Top surgery for transgender women and nonbinary people

Overview

Top surgery for transgender women and nonbinary people is a procedure to increase breast size and change the shape of the chest. It's also called feminizing breast surgery, breast augmentation, chest construction or breast mammoplasty.

Top surgery for transgender women and nonbinary people might involve placing breast implants or tissue expanders under chest tissue. In some cases, fat is taken from other parts of the body and injected into the chest. Both techniques might be used, if needed.

Top surgery for transgender women 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/incongruence). The procedure can help transgender women and nonbinary people transition physically to their self-affirmed gender.

Why it's done

Transgender women and nonbinary people who seek top surgery might experience discomfort because their gender identity doesn't match their sex assigned at birth.

While many transgender women and nonbinary people use hormone therapy to stimulate breast growth, they might not feel that their resulting breast size is adequate. Some wear artificial breasts or padded bras. Others choose to have surgery to change the appearance of their chest. Transgender and nonbinary people relate to their bodies differently and need to make individual decisions.

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 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

Your health care provider may also recommend that you undergo hormone therapy as appropriate to your gender goals prior to feminizing breast surgery. The recommendation is to take hormone therapy for a minimum of 12 months before surgery unless you have a medical contraindication or you're otherwise unable or unwilling to take hormones.

Risks

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

Other complications might include:

Scar tissue that distorts the shape of the breast implant
Fluid accumulation beneath the skin
A solid swelling of clotted blood within your tissues
Breast pain
Imbalance of the breasts or breast creases
Implant displacement, leak or infection
Dissatisfaction with appearance after surgery

Correcting these complications might require more surgery. Within 10 years of surgery, you might also need implant replacement.

How you prepare

Top surgery for transgender women and nonbinary people is typically deferred until adulthood.

Before top surgery, you'll meet with a plastic or reconstructive breast surgeon. Consult a surgeon who is board certified and experienced in this procedure. The surgeon will describe your options and potential results. The surgeon will also provide information on the anesthesia, the location of the operation and the kind of follow-up procedures that might be necessary.

Follow your health care provider's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking.

In addition, before you can have top surgery, you'll be required to meet certain criteria. To start, your health care provider will evaluate your health to address any medical conditions that might affect 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 and alcohol abuse
Testing for HIV and other sexually transmitted infections, along with treatment, if necessary

The purpose of hormone therapy prior to breast augmentation is to maximize breast growth to help you obtain optimal results.

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

Risks
Benefits
Cost
Alternatives to surgery
Potential complications
Procedure irreversibility

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 women 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 women and nonbinary people is typically done as an outpatient procedure. You'll be given general anesthesia.

During the procedure

The principles of breast augmentation for transgender women and nonbinary people are similar to surgeries performed for cisgender women.

However, transgender women typically have broader chests and larger and thicker pectoral muscles. They also typically have smaller nipples and areolas. In addition, they have shorter distances between their nipples and the creases under their breasts (inframammary fold). Because of their wider chests, transgender women often have a wide space between their breasts, even with larger implants.

During top surgery, the surgeon may make incisions around the areola, near the armpit or at the level of the inframammary fold. Silicone or saline implants will be placed through the incision under breast tissue.

When the implant is in place, the surgeon will close the incision — typically with stitches — and bandage it with skin adhesive and surgical tape.

If feminizing hormones haven't made your breasts large enough, you might need an initial surgery to have devices called tissue expanders placed in front of your chest muscles. You'll visit your health care provider every few weeks after surgery to have a small amount of saline injected into the tissue expanders. This will slowly stretch your chest skin and other tissues to make room for the implants.

When your skin has been stretched, you'll have another surgery to remove the expanders and place your implants.

After the procedure

You might need someone to accompany you home after surgery. Your surgeon might require that you stay locally for a few days.

Soreness and swelling are likely for a few weeks after surgery. Bruising is possible, too. Expect scars to fade over time but not disappear completely. You'll wear a compression bra for three weeks.

To decrease the risk of displacing a breast implant, limit upper body exercise for the first several weeks after surgery.