Top Surgery for Trans Men

 “Top surgery” or bilateral mastectomy with male chest wall recontouring and nipple and areolar reconstruction, is a procedure designed to remove breast tissue and reshape the nipple and areola in order to create a more masculine chest appearance. Alongside hormone therapy, top surgery is typically one of the first steps for patients who are transitioning from female to male; this may also be the only surgical procedure undergone by many trans men.  Patients who opt for bilateral mastectomy can expect to experience a number of benefits, including a greater congruence between their outside appearance and experienced gender, improved self-esteem and self-image.

Before and After Photos of Top Surgery 

Top Surgery Procedure

There are a number of surgical techniques that may be utilized to accomplish the desired breast tissue removal. The surgery procedure that will yield the best results needs to be customized for the patient based on many factors.  The amount of breast tissue, the degree of breast skin droop, the quality of breast skin, and your chest width - all need to be assessed.  Based on those factors as well as the patient's specific desires, a plan is made for top surgery.

 

The most common technique is called a bilateral mastectomy with a double incision.  In this procedure, the mastectomy (removal of the breast tissue) is performed through an incision that lies in the fold underneath the pectoralis major muscle in the horizontal direction.  The nipple is then reconstructed and the areola is resized and shaped and placed around the nipple. This technique allows for the removal of essentially all of the breast tissue (including milk ducts) and excess skin, along with proper placement and downsizing of the nipples. This technique is utilized most frequently because the majority of patients have a combination of excess skin and a naturally low nipple position.  

The peri-areolar technique consists of breast tissue removal through a small incision around the nipple. This technique carries the advantage of significantly reduced scarring. However, only a relatively small number of patients are considered good candidates for this procedure. The suitable candidate for this type of mastectomy is typically the young, slim patient with a small amount of breast tissue, no excess skin, and a nipple position that does not require major modification. 

Some patients have inquired about the possibility of using a “pedicled” technique to preserve sensation to the nipple; however, this technique has to leave a significant amount of breast tissue to preserve the nerves and usually results in some fullness, that can still look like a breast.  

Patients who have a very large amount of breast tissue or chest wall fat tissue may benefit from combining lateral chest wall liposuction with their mastectomy. The decision as to whether or not this is needed will be made at the time of the consultation.

Who is a Candidate for Top Surgery?

All patients are carefully evaluated.  If you have the diagnosis of gender dysphoria, are in good physical and emotional health  - you are a candidate. You do not "need" to be on hormones, and if you are on hormones, you do not need to stop taking them prior to the procedure. It is important to have support both emotional and physical following the operation.  Patients need to understand very carefully the risks and benefits and realize that this is not a reversible procedure.  Patients also need to understand that in most cases they will lose nipple sensation.  For insurance coverage, patients generally need to have been seeing a mental health professional who has given them the diagnosis of gender dsyphoria.

Post Surgery Recovery 

A special dressing will stay on the nipple graft for 5-7 days for the double incision procedure and drainage tubes. Peri-areolar patients have drains but no special dressing and may shower post op day 2. Postoperative discomfort is typically mild to moderate and is controlled by pain medication. Arm use should be restricted during the first week. This includes driving, lifting, or reaching. At one week, normal daily activities may be resumed; vigorous exercise and weight-lifting can begin again at 3-6 weeks post-surgery. Scars are permanent, but they should fade gradually over the first year after surgery.  Dr. Hazen will develop both a post op scar and exercise routine to maximize your results.

Why Choose Dr. Hazen

Dr. Alexes Hazen has years of experience doing transgender mastectomies and is considered a top surgery expert. Dr. Hazen has written papers for peer review journals on both technique and outcomes for these procedures.  Additionally Dr. Hazen listens to your particular desires for how you want your chest to look and tries to deliver that result to you.  Her staff makes you feel comfortable, respected and safe.

What to Expect From Your Consultation

After welcoming you, Dr. Hazen takes a thorough look at your medical history and conditions, including your hospitalizations and medications taken.  A physical exam is performed.  Your goals and desires for surgery are fully explored, and Dr. Hazen gives a comprehensive explanation of the surgical procedures that are possible for you, including complications and risks.  She describes your special recovery process.  Now, you have the option to have your pre-operative photos taken (saves a visit). Dr. Hazen and you may explore any issues that are blocking or interfering with the surgery actually happening, including anxieties around it. Then a plan is made with a timeline. Should the surgery not be covered by insurance, you'll be informed about the estimated costs for surgery and anesthesia.