The Surgeon Minute

Transgender Top Surgery

Transgender Top Surgery

Plastic surgery gives the transgender community the option of aligning their inner and outer selves. For those suffering, living as a sex that is not your own is something no one should have to endure. “Top surgery” is a phrase that specifically refers to either a breast augmentation in the male-to-female patient, or a subcutaneous mastectomy or removal of the breast tissue in the female-to-male patient.

“That oversimplifies what top surgery is because it’s really about making a more feminine chest in your trans-female patients or making a more masculine chest in your trans-male patients,” explains Dr. Dustin Reid, a board certified plastic surgeon in Austin. He breaks down the different variations of top surgery, as well as what to look for when choosing a plastic surgeon for your transgender top surgery.

What is Transgender Top Surgery?

“Transgender top surgery” is a phrase that the transgender community uses to describe the procedure, or procedures, that will take the top half of the body from male-to-female or female-to-male. It typically involves a breast augmentation for the former group of patients and some form of a mastectomy for the latter group of patients.

However, it is much more complex than simply adding or subtracting volume. For starters, the nipple and areola are in a different position depending on your sex. Also, each sex has a different degree of breast tissue. This differs not just between the sexes, but also by each patient’s individual anatomy. Top surgery is thus complex and requires the plastic surgeon to rearrange where things go in order to make a chest look either more feminine or more masculine.

Male-to-Female Top Surgery

There are different types of top surgery and the right one is going to depend on the patient. For the male-to-female patients, the surgery a variation of a breast augmentation, although it’s more involved than placing a breast implant in woman who simply wants more volume. With the transgender patient, the plastic surgeon will need to determine the proper placement of the inframammary fold in order to create a breast that works with that individual’s body. It’s not just about delivering a desired outcome or “look,” it is about sculpting a pair of breasts that are proportional to the rest of the torso and which create a totally natural-looking, feminine chest.

Female-to-Male Top Surgery

In the female-to-male patient, the right top surgery procedure is going to depend on the amount of the patient’s native breast tissue and the size of the areola and nipple, as well as where they’re placed on the chest wall. There are really 3 different options. The simplest is a keyhole operation. Here, the surgeon makes an incision along the bottom of the areola through which he or she removes the breast tissue. It’s a simple procedure, similar to the surgery for gynecomastia. However, it only works in those patients with a small amount of breast tissue, small nipples and a small areola. Furthermore, the nipple and areola complex need to naturally be in the right position; “the nipple and areola belong in a lower and more lateral position in a male,” explains Dr. Reid.

Female-to-male top surgery.

The next option is the periareolar approach in which the surgeon makes an incision all the way around the nipple. This allows he or she to not only remove the excess breast tissue, but also reduce the size of the areola. Again, this approach only works for patients who have a small to moderate amount of breast tissue, and no ptosis or droopiness in the breasts.

Potential Top Surgery Complications

The keyhole and periareolar approach have the highest complication rate and the highest re-operation rate. This is because patients and their surgeons will push the limits of what can be accomplished. Complications include:

  • contour irregularity
  • lumpy & bumpiness
  • folding

Even though the complication rates are higher, many patients are willing to accept some small complications in an attempt to avoid the next option which is the double incision operation. This entails an incision all along the inframammary fold. The surgeon removes all of the breast tissue and skin which gives a very masculine contour to the chest. He or she may perform liposuction to remove excess fat and improve contour. Then, the nipple and areola are put back in their appropriate spot on the newly created chest as skin grafts. This approach always gives a beautiful result, but it also produces the longest scar.

Scars — Totally Worth It

Scars on the breast sound scarier than they actually are. In general, incision lines on the chest heal very well. The incisions in the female-to-male patient are under more “tension than a typical breast lift,” says Dr. Reid, so they can sometimes be a bit wider. Usually within 6 months to a year, the scars look good, and most patients feel that the scars are totally worth it. “These patients are really about just not having their breasts anymore and being able to wear a t-shirt, just looking more masculine, so I’ve found them to be extraordinarily happy with the results,” shares Dr. Reid.

If you are a transgender patient who is looking for a surgeon, it’s important to find one with a lot of experience doing transgender top surgery. This means that he or she performs this surgery frequently, and is an expert in the field. This will also help to ensure that the office, staff and operating room are equipped for transgender surgery and trained to make you feel as comfortable as possible. “Doing transgender surgery is one of my favorite operations,” explains Dr. Reid. He finds it incredibly rewarding. The patients are so happy with their outcomes, and “you feel like you are making such an extraordinary difference in someone’s life. I love it.”

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