Top Surgery: What to Expect on the Day of Surgery

Gender-Affirming Chest Reconstruction

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Top surgery, also known as gender-affirming chest reconstruction, is usually done as a day surgery or outpatient procedure. It may also be done with an overnight or short hospital stay.

Generally, you will come to the hospital or surgery center the morning of your procedure and leave later that day or early the next day. As this procedure is performed under general anesthesia, it is important to have someone to bring you to and from the hospital.

Gender Dysphoria

Top surgery is a procedure that may be used to address gender dysphoria in transgender men and other transmasculine individuals. Many binary and non-binary transmasculine individuals are uncomfortable with their chests.

Top surgery allows them to have a flatter, more masculine chest contour without the need for binding. While not all transmasculine people want top surgery, it is one of the more common gender-affirming procedures.

In the Hospital Sick Male Patient Sleeps on the Bed. Heart Rate Monitor Equipment is on His Finger.
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Before the Surgery

To some extent, what happens on the morning of surgery is going to depend on where you are getting surgery. You will likely have your vitals taken. You may be required to give a urine sample to check for pregnancy. You will generally be asked to remove all metal body jewelry as well.

While you are waiting for surgery, an IV will be started that will be used during your surgery. If you are uncomfortable with needles, it is alright to ask for something to distract yourself while the IV is placed. You may also be able to listen to music or do other things on your phone while you wait.

The anesthesiologist and your surgeon will likely both come to talk with you before the surgery. You may need to sign additional consent forms for anesthesia or surgery if you have not already done so. If you have any remaining questions, this is a good time to ask them.

Do I Really Need a Pregnancy Test?

A lot of transgender men and other transmasculine people are, understandably, bothered by the need to undergo a urine HCG screen (i.e. pregnancy test) prior to having surgery. They may also think that it's unnecessary if they are on testosterone or don't have any sexual exposure to semen.

However, most institutions require a pre-operative urine HCG for anyone who has a uterus and ovaries and is of reproductive age—regardless of whether or not that person is actually at risk of pregnancy.

If you have had a hysterectomy, you should not need to have a pregnancy test—although the medical staff may have no way of determining that clearly from your records. However, testosterone is not a contraceptive, even though it does make pregnancy less likely.

During the Surgery

There are several different techniques that can be used for top surgery. The surgical technique used often depends on the surgeon's experience, patient preferences, and the size and shape of the patient's body and breasts and skin quality.

The most common technique is double incision mastectomy with free nipple grafts–and is best suited for patients with medium to large breasts. However, there are other techniques such as keyhole surgery and peri-areolar surgery.

There are some significant differences in healing and side effects between techniques that do and do not involve free nipple grafts. A free nipple graft is when the nipple is entirely removed from the chest, re-sized, and then placed in a more lateral position on the chest.

This surgery is performed under general anesthesia. That means that you will be unconscious for the entire procedure. Some people describe going under anesthesia as "going to sleep," but that can be misleading.

When you are under general anesthesia, you will have no awareness of your surroundings or time passing, and you will not feel any pain. Some people describe the sensation as having jumped forward in time.

Once you are under, the surgical team may or may not place a urinary catheter. The use of a catheter depends on the preferences of the surgical team and how long the surgery is expected to take. Your skin will then be cleaned and prepared for surgery.

If you are having a procedure involving free nipple grafts, a horizontal incision is made at the lower border of the pectoralis (chest) muscle, and a second incision is made to remove the nipple, which will be safely kept aside. The breast tissue will be removed along with the extra skin.

The scar that is formed is usually placed in the location of the inframammary fold to give the impression of a pectoral shadow. Then the nipples will be made smaller and placed in a more lateral position (wider apart) on the chest.

Special dressings called bolsters are used to cover the nipples and keep them safe during the early phases of healing.

If you are having a keyhole, inverted-T, peri-areolar, or other procedure that does not involve nipple grafts, an incision will be made around the nipple (and possibly vertically below it) and the breast tissue will be removed.

In these procedures, only a small amount of skin, if any, can be removed. Therefore, this type of top surgery is only appropriate for people with very small chests and good skin quality.

At the end of the main top surgery procedure, the surgeon will most likely place drains on either side of your chest. These are plastic tubes that are used to remove excess fluid from the surgical site during healing.

You will usually need to empty your drains a couple of times a day for approximately the first week after surgery. The amount of fluid will gradually decrease until it is safe for the surgeon to remove them.

The entire surgery usually takes between three to five hours.

After the Surgery

When you wake up after top surgery you will be wearing a compression vest and the drains will be coming out the sides. It is important to keep this compression vest on at all times until your surgeon gives you the clearance to take it off. The vest helps to keep you from having bleeding under the skin or fluid collection after surgery.

If you had free nipple grafts, there will be special dressings called bolsters sewn onto your skin under the compression vest. You should not attempt to remove or change these dressings. They will generally be removed at your first post-operative visit, depending on timing.

Usually your surgical team will monitor you for a couple of hours after surgery in order to make certain that you don't have any issues, such as nausea, from the anesthesia. Some surgeons prefer to keep patients overnight or for a day or two, in order to monitor them for longer periods.

When you go home, you may be given enough opioid pain medication to last you a few days. However, many people find that they can manage the pain of top surgery with ibuprofen and acetaminophen if they do not want to take opioids or deal with the side effects.

You will be told to keep an eye out for swelling and pain on one side of the body, which may represent a collection of blood (hematoma) or other fluid (seroma) that needs to be addressed by the surgeon. Signs that may indicate a need to return earlier for follow-up include:

  • Fever
  • Shortness of breath
  • Increased pain on one side of the chest
  • Increased drainage
  • Change in color of drainage

Most people feel up to resuming their normal activities a few days to a week after having top surgery. The initial post-operative visit usually takes place at around day seven. That is when the drains are removed and, if necessary, the nipple bolsters.

People generally feel much better after that visit and a common saying is, "drains out, pain's out." You will not be able to shower your upper body until after that first visit, although you should wash your lower body if you can.

It is important to follow the surgical restrictions given to you by your doctor. These usually involve restricting arm movements and avoiding lifting for four to six weeks. If you need accommodations for work or school, talk to your surgeon about getting a note before leaving the surgical center.

A Word From Verywell

For those individuals who choose to have it, top surgery can make an enormous difference in their quality of life. Serious complications are rare, although depending on the technique, revisions may end up being needed for aesthetic reasons.

When meeting with a surgeon to explore top surgery, it's good to ask about their complication and revision rates. You should also ask to see photos of surgical outcomes, ideally of patients with a body- and skin-type similar to your own.

If you are traveling for surgery, you should also plan on staying in the area for at least a week. That will let the surgeon take care of any early post-operative issues promptly, as well as perform standard post-operative care.

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