Top surgery for transgender men and nonbinary people

Overview

Top surgery for transgender men and nonbinary people is a procedure to remove breast or chest tissue (subcutaneous mastectomy). It's also called masculinizing chest surgery.

If your chest size is small, you might be able to have surgery that spares your skin, nipple and areola. This type of surgery is called nipple-sparing subcutaneous mastectomy. If you have a larger chest, you might need to have your nipples and areolas taken off, resized and placed back into position.

Top surgery for transgender men and nonbinary people might be done as a step in the process of treating discomfort when gender identity differs from sex assigned at birth (gender dysphoria). The procedure can help transgender men and nonbinary people transition physically to their self-affirmed gender.

Why it's done

Transgender men and nonbinary people who seek top surgery might experience discomfort when their gender identity doesn't match the gender they were assigned at birth (gender dysphoria).

For some transgender men and nonbinary people, top surgery is a natural step — and important to their sense of self. However, many don't choose to have surgery. Transgender and nonbinary people relate to their bodies differently and need to make individual choices that best suit their needs.

Before having top surgery, most surgeons and insurance companies require obtaining one letter of support from a mental health provider competent in transgender health. The mental health provider will determine that you meet the World Professional Association of Transgender Health (WPATH) standards of care criteria.

The criteria state that you must:

• Have persistent, well-documented gender dysphoria
• Be able to make a fully informed decision and to consent to treatment
• Have reached legal age to make health care decisions in your country (age of majority or age 18 in the U.S.)
• Be managing any significant medical or mental health concerns

Risks

Like any other type of major surgery, top surgery for transgender men and nonbinary people poses a risk of bleeding, infection and an adverse reaction to anesthesia.

Other complications might include:

• Poor wound healing
• Fluid buildup beneath the skin
• A solid swelling of clotted blood within your tissues
• Damaged or dead body tissue, such as in the nipple
• Scarring
• Not being satisfied with appearance after surgery
• An imbalance in chest tissue

How you prepare

Masculinizing surgeries are typically deferred until adulthood.

Hormone therapy isn't required before top surgery for transgender men and nonbinary people. In some, waiting for the chest muscle growth that can occur with testosterone therapy may provide the best surgical result. If you've been taking testosterone therapy, you'll have blood tests to ensure the testosterone level is in your target range before your surgery.

Before surgery, you'll meet with your surgeon. Consult a surgeon who is board certified and experienced in this procedure. Your surgeon will describe your options and potential results.

The surgeon will provide information on the anesthesia, the location of the operation and the follow-up procedures that might be necessary. Follow your health care provider's instructions on preparing for your procedure. You'll be given guidelines on eating and drinking, adjusting current medications, and quitting smoking.

In addition, you'll be required to meet certain criteria before you can have top surgery. To start, your health care provider will evaluate your health to check for or address any medical conditions that might affect or rule out treatment.

The evaluation might include:

• A review of your personal and family medical history
• A physical exam
• Lab tests measuring your testosterone levels
• Age- and sex-appropriate screenings
• Identification and management of tobacco use, drug abuse, alcohol abuse
• Testing for HIV and other sexually transmitted infections, along with treatment, if necessary

World Professional Association of Transgender Health (WPATH) standards of care criteria requires obtaining one letter of support from a mental health provider competent in transgender health. You'll need a mental health evaluation to receive a letter of support.

The mental health evaluation might cover:

• Your gender identity and dysphoria
• The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
• Mood or other mental health concerns
• Sexual health concerns
• Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
• Protective factors such as social support from family, friends and peers
• Your goals, risks and expectations of treatment and your future care plans

Consent

Since top surgery for transgender men and nonbinary people will cause irreversible physical changes, you must give informed consent after thoroughly discussing:

• Risks
• Benefits
• Cost
• Alternatives to surgery
• Social and legal implications
• Potential complications
• That the surgery can't be reversed

Health insurance might not cover surgical procedures considered cosmetic for the general population, even though these procedures are medically necessary to alleviate your gender dysphoria.

You might also consider talking to other transgender men and nonbinary people who've had top surgery before taking this step. They can help you shape your expectations of what can be achieved.

What you can expect

Top surgery for transgender men and nonbinary people is typically done as an outpatient procedure. You'll be given general anesthesia.

During the procedure

Top surgery involves more than a mastectomy for the treatment of breast cancer. Special techniques are used to contour and reduce the chest wall, position the nipples and areola, and minimize scarring.

If your chest size is small, you might be able to have surgery that spares your skin, nipple and areola (subcutaneous nipple-sparing mastectomy). This procedure minimizes scarring, has a faster healing time and usually preserves sensation in the nipples. During this surgery, incisions are made around the borders of the areolae and the surrounding skin. Chest tissue is removed through the incisions and some skin also might be removed. Remaining skin is reattached at the border of the areola.

If you have more chest tissue, you might need to have your nipples and areolas taken off, resized and placed back into position to create the appearance of a more masculine chest. This causes more scarring and loss of sensation to the nipple. Non-erotic sensation typically returns in months to years.

If you are a carrier of genetic mutations that increase your risk of breast cancer, you might also choose to have your nipples and areolas completely removed and subsequent surgery or tattooing to recreate their appearance.

After top surgery, you might need additional surgery to correct scarring, chest contour, or the placement of the nipples and areola.

After the procedure

After surgery, your chest will remain in a compression wrap for several weeks. You'll likely have one or two small plastic tubes placed where your chest tissue was removed to drain any fluids that accumulate after surgery. You'll need to sleep with your torso elevated for the first week after surgery. Avoid lifting more than 10 to 15 pounds for several weeks.

Some chest tissue will likely remain regardless of the surgical technique. As a result, your doctor will talk to you about the need for continuing routine breast cancer screening.

Results

Top surgery can play an important role in relieving gender dysphoria for transgender men and nonbinary people and improving their quality of life.

Research suggests that most transgender men and nonbinary people are satisfied with their surgical results. In a 2021 review of studies of transgender men who had chest surgery, satisfaction with the procedure was high.