Personalized Non-Flat Top Surgery: Your Path to Confidence

Medically reviewed by Jennifer Richman on November 20, 2024.

What is Non-Flat Top Surgery?

Top surgery is a gender affirming procedure that can produce a large diversity of results. Trans, non-binary and trans masculine people can use top surgery to increase, decrease or flatten the overall shape and size of the chest. While many patients undergo top surgery to achieve a flat chest, others opt for techniques that retain some tissue. Here, we provide information on non-flat top surgery techniques, results and recovery.

Techniques

Techniques of non-flat top surgery differ in their incisions, sensation and overall contour. It can be helpful to have an understanding of each technique to decide if one is right for you.

Buttonhole: 

During buttonhole top surgery, your surgeon will create an incision around the nipple and at the base of the pectoral muscle. From here, tissue is removed and the chest is sculpted into a “mound” shape. The result is less breastlike in shape, but some volume is maintained in the chest, resulting in a non-flat overall contour.

Inverted T Anchor: The inverted T or anchor technique, similar to buttonhole, reduces significant chest volume but will not create a flat contour. This is due to the surgeon leaving behind the pedicle: tissue that keeps the nipple alive. You can expect to have a non-flat, teardrop to your chest. 

Breast Reduction:

While the techniques mentioned above reduce the size of a patient’s breasts, they bear some key distinctions. Some patients pursue a traditional breast reduction to affirm their gender, but it is not generally viewed as a gender affirming surgery nor as top surgery. More common reasons include reducing strain on the back or physical discomfort. Generally speaking, a breast reduction is accomplished with one of the aforementioned techniques. 

Reasons for Choosing Non-Flat Top Surgery

Non-flat top surgery addresses the many motivations behind patients wanting a chest with some volume.

Aesthetic Preferences: Many patients who choose non-flat top surgery choose so for aesthetic reasons and prefer the teardrop or mound shapes that T anchor and buttonhole create. For example, plus sized transmasculine patients may want a chest proportional to their body size and fat. That said, BMI is not a barrier at GCC if you would prefer a flattening method.

Gender Expression: Some non-binary patients have mentioned non-flat top surgery allows for them to accentuate or conceal their chest. Non-flat techniques can allow for a more gender fluid appearance depending on clothing or binding. This flexibility is important for many who do not feel that they fit into the binary surrounding chest size.

Who is a Suitable Candidate?

As mentioned above, the Gender Confirmation Center does not have requirements around BMI or hormonal replacement therapy (HRT) for any form of top surgery. While inverted T or anchor technique can be a good fit for you if you have extra skin, buttonhole is best suited for patients with less tissue in the chest. Removing less tissue during buttonhole surgery allows for the nerve to stay connected to the pedicle. If you have undergone a breast reduction in the past, you may want to make special considerations.

Preparing for Non-Flat Top Surgery

Pre-Consultation Planning 

In general, eating a balanced diet and staying active can help keep you healthy before surgery. Patients must stop smoking and quit nicotine at least three weeks before surgery to avoid complications. Similarly, patients cannot consume alcohol in the week before surgery. Some patients want more defined pectoral muscles, and engage in chest exercises. Note that your pectoral muscles may not be as visible with non-flat top surgery. Keep in mind that these are general guidelines and living a healthy lifestyle before surgery means something different for everyone. Other tips for preparation include making arrangements for where you will stay during surgery, how you will prepare food and moving important items in your home to an accessible height.

Consultation with a Plastic Surgeon

A vital first step in accessing top surgery is scheduling a consultation with a board certified surgeon. At the GCC, all of our consultations are free of charge and can be scheduled virtually or in-person. Coming into your consultation aware of your options can help facilitate communication between you and your surgeon. Communicating your medical history, transition and surgical goals allows for your surgeon to provide specialized information and insight into what methods you may be best suited for.

Mental Preparation

Top surgery is a big step in your transition, and while most feel euphoric with their results, surgery can still be emotionally and physically taxing. Creating a robust support network can help you manage the ups and downs of recovery. It can be helpful to reach out to therapists, loved ones and community resources. Reminding oneself that how you feel about surgery recovery is different than how you feel about your chest. Distress around surgery is not the same as feeling distress at reducing chest size. For most patients, the discomfort they feel from surgery is well worth it to experience the joys of gender euphoria.

The Procedure: What to Expect

Inverted T Anchor and Buttonhole Surgery Overview: 

Anesthesia: Surgery is performed under general anesthesia for your comfort. You will be unconscious throughout surgery and will not feel anything.

Incisions: If you opt for inverted T/anchor method, your surgeon will make incisions around both areolas and a vertical incision down from the nipple, connecting to horizontal incisions along the pectoral muscle. This creates the inverted “T” shape. During a buttonhole procedure, incisions are made in the same areas, but will not make a connecting incision from the nipple to the horizontal chest incisions.

Tissue Removal and Sculpting: In both procedures, breast tissue and skin are removed, and the remaining tissue is altered to create your desired chest contour.

Nipple Repositioning: During an inverted T and buttonhole procedure, the nipple and areola is repositioned to a more preferable location on the chest. Repositioning is limited by the pedicle, as it must stay connected to the nipple-areola complex. However, if you opt for nipple grafts, the nipples may be fully repositioned.

Closure: Your Incisions will then be closed with sutures, and your chest will be wrapped in dressing. Dressings must stay on your chest until your first post-operative appointment, where your surgeon will likely remove them.

Recovery Process

Recovery Timeline

Week One: You must take plenty of rest. You may experience some swelling and discomfort during this time, which can be addressed with pain medication. The surgical site cannot get wet, and you will need to take sponge baths or use washcloths and wipes.

1-3 weeks: After 2 weeks, you can expect to return to work with some limitations on lifting above 10 pounds and physical exertion. Be careful to not lift your elbows above your shoulders, as this can stretch your incisions.

After 3 weeks: At this point you can gradually resume physical activities, but you should avoid lifting above 25 lbs or weight bearing and upper body workouts. After your incisions have started to heal, you can begin scar care and massage.

After 6 weeks: Patients at this point can return to regular exercise and activity.

Post-Operative Care Tips

Your surgeon may provide you with post-operative instructions on caring for your surgical sites after surgery. This may include information on emptying your drains or how to redress your incision. We highly recommend having a support person to help you with these tasks and navigate day-to-day activities. Recovery from surgery can also be emotionally taxing for patients. Establishing support networks for both your physical and emotional recovery needs helps with the highs and lows after receiving top surgery. 

Risks and Complications

Buttonhole and Inverted T/Anchor patients have less of a chance of nipple rejection as the original blood supply stays connected to the nipple. However, patients with less skin elasticity and those who would like to remove large amounts of tissue may experience skin folding. It is less possible to shift the contour of your chest in significant ways with non-flat techniques. If these complications concern you, bringing them up during your consultation can help you and your surgeon navigate how best to address these.

Results and Long-Term Effects

Expected Results: 

You can expect non-flat top surgery techniques to significantly reduce volume in the chest while still maintaining some visible tissue. Immediately post-op, your chest may not look as you expect. What you see at this healing stage is not what your chest will look like once fully healed, which can take up to a year. The buttonhole and inverted T techniques leave behind horizontal scars along the pectoral muscle, while the circular incision around the nipples will not be visible. The connecting scar from the nipple to the chest from inverted T will be visible. The expected results from buttonhole and inverted T are very diverse and you can get a sense for what your results may look like in our before and after gallery.

Long-Term Considerations: 

Over time, scarring fades quite significantly. You will also feel sensation come back to your chest and nipples, often in the form of “tingling” or “zaps”. For non-flat techniques, you can expect to regain heightened sensitivity in the nipples. 

Significant weight gain or loss can change the appearance of the chest. Rapid or drastic changes in weight may cause stretch marks or stretching of your scars.To mitigate these effects, you will need to stay at a stable weight for 3-6 months before surgery. 

If you opt for a flattening technique of top surgery after receiving a non-flat technique, you will have to make certain considerations. You may only qualify for double incision or you may need nipple grafts. However, many patients are perfectly content with these considerations. Non-flat techniques are also not necessarily a step to getting a flat chest. Having a flat or non-flat chest does not make someone more or less transgender or masculine.  

Cost Considerations and Insurance Coverage

The GCC’s insurance advocacy team has had a 90% success rate in securing insurance coverage for our patients. Insurance coverage for non-flat techniques will depend on your insurance provider, plan and necessary documents. Keep in mind that requirements around breast reductions and traditional top surgery can be very different. Reaching out to your insurance company is often the best way to understand what you will need for coverage. 

FAQ

Will my scars be visible?

You will have visible scarring along your chest from most forms of non-flat top surgery. For some, the overhang of their chest tissue may cover chest wall incisions. 

Can I combine non-flat top surgery with other procedures?

Yes, many patients are also interested in additional procedures, such as liposuction or body contouring. Others later choose flattening top surgery or a second breast reduction, which is possible with some caveats. 

What is the difference between an aggressive breast reduction and non-flat top surgery?

There is not much of a difference between an aggressive breast reduction and inverted T/anchor. Buttonhole differs from a breast reduction in that no vertical incision is made from the nipple to the chest, giving a less traditionally feminine or teardrop shape to the chest. Many people feel that calling their top surgery a breast reduction feels inaccurate and feel discomfort at centering it around breast tissue. We accept the various motivations behind seeking chest reconstruction, and it is a deeply personal process. 

What is the difference between buttonhole and inverted T anchor?

The amount of excess skin that needs to be removed in inverted T is usually greater and is recommended if you want greater amounts of breast tissue removed. This is due to the vertical incision from the nipple, which allows for more tissue to be taken out. Buttonhole will also create a more mound-like shape compared to the teardrop shape from inverted-T. Some patients feel this mound shape is more traditionally masculine in presentation.