Transgender healthcare is any and all healthcare that supports transgender people in their health and well-being. It can include primary care, as well as specialized medical care or gender-affirming care that supports their gender transition or gender affirmation goals. Transgender healthcare can include gender-affirming hormone therapy (GAHT, sometimes called HRT), gender-affirming surgery including feminine facialization surgery (FFS), top surgery, breast augmentation and other surgeries, emotional support, mental health services, peer support, reproductive medicine, and other types of care.
What are your options for top surgery? How do you plan to pay for the procedures you want? Are there rules and recommendations? Do you want to keep your nipples? You may have lots of questions about top surgery—whether you’re looking for a more feminine chest or hoping to look more masculine. Here are some common terms, definitions, and questions you may have about top surgery:
TABLE OF CONTENTS
- Top surgery
- Top surgery for trans men or trans masculine people
- Masculinizing surgery
- Feminizing surgery
- Nonbinary chest surgery
- Chest surgery
- Breast augmentation
- Breast implants
- Breast removal, reduction, or reconstruction
- Types of top surgery
- Types of surgical incisions in masculinizing chest surgery
- Chest tattoos
- Nipple placement
- Nipple removal
- Nipple sensitivity after surgery
- Skin care for top surgery
- Recovering from top surgery
- Activity limitations before and after top surgery
- Pain medications after top surgery
- What’s the difference between top surgery and mastectomy?
- How much does top surgery cost?
- How long do I have to be on hormones before I can get top surgery?
- How can I get top surgery covered by insurance?
- How long after top surgery will I feel normal?
- Does top surgery hurt?
- When can I stop wearing a chest binder?
Top surgery is a gender-neutral name for a gender-affirming surgery that removes or augments breast tissue and often reshapes or respositions the nipple. Top surgery reconstructs the chest to look more masculine, androgynous, or feminine and is sometimes called a chest masculinization or chest feminization. Other words folks use for top surgery include mastectomy and breast augmentation. Some surgeons will require a certain amount of time on testosterone or estrogen before top surgery, but clinics vary. Top surgery is typically an outpatient procedure (you can leave the hospital the same day) and healing occurs over a period of weeks and months.
Top surgery for trans men or trans masculine people
Top surgery for trans men, transmasculine people, or others who want to affirm their gender with a flatter chest generally includes removing breast/chest tissue. It is sometimes called FTM top surgery. It also typically includes reshaping, repositioning, or making the nipples smaller (nipple grafts). Some people choose to remove their nipples entirely. Some common types of top surgery are known as keyhole, buttonhole, double incision (DI), inverted-T or T-anchor, and peri areolar.
Any surgical procedure that makes someone look more masculine falls into this category of surgery. This can include top surgery, bottom surgery, phalloplasty, jaw implants, certain types of facial fillers, liposuction, and other body sculpting procedures. Masculinizing top surgery is sometimes also called subcutaneous mastectomy or male/masculinizing chest contouring.
Any surgical procedure that makes someone look more feminine falls into this category of surgery. This can include breast augmentation, bottom surgery, orchiectomy, jaw shaving, certain types of facial fillers, liposuction, and other body sculpting procedures.
Nonbinary chest surgery
Since every nonbinary person defines their own gender expression, there is no one-size-fits all surgery for nonbinary folks. Nonbinary chest surgery includes top surgery, breast reduction surgery, and breast augmentation.
This term describes any type of surgery that changes the look of someone’s chest and includes top surgery, mastectomy, and breast augmentation.
Breast augmentation is an aesthetic surgery that creates the look of breasts using silicone or gel implants. Top surgery for trans women, transfeminine people, or others who want to affirm their gender with a more feminine-looking chest generally includes implanting, reshaping, repositioning, or augmenting the breast/chest tissue. It is sometimes called MTF top surgery. It also typically includes reshaping and repositioning the nipples (nipple grafts). Some people choose to remove their nipples entirely.
Some people choose to transfer fat from one part of their body to their chests in order to create breasts. This is called “fat grafting.” Others use medical implants. Using silicone or saline to augment breast size is a multi-step process called “lipofilling.” After inserting a thick pouch under the chest or pectoral muscles—either through incisions in the armpit area or a small incision in the belly button—the pouches are filled. This happens slowly over multiple visits so the skin has time to stretch and recover. The pouches or implants can be adjusted to the desired size in most cases to give a feminine, curvy look.
Because estrogen, progesterone, and T blockers can all stimulate breast growth, the WPATH Standards of Care recommend that anyone seeking breast augmentation as a gender-affirming top surgery take E for one year or more.
Small, contoured pouches of silicone, gel, or another body-safe material that are inserted under the chest or pectoral muscles. Breast implants make someone’s breasts look larger, fuller, or more lifted depending on their placement.
Breast removal, reduction, or reconstruction
Not everyone calls their chest by the same terms. For some people, the word “breast” may not be their preferred term or may cause gender dysphoria. In the surgical field, “breast” is not considered a gendered term, as every person has breast tissue. Surgeons sometimes refer to top surgery and mastectomy as breast removal, reduction, or reconstruction.
A treatment for breast cancer or other health issues, mastectomy is the total removal of all breast tissue. This procedure can be preventative for people who have the BRCA gene, a gene receptor that dramatically increases the likelihood of developing breast cancer. Often, people who undergo a mastectomy also get breast implants.
Types of top surgery
“Top surgery” is a general term that describes gender-affirming surgery on the chest. Top surgery is considered an aesthetic surgery that helps someone align their appearance with their gender identity and alleviate gender dysphoria. It can include breast augmentation, mastectomy, breast reduction, or masculinizing surgery.
Types of surgical incisions in masculinizing chest surgery
Trans men, transmasculine people, nonbinary people, FTM folks, and others who want a more masculine appearance may all want this type of top surgery. When you meet with your surgeon for a consultation, you will let them know your desired outcome. This includes the size and shape of your chest, whether you would like to keep your nipples, and what incisions will be used. Some types of incisions and procedures are:
Keyhole – a small incision is made around the lower half of the areola. Breast tissue is removed through this incision. The ultimate scar is fairly inconspicuous and rounded to the edge of the nipple. It is recommended for people with small breasts and firm skin.
Concentric circle – a variation of the Keyhole technique that removes a “donut” of skin around the areola to remove excess skin at or within the margin of the areola. (It’s also called the periareolar, circumareolar, or donut technique.) This technique is used when there is some excess skin present and/or a large areola that needs to be reduced in size.
Lollipop – a circular incision around the areola is combined with a vertical incision which extends down the chest from the underside of the areola. This incision removes a moderate amount of skin and can resize the areola. The lollipop incision surgery technique is not used frequently because it is designed for people who have a little extra skin tissue, want to leave their nipples in the same position, and are not candidates for a concentric circle incision.
Double incision free nipple graft – an incision is made in or near the crease at the bottom of the breast and the nipples and areolas complexes are removed, trimmed to the desired stage, and then grafted back onto the newly reshaped chest. This process combines breast tissue removal with the removal of a large amount of skin. Double incision free nipple graft incision is used for moderately sized or larger breasts and those with substantial excess skin excess or skin that is very lax. This incision creates the types of bold, horizontal chest scars that you may have seen folks sporting in photos or at the beach!
Inverted “T” – an incision is made around the areola and then down to and along the crease at the lower part of the breast, making a T or anchor shape. (This type of incision is commonly used in most breast reduction procedures but is less commonly used in top surgery because it creates the look of smaller breasts instead of a mound shape.) With the inverted T, the nipples can either stay where they are on the chest or be removed and repositioned.
Buttonhole – The buttonhole procedure is used as an alternative to the inverted-T. In the buttonhole, there is one incision made around the areola and a second incision made along the crease at the lower part of the breast. However, there is no vertical incision connecting the two. The buttonhole removes less skin and does not reposition the nipple and areola. It creates a mound-like shape (as opposed to a breast-type shape) on each side of the chest.
Fish mouth – this incision goes around the nipple and extends into a short incision on either side of the areola, making the shape of a fish’s mouth. This incision removes unwanted chest tissue and results in a flatter chest, may preserve more nipple sensation, and has a very non-traditional incision location, across the mid-level of the chest.
While you may have aesthetic preferences about scar placement and shape, the surgeon will ultimately decide what types of incisions are appropriate for your top surgery. This decision is based on your initial breast or chest size, your skin’s degree of laxity (how much it droops or its reflexiveness), the size and location of your areola, and the shape of your chest wall.
Some people who get top surgery get chest tattoos to cover, highlight, or decorate their chests. Tattoos can cover scars and make them less obvious or can be a decorative addition.
As part of top surgery, you may get to decide whether to keep your nipples and where your nipples will go on your newly reshaped chest. Most top surgery retains the nerve structures of the nipple. Your surgeon will mark your chest to show the position of your nipples prior to your top surgery.
Some people don’t want to keep their nipples when they get top surgery, so they opt to have them removed during the procedure. If you decide to keep your nipples, it is very common to have them resized so they are in proportion to your new chest. When the surgeon makes the incision in your chest, your nipples can be reduced in size at the same time by extending the incision around the whole areola (nipple area) and removing a “donut” of skin.
Nipple sensitivity after surgery
Top surgery, mastectomy that preserves the nipples, and breast augmentation all affect the nerve structures of the chest. Many people retain most of their nipple sensitivity after surgery, but it can take a while for sensation to return.
Skin care for top surgery
Preparing for surgery is more than just paperwork. While bottom surgery happens below the belt and internally, you can take good care of your skin and body to ensure that you are ready for your procedure. Healthy skin and bones heal faster, so think of your self-care routine as an investment in your future wellness! Skin care before and after surgery can prevent keloid scarring as well. Proper hydration, using moisturizer, and taking a multivitamin can all help you get ready for your upcoming procedure. Follow your surgeon’s guidance and learn more about skin care here.
Recovering from top surgery
Top surgery is a major surgery, so recovering will take time—up to six weeks for some people. Many people sleep sitting up while they’re healing. It’s important to take a break from physical activity, including exercise, cooking, or any activity that stresses the chest. Follow your surgeon’s guidance to get the most out of your healing and give your body a chance to settle into its new shape.
Activity limitations before and after top surgery
Prior to top surgery, there are no activity limitations unless specified by your surgeon. Obviously, you should try to avoid illness and injury prior to surgery—you don’t want to have to reschedule because you got hurt doing something! After top surgery, you will need to rest for at least ten days before returning to gentle exercise, such as slow walking. Six weeks after surgery, most people are able to start lifting weights. If you’re a swimmer, ask your doctor when you can get back in the water!
Pain medications after top surgery
Since gender-affirming surgery is a major medical procedure, pain management is important to the healing process. Opioids, acetaminophen, ibuprofen, ice packs, and other comfort measures can help you get through the first week. Talk to your doctor about your pain needs to make a plan.
What’s the difference between top surgery and mastectomy?
Top surgery is an aesthetic procedure that reshapes the chest to align with someone’s gender expression. Often, surgeons leave some breast tissue as well as nipples in order to create a natural look. Mastectomy is the removal of all breast tissue and in some cases, the nipples as well. This can be confusing, since “mastectomy” in a surgical setting simply means “removal of breast tissue.” Make sure your surgeon understands your reasons and desired results for your top surgery.
How much does top surgery cost?
There is no set price for top surgery. Top surgery for trans men, transmasculine people, FTM folks, and nonbinary people can range from $6,000 to $10,000, not including anesthesia and aftercare. Breast augmentation for trans women, transfeminine people, MTF folks, and nonbinary people can range from $8,000-$9,500, not including anesthesia and aftercare. Breast augmentation can happen in multiple stages. After the initial surgery, there would be a second or even third appointment to slowly expand the implants and ensure that your breasts look the way you want.
Top surgery is not usually a procedure where you would need to stay in the hospital overnight, but some people do hire a nurse to help them while they are recovering. People who travel out of town or to another country to have their surgery would pay travel costs, including hotel, meals, and transportation. Some people use insurance to pay some or all of their top surgery costs. Others crowdfund, pay out of pocket, or rely on gender-affirming grants.
How long do I have to be on hormones before I can get top surgery?
The short answer: it depends. Some surgeons require their patient to be on hormones for at least one year, since the body changes dramatically while using GAHT. The WPATH Standards of Care state that the criteria for any gender-affirming top surgery are:
Persistent, well-documented gender dysphoria;
Capacity to make a fully informed decision and to consent for treatment;
Age of majority in a given country (if younger, follow the SOC for children and adolescents);
If significant medical or mental health concerns are present, they must be reasonably well controlled.
The Standards of Care recommend that people who want breast augmentation (implants/lipofilling) as gender-affirming top surgery undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. This is suggested because taking E or other medications will maximize breast growth and help obtain better surgical (aesthetic) results.
The criteria for top surgery for trans men, transmasculine people, nonbinary folks, and FTM people are different. This type of masculinizing top surgery does not come with the recommended prerequisite of gender-affirming hormone therapy. This may vary from surgeon to surgeon—some doctors say that being on T for a year or more will change the texture of your breast tissue, shift your body fat, and give you a more masculine appearance. This would support a better surgical outcome.
If hormones are not appropriate for your gender identity, it is possible to bypass this requirement with a letter from your doctor.
How can I get top surgery covered by insurance?
Every insurance plan is different, so check your plan’s coverage for gender-affirming surgery. You may also need to work with a primary care doctor, get a letter of support for the procedure you want, and find a surgeon who knows how to perform top surgery.
How long after top surgery will I feel normal?
Many people say they feel intense gender euphoria when they wake up from surgery. Even before the bandages come off, they feel happy in a completely new way. Most people experience pain and discomfort for the first few days after surgery, but can get back on their feet within two weeks. Everyone’s experience is different—so don’t rush yourself.
Does top surgery hurt?
Top surgery is performed under anesthesia, so you will be unconscious during the procedure. The recovery period can be uncomfortable and even painful for some people. Your doctor will offer you medications to manage your pain. Some people say that the drains, tape or bandages, and general soreness are more painful than the incisions themselves. Luckily, the healing period for top surgery is relatively short and most people are back to pain-free living within a month.
When can I stop wearing a chest binder?
You will need to wear your binder or a stiff medical binder for several weeks after your top surgery. This helps support your chest while you are healing and keep your skin and tissues in place. If you’re trans masc and used to wearing a binder, this step might feel like overkill, but it’s actually really important! You may have less to compress, but wearing a medical binder helps flatten your chest as it heals. It may also support you if you need to use drains or have a lot of bandages, gauze, or pads covering your incisions. When your surgeon has completed your post-op check-up and given you the all-clear, you can stop wearing your chest binder.