.78 points. Psychosocial functioning improved from 35 to 79.2 (p<0.001). Sexual functioning improved from 33.9 to 67.2 (p<0.001).

Mental Health Outcomes#

In a secondary analysis of the 2015 U.S. Transgender Survey, respondents reporting one or more gender-affirming surgeries at least two years earlier had lower adjusted odds of past-month severe psychological distress (aOR 0.58) and past-year suicidal ideation (aOR 0.56) than respondents who desired surgery but had not had it (Almazan & Keuroghlian, 2021). These are adjusted observational associations, not causal percentage reductions. Bränström and Pachankis (2020) separately studied mental-health-treatment utilization in Sweden; its observational design also does not establish causal consequences.

These outcomes persist across studies using different methodologies and populations. This isn't a niche finding—it's a robust pattern across the research literature.

Regret Rates in Context#

Regret rates for gender-affirming surgery are among the lowest in medicine. A meta-analysis of 27 studies (n=7,928) found pooled regret prevalence of 1% (95% CI <1-2%), with mastectomy specifically at less than 1% (Bustos et al., 2021).

For comparison with other surgeries: gender-affirming mastectomy has less than 1% regret, breast reconstruction has 0-47.1%, cosmetic breast augmentation has 5.1-9.1%, body contouring has 10.82-33.3%, prostatectomy has approximately 30%, bariatric surgery has up to 19.5%, and the average for all surgical interventions is 14-21%.

Gender-affirming surgery regret rates are 7-14 times lower than the average for surgical interventions.

In the rare cases where regret occurs, factors associated include poor social/family support, difficulty with social acceptance, poor surgical outcomes, loss of sensation, and personality disorders. These factors point to the importance of support systems and realistic expectations, not to problems with surgery itself.

Living in an Affirmed Body#

Beyond statistics, the qualitative research captures what top surgery means to those who undergo it: the ability to move through the world without constant awareness of the chest; elimination of binding and its associated discomforts; comfort with intimate situations previously avoided; simple pleasures like swimming shirtless, wearing fitted clothing, looking in a mirror; and integration of physical embodiment with internal sense of self.

For many, top surgery represents the single most impactful step in their transition. The relief of waking up in a body that matches who you are—or at least comes closer—is difficult to capture in statistics. But the statistics confirm what patients report: this surgery works, and it works remarkably well.

Insurance, Access, and Choosing a Surgeon#

Current Insurance Landscape (2024-2025)#

Virtually all major insurance companies now recognize transgender-related care as medically necessary. Coverage has expanded dramatically over the past decade.

Coverage rates show that 96% of surveyed insurers cover masculinizing chest surgery. Only 68% cover feminizing breast augmentation (lower due to "cosmetic" classification challenges). This disparity reflects the historical classification of breast augmentation as cosmetic rather than medically necessary—a classification that doesn't reflect the real impact of chest dysphoria for transgender women.

Twenty-four states plus the District of Columbia prohibit transgender exclusions in health insurance. Only Arkansas (all ages) and Mississippi (minors) explicitly permit insurers to refuse coverage. The remaining states have no explicit policy, meaning coverage depends on individual plan language.

Recent legal developments show competing pressures. The Fourth Circuit ruled in April 2024 that state health plans must cover gender-affirming care. However, Idaho has prohibited public funding, and new HHS regulations affect ACA Essential Health Benefits definitions. The landscape continues to evolve.

Coverage Requirements#

SOC8 provides clinical assessment guidance rather than a universal top-surgery paperwork rule. If written documentation is required, one assessment letter from a competent health-care professional can be sufficient; the surgeon, program, and insurer determine their own documentation requirements (Coleman et al., 2022).

Notably, hormone therapy is not required before chest surgery—a key distinction from most bottom surgery requirements.

Common insurer criteria include documented gender dysphoria, mental health assessment confirming readiness, capacity to consent and understand risks, age of majority (18+) though some plans cover minors with parental consent, and managed coexisting mental health conditions.

Prior Authorization Process#

Prior authorization typically takes 15-30 business days for standard review (Harvard Health Publishing, 2023). Required documentation includes mental health letter(s), letter of medical necessity from surgeon, treatment history, and sometimes photos.

Common denial reasons include missing documentation, "cosmetic" classification (particularly for nipple grafts as separate procedure and for feminizing augmentation), out-of-network providers, and CPT code issues. See U.S. Insurance, Costs, and Documents for comprehensive guidance on the prior authorization process.

Appealing Denials#

Appeals success rates are high when denials are appropriately challenged—Gender Confirmation Center reports 90% success in securing approval through appeal. The takeaway: don't accept an initial denial as final. See U.S. Insurance, Costs, and Documents for detailed appeal strategies and documentation requirements.

Choosing a Surgeon#

Board certification by the American Board of Plastic Surgery (ABPS) is the gold standard. This requires 4 years medical school, 6 years surgical training, written and oral examinations, and ongoing maintenance of certification.

"Cosmetic surgeon" does not equal board-certified plastic surgeon. No ABMS-recognized board has "cosmetic surgery" in its name. Verify credentials at plasticsurgery.org.

Experience and volume matter. Experienced surgeons have performed hundreds to thousands of procedures. Ask: How many of this specific procedure have you performed? What is your complication rate? What is your revision rate?

Request before/after photos of patients with similar body types, chest sizes, and goals at different healing stages. Look for results at 1 year, not just early post-op. Look for variety of body types. Look for outcomes that match your aesthetic goals.

During consultation, consider: Does the surgeon listen to your specific goals? Are they comfortable with nonbinary or non-standard outcomes if that's what you want? What is their approach to nipple sizing and placement? What is their revision policy if results are suboptimal?

Red flags include lack of board certification or vague credentials, surgery performed in non-accredited facilities, high-pressure sales tactics or financing pushed aggressively, claims of zero risks or guaranteed perfect results, immediate availability (experienced surgeons typically book 3+ months out), no portfolio available or unwillingness to show results, consultation conducted only by assistants without surgeon involvement, persistent use of wrong pronouns after correction, and dismissiveness about your specific goals or concerns.

Cost Considerations#

Self-pay costs (2024-2025) for double incision run $14,000-$17,000. Periareolar/keyhole costs $8,000-$12,000. Feminizing augmentation costs $8,000-$15,000.

Additional costs include pathology examination (~$300+), prescriptions ($50-200), compression garments ($50-150), scar care products ($50-200 over healing period), travel and lodging if applicable, and 2-3 weeks lost wages for most occupations.

Several organizations offer grants for top surgery—Point of Pride provides free chest binders and operates a surgery fund, with additional programs available. See U.S. Insurance, Costs, and Documents for a comprehensive list of grant programs and application guidance.

Reflection Questions#

Before pursuing top surgery, consider:

What are my specific goals for my chest? Complete flatness? Augmentation? Something in between?
How important is nipple sensation to me? Would I choose a procedure with better sensation outcomes even if it meant higher revision risk?
How do I feel about visible scarring? Have I looked at many post-surgical photos at various stages of healing?
Do I have adequate support for the recovery period? Who will be my caregiver for the first week?
What are my expectations about how surgery will affect my daily life, my sense of embodiment, my mental health?
If I experienced a complication requiring revision, how would I cope emotionally and practically?
For nonbinary individuals: Have I clearly articulated my non-standard goals? Is my surgeon experienced with and receptive to these goals?
Am I making this decision from a place of self-knowledge rather than external pressure?
What questions remain unanswered that I need to address before proceeding?
Looking back from five years in the future, what would I want my past self to have considered?

References#

Bränström, R., & Pachankis, J. E. (2020). Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: A total population study. American Journal of Psychiatry, 177(8), 727-734. https://doi.org/10.1176/appi.ajp.2019.19010080

Bustos, V. P., Bustos, S. S., Mascaro, A., Del Corral, G., Forte, A. J., Ciudad, P., Kim, E. A., Langstein, H. N., & Manrique, O. J. (2021). Regret after gender-affirmation surgery: A systematic review and meta-analysis of prevalence. Plastic and Reconstructive Surgery Global Open, 9(3), e3477. https://doi.org/10.1097/GOX.0000000000003477

Bustos, S. S., Kuruoglu, D., Yan, M., Bustos, V. P., Forte, A. J., & Manrique, O. J. (2021). Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: A systematic review of techniques and outcomes. Annals of Translational Medicine, 9(7), 612. https://doi.org/10.21037/atm-20-4522

Cambridge University Hospitals NHS Foundation Trust. (2023). Scar massage information. https://www.cuh.nhs.uk/patient-information/scar-massage-information/

Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., ... Arcelus, J. (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

de Blok, C. J. M., Klaver, M., Wiepjes, C. M., Nota, N. M., Heijboer, A. C., Fisher, A. D., Schreiner, T., T'Sjoen, G., & den Heijer, M. (2018). Breast development in transwomen after 1 year of cross-sex hormone therapy: Results of a prospective multicenter study. The Journal of Clinical Endocrinology & Metabolism, 103(2), 532-538. https://doi.org/10.1210/jc.2017-01927

Donaldson, A., Hall, A., Neufeld, J., Obadah, V., Giknis, F., Xie, R., Margolin, G., Harlow, S., Buchanan, C., Dowshen, N., & Chen, D. (2022). Top surgery and chest dysphoria among transmasculine and nonbinary adolescents and young adults. JAMA Pediatrics, 176(11), 1060-1068. https://doi.org/10.1001/jamapediatrics.2022.2791

Gender Confirmation Center. (2024). Periareolar top surgery: Procedure, recovery & results. https://www.genderconfirmation.com/periareolar-top-surgery/

Gender Confirmation Center. (2024). The comprehensive guide to inverted T top surgery: Maintaining sensation and volume. https://www.genderconfirmation.com/inverted-t-top-surgery/

Hager, S., Wilflingseder, J., Gassner, E., & Gassner, R. (2022). Complications and satisfaction in transwomen receiving breast augmentation: Short- and long-term outcomes. Archives of Gynecology and Obstetrics, 306(6), 2155-2162. https://doi.org/10.1007/s00404-022-06603-3

Harvard Health Publishing. (2023). Prior authorization: What is it, when might you need it, and how do you get it? Harvard Medical School. https://www.health.harvard.edu/staying-healthy/prior-authorization-what-is-it-when-might-you-need-it-and-how-do-you-get-it

Jiang, Q., Chen, J., Tian, F., & Liu, Z. (2021). Silicone gel sheeting for treating hypertrophic scars. Cochrane Database of Systematic Reviews, 9, CD013357. https://doi.org/10.1002/14651858.CD013357.pub2

Movement Advancement Project. (2024). Healthcare laws and policies. https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies

Naides, A. I., Chen, A. D., Schechter, M., Bienstock, A., Bluebond-Langner, R., & Ascherman, J. A. (2022). Hematoma following gender-affirming mastectomy: A systematic review of the evidence. Journal of Plastic, Reconstructive & Aesthetic Surgery, 75(7), 2343-2351. https://doi.org/10.1016/j.bjps.2022.02.012

Patel, H., Samaha, Y., Ives, G., Chen, H., & Coon, D. (2021). Chest feminization in male-to-female transgender patients: A review of options. Transgender Health, 6(5), 244-255. https://doi.org/10.1089/trgh.2020.0057

Point of Pride. (2024). My insurance has denied my gender-affirming surgery. Now what? https://www.pointofpride.org/blog/my-insurance-has-denied-my-gender-affirming-surgery-now-what

Roblee, C. V., Heston, A., Ascha, M., Berli, J. U., Schechter, L. S., & Bluebond-Langner, R. (2024). Patient-reported and clinical outcomes following gender-affirming chest surgery: A comparison of binary and nonbinary transmasculine individuals. Plastic and Reconstructive Surgery Global Open, 12(11), e6297. https://doi.org/10.1097/GOX.0000000000006297

Rochlin, D. H., Brazio, P., Wapnir, I., & Nguyen, D. (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

Rothenberg, S. S., Becker, D., Englesbe, M. J., Sandberg, D., & Sood, R. (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

Sørensen, L. T. (2012). Wound healing and infection in surgery: The pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: A systematic review. Annals of Surgery, 255(6), 1069-1079. https://doi.org/10.1097/SLA.0b013e31824f632d

Thomas, J. R., & Somenek, M. (2012). Scar revision review. Archives of Facial Plastic Surgery, 14(3), 162-174. https://doi.org/10.1001/archfacial.2012.223

UCSF Transgender Care. (2023). Postoperative care and common issues after masculinizing chest surgery. University of California San Francisco Gender Affirming Health Program. https://transcare.ucsf.edu/guidelines/chest-surgery-masculinizing

Vuurman, M. A., van der Sluis, W. B., de Nie, I., Huang, S., Liberton, N., Nio, D., Djordjevic, M. L., Meijerink, W. J. H. J., & Bouman, M. B. (2021). Long-term follow-up and trends in breast augmentation in 527 transgender women and nonbinary individuals: A 30-year experience in Amsterdam. Journal of Plastic, Reconstructive & Aesthetic Surgery, 74(9), 2096-2102. https://doi.org/10.1016/j.bjps.2021.02.012

Wilson, S. C., Morrison, S. D., Anzai, L., Massie, J. P., Poudrier, G., Motosko, C. C., & Hazen, A. (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

Last updated February 19, 2026

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).

SOC8 does not prescribe a universal 12-month feminizing-hormone requirement before augmentation. When hormones are wanted and appropriate, time for development can inform individualized planning; surgeon and insurer requirements vary (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).

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#

SOC8 recommends assessment by a health-care professional competent in transgender health. If written documentation is required, one assessment letter from a competent health-care professional can be sufficient, while surgeon and insurer requirements vary. Hormone therapy is not a universal prerequisite for chest surgery (Coleman et al., 2022).

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.

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). In the 2015 U.S. Transgender Survey secondary analysis, people reporting gender-affirming surgery at least two years earlier had lower adjusted odds of severe psychological distress (aOR 0.58) and suicidal ideation (aOR 0.56) than people who desired surgery but had not had it (Almazan & Keuroghlian, 2021); the observational association does not establish causation.

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?

References#

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
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
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
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
Gender Confirmation Center. (2024). Periareolar top surgery and inverted T top surgery guides. https://www.genderconfirmation.com
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
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
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
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
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
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
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
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