Top Surgery vs Mastectomy: Understanding the Key Differences for Gender-Affirming and Medical Needs

Medically reviewed by Jennifer Richman on October 21, 2024.

What is Top Surgery?

Top surgery is a broad category of gender-affirming procedures intended to give a patient a greater sense of congruence between the appearance of their chest and their gender identity. A surgeon may reduce or increase chest volume depending on the patient’s goals. We will be discussing masculinizing top surgery, a form of chest reconstruction that is frequently requested by transmasculine and nonbinary patients. Top surgery techniques are diverse and address the many reasons behind seeking chest reconstruction. Procedures such as double incision or keyhole remove all tissue and create a flattened chest, while buttonhole or inverted-T simply reduce chest volume.

What is a Mastectomy?

A mastectomy is traditionally defined as the removal of all or part of one’s breasts.1 The most common reason one may need a mastectomy is due to malignant breast tissue or cancer prophylaxis. After a mastectomy is performed, some patients use chest reconstruction to restore breasts.

Top Surgery vs Mastectomy: Procedure Comparison

While both of these procedures involve removing chest tissue, there are significant differences in technique, goals, and final result. The primary goal of top surgery is to affirm an individual’s gender, and the main goal of a mastectomy is to excise tissue. Top surgery is not performed to restore physical health, but a mastectomy focuses on treating a physical ailment.

Reasons for Surgery

Top Surgery for Gender Affirmation

Top surgery addresses feelings of incongruence with one’s body and gender. There are many reasons one can undergo top surgery, from chest movement dysphoria to wanting your chest to have a more conventionally masculine appearance. Top surgery patients actively seek out this procedure and it carries a very low post–op regret rate. Please note that many insurance providers understand this surgery to be medically necessary as a means of treating persistent feelings of gender dysphoria. As a result, many transmasculine and non-binary patients can reduce the costs of top surgery through insurance coverage.

Mastectomy for Medical Necessity

A mastectomy is used as a treatment for malignant breast tissue or for preventative reasons. Patients who carry a certain BRCA genetic mutation or have a family history of breast cancer may wish to undergo a preventative mastectomy. The surrounding circumstances may not be as positive and affirming when compared to top surgery. Regardless, many patients and cancer survivors who experience a mastectomy feel pride over their chest and how it has reflected their fight with cancer.

Types of Procedures

Top Surgery Techniques

Top surgery techniques vary in final appearance, chest sensitivity, scarring and function. Embracing gender diversity opens the possibility for many forms of chest presentation. You can choose to remove all chest tissue or you may just want a reduction. You can choose to preserve your nipples, receive nipple grafts (to have greater control over their dimensions and position on the chest) or opt for no nipples. Patients can use medical tattooing to create nipples after surgery.

Mastectomy Techniques

Mastectomy techniques are categorized by the amount of breast tissue removed: total/simple, radical, or modified radical. A simple or total mastectomy involves full removal of breast tissue and lymph nodes, while radical mastectomy removes minimal tissue. A mastectomy may also be categorized as a double or bilateral mastectomy, which is the removal of both breasts.1

Many patients will choose to have further chest reconstruction to restore breasts. Patients may use medical tattooing or nipple grafting to feel more comfortable with how their chest looks.

You may notice that some techniques of top surgery are alternatively referred to as a total mastectomy on billing or paperwork. You may also see terminology on your paperwork and bills such as “masculinizing mastectomy” or “top surgery mastectomy”. These all simply mean that all breast tissue is removed.

Recovery

Recovery from a mastectomy and top surgery can look very similar. They are both usually outpatient procedures, so you can expect to be out of the hospital on the same day of your surgery.2 Depending on how much tissue is removed, you may go home with drains. If all is healing well, you can expect that at your follow-up appointment, drains will be removed.

Timeline

Around 68% of patients who undergo a mastectomy are able to return to work after approximately a month.3​​ The top surgery timeline is shorter, and you are able to return to work after one to two weeks with limitations on lifting. However, with both procedures if you undergo multiple procedures in one surgery, your recovery time will be longer. Certain types of mastectomy and top surgery may heal differently. For example, a double mastectomy is more intensive than a partial one.

In general, you should also avoid heavy lifting until about the six week mark. This will help you recover faster and minimize scarring and stretch marks. For information about recovering shoulder mobility after top surgery, you can check out our free physical therapy guide for patients here.

Complications

The removal of lymph nodes during a mastectomy may cause lymphedema, a form of post-operative swelling.4 Top surgery does not involve lymph node removal, so the risk for lymphedema is negligible, but top surgery does carry the risk of developing hematomas or seromas in the chest. Your surgeon can address these complications by various methods of draining. Other complications such as unfavorable scarring can usually be addressed by revisions after a full recovery is made.

Post-Op Impacts

Both surgeries can be taxing on the body and it is important to make considerations for yourself as you recover. Depending on the reasons you seek out surgery, post-op impacts can vary. This is especially true when looking at the differences between top surgery and mastectomy.

Changes to Nipple Sensation

Many mastectomy and top surgery techniques remove the nipple-areola complex from their original blood and nerve supply. As a result, patients who experienced nipple sensitivity before surgery often report that their nipples become desensitized depending on the type of procedure they undergo. Specifically, after recovery, nipples may only have a tactile level of sensitivity––meaning they feel similar to the skin at the top of the chest or sternum. Top surgery and mastectomy patients who would like to maintain a high level of sensitivity in their nipples post-op can undergo a nerve reconstruction or nerve innervation technique.

For mastectomy patients, this is usually performed during a procedure where tissue is removed and a breast implant is placed to reconstruct the breast. Nerve reconstruction or innervation reconnects the nipples to their nerve supply, giving patients the possibility of experiencing heightened sensitivity again.

Mental Health: Top Surgery vs. Mastectomy

Multiple, peer-reviewed studies have shown that top surgery vastly improves trans and nonbinary individuals’ quality of life. Not only is there a tremendously low regret rate for top surgery, it has also been shown to be associated with consistent improvements in patient satisfaction with their body and overall appearance. The feeling of gender euphoria that top surgery brings patients is one of the reasons why they experience better overall mental health.

Mastectomy patients may also experience greater joy after removal of malignant tissue. Those who carry a genetic risk for breast cancer can experience peace of mind afterwards. That said, patients who need a mastectomy may mourn the loss of their breasts as a source of positive self-image. It can help to reach out to loved ones or mental health providers to address these feelings. Some find resources for chest reconstruction, such as breast augmentation, helpful, as it can affirm the gender of those who have had to receive a mastectomy.

Physical Health

Your body changes in significant ways after either a mastectomy or top surgery. The ways in which your chest functions can change. You may lose sensitivity in your nipples and experience difficulties or an impossibility to lactate. Many top surgery and mastectomy patients opt for measures to regain or maintain sensitivity and nipples. Others may receive nipple grafts or later pursue medical tattooing. General soreness and numbness will occur with any surgery, but you can regain some sensitivity.

Double incision, the most common type of top surgery, and mastectomy patients can expect to have horizontal scars along the chest wall. Scars for top surgery are often sculpted to reflect aesthetic goals, such as alignment with pectoral muscles. With both procedures, you can expect to follow similar scar care instructions, including scar massage and silicone therapy.

Cost and Insurance Coverage

We do not perform mastectomies at GCC for cancer or other medical purposes. We refer to procedures involving chest tissue removal as forms of top surgery for the purpose of gender affirmation. A consultation for top surgery at GCC is free of cost, and the out-of-pocket cost for top surgery falls in the range of $8,500 to $11,500. Our insurance advocacy team will work with you to secure insurance approval for your top surgery, and has had a 90% success rate of doing so. For insurance requirements around a mastectomy, you can view your rights after a mastectomy according to the US Department of Labour.

FAQ

Why is top surgery sometimes called a mastectomy?

Mastectomy is a medical term generally applied to any procedure that involves breast tissue removal. You may notice that the two terms are used interchangeably, especially in medical settings. There are many similarities between the two, but most in the transgender and non-binary community prefer “top surgery”. This can be due to many reasons, including that a mastectomy can be used to remove malignancies, while top surgery is a procedure used to improve the lives of transgender and non-binary patients.

How does scarring differ between top surgery and mastectomy?

While scarring from both procedures can be similar, you have much more control over your top surgery scars and more options on how scars can look. There are less aesthetic concerns and gender presentation concerns while performing a mastectomy. For example, scars from double incision top surgery often replicate the contour of a pectoral muscle. Additionally, the keyhole and periareolar technique will create minimal scarring.

Can top surgery and mastectomy be combined with other surgeries?

Top surgery at GCC can be combined with additional procedures such as nipple grafting, liposuction, nipple neurotization or pectoral implants. These may impact recovery time and increase your chances of complications, but also lower the overall cost of the procedures. It is important to discuss these with your surgeon to understand if you may be a good candidate for receiving multiple procedures. Mastectomy can include additional procedures, often performed after the initial surgery. For example, many want to reconstruct breasts and will request simultaneous reconstruction, most often using silicone or saline implants in the cis population.

Which procedure has a faster recovery time?

Your recovery time is highly dependent on procedure type. If you have several complications afterwards, are a frequent smoker or overexert yourself in recovery, your timeline may be extended for top surgery. Generally speaking, top surgery will often have a faster recovery time than a mastectomy performed for cancer.

Are both surgeries covered by insurance?

Both a mastectomy and top surgery can be covered by insurance. The requirements for each procedure are different and it is best to view your individual provider to understand what is necessary. Top surgery may require letters from mental health professionals and you can reach out to our advocacy team. Individual requirements will also vary based on your provider. It is best to check your individual plan. According to the Department of Labour, your insurance cannot charge you outside of your deductible and coinsurance for a mastectomy for medical reasons, regardless of cancer status.

Sources

1 Goethals A, Rose J. Mastectomy. [Updated 2022 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available at: https://www.ncbi.nlm.nih.gov/books/NBK538212/

2 Vuong B, Dusendang JR, Chang SB, et al. Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care. J Am Coll Surg. 2021;232(1):35-44. doi:10.1016/j.jamcollsurg.2020.09.015. Available at: https://www.sciencedirect.com/science/article/pii/S1072751520323759

3 Bustos VP, Bustos SS, Mascaro A, et al. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence [published correction appears in Plast Reconstr Surg Glob Open. 2022 Apr 28;10(4):e4340. doi: 10.1097/GOX.0000000000004340]. Plast Reconstr Surg Glob Open. 2021;9(3):e3477. Published 2021 Mar 19. doi:10.1097/GOX.0000000000003477. Available at: https://journals.lww.com/prsgo/fulltext/2021/03000/regret_after_gender_affirmation_surgery__a.22.aspx?fbclid=IwAR0d4loq_JhUQZErZCW-mTZvXjBm1H67vGvMDsRRCecb_VCzsV2yhuD5oCQ