Purpose of Top Surgery

(Gender Affirming Chest Reconstruction)

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Top surgery, or gender affirming chest reconstruction, is a procedure used to create a masculine chest contour for transmasculine individuals (those assigned female at birth with a more masculine gender identity.) There are several steps to this procedure:

  • Mastectomy, or removal of the breasts
  • Removing and resizing the nipples and areolae, as male nipples are usually smaller
  • Replacing the nipples in a more masculine location, towards the outer edges of the chest
  • Contouring of the chest wall
Portrait of a transgender man in living room
Patryce Bak / Getty Images

Not all top surgery patients will need all procedure elements described above. Plastic surgeons use different approaches and techniques for top surgery, and different people have different body shapes and contouring concerns.

However, it is important to be clear that top surgery is not an elective surgery. Top surgery is a medically necessary procedure for individuals who experience gender dysphoria related to their chest.

Top Surgery for Women?

Top surgery is most often used to describe gender affirming chest reconstruction for transgender men and non-binary people who are assigned female at birth. However, some transgender women also refer to breast augmentation as top surgery.

In this article, we are solely discussing top surgery for transmasculine individuals, not transfeminine breast augmentation.

Diagnosis Related to Top Surgery

The sole indication for top surgery is gender dysphoria. This is generally coded as an F64.* diagnosis. Gender dysphoria is when a person experiences discomfort or difficulty with their body because it does not reflect their internal sense of themselves.

Top surgery is appropriate for individuals assigned female at birth who have a non-binary or male gender identity and experience dysphoria related to the size and/or shape of their chest.

Criteria

Access to top surgery is generally regulated by the World Professional Association of Transgender Health's Standards of Care. These standards are followed by most insurance companies to determine coverage. In general, for someone to access top surgery, they are expected to meet the following criteria:

  • Diagnosis of gender dysphoria
  • Having lived in their affirmed gender for at least 12 months
  • There is no requirement for hormone use, but if a person is taking testosterone, they should ideally have been on it for at least 12 months.

These criteria are often required to be documented in two letters. The first letter is usually from either the primary care provider or the doctor providing hormones.

The second letter is usually from the person's therapist or another behavioral health provider. These letters are also expected to document any other significant medical or mental health problems that could affect surgery.

The letter requirements for top surgery are considered to be a form of gatekeeping by many individuals in the transgender community, as similar letters are not required for similar surgeries among cisgender individuals.

This may indeed be the case, but they also provide documentation of the requirements for surgery, which may not be easily measurable by a consulting surgeon.

Eligibility for Breast Reduction vs. Chest Reconstruction

Breast reduction is a similar, but not identical, surgery to chest reconstruction. In order to determine eligibility for breast reduction, surgeons must document that the patient has a significant history of pain and there is a large enough volume of breast tissue they intend to remove.

In contrast, for gender affirming chest reconstruction, the documentation is around gender dysphoria, rather than any physical characteristics or discomfort.

Tests and Labs

In general, there are no specific tests or labs required for top surgery. However, some surgeons may require a cotinine test for individuals who have a history of nicotine use. This is because top surgery involves a free-flap transfer (removing and replacing the nipples), and nicotine in the system can compromise blood flow and make complications more likely.

Different surgeons have different requirements around when individuals have to stop using nicotine prior to surgery and for how long they have to stay nicotine free after surgery.

Individuals with other health conditions may require clearance related to those specific conditions prior to surgery. Your top surgeon may ask you to get a note from any specialists who you see on a regular basis in order to clear you for surgery. You may also be asked to see a specialist, such as a cardiologist, if you have a history of certain medical problems but no ongoing care.

Acne Medication and Surgery

Individuals who are taking the acne medication isotretinoin (Accutane) will often be asked to discontinue use for several months prior to surgery. There is limited, low-quality evidence that use of this drug in the six to 12 months prior to surgery may increase the risk of abnormal scarring and/or delayed wound healing. 

As scar appearance can be linked to patient satisfaction with top surgery, many surgeons are particularly cautious around the timing of this procedure.

If you take any systemic acne medication it is important to discuss this with your surgeon prior to scheduling your procedure. It is also good to discuss your use of any topical medications for acne on your chest. You should also let your surgeon know if you use other products for chest rashes or skin breakdown.

A Word From Verywell

Top surgery is a medically necessary procedure to address gender dysphoria in transmasculine people. It has been shown to have substantial benefits for health and wellbeing. Although not all transmasculine individuals are interested in top surgery, those who want it can experience significant benefits.

The major expected downsides of top surgery are loss of nipple sensation and inability to chest feed (breastfeed) should a person become pregnant. (Although there are reports of individuals able to chest feed after certain types of top surgery, this ability should not be assumed.)

There are some transmasculine individuals who think of top surgery not as a way to get rid of gender dysphoria but to increase gender euphoria. Gender euphoria is the idea of being excited and happy that the body you are in reflects your gender identity.

Some people see gender euphoria as a less pathologizing framework than gender dysphoria for looking at gender surgeries and other forms of gender affirmation. However, realistically, gender euphoria and gender dysphoria describe different experiences and either or both may feel more relevant to any given individual.

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