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Buttonhole Top Surgery: Maintaining Sensation with Gender-Affirming Results

Understanding Buttonhole Top Surgery

Buttonhole top surgery is a newer technique that involves creating an incision around the nipple and at the base of the pectoral muscle to remove chest tissue. The chest is sculpted into a “moundlike” shape. The buttonhole technique has many similarities to the inverted T incision, but it does not include a connecting incision from the areola to the pectoral muscle. Similar to inverted T, it gives patients a higher probability of maintaining heightened sensation in the nipples. 

The ideal buttonhole top surgery candidate is someone with a medium to small amount of tissue starting off, who is interested in maintaining heightened nipple sensitivity while achieving a less “breastlike” shape to their chest. To ensure you feel confident and informed as you begin your chest reconstruction journey, below we have provided information on the benefits, recovery and results of the buttonhole procedure.

Expected Results Over Time: The Buttonhole Incision

Mossser FTM Top Surgery Before and After 1

Mosser FTM Top Surgery Before and After 2

Mosser FTM Top Surgery Before and After 3

Mosser FTM Top Surgery Before and After 4

 

We encourage our patients to keep in mind that the appearance of your chest immediately after surgery is not what your healed chest will look like. It can take up to a year to fully heal from top surgery. In this time frame, scars will mature and swelling will significantly decrease. As you heal, you may notice that sensitivity will gradually return to your chest and nipples, often in the form of tingling or itching sensations under the skin.

The buttonhole technique leaves behind a scar at the base of the pectoral muscle, somewhat like a double incision technique. The circular incision usually heals so that it is camouflage into the areola, which does not leave a visible scar. For many transmasculine and non-binary patients, having visible scars represents a piece of their identity and connects them to a broader community. Others may look into non-surgical scar treatments to reduce the appearance of their scars. Ultimately, the expected result from buttonhole varies and you can view different results in our before and after gallery.

Is Buttonhole Top Surgery Right for Me?

Buttonhole technique is often chosen by transmasculine, non-binary and gender non-conformming individuals seeking a chest reconstruction or what some call an aggressive breast reduction. The following are benefits that encourage many to choose buttonhole:

1. Nipple Sensitivity: You would like to continue experiencing heightened levels of nipple sensitivity after surgery. With buttonhole, there is a greater chance that you will be able to feel pressure and temperature in the nipple-areola complex post-op. Typically in top surgery, in order to achieve complete chest flatness, nipple sensitivity must be sacrificed. If you are interested in maintaining nipple sensitivity with a flat chest, we encourage you to look into the double incision nerve reconstruction technique.
2. Moundlike Chest Contour: You are looking for a reduction in chest size, but not complete flatness. Buttonhole technique will result in a moundlike shape to each side of your chest, and you will likely still experience chest movement (i.e “bounce”). Some non-binary patients enjoy the less gendered shape and reduction of size that allows them to conceal or accentuate their chest size. Some transmasculine patients appreciate that the volume left behind has greater congruence with the rest of their body shape.
3. Scarring: You are okay with having scars along the pectoral muscle. The results of buttonhole scars bear similarity to double incision results. Unlike the Inverted T technique, there is no connecting scar from the nipple to the base of the pectorals.
4. Greater Precision in Chest Sculpting: You are looking for more control in the shape of your chest. Due to the use of an incision along the pectoral muscle, surgeons have more control over sculpting of the chest as compared to periareolar or keyhole.
5. Pectoral Muscle Appearance: You are ok with less pectoral muscle definition. This results from the leftover tissue near the nipple concealing underlying chest tissue.
6. Nipple Size and Placement: You are okay with not having complete control over the repositioning and resizing of your nipple. In order to maintain sensation, the areola stays connected to its initial nerve and blood supply. Some areola resizing may be possible without changes to sensitivity.

The Buttonhole Technique: Step-by-Step

Buttonhole surgery follows these general steps:

1. Anesthesia: For your comfort and safety, surgery is performed under general anesthesia. This means you will be completely unconscious throughout surgery and will not feel anything.
2. Incisions: The surgeon will make incisions around the areola and a horizontal incision across the chest muscle.
3. Tissue Removal and Sculpting: Chest tissue and skin are removed, and remaining tissue is sculpted to create the desired chest contour.
4. Nipple Repositioning: The nipple-areola complex is repositioned to a location similar to most cisgendered men, or can be modified slightly according to patient preference. Since the nipple-areola complex stays attached to the original nerve and blood supply (in what is called the “pedicle”), repositioning is limited by the need to maintain proximity to the pedicle.
5. Closure: Incisions are closed with sutures and surgical adhesives and dressing are placed to protect the surgical site. Your dressings will remain on your chest until your first post-operative appointment with your surgeon, about a week after the operation.

Your surgery may vary based on surgeon experience, your individual anatomy and the unique, surgical plan you and your surgeon make during a free consultation. This procedure is most often an outpatient service, meaning that you can expect to return home the day of surgery. You will need a support person to pick you up from the hospital or surgical center in order to be discharged.

Pre-Operative Considerations and Candidacy

For many patients, it can help ease preoperative anxiety to go through the following considerations before undergoing top surgery.

1. Consultation: If you do not know where to start, requesting a free consultation is the first step in accessing top surgery. A consultation with a board certified surgeon is an opportunity to discuss your unique goals, questions and medical history. At the Gender Confirmation Center (GCC), all of our consultations are free of charge and are offered both virtually and in-person.
2. Suitability: You may be best suited for buttonhole surgery if you do not have a large amount of mammary or excess skin tissue to remove. This technique has limitations on how much tissue can be removed while keeping the nippleconnected to its original blood and nerve supply.
3. Possible Complications: Buttonhole patients have less of a chance of nipple rejection as the original blood supply is maintained in the nipple. While this technique can provide many benefits, we advise being mindful of limitations and complications. Patients with less skin elasticity and those who would like to remove large amounts of tissue may result in skin folding. Discussing these concerns with your surgeon in a consultation can help mitigate complications and ease worry.
4. Medication and Supplement Adjustments: Our practice does not require that patients have a certain Body Mass Index (BMI) or hormone replacement therapy (HRT) for top surgery. However, we do have several other requirements before your surgery. In order to facilitate proper healing, reduce anesthetic complications and bleeding risks, you will need to stop certain medications, herbal remedies and supplements. Patients cannot consume alcohol in the week before and after surgery. Smoking and nicotine use should be stopped completely for three weeks before and after surgery. For more information, we encourage discussing your medications and lifestyle in your surgical consultation.
5. Arrange for Support: After top surgery, you will not be able to lift anything above 5 lbs nor should you raise your arms above your shoulder for about 3 weeks. We recommend having a support person to help you navigate daily activities during this time. Likewise, recovery from a major operation can be emotionally taxing for many patients. We encourage you to tap into your support network for both your physical and emotional recovery needs.

Recovery Process

• Week One: Take plenty of rest and be mindful of swelling and discomfort. You will not be able to wet your surgical site during this time, so you will need to take sponge baths or clean yourself with a wash rag or wipes.
• 1-3 weeks: You can expect to return to work with some physical limitations on heavy lifting and exertion after about 2 weeks. You should limit your arm mobility during this time, being careful not to lift your elbows above your shoulders.
• After 3 weeks: You may gradually resume physical activities, but you should not be lifting above 25 lbs or engaging in weight bearing or upper body exercise. You can also begin scar care such as massage or silicone therapy.
• After 6 weeks: Most patients can resume normal physical activity and weight lifting.

Frequently Asked Questions (FAQ)

• What is the difference between buttonhole and double incision top surgery?

• The double incision and buttonhole techniques both leave one or two horizontal scars at the base of the chest. However, the buttonhole incision differs in two key aspects: (1) complete chest flatness cannot be achieved and (2) there is a greater possibility of maintaining nipple sensitivity. Double incision will create a flat chest presentation, while buttonhole creates two “mounds”. The “mounds” of tissue left behind can help ensure that the nipple stays attached to its original nerve and blood supply. Note that if you wish to undergo double incision to achieve complete chest flatness, sensitivity may be preserved through nipple-sparing or nerve reconstruction methods.

• Is buttonhole top surgery more expensive than traditional methods?

• Top surgery generally varies in cost from $8,500-11,500 and includes surgeon’s fees, anesthesia fees, operating room fees and post-operative garments. This accounts for buttonhole technique and you can expect your procedure to fall within this range. The cost of your individual surgery can vary, and your surgeon can give you a more specific quote after your free consultation. Insurance coverage or grants can significantly reduce the cost of surgery.

• Will insurance cover buttonhole top surgery?

• Many insurance plans will cover the costs of gender-affirming top surgery. To secure coverage, you will likely need a letter from a mental health provider that states you meet WPATH guidelines or a referral from a licensed primary care provider. Requirements depend heavily on your individual plan, and it can be helpful to reach out to your insurance provider. At the GCC, you can leave the insurance worries to us. Our insurance advocacy team has a 90% success rate in securing approval for patients

• Why do some patients have a single, joined scar at the base of their chest instead of two top surgery scars?

• Joining top surgery scars in the middle of the chest is a technique requested by some patients to ensure chest flatness by taking out excess skin. If the appearance of a joined scar is not appealing to a patient, other techniques can be used to tighten skin and reduce the chance of dog ear formation. For example, surgeons can extend the incision under the armpit, use chest liposuction and/or curve the incisions upward in the middle of the chest.

• Can I combine buttonhole top surgery with other procedures?

• Coupling top surgery with additional procedures such as body contouring–liposuction and/or pectoral silicone implants–is possible. Combining multiple procedures into a single surgery may lower the overall expense and recovery time. However, this may carry a higher risk of complications. Consulting with your surgeon can help clarify potential risks and your candidacy for multiple procedures.

• How long will I need to take off work?

• Most patients, if healing permits, are able to return to work after 1-2 weeks after top surgery with some limitations. It is essential to your healing that you take it easy, and avoid heavy lifting above 5 lbs and engaging in any other strenuous activity. A good rule of thumb is that you should not be breaking a sweat during the first 3 weeks of healing.