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Comprehensive Guide to Periareolar Top Surgery: Maintaining Sensation with Gender-Affirming Results

Medically reviewed by Jennifer Richman on October 1, 2024.

What is Periareolar Top Surgery?

Welcome to our page on periareolar top surgery, also referred to as “peri” or the “doughnut incision.” This is a form of chest reconstruction top surgery that creates an incision around the areola to remove tissue. This procedure is selected by patients who have a relatively small amount of tissue and skin to remove, who are interested in the possibility of preserving nipple sensitivity while also creating a flat chest appearance. Periareolar scars are less visible since they often camouflage into the areola as they heal. In this article you can learn more about choosing peri, scarring and general recovery.

Periareolar Results

The following are some of our surgeons’ before and after results for periareolar top surgery patients. You can see more in the before and after photo gallery section of our website.

Mossser FTM Top Surgery Before and After 1

Mosser FTM Top Surgery Before and After 2

Mosser FTM Top Surgery Before and After 3

 

Periareolar tends to have a higher revision rate than other techniques due to surgeons having less control on how they can mold chest tissue and nipple placement. Perfect uniform thickness across the chest is difficult for even the most experienced surgeons, and incongruence may result in subtle rippling across the chest. Ultimately, your individual results will vary and it is best to discuss with your surgeon about your desired chest reconstruction goals.

Your scars will continue to heal for a year after your surgery, and you can expect for the rippling around your nipples to fade within a few months. Similarly, swelling should slowly fade in the weeks and months after surgery. To help this process along, patients often find scar massage with unscented moisturizer and silicone therapy to be helpful in scar management. These should only be performed after your incisions have healed, typically at least after three weeks from the date of surgery. It is best to discuss scar care with your care team to understand your options. You can read more about scar care here.

Is the Periareolar Technique Right for Me?

Periareolar bears similarities to the keyhole technique, as patients are more likely to maintain nipple sensation and scars are concealed around the borders of the areolas. An ideal candidate for the keyhole or periareolar approach has only a small amount of tissue overhang preoperatively. Patients who have more skin and tissue than is required for the keyhole incision often choose periareolar. There are many considerations to keep in mind when deciding if periareolar best fits what you want your chest to look and feel like.

1. Nipple Sensation: Keyhole and peri techniques could be a good fit if you are interested in maintaining your current level of nipple sensitivity. Immediately after your surgery, you may feel numbness in your nipples. In the following months, it is normal to feel “tingling” and itching sensations below the skin as your nerves heal. The majority of patients report recovering most or all sensation. This is due to the fact that the nipple-areolar complex remains attached to its original nerve and blood supply.
2. Flat Chest Presentation: You may be looking to have all chest tissue removed to create a flat, or “masculinized” chest appearance. Minimal excess skin is removed in periareolar, so larger chested patients looking for chest and skin tightness may prefer the double incision.
3. Minimal Scarring: You may not want scarring along the chest well–i.e., at the base of the pectoral muscles. Since the only incisions made are around the areola, there will be no visible scars on the chest wall. Most patients that carefully follow scar care instructions will see their scars fade.
4. Nipple Size/Placement: You want to reduce the size of your areolas or have what some people consider a conventionally masculine areola size. Similarly, if you are content with where your nipples sit on your chest, periareolar will not change the nipple placement. Keep in mind that the “purse string stitch” may alter the shape or size of the nipple, sometimes creating a “sunburst” or “ripple” around the nipple.

If you are interested in having more control over the shape and size of your nipples, you may want to look into nipple grafts. This technique gives the surgeon greater flexibility on where your nipples sit on your chest, as well as their size and shape. Nipple grafts do not always have to mean losing complete sensation in your nipples. At the Gender Confirmation Center (GCC), we offer nipple sparing double incision as well as double incision with nerve reconstruction to preserve heightened nipple sensitivity. If skin tightness is a concern, double incision may also be a better option to mitigate laxity, folding of skin and rippling.

Preparing for Periareolar Top Surgery

Preparation for top surgery can be both a daunting and exciting process for our patients. It may be difficult to understand what arrangements you need to make before you undergo surgery. You can make this journey smoother by considering the following steps leading up to periareolar top surgery.

Choosing a Surgeon

When choosing a surgeon for top surgery, patients should look for gender competent providers with experience in the periareolar technique. They should be able to provide you with before and after images of past procedures to give you a sense of how your own results may look. Our surgeons at GCC are highly experienced with periareolar technique; you can learn more about our board-certified surgeons here.

Surgical Consultation

One of the most important steps before your surgery is scheduling a consultation. This is especially important so that your surgeon can assess if you are a good candidate for peri. Likewise, the consultation is your space to ask the surgeon any questions you may have, review your medical history and discuss your goals. At GCC, all of our consultations are free of charge and are offered both virtually and in-person.

Qualifying for Periareolar

At the GCC we do not impose body mass index (BMI) restrictions or hormone replacement therapy (HRT) requirements for gender-affirming top surgery patients. Patients with minimal excess skin and smaller chest sizes are best suited for periareolar surgery. Excess skin may result in loose folds in the lower chest or visibility of wrinkling around the areola. Not meeting these requirements does not disqualify you from receiving top surgery. Techniques such as double incision can be performed regardless of skin elasticity, chest size or excess skin.

Organizing Support for Recovery

In the first three weeks after surgery, you will not be able to lift anything above 5 lbs nor should you lift your arms above your head. We recommend having a caretaker to help you navigate daily activities during this time. Recovery from surgery can be both mentally and physically taxing as your body heals from a major operation. During this time, you might find it helpful to speak to loved ones and/or a mental health professional. We encourage our patients to practice self-compassion and patience as they recover, and recognize that support from loved ones can help greatly with that.

Medical and Lifestyle Considerations

In order to facilitate proper healing, reduce anesthetic complications and bleeding risks, patients may need to stop taking certain medications, herbal remedies and supplements. Patients cannot consume alcohol in the week before and after surgery. Likewise, smoking of any kind alongside any nicotine use should be stopped completely for at least three weeks before and after surgery. For more information, we encourage candidly discussing your individual lifestyle habits with your surgeon in a free consultation.

Procedure Details

1. Anesthesia: For your comfort and safety, surgery is performed under general anesthesia. This means you will be completely unconscious and experience no pain.
2. Incisions: The surgeon will make a circular incision around the areola.
3. Areola Resizing: The areola can be resized to about 22 mm in diameter, which is around the average size for a cisgendered man. Not all patients opt to have their areola resized. For more information, click here.
4. Intermediate Skin Removal: An outer circle of skin around the areola is removed. This helps tighten the skin to create a flat chest. For some patients, this may result in the appearance of ripples around the areola.
5. Tissue Removal: From an incision created in the exposed tissue, chest tissue is removed from underneath layers of the skin.
6. Purse String Stitch: After removal of tissue, the surgeon will perform a “purse string” stitch which will close the gap between the areola and surrounding skin. This will result in a “pleating” around the nipple that is most often temporary.
7. Closure: Incisions made are closed with sutures or surgical adhesives, and dressing are placed to protect the surgical site for about a week post-op.

Your individual surgery may vary based on surgeon experience and your individual anatomy. This procedure is an outpatient service meaning that most patients can expect to be discharged the day of surgery. You will need a support person to pick you up from the surgical center or hospital.

Periareolar Recovery and Aftercare

Recovering from periareolar top surgery looks similar to general recovery from top surgery. While your individual recovery can vary you can expect the following and take the following steps to optimize healing.

1. Managing Post-Operative Discomfort: After surgery, you should expect to experience discomfort, swelling and bruising. This is a normal part of the process, and your surgeon will provide you with pain medication and instructions on taking care of your surgical site. You can expect to have dressings on the nipple area with periareolar technique until at least your first post-operative appointment about a week after surgery.
2. Drainage Tubes: Peri patients can expect to come home with surgical drains if chest liposuction is performed to help contour the chest. Drains serve to reduce excessive fluid build up. You and your caretaker will be instructed on how to empty the drains and monitor drainage fluid once you wake up after surgery. You can expect to have your drains removed at your first follow-up appointment if fluid is draining properly.
3. Follow-up Appointments: It is vital to attend your post-operative appointments to monitor your healing and address any complications and concerns. This is usually scheduled 6-8 days after your surgery. It is recommended for out-of-town patients to stay in the area long enough to attend these appointments. At your first follow-up appointment your dressings and likely your drains will be removed.
4. Activity Restrictions: To maximize healing and reduce stretching of scars, patients cannot lift more than 5 lbs nor should they raise their arms above their shoulder for about 3 weeks. Patients will not be able to shower or bathe until they have had their drains and dressings removed. As an alternative, patients can use a wash rag or sponge to wash themselves. Avoid getting any water near your surgical site.

FAQ

• Can nipple sensation be preserved with periareolar?

• With periareolar top surgery, it is more likely that you will maintain the same level of nipple sensitivity that you had pre-op. This is because your areola is still attached to its original blood supply and nerves on the chest. Patients may feel temperature and pressure, and have potential to retain erotic sensation. Immediately after surgery, numbness in the nipples and chest is very normal. Most patients will recover most or all sensation back.

• Can I have periareolar if I have a large chest?

• Periareolar technique is dependent on skin elasticity and how much excess skin you have around the chest. Patients with good skin elasticity are good candidates, as the skin can more easily mold to the new shape of the chest without resulting in skin folds. Periareolar does not change nipple placement, and patients with larger chest sizes may not qualify due to where the nipples sit on the chest. If you have more excess skin and chest tissue your surgeon may recommend double incision, which allows for more control over final results and nipple dimensions.