Some transgender or nonbinary people have top surgery to alter the appearance of their chest to align with their gender identity.
Transgender men and nonbinary people may have transmasculine top surgery. This removes breast or chest tissue to give the chest a masculine or nonbinary appearance.
A medical name for this procedure is a “subcutaneous mastectomy.”
Transgender women and nonbinary people may have a procedure to increase the size and shape of their breasts with implants or lipofilling. A medical name for this procedure is breast augmentation.
This article looks at top surgery in more detail, including who might have it and what it may involve.
Top surgery can alter the appearance of the chest to align with a person’s gender identity.
People may have top surgery to help treat gender dysphoria. Gender dysphoria is a psychological condition. People with this condition experience distress due to the difference between their sex assigned at birth and their gender identity.
Transgender men or nonbinary people may have top surgery to remove breast tissue.
Transgender women or nonbinary people may have top surgery to increase the size of the breasts and otherwise alter their shape.
The World Professional Association for Transgender Health (WPATH) Standards of Care outline certain criteria for top surgery. They say this is to help protect the health and well-being of potential candidates.
For people to undergo top surgery, according to WPATH, they must meet these criteria:
- The person has persistent gender dysphoria that has been well-documented by a qualified mental health professional.
- They are able to make a fully informed decision and provide their consent for the treatment.
- They are the age of majority in their country — otherwise the standards of care for children and adolescents apply.
- Any preexisting, significant medical or mental health conditions are under reasonable control.
Hormone therapy is not a prerequisite for top surgery to remove breast tissue.
For people undergoing transfeminine top surgery, WPATH recommends having feminizing hormone therapy, or estrogen hormone therapy, for at least 1 year before the surgery, though this is not a set criteria. The aim is to help promote breast growth, and it may lead to better outcomes.
John Hopkins Medicine advises people who are considering top surgery to read through the WPATH Standards of Care and look for healthcare facilities that reference those standards.
A person may have an initial interview with a clinical specialist to discuss their medical history and any requirements. The next step may be a discussion with the surgeon to talk through the specifics of the procedure.
Before top surgery, a person has a consultation with their surgeon. The surgeon explains the procedures available and the advantages and disadvantages of different techniques, including the risks.
During the consultation, a person can expect to discuss:
- their transition process
- their surgical goals
- any medical conditions, including drug allergies
- any current medications or other treatments
- any previous surgeries
- evaluates the person’s general health
- examines their chest and breasts, taking measurements and examining the skin
- takes photographs
- discusses surgical options and outcomes
At a future consultation, a person can discuss their before and after photos with the surgeon.
People may find it helpful to speak with others who have undergone top surgery or to read firsthand accounts.
The American Society of Plastic Surgeons (ASPS) explains that transmasculine, or female-to-nonbinary, top surgery may involve these steps:
- The person receives a general anesthetic or intravenous sedative.
- The surgeon removes breast tissue and sometimes excess skin from the chest.
- They reposition any remaining tissue to create a masculine shape to the chest.
- In some cases, the surgeon may reposition or reduce the size of the nipple and areola.
There are different techniques, and the surgeon discusses each in detail with the person beforehand.
The chosen approach may depend on:
- the amount of breast or chest tissue
- the person’s desire for nipple sensation
- the amount of excess skin
Different techniques include:
|Keyhole||This involves making a small incision around the nipples to remove excess tissue and reduce the nipples’ size.|
|Peri-areolar||Peri-areolar top surgery may be suitable for people with smaller chests. |
A surgeon makes two circular incisions around the areolas to remove breast tissue, before resizing and replacing the areolas.
|Minimal scar||This less invasive technique may suit people who require minimal breast tissue removal. |
A surgeon makes a small incision at the side of the chest, and around part of each areola. They may then use liposuction to remove fat from the chest.
|Double incision||This involves removing tissue from two incisions across the left and right sides of the chest. The incisions highlight the natural pectoral muscles.|
|Inverted T||This method is similar to the double incision technique, but the surgeon makes an additional incision from the bottom of the areola to the incision along the pectoral muscle. |
This allows the surgeon to reduce each nipple’s size and reposition it without severing the nipple stalk. In this case, the person still has nipple sensation.
|Buttonhole technique||This involves making two incisions beneath the breasts and one around each areola. This allows the surgeon to remove breast tissue and excess skin.|
On each side, the surgeon then makes a circular incision for the new placement of the areola. They then move the nipple and areola into the new opening and secure them in place.
Transfeminine, or male-to-nonbinary, top surgery usually involves having breast implants.
The procedure may involve these steps:
- The person receives an intravenous sedative or a general anesthetic.
- The surgeon makes the incisions and places the implants in the chest.
- They close the incisions, and the person later recovers consciousness.
At an earlier consultation, the person and their surgeon discuss which type of implants are most suitable.
Alternately, the surgeon may use a technique called lipofilling. This involves having liposuction. Then, the surgeon moves the fat from elsewhere in the body into into the breasts to increase their size and otherwise change their shape.
To prepare for the surgery, a person needs to:
- have a letter of recommendation from their therapist
- stop smoking, if this applies
- avoid aspirin, herbal supplements, and anti-inflammatory drugs
- undergo testing and medical evaluations
It is important to follow the surgeon’s aftercare instructions.
For transmasculine top surgery, this may include:
- wearing support bandages around the chest to help reduce swelling and support the chest
- having a temporary tube attached to the chest to drain excess fluid
- attending any follow-up appointments, as necessary
It may take several weeks for the swelling to reduce and the chest to be the person’s desired shape.
For transfeminine top surgery, aftercare may include:
- wearing bandages or a support bra to reduce swelling and support healing
- attending any follow-up appointments, as necessary
It may take several weeks for the swelling to reduce and the breasts to reach the person’s desired shape.
The surgeon and other healthcare professionals should describe the risks of top surgery, which can include:
- loss of nipple sensation
- poor wound healing
Transmasculine surgery can also lead to the loss of the nipple and areola.
Additional risks of transfeminine surgery can include:
- an implant leak
- capsular contracture, the formation of scar tissue around an implant
- the need to replace or remove the implants in the future
- anaplastic large cell lymphoma, a rare type of non-Hodgkin lymphoma
The cost of top surgery may vary, depending on the facility, its location, and the experience of the surgeon.
Other factors that affect the cost include:
- the surgeon’s fee
- the anesthesia fees
- post-surgery garments
- tests and X-rays
Some insurance providers may cover some of the costs of transmasculine top surgery and some of the costs of transfeminine top surgery.
People in the United States can learn about what to look for in insurance coverage here.
People can find plastic surgeons who are board-certified members of the ASPS here.
Also, some surgeons are members of WPATH. This often means that they have undergone additional training in transgender medical care. A person can find surgeons who are members of WPATH here.
Organizations offering services, support, and resources for transgender and nonbinary people include:
- John Hopkins Medicine Center for Transgender Health
- University of California, San Francisco Transgender Care
- National Center for Transgender Equality
- Transgender Health Resources from the American Academy of Family Physicians
- Transbucket, which provides information about surgical transitions
- The Trevor Project, which offers an online support network for young LGBTQIA+ people
- the Trans Lifeline resource page
Below are answers to common questions about top surgery.
Is top surgery painful?
People may experience discomfort in the first few days after the surgery. People may be able to return to regular activities within 4–5 days.
However, it may be necessary to limit some physical activities to allow for optimal healing.
Is top surgery permanent?
As WPATH notes, top surgeries are irreversible. Full consent and understanding of the procedure is crucial.
How will top surgery change nipple sensation?
With the removal of breast tissue, people may lose some sensation in their chest. Over time, some nipple and chest sensation may return.
Loss of nipple sensation with breast implants is less common.
Some people have top surgery to alter the appearance of their chest so that it aligns with their gender identity.
Transfeminine, or male-to-nonbinary, top surgery involves changing the shape of the breasts with implants or lipofilling.
Transmasculine, or female-to-nonbinary, surgery involves removing breast or chest tissue.
Before a person has top surgery, they need to meet a set of requirements, such as having well-documented and persistent gender dysphoria.
People can consult transgender-friendly healthcare professionals to discuss surgery options and the desired outcomes.