Top surgery for transgender men is a surgical procedure to remove your breast tissue (subcutaneous mastectomy). It is also called masculinizing chest surgery.
If your breast size is small, you might be able to have surgery that spares your skin, nipple and areola (nipple-sparing subcutaneous mastectomy). If you have larger breasts, you might need to have your nipples and areolas taken off, resized and grafted back into position.
Top surgery for transgender men might be done as a step in the process of treating distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria). The procedure can help transgender men transition physically to their self-affirmed gender.
Why it's done
Transgender men who seek top surgery might experience distress due to a difference between experienced or expressed gender and gender assigned at birth (gender dysphoria).
For some transgender men, top surgery is a natural step — and important to their sense of self. However, many don't choose to have surgery. Transgender people relate to their bodies differently and need to make individual choices that best suit their needs.
Your doctor might recommend against this surgery if you have:
- Unmanaged mental health conditions
- Significant health conditions, such as heart or kidney disease, a bleeding disorder, or a history of blood clots in a deep vein (deep vein thrombosis) or in a lung (venous thromboembolism)
- Any condition that limits your ability to give your informed consent
Like any other type of major surgery, top surgery for transgender men poses a risk of bleeding, infection and an adverse reaction to anesthesia. Other complications might include:
- Poor wound healing
- Fluid accumulation beneath the skin (seroma)
- A solid swelling of clotted blood within your tissues (hematoma)
- Damaged or dead body tissue (tissue necrosis), such as in the nipple
- Dissatisfaction with appearance after surgery
How you prepare
Masculinizing surgeries are typically deferred until adulthood.
Hormone therapy isn't required before top surgery for transgender men. In some, waiting for the chest muscle growth that occurs with testosterone therapy will 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 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 kind of follow-up procedures that might be necessary. Follow your doctor'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 doctor will evaluate your health to rule out or address any medical conditions that might affect or contraindicate treatment. The evaluation might include:
- A review of your personal and family medical history
- A physical exam, including an assessment of your internal reproductive organs
- Lab tests measuring your lipids, blood sugar, blood count, liver enzymes and electrolytes
- A review of your immunizations
- Age- and sex-appropriate screenings
- Identification and management of tobacco use, drug abuse, alcohol abuse, HIV and other sexually transmitted infections
- Discussion about contraception and future fertility
Although giving your informed consent after a discussion about the risks and benefits of the procedure is an acceptable standard of care, most surgeons and insurance companies will require a mental health evaluation by a provider with expertise in transgender health. The evaluation might assess:
- 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
Before having top surgery, most surgeons and insurance companies require obtaining one letter of support from a mental health provider competent in transgender health. He or she 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
- Have the capacity to make a fully informed decision and to consent to treatment
- Be of 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
Since top surgery for transgender men will cause irreversible physical changes, you must give informed consent after thoroughly discussing:
- Social and legal implications
- Potential complications
- Procedure irreversibility
Health insurance might not cover surgical procedures considered cosmetic for the general population, even though these procedures might be essential to alleviating your gender dysphoria.
You might also consider talking to other transgender men who've had top surgery before taking this step. They can help you shape your expectations of what can be achieved and what personal and social problems you might experience during treatment.
What you can expect
Top surgery for transgender men 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 breast 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. Breast 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 larger breasts, you might need to have your nipples and areolas taken off, resized and grafted back into position to create the appearance of a male 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 breasts were 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 breast 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.
Top surgery can play an important role in relieving gender dysphoria for transgender men and improving their quality of life.
Research suggests that most transgender men are satisfied with their surgical results. In a 2017 study of transgender men who had chest surgery, 48 out of 57 people felt comfortable taking their shirts off in front of others.