Top Surgery

Recontouring of the female chest to a male chest is often referred to as ‘Top Surgery’. The surgery forms part of a spectrum of procedures that are available in the gender transformation process. Top surgery plays an important role in the transition process and can have significant psychological benefits, in the context of gender dysphoria. Top surgery to address female anatomical breasts entails masculinising the chest through surgical removal of the breast tissue. There are various goals in achieving an appropriately contoured male chest. These include:

  • Removal of the breast mound to ensure a flat chest contour
  • Optimal placement of the scar that can mimic the lower border of the pectoralis muscle
  • Repositioning of the nipple to a position that is more consistent with a male chest
  • Reduction size and shape of the areola

There are two general surgical approaches to ‘top surgery’. This can entail removal of the breast tissue via a double incision (incisions are re-opposed) and reattachment of the nipple as a graft. The alternative method entails removal of the breast tissue via a peri-areola incision (around the nipple).

There are advantages and disadvantages to each approach and these are outlined in the relevant sections below. The decision to proceed with one or the other can be determined following the consultation process and is often determined by your current breast size and how much breast skin currently exists.

Approach 1 (Double incision and nipple reattachment)

This is often undertaken to address moderate to large sized breast mounds, as excellent contour can be achieved. It also enables complete freedom in repositioning the nipple. With this approach, pre-operative markings are undertaken based on the location of the planned final scar. The final scar is typically located adjacent to the lower border of the pectoralis muscle. This might not necessarily fall in line with the existing female breast fold. It is important that the new scar is not automatically placed in the existing breast crease, as this may in fact result in a more visible scar.

Following administration of anaesthesia, the new nipple areola size is determined and marked. Both nipple areola complexes (NAC) are removed, and are stored appropriately for later grafting. An incision is made in the pre-operatively determined position, taking into account the above scar considerations. From the upper incision, the breast tissue beneath the skin is removed with cautery. Once the breast tissue below this upper skin flap, the upper skin is re-draped in a downward direction.

The excess skin is then determined and removed. The same approach is taken to remove the breast tissue lying below the lower incision. A drain is typically placed in the space under the skin to enable removal of post-operative tissue fluid. The skin flaps are then sutured together. The nipple is then reattached as a graft. It is important that your surgeon has a good understanding of where ideal nipple position is situated in a male chest. There are certain parameters that are followed in positioning the nipple in the most optimal position. Nipple diameter size is also reduced to ensure a result that is consistent with a male nipple areola complex. Once the position is determined and the nipple areola complex is applied as a graft, the graft is secured in place with a special dressing to optimise graft take. A compression garment is also applied to minimise swelling and support the wound.

 

Approach 2 (Peri-areolar incision)

This approach is often more suited to a smaller breast as the expected amount of small skin excess can be removed via the peri-areola (around the nipple) incision. Whilst the main advantage of this approach over approach 1, is the avoidance of a scar across the chest, the contour achieved may not be as optimal, as typically a portion of gland is preserved below the nipple to ensure adequate blood supply. This technique is primarily suited to smaller breasts where a significant amount of skin removal is not required.

The technique entails the placement of an two circular incisions (one reflecting the new arola size, and the other larger) around the nipple. The intervening skin is then removed. The breast tissue is then removed through this opening, preserving a small mound to ensure adequate blood supply to the nipple.

This is known as the pedicle. Once removed the skin and breast tissue has been removed, a drain is placed with in the pocket to enable clearance of post-surgical fluid. The outer incision is cinched inward and sutured to the inner incision that surrounds the NAC. The wound is then dressed, and a compression garment is applied. The surgical garment is worn for a duration of 4-6 weeks.

 

Top Surgery Frequently Asked Questions

The above considerations are important factors in determining which approach is most suitable to your specific needs. The most suitable method of surgery is to a large part determined by the existing size of your breasts, with larger breasts requiring the double incision with graft approach. Skin tone and its ability to retract is also an important consideration if one is considering the peri-areola approach. Dr Reddy will assess your specific requirements and will be able to advise and guide you on the preferred approach in achieving the desired results.

The consultation is typically one hour in duration. A detailed history is undertaken, focused specifically on general health, your past breast history, and history of hormone therapy. This is followed by examination of your breasts, with various measurements detailing your current breast size, nipple position and amount of breast tissue present. Three dimensional photos are undertaken to provide an accurate assessment of your breast volume and shape.

Following this assessment, Dr Reddy will discuss the surgical options with you so that you will have a very clear understanding of the two approaches and what may be the most favourable option in your specific case.
You will also provided with an information pack which will serve as a useful summary of the consultation process. After you have had time to go home and digest the information, Dr Reddy routinely sees his patients again for a follow up visit. This is an opportunity for any further questions to be addressed. Whilst your date of surgery may have already been previously arranged, your Hospital paperwork will be completed at this visit.

Information pertaining to your pre-operative requirements will also be provided to you, including but not limited to:

  • Surgical consent forms
  • Pre-operative blood tests (if required)
  • Post-surgery compression garment
  • Post-operative appointment details

Once your surgery has been booked, the hospital will contact you one business day prior, and advise you on what time to fast and when to arrive at the hospital. Once in the surgical unit, you will the meet various members of the team, including the nursing staff and your anaesthetist. After meeting with Dr Reddy, pre-operative surgical markings will be undertaken in the pre-surgical bay. Following anaesthesia and surgery, Dr Reddy will see you in recovery and again on the ward once you have completely recovered from the anaesthetic.
You will generally remain in Hospital for one to two days depending on how you are feeling. You may go home with drains and you will be advised on how to care for these. When you are ready to go home, antibiotics and pain killers will be provided to you for use at home. Your first post-operative review will take place between day 5 and 7 and your surgical dressings will be removed at this point in time.

Scars will typically improve with scar management and time. It typically takes 12 months for complete scar maturation, although in reality, it often continues to further blend in and become subtle with time.

Following surgery, a surgical tape is typically applied to the wound. Following the removal of the tape, it is important to keep the wound clean and moisturise the wound. You will be able to shower directly over the wound approximately 5-7 days after surgery. Dr Reddy will advise you on his particular scar care regime, but this will typically involve a combination of surgical taping and the use of a silicone based scar gel. Sun protection is also important during the first 6 months as UV exposure can have a negative impact on your scar outcome.

The incidence of unwanted complications is extremely low, but include:

  • Haematoma
  • Infection
  • Suboptimal scar
  • Delayed skin or nipple healing
  • Uneven contour
  • Seroma

It is important to refrain from smoking for at least 6 weeks prior to surgery as this will minimise the risks of delayed wound healing. It will also reduce post-operative infection risk and provide more favourable conditions for an optimal scar outcome. Please inform Dr Reddy if you are taking any blood thinning medications or herbal supplements. Many over the counter supplements (fish oil, krill oils, Turmeric, Garlic, Ginseng, Hair Skin & Nails) can increase the risk of bleeding. These should be stopped at least 3 weeks prior to surgery. It is also important that the advised post-operative instructions are followed as these measures can potentially reduce the risks of any unwanted sequela.

Following top surgery, you will generally stay in the hospital for one to two days. Your pain is typically well managed with oral analgesic medication and this will also be provided to you at the time of discharge from the hospital. Anticipate a 4 week recovery period on average. You may be able to return to work 3 weeks after surgery, providing your work is more sedentary in nature. If your work is more physical in nature, then a 6 week recovery period is likely to be required. You may commence light walking 2 weeks after surgery, but you should refrain from any more rigorous exercise regime for at least a 6 week period following surgery.

Dr Reddy will keep an eye on you during the recovery period. You will first return to the clinic approximately one week after surgery. Dressings are typically removed at this appointment and scar care advice is provided. If you have drains, these are typically removed at this visit. Dr Reddy will continue to review you over the subsequent months and this is all included aftercare as part of your surgical journey.