What Is Transgender Top Surgery?

When transgender and other gender diverse people are interested in surgically transitioning, one thing they may be interested in is top surgery. Top surgery refers to the group of surgeries that transgender people, both binary and non-binary, use to reshape their chests. (This is in contrast to bottom surgery, which is used to reshape the genitalia. Bottom surgeries include phalloplasty, metoidioplasty, and vaginoplasty.)

Not all transgender people are interested in surgical transition. However, the 2015 National Transgender Discrimination Survey found that more than 70 percent of gender diverse people assigned "female" on their original birth certificates (AFAB) either had already had or wanted top surgery, as did more than 44 percent of people assigned male on their original birth certificate.

One of the reasons that transfeminine people may be less interested in top surgery than transmasculine people is that many of them experience sufficient breast growth on estrogen to address any chest dysphoria. Another reason is that top surgery may be less likely to be covered by insurance for transfeminine people than in transmasculine people.

What Is Chest Dysphoria?

Gender dysphoria is the experience of feeling uncomfortable or unhappy in your body because your body doesn't match your gender identity. Chest dysphoria is the experience of feeling uncomfortable or unhappy with your chest because it doesn't match your gender identity. For example, a young transgender person who underwent puberty and has breasts may feel uncomfortable with their breasts. This chest dysphoria could affect them while wearing clothes or while naked.

A transgender woman who has broad shoulders and small breasts may also feel uncomfortable with her silhouette when she's dressed (or when she's not).

Some individuals with chest dysphoria may deal with their chest dysphoria without surgery. Transmasculine people may wear a binder to flatten their chest under clothing. This can be a good solution for some. However, for others, binders can be uncomfortable or even painful. Binders can make it difficult to breathe or exercise. Some people who bind frequently or for very long periods of time may also experience rashes or skin breakdown.

Transfeminine people who are comfortable with their bodies but want to change their silhouette in clothing may wear padded bras or use silicone breast pads. Such techniques are also used by cisgender women who want to appear to have larger breasts when clothed.

Top Surgery for Transgender Women and Transfeminine People

Top surgery for transgender women and other transfeminine individuals is the same as breast augmentation. It involves the insertion of a silicone or saline implant inside or beneath the breast in order to increase breast size. It is highly recommended that transgender women be on estrogen for at least one year before undergoing breast augmentation. This maximizes natural breast growth, which may be sufficient for some women to feel happy in their bodies.

Maximizing breast growth also makes it safer and easier for the surgeon to perform the augmentation. A year on estrogen may also be required for insurers to cover top surgery for transgender women if they cover transgender surgeries at all.

Top Surgery for Transgender Men and Transmasculine People

There are two broad categories of top surgery for transmasculine individuals—nipple sparing and surgery involving nipple grafts. Nipple-sparing surgeries are surgeries that leave the nipple in place and, generally, do not remove much if any skin. These surgeries have the benefit of maintaining nipple sensation after surgery. However, only a very small number have chests suitable for this type of surgery.

In order to undergo nipple-sparing surgery, you must have small breasts and good skin elasticity. You must also be aware that your nipple size and placement may not be as typical as is seen with top surgeries that involve free nipple grafts. This is because assigned male's nipples are usually smaller and more widely set than assigned female's nipples. People who have nipple sparing surgery may be more likely to request a surgical revision (second surgery) in the future than those who don't.

Surgeries involving nipple grafts are used for individuals with larger chests or larger nipples that need to be reshaped to get a good aesthetic outcome. There are various ways that these surgeries can be performed, but one common way is a double incision mastectomy with free nipple grafts. This surgery leaves two long scars on the chest, but it generally provides a good chest contour. It also allows the surgeon to resize the nipples and place them in an ideal position to get a typical assigned male appearance.

Some downsides of this surgery include loss of nipple sensation and the risk of nipple loss. Of note, some people choose to have this surgery without nipple grafting (because they either don't mind if they don't have nipples at all or because their insurance won't cover nipple grafting).

Different surgeons use different incision types and place their scars differently. You will need to find someone who you feel comfortable with and whose outcomes fit your surgical goals. As many transmasculine people report that one of their goals with surgery is to go shirtless in places where others go shirtless, comfort with scar placement is important.

Benefits of Top Surgery

Because more transmasculine than transfeminine individuals undergo top surgery, much of the research on satisfaction with surgery is in this population. Overall, studies have found that outcomes from top surgery in transgender men and transmasculine people broadly are extremely positive. Transmasculine people who have had top surgery often feel more confident and less anxious than before their surgery or in comparison to others who have not had surgery.

They are also more physically active and more comfortable engaging in activities with friends and partners.

Similar improvements were seen in one published study looking at outcomes of breast augmentation in transgender women and transfeminine women.

People often ask whether patients seeking top surgery regret the decision to have it. Although this is not a well-researched area, studies that have asked the question have generally found that few to no patients regret having top surgery. Regret has also been reported as extremely low (in the vicinity of .1 percent) for transgender individuals undergoing bottom surgery.

Things to Ask Yourself

Top surgery has the potential to greatly improve the quality of life for transgender people, both binary and non-binary, whose chest dysphoria can't be resolved through non-surgical means. However, before you have top surgery, it's important to be realistic about your goals for surgery. It's also to be realistic about your readiness for surgery. Talk to a surgeon about how you'll need to care for yourself after surgery, and then ask yourself questions such as:

• Can I take that much time off work or school?
• Can I follow the recommendations for limiting my activity?
• Do I have someone to help me after surgery if I need it?
• Do I have a safe place to recover?
• Can I stop smoking or follow other health recommendations my surgeon gave me?

If the answer to one or more of these questions is no, you might want to wait to have surgery.

A Word From Verywell

The outcome of top surgery, including the appearance of your scars, depends a lot on whether you can follow instructions for limiting activity and taking care of yourself. That's true both before and after surgery. So if you're not ready to follow guidelines for self-care, it may make more sense to wait to have surgery until you are. Sometimes a second surgery is unavoidable. However, if it's at all possible, you want to have top surgery only once.