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Double Incision – The Most Popular Top Surgery Procedure

Medically reviewed by Paul Gonzales on April 29, 2024.

What is Double Incision Top Surgery?

The double incision method, sometimes called a double incision gender-affirming mastectomy, is the most popular form of chest reconstruction top surgery, formerly referred to as FTM top surgery. This procedure involves the surgical removal of chest tissue and excess skin, as well as resizing and placement of the areolas as skin grafts. The result is a flatter chest with a horizontal scar on each side, generally on or around the bottom of the pectoral muscles.

This article provides information on the surgical outcomes that are important to consider when pursuing the double incision method, including risks, nipple skin grafts, location of nipples, nipple sensation, chest flatness and tightness, and top surgery scars. On some occasions, this procedure can be performed with a nipple-sparing or nerve sensation preservation technique. Find out if you are a good candidate for this gender-affirming procedure by reading more.

Benefits of Double Incision Top Surgery

The double incision is among the most common procedures for chest reconstruction top surgery, accounting for more than 80% of top surgeries performed by our surgeons. It can provide significant physical and emotional benefits for individuals seeking to align their bodies with their gender identity.

• Flattest chest contour:  The double incision method has the highest probability of achieving the highest degrees of flatness and tightness for a more masculine chest contour. Tightness means that skin will be contoured closely to the pectoral muscle and/or other tissues underneath.
• Customized incisions and nipples: The procedure allows for customization of incision shape (i.e., straight, curved, hockey stick), as well as the size and dimensions of the nipple and areola skin grafts. The nipple grafts can also be placed freely anywhere on the chest, hence the term “free nipple grafts” (FNG). Additionally, some patients may opt to have their nipples removed entirely.
• Maintaining heightened nipple sensation: Generally speaking, a FNG procedure allows patients to have the greatest control over the dimensions and placement of the nipple-areola complex on their new chest; however, this procedure may result in the loss of heightened, erotic nipple sensation. Patients can now opt for a DI with nerve preservation so that heightened, erotic sensation is maintained in the nipple areola complex after surgery.
• Suitable for all body types: While procedures like keyhole or periareolar incisions may be limited to those with minimal chest tissue or very elastic skin, the double incision is suitable for patients with larger chest sizes and greater excess skin.

Concerns with Double Incision Top Surgery

• Nipple skin graft concerns: The free nipple grafting procedure depends on the nipple graft’s ability to heal and connect with blood vessels in its new location. A common misconception about free nipple grafts (FNG) is the high probability of failure, which may result in discoloration or loss of pigmentation. In our practice, this is extremely uncommon. However, it is a possibility that should still be considered. Patients who do experience nipple discoloration may choose to correct their pigmentation after a year through medical tattooing.
• Reduced or loss of nipple sensation: The ability of free nipple grafts to connect with nerves in their new location may vary between patients. Some may have reduced or loss of heightened or erotic sensation to the nipples. Alternatively, some may report having hypersensitive sensation if the nerves heal in a disorganized manner. But ultimately, the sensitivity of nipples for most patients can be described as similar to the feeling of touching the skin of the upper chest. Thus, if maintaining an erotic or high level of nipple sensation is a priority, patients should consider techniques such as a buttonhole incision or nerve preservation double incision in their surgical consultation.
• Possibility of post-mastectomy pain syndrome: Normal skin sensation is generally maintained after surgery but some may experience burning pain on one or both sides of the chest due to nerve irritation. Post-mastectomy pain syndrome may last up to 6 months or more but in our experience, this can subside within 3-6 weeks after surgery. In some cases, scar massage and engaging in appropriate mobility exercises can help prevent and reduce pain.
• Visible scar appearance: As the name suggests, this procedure creates two incisions, leaving one scar on both sides of the chest. For some patients with excess skin in the middle of the chest, joining the incisions at the center may be performed to make the skin as flat and tight as possible. This may result in a single horizontal scar that may be more visible. Learn more about factors that affect the appearance of top surgery scars here.
• Dog ears: Dog ears are protrusions of excess tissue visible around the outer edges of scars near the armpit and are a common complication for double incision top surgery. They are most common in patients with significant breast tissue removal, prior breast reduction surgery, or looser, less elastic skin. Dog ears may be prevented by extending incisions toward the back during the initial top surgery or through a simple revision surgery post-op.

Recovery Process

The recovery process for double incision top surgery can vary depending on the individual, but typically involves the following timeline:

• Week 1: Moderate amounts of pain or discomfort, with compression garments in place to help reduce swelling. Surgical drains may be present for at least 6-7 days and removed at post-op appointment once with minimal output. Pain medication and rest are recommended. Only light walking is allowed.
• Week 2-3: Dressing changes will be performed daily for optimal nipple graft healing. Compression garments are recommended to reduce swelling. Strenuous activities or lifting anything over 5 lbs. should be avoided until 3 weeks after surgery. Restricting arm movement below shoulder level is advised.
• Week 4-6: Some swelling may still be present. Normal activities are permitted but lifting anything over 25 lbs. should be avoided until 6 weeks after surgery. Physical therapy may be started to increase range of motion in shoulders. See our guide here.
• Week 6-8: Most swelling and bruising have subsided. Weight-bearing activities may be resumed. Patients can also progressively work on regaining overhead range of motion in their shoulders with the guidance of a professional.
• 3-6 months: Final results become more apparent as most swelling resolves and scars mature. For more information on scar care, click here.

Choosing a Surgeon

Selecting a qualified and experienced surgeon is crucial for ensuring the best possible outcome and minimizing risks. When choosing a surgeon for double incision top surgery, consider the following factors:

• Board certification in plastic surgery and/or training in gender-affirming surgery
• Extensive experience performing double incision top surgery specifically
• Positive patient reviews and before/after photo galleries
• Open communication and a commitment to understanding your goals
• Accredited surgical facility with appropriate safety measures

Cost and Insurance Coverage

The cost of double incision top surgery can vary significantly depending on factors such as the geographic location, the surgeon’s experience, and the surgical facility. With the GCC, total costs can be between $14,000 and $17,000 for cash-pay patients who do not have any form of insurance coverage. To learn more about the GCC’s top surgery costs, click here.

Insurance coverage can drastically reduce the costs of gender-affirming surgery. Many insurance plans, including Medicaid, cover gender-affirming surgeries like double incision top surgery. However, coverage and requirements vary by plan and state. It is essential to check with your insurance provider for specific details on coverage, pre-authorization requirements, and any exclusions or limitations.

If insurance coverage is unavailable or insufficient, financing options such as medical loans or crowdfunding campaigns may be worth exploring. Additionally, some LGBTQ+ organizations and advocacy groups offer resources for financial assistance with gender-affirming care.

FAQs

Q: How visible are the scars after double incision top surgery?

The visibility of scars after double incision top surgery depends on several factors, including the surgical technique used, individual healing progress, and skin tone. While the scars are permanent, they may be placed beneath the chest muscle to make them less noticeable or to contour the pectoral muscle. With proper scar care and time to heal, the scars may fade and become less prominent.

Q: Can I still chest-feed or breastfeed after double incision top surgery?

Double incision top surgery involves the removal of breast tissue, including the milk ducts and glandular tissue responsible for producing milk. Therefore, breastfeeding may not be possible after undergoing this procedure. If this is a priority or concern, discuss this with your surgeon during your consultation. In the video below, Dr. Jacobs (he/him) addresses the unlikelihood that patients will be able to chest-feed after top surgery. Still, he mentions, there is a chance that the infant can bond with their parent’s chest even if they are incapable of milk production.

Q: How soon can I return to work or school after surgery?

The timeline for returning to work or school after double incision top surgery varies, but most individuals can expect to take at least 2-4 weeks off for initial recovery. Your surgeon will provide specific guidance based on your circumstances and the physical demands of your job or activities.

Q: Are there any risks or potential complications associated with double incision top surgery?

As with any surgical procedure, there are potential risks and complications associated with double incision top surgery. These can include bleeding, infection, poor wound healing, scarring, and adverse reactions to anesthesia. However, these risks are generally low when the surgery is performed by a qualified and experienced surgeon. Your surgeon will discuss the specific risks and steps to minimize them during your consultation.

Q: How long do results of double incision top surgery typically last?

The results of double incision top surgery are generally considered permanent but any weight fluctuations may naturally alter the chest contour. Also, it’s important to note that as the skin continues to age, its appearance and laxity may naturally change over time. Dr. Jacobs (he/him), one of our expert top surgeons, addresses the question of how significant weight fluctuation after top surgery might impact your results: