The Real You: FTM Top Surgery

Reviewed by Mark P. Solomon, MD, FACS

Transgender men may consider breast removal surgery at any point during their transition. This procedure is often referred to as "top surgery" or female-to-male (FTM) chest surgery. The goal is to make the chest appear more masculine.

Top surgery, which is a type of chest reconstruction or chest "recontouring," is an alternative to chest binders, which some transgender men wear to hide their breasts, and testosterone therapy, which typically leads to a more masculinized chest but in some cases does not reduce the size of the breasts. (In some, testosterone may actually increase the size of the chest muscles, which can make the breasts appear larger.)

If you are thinking about top surgery, schedule a consultation with a board certified plastic surgeon who has experience performing this procedure in transgender men. Ask to see before and after photos of former patients, or even to speak with some of them to get a better sense of the transition process.

You may be required to show a letter of recommendation from a mental health professional due to the psychosocial issues associated with transition. Your surgeon will examine your chest and listen to your concerns and goals to make sure they are realistic and can be met with top surgery.

Types of FTM Top Surgery

The three types of chest reconstruction are:

  • Double incision/bilateral mastectomy
  • The keyhole method
  • Reconstruction with peri-areolar incision

The double incision/bilateral mastectomy option is similar to the surgery used to treat or prevent breast cancer. It involves removing excess skin and breast tissue through incisions crafted below the base of the breast. The surgeon then replaces the nipples and areolae as grafts if they are initially in a low position. (The areola is the colored ring around the nipple.) If the nipple areola complex is in the correct position, it is left intact. This is the preferred surgery if there is a large amount of breast tissue and/or excessive skin laxity.

Another option for patients with a large amount of breast tissue and skin is to use a keyhole approach, similar to breast reduction. This option can keep the blood flow to the nipple intact while allowing the surgeon to move the nipple-areola complex to a more masculine location.

The peri-areolar method is often the better suited approach for transgender men with smaller breasts. The fatty breast tissue is cut/and or liposuctioned out via a small incision around the border of the areola. The nipple is usually not resized or repositioned, but in some cases your surgeon may need to reduce the size of the nipples so that they appear more masculine.

Each of these procedures has its own set of risks and benefits. There is a recovery period following all of them. These are factors that you should consider carefully. Can you take time off? Will you be able to comply with the pre- and post-operative instructions?

How Much Does Top Surgery Cost?

The cost of top surgery is another factor. Your insurer may cover some or all of cost of FTM chest surgery. Contact your provider to see what is covered before you commit. And keep in mind that financing plans are also likely available.

About the Reviewer of This Article

Mark P. Solomon, MD, FACS, is a Philadelphia and New York plastic surgeon who is certified by the American Board of Plastic Surgery. He routinely treats transgender men and women.