Top surgery - trans masculine
Many trans and non-binary patients think about top surgery. Masculinising top surgery removes the breast tissue and the excess skin to create a neat flat chest. For most patients this uses the “double scar” technique. There is the option of free nipple grafts for nipple preservation, although this has limitations. Alternatives include nipple-areolar tattooing or going without nipples. When there is very little excess skin (very modest breasts) it may be possible to have a different technique that preserves the nipple
Key points
  • Operation to create a more male-looking chest
  • Usually an overnight stay
  • Wound drain (plastic tube) for a few days
  • Low (but not zero) risk
  • With or without nipple grafts
Alternatives

Gender identity is a spectrum and top surgery is not mandatory for anyone and avoiding surgery avoids the potential risks that go with any procedure. For some people the body changes from taking testosterone are sufficient and how their chest looks is less important. Binding can help to achieve a more flat look, but is often uncomfortable and restrictive.

Alternatives to nipple grafting include nipple areola tattooing, going without nipples or even decorative tattooing.
Potential problems
  • Bleeding, including a pocket of blood under the skin (haematoma) (5%)
  • Asymmetry 
  • Seroma
  • Wound infection (<5%)
  • Scar widening
  • Nipple necrosis or even graft failure
  • Residual bulginess
  • Decision regret (1%)
  • Risk of anaesthesia (low)
Associated treatment
Many trans and non-binary people choose to take gender affirming hormone therapy, but this is not a prerequisite for top surgery. For some, the changes that go with taking hormone therapy are more important and for others how the chest looks and feels is more important. Surgery to create a more male-looking chest can be very effective but isn’t perfect. Your own natural body/chest shave has the biggest impact on the final outcome. If you are able to build pec muscles through exercise it will help to make the tie look more masculine in the long run, but this can be challenging and can take a lot of dedication. 
Nipple grafts usually require fairly close monitoring for a few weeks after surgery and will often scab over and become quite weepy for a little while before they fully heal. The size, shape and position can alter slightly in the weeks after surgery as the tissue tension adjusts to the new normal. Nipple areolar tattooing puts you in control of size shape and position, but does incur an extra cost and means being without nipples for a period of time.
On the day of surgery
You will need to fast for 6 hours before surgery. You can take any medications as normal and continue to drink water until 2 hours before surgery.
You should shower and wash well in the morning. Bring something to do as there will be a lot of waiting.
When you arrive you will be checked in by the nurses and change into a gown and stockings ready for the operation.
In the holding bay
You will see your surgeon and anaesthetist, have a drip put in and have the operative site marked. You might also be given premedication.
In recovery
After surgery you will go to recovery. You will be watched closely until you are alert and well enough to return to the ward. You might be given medication for any sickness or pain.
Driving
You need to be able to concentrate properly and perform an emergency stop without any distracting pain. You will probably need to avoid driving for 1-2 weeks, but check with your insurance company.
Work
Getting back to work can be necessary or helpful for many, but you should plan for about 4 weeks off. You might be able to do some light or admin work after about 2 weeks.
After surgery
Swelling or bruising is common and usually settles on its own. A post-surgery compression garment (available on request) can help and is ideally worn most of the time for about 6 weeks.
You will probably have a drain (plastic tube) to prevent fluid building up in the wound. This is usually removed after about a week. You can shower carefully straight away. Try not to soak your dressings and pat them dry afterwards.
Pain and discomfort can usually be managed with simple painkiller tablets.
Eat healthily and try to exercise a little every day. You will probably find your movement restricted for several weeks. The exercises emailed to you should help to minimise stiffness.
Scars usually stay quite red for some time and take up to two years to fully fade to white
If you have any concerns call the team - we would rather know about it and you are never wasting our time! We can always arrange for you to come to the clinic if needed and if you are unwell out of hours you can always attend the emergency department.
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