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FTM/N Top Surgery FAQ

For questions not answered here, or for a printable version, you may download our PDF, Top Surgery: Your Questions Answered.

• What techniques of chest reconstruction top surgery does our office perform?

• Our surgeons have expertise in multiple surgery techniques including double incision, periareolar, keyhole, fishmouth, lollipop, buttonhole, inverted t-anchor, and other variations. Your surgery will be individualized based on your body and your goals for your surgery.

• How do I know which technique of chest reconstruction top surgery I should get?

• The procedure that’s right for you begins with chest size, but also has a lot to do with the amount of extra skin and chest tissue you have. The Mosser Method is a simple guide to help you answer this question.

  During your consultation, your surgeon will evaluate your chest (through photos or in-person) and discuss the best possible options with you, including pros and cons, and taking into account any individualized desires or needs.

• Why is the double incision method the most common style?

• Most patients have enough chest tissue where another technique would be less advisable. The double incision is unparalleled in its ability to achieve the tightest and flattest chest with full customization of nipple-areolar complex location relative to the muscle and horizontal scar. It accounts for more than 80% of chest reconstruction top surgeries performed by our office.

• If my chest size is between DI and periareolar, which one should I choose?

• It is best to discuss this with your surgeon individually during a consultation, as there are many other variables that may affect your outcome other than chest size, such as skin elasticity, scarring, nipple placement and sensation, and other factors.

• What are other techniques besides DI and periareolar? And are they recommended?

• Less common techniques include fishmouth, lollipop, buttonhole, and inverted t-anchor. In some ways, these are a variation of the standard DI or peri or both. There are several advantages and disadvantages to each, depending on your body type, chest size, skin elasticity, and other needs regarding scar size, scar placement, areola size, nipple sensation, remaining tissue, etc.

• How different are the results if I have never been on testosterone?

• For the most part, there is no difference. People who have been on testosterone for several years may have more chest hair to hide their scars, or it may be easier for them to be able to gain significant chest muscles, which may result in a more stereotypically male-looking chest.

• How will my chest look if I later go on testosterone or gain a lot of muscle?

• Going on testosterone after surgery will generally not affect the results of your chest surgery. Gaining significant muscle in the pectoral area might hide the scar, but it should not adversely impact your outcome.

  Chest reconstruction surgery will give you a permanent outcome. However, significant fluctuations in your weight may impact the appearance of your chest. Gaining weight very quickly or soon after surgery could affect your skin or scarring. In most cases, you would need to gain (or lose) a great deal of weight for the chest contour to change substantially.

  It is always best to discuss any plans for body changes with your surgeon before surgery.

• Does chest reconstruction top surgery remove 100% of breast tissue?

• No. A little tissue is always left over to retain the contour of the chest – otherwise your chest would look concave. This is one big difference between gender confirming chest reconstruction and a mastectomy due to breast cancer.

• What is the difference between gender confirming chest reconstruction top surgery and a mastectomy?

• In a mastectomy due to breast cancer, nearly 100% of the tissue is removed. This is not the case with chest reconstruction top surgery in which more like 93-95% is removed. Moreover, in chest reconstruction top surgery, the surgeon is careful to ensure scar placement follows the natural pectoral lines to create an aesthetically natural look, and you get to keep your nipples and customize their placement if you choose.

• What is the difference between chest reconstruction top surgery and a breast reduction?

• The biggest difference between the two procedures is the amount of skin and tissue removed. Breast reduction can be used to minimize, but not completely eliminate the breasts.  After a breast reduction there will still be ‘cone shaped’ tissue that looks like breast-shaped tissue, even if they are smaller.
  

  Chest reconstruction removes nearly all underlying fat and tissue (including milk producing ducts and glands) to give the appearance of what some would consider a conventionally masculine-looking chest. In some cases, chest reconstruction surgery also entails nipple resizing and relocation.

• Can I have chest reconstruction top surgery after a breast reduction?

• It is certainly possible. If you have not had a breast reduction yet but are on the fence between chest reconstruction top surgery and a breast reduction, it can be good to consider whether or not you will ultimately want a completely flat chest in the future. It is not recommended to have both due to increased scarring. However, if you have previously had a breast reduction and now want chest reconstruction, you will likely have more scars than an initial chest reconstruction top surgery, but it is still absolutely possible to have this surgery. Also important to note is that, a breast reduction is effective at improving back and neck pain from large breasts, but is not necessarily an effective way of treating gender incongruence if the ultimate goal is a flat chest..
  

• Can I just lose weight to reduce my chest size?

• Losing weight may result in a decreased chest size; however, you cannot eliminate all chest tissue in this manner. Some people feel more comfortable once they reduce their chest size, while others opt for surgery regardless. Large amounts of weight loss are generally unsustainable and thus should not be counted on for a way to reduce chest-related discomfort or gender incongruence; surgery is often necessary for a drastic change in chest size.
  

• Is chest binding an alternative to top surgery?

• Chest binding is an effective alternative to invasive surgery for some people. For others, breast binding is only a moderately successful, short-term alternative to chest reconstruction top surgery.

  Binding may result in pain, discomfort, or other physical restrictions. If you are binding, please do so safely.

  Chest binding is a method used by many trans, non-binary, and gender expansive folks to achieve a flat chest appearance.

• Can I still get chest reconstruction top surgery even if I’ve been binding for a very long time?

• Generally speaking, chest binding will not cause problems with your surgical plan.

  Binding over a long period of time (many years) can alter your skin’s natural elasticity, which may have some minor effects on your final aesthetic outcome. Your surgeon will be able to help you formulate realistic surgical expectations following a consultation.

• How can I best keep nipple sensation?

• Changes in nipple sensation vary by technique, which depends on your chest size and other individual factors. If you are very attached to keeping nipple sensation, it makes sense to consider the Inverted T-Anchor or Buttonhole procedure as alternatives.

• What is a free nipple graft?

• Skin grafts are rather miraculous things! We can take a piece of a person’s body, remove it, and put it somewhere else where it will stay and survive.

  A nipple graft is not simply “pasted on” skin; rather, the nipple attaches to your skin, where it develops new blood vessels that grow into the graft. After only a few weeks, the grafts usually have the strength of non-grafted tissue, and in most cases regain sensation resembling that of your skin.

  For an overview, you can download the Nipple Graft Survival Guide, or read the extended explanation and video about the process of nipple grafting.

• Do you lose all nipple sensation with a free nipple graft?

• Definitely not!

  In a Double Incision where a free nipple graft is necessary, sensation is still present, but is diminished from the “hypersensation” of the nipples that is usually present before surgery. Despite diminished nipple sensation following chest reconstruction top surgery, most patients report increased sexual satisfaction.

  Though very uncommon in our practice (less than 2%), it is possible to lose all nipple sensation following chest reconstruction top surgery. Patients who smoke or those diagnosed with diabetes or an autoimmune disease run an increased risk of partial or total nipple graft failure.

• Can I ask for no nipples?

• Absolutely. we always try to accommodate any individual requests.

• Can I get a nipple tattoo / scar tattoo after top surgery?

• Many patients opt for decorative tattoos to cover or embellish their scars. Some of our patients have agreed to be displayed in our Before and After gallery. As always, this is a very personal choice.

  Although extremely rare in our practice (less than 2%), in the case of a nipple graft failure a nipple tattoo reconstruction is an option. An innovative approach is to have a nipple tattoo made that uses optical illusion to create a very realistic 3-D type appearance, even though the skin is still quite flat.

• Will my scars “out” me as trans?

• As with everything, this will depend on your situation and circumstances. Generally speaking, most people do not “read” top surgery scars as being specific to gender surgery, unless by coincidence they happen to be familiar with FTM top surgery.

• Can I get pregnant after having chest reconstruction surgery?

• You can get pregnant after chest reconstruction top surgery, although you will not be able to chest/breastfeed unless you only had a reduction. Having chest reconstruction top surgery otherwise has no effect on your fertility and reproductive capacity.

• Am I at risk for breast cancer after chest reconstruction surgery?

• Though chest reconstruction surgery significantly reduces your risk of developing breast cancer, there will still be some breast tissue that remains in the chest wall after surgery. For this reason, you should still routinely check for breast cancer with your primary care physician.

• Will my breasts grow back after top surgery?

• No.

• Is there a difference between all the terms used to refer to chest reconstruction top surgery?

• We use the term “chest reconstruction top surgery” at the Gender Confirmation Center as a broad term to describe what others may refer to as top surgery, chest masculinization surgery, or double mastectomy, in an effort to use a term that is affirming and acceptable to a broad audience. Top surgery is the most popular term used in and around the community.