Gender-Affirming Top Surgery

• Dr. Alexander Facque (he/him)

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  Dr. Alexander Facque (he/him) is a board-certified plastic surgeon and proud member of the LGBTQ+ community. Dr. Facque got his start in gender-affirming care as a resident at the Icahn School of Medicine at the Mount Sinai Medical Center in New York, where he first recognized the importance of providing safe and accessible surgeries to trans and non-binary patients. He then spent a year training and expanding his knowledge under Dr. Loren Schechter, one of the world’s foremost gender-affirming surgeons, as a fellow at Weiss Memorial Hospital’s Gender Confirmation Surgery and Practice Leadership in Chicago. Dr. Facque officially joined our team in 2020 and brought with him over 5 years of previous experience in gender affirming care.
  
• Dr. Zara Ley (she/her/they)

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  Dr. Ellie Zara Ley (she/her) is a board-certified plastic surgeon and the only transgender woman of color to offer a full-spectrum specialization in gender affirming surgery: top surgery, bottom surgery, facial surgery and body contouring. She also specializes transgender adolescent care. She is highly trained, having completing her general surgery residency at University of Arizona, a fellowship in plastic and reconstructive surgery at the University of Utah, a fellowship in craniofacial and pediatric plastic surgery at Primary Children’s Hospital in Salt Lake City and another in hand surgery and microsurgery at the University of Southern California. Prior to joining our team in 2022, she worked as an assistant clinical instructor of plastic surgery at the University of Utah and had her own private practice in Arizona.
  
• Dr. Daniel Jacobs (he/him)

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  Dr. Daniel Jacobs (he/him) brings over 30 years of experience in reconstructive plastic surgery and research. He completed a General Surgery residency at LAC/USC School of Medicine and a Plastic Surgery residency at USC School of Medicine. His exceptional work has been recognized through prestigious medical awards such as the ‘Sidney R. Garfield, MD Exceptional Contribution Award’ in 2017, San Jose Kaiser Permanente’s ‘Outstanding Inpatient Physician of the Year’ in 2017, and the ‘Outstanding Achievement in Medicine’ award from Santa Clara Medical Association in 2016.
  
• Dr. Efstathios Karamanos (he/him)

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  Dr. Efstathios Karamanos (he/him) is a board-certified plastic and reconstructive surgeon with expertise in microsurgery, breast reconstruction, body contouring, and facial surgery. He has trained at leading institutions in both the United States and Europe and currently serves as Assistant Professor of Surgery at the California University of Science and Medicine. Dr. Karamanos is widely published, serves on multiple editorial boards, and is an active member of national surgical societies.
• Dr. Eric Lin (he/him)

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  Dr. Eric Lin (he/him) is a board-certified plastic and reconstructive surgeon with nearly 30 years of experience in a variety of breast surgeries. He values the importance of learning about patients’ perspectives to best help them achieve their desired goals. In addition to offering gender surgeries, Dr Lin also remains active as a post-cancer reconstructive surgeon and serves as Clinical Associate Professor of Plastic Surgery at the California Northstate University, College of Medicine.
• Dr. Scott Mosser (he/him)

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  Dr. Scott Mosser (he/him) is a board-certified plastic surgeon who has over 15 years of experience serving gender diverse patients. He has devoted himself exclusively to gender affirming care since founding the GCC in 2013. Dr. Mosser is also a cofounder of the American Society of Gender Surgeons (ASGS), a member of the American Society of Plastic Surgeons (ASPS), the World Professional Association of Transgender Health, (WPATH), the United States Professional Association of Transgender Health (USPATH), and is a Fellow of the American College of Surgeons (FACS).
• Dr. Ari Wes (he/him)

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  Dr. Ari Wes (he/him) is a plastic and reconstructive surgeon at the Gender Confirmation Center specializing in gender-affirming facial surgery and top surgery. Over the past decade, his training and clinical practice have focused extensively on gender-affirming care, with dedicated experience in facial feminization and chest surgery and a sustained commitment to transgender, nonbinary, and gender-diverse patients. He trained at the Hospital of the University of Pennsylvania and the Perelman School of Medicine, where he developed expertise in craniofacial surgery, breast reconstruction, body contouring, and surgical outcomes research. He is committed to clear communication, thoughtful planning, and meticulous technique so patients feel informed and supported throughout their surgical care.

In order to get top surgery, any patient needs to follow certain key steps: completing a surgical consultation, disclosing your full medical history and passing medical clearance, fulfilling insurance requirements, paying for surgery, and preparing for your procedure. We go over the most important steps below:

• What are the steps involved in getting top surgery?

• The first step in almost any surgical journey is requesting a consultation. At the GCC, both virtual and in-person consultations are free-of-cost to patients. If you have questions about each step in the process, you can refer to our top surgery timeline guide.

• Do I need a letter of approval from a therapist, psychiatrist or primary care doctor to get top surgery with GCC?

• Letters of support or clearance letters from a certified, mental health professional are welcome and valuable, but not a requirement for adults who seek surgery with the GCC. This is because we use the informed consent model, which means that a letter from a therapist is not required unless the patient is seeking insurance approval.

  Insurance providers that cover gender-affirming care always require a letter of support from a licensed mental health professional. If our surgeons are outside of your provider network, you will also need a reference letter from your primary care provider to request insurance coverage. For more information, click here.

• Will my insurance cover top surgery?

• At the GCC, you can leave the insurance worries to us. We provide an insurance concierge service to interested patients. After soliciting any necessary documents from you, our insurance advocacy team will get to work to secure full or partial coverage for your medically necessary, gender affirming procedure. Our team has a 90% success rate in securing coverage for insured patients. Learn more about that process here.

• How can I finance my surgery if it’s not covered or only partially covered by insurance?

• We have compiled a list of scholarships for gender affirming surgeries alongside trusted, medical credit agencies you can use to help finance your surgery with us. You can also find estimated costs for each procedure we offer if you plan on paying entirely out of pocket. Click here for more.

• Do I need to be taking testosterone hormone replacement therapy to get top surgery?

• Taking testosterone is not required before undergoing top surgery by us or by insurance providers. At the GCC, we are committed to serving patients of all gender identities. We believe in taking an individualized approach with each patient to design surgery to meet their unique goals. That said, if you have questions about how testosterone might impact top surgery results, click here.

• What about patients who are traveling from out of town to San Francisco for surgery?

• Many trans, non-binary and gender expansive patients need to travel to access quality, reliable gender affirming surgical care. At the GCC, we are very accustomed to working with patients from out of town. We have compiled a guide on preoperative consultations and post-operative follow-up protocols for patients who do not live in the San Francisco Bay Area.
  For recommendations on travel and lodging, click here.

• How can I best prepare for top surgery?

• Prior to surgery, we recommend that patients work to maintain good physical and mental health. Minimizing or eliminating the consumption of alcohol and nicotine can also help ensure a positive surgical outcome. Learn more about our guidelines and recommendations here.

• How might top surgery and testosterone hormone replacement therapy (HRT) impact someone’s ability to get pregnant? How might pregnancy affect a patient’s top surgery results?

• Though there is sparse medical research on the subject, many people who have been on testosterone hormone replacement therapy (HRT) and/or have had top surgery can still carry a pregnancy to term. There is evidence to suggest that some top surgery patients may experience mammary tissue growth during pregnancy. For more information about chestfeeding, HRT, top surgery and pregnancy, click here. For more specific questions, we recommend speaking with a trans or gender-competent medical provider.

• Can I get top surgery with other procedures like body masculinization or gender affirming body contouring?

• Absolutely! Many of our patients opt for liposuction not only around their chest, but also around other parts of their body to alter their frame or silhouette. You can read more about the liposuction services we offer in our articles about body masculinization surgery and body contouring options for non-binary patients. Some patients also undergo top surgery alongside an abdominoplasty.

Top surgery encompasses a variety of mastectomy and breast reduction techniques as well as the possibility for liposuction. If you have questions about which procedure type would be best for you, you can ask one of our board-certified surgeons in a free consultation. Likewise, you can learn more about how we help patients determine which incision type, you can read more here. Below, we go over every incision type our surgical center offers and why patients tend to opt for them:

Minimal Scarring Options for Patients with Minimal Tissue

The keyhole and periareolar techniques create incisions around the nipple-areola complex, which often leave scars that are invisible because they heal into the coloring of the areolas. These options are ideal for patients with minimal to moderate amounts of tissue.

Flatness vs. Volume

For patients who don’t qualify for minimal scarring options, the question then becomes how much volume they would like left behind on their chests after surgery.

• Patients who would like to have a completely flat chest often choose between the following techniques: double incision, lollipop incision and fish mouth or batwing incision
• Patients who would like to retain some volume to their chest after surgery often choose between the following techniques: double incision, inverted T and buttonhole.

Nipple Sensation & Appearance

Top surgery gives patients the option to change the dimensions and positioning of their nipple-areolar complexes through free nipple grafting. Alternatively, some patients opt to have their nipples and areolas be removed entirely. For patients who would like to keep their nipples, you can consider the following options:

• Patients who are interested in preserving high levels of sensitivity in their nipples can opt for a double incision with nerve grafting, a periareolar, a keyhole, an inverted T or a buttonhole technique.
• Patients who would like to have the amount of sensibility in their nipples reduced can opt for any procedure that involves nipple grafting.

What Options Exist for Non-binary and Gender Expansive Patients Seeking Top Surgery?

Non-binary and gender expansive are two names for gender identities that transcend the two binary genders: male or female. At GCC, we recognize that there is no one way to “look non-binary,” just as there is no single, correct way to “look like a woman or man.”

That said, due to our high-volume of non binary patients, we have developed a series of top surgery techniques that respond to the interests commonly expressed by this group. Our approach is based on agreeing with a patient on the most suitable techniques to help them achieve their aesthetic goals and put them at the smallest risk possible for medical complications.

How Might Chest Binding and Nipple Piercing Affect Top Surgery Results? When Can I Get My Nipples Pierced After Surgery?

Patients who previously used a chest binder and/or have had nipple piercings are still eligible for top surgery. The effects of chest binding on top surgery results are minimal at best. Still, long-term binding may affect skin elasticity.

In terms of piercings, please inform your surgeon if you had nipple piercings in the past. Any chest piercings will need to be removed prior to the operation. You can find more information on chest binding here, and our guidelines around nipple piercings here.
In the video below, Dr. Eric Lin (he/him) describes some of our best practices around nipple piercings and top surgery:

Generally speaking, it can take 6-12 to see your final top surgery results since it takes that long for swelling to fully resolve and scars to mature. Most patients can return to work 1-2 weeks after surgery, but it will take 6 weeks to be able to return to rigorous physical activity.

We have put together a series of guides to cover the most common inquiries patients and their loved ones have about complications and recovery from top surgery. Every patient’s process is different. If you have inquiries about your unique situation or medical history, we can take that into account when crafting your unique surgical plan in a free, virtual consultation.

• For the general timeline for healing after surgery, click here
• For a guide on physical rehabilitation for pain and mobility, click here
• For guidelines on limiting arm movement post-op, click here
• For tips for speeding up the recovery process, click here
• For information on returning to work after surgery, click here
• For information on resuming exercise after surgery, click here
• For instructions on incision and scar care, click here
• For instructions on caring for nipple grafts, click here
• For information on surgical drains, click here
• For information on potential complications from top surgery, click here