Female to Male chest gender affirmation or “top” surgery refers to surgery used to contour the chest to a more masculine shape. Surgery can include:
- Removal of breast (mammary) tissue
- Removal or tightening of excess skin
- Elimination of the inframammary fold
- Reconstruction and repositioning of the nipple and areola so that it is more proportionate and aesthetically pleasing to the chest
The two main types of procedures are:
This option only works well for smaller breasts where there is minimal skin excess, and the skin is good quality. This is where the nipple and areolar are not removed, but instead lifted up and the breast tissue accessed and removed from beneath. The incision can be made along the bottom of the areolar (“Keyhole Top Surgery”), or around the entire areola (“Peri-areolar Top Surgery”) depending on the amount of excess skin available.
Total Mastectomy with Nipple/Areolar Repositioning
Often known as the “double incision mastectomy”, this technique is usually required for moderate to large breasts, when there is a larger amount of excess skin, the chest skin is stretched or loose, or there is drooping of the breasts.
The technique our plastic surgeon, Dr Steve Merten, uses for this surgery aims at placing the scars in the most natural and subtle position – below the breast and angling towards the armpit behind the hollow of the chest muscle.
In this surgery, the nipple/areola needs to be moved and positioned into the correct masculine position. Whenever possible, Dr Merten does this by maintaining internal vascular connections to the nipple, which allows the most natural outcome, best healing and increased potential for nipple sensation. This is known as a “pedicled” technique. If this is not technically possible, then the nipple/areolar is repositioned as a “graft”, where it is completely removed, then sewn into the new position.
These operations have different outcomes, particularly in terms of scars and nipple sensation, however in creating a more masculine appearance, surgery always aims where possible, to preserve as much nipple sensation as possible, with as minimal scarring as possible.
It is vital to have a full understanding of the likely outcome for your own chest, and go into surgery with both positive health and attitude. It is imperative that your are not smoking before or immediately after this surgery, as this may have major complications and a much less satisfactory outcome.
Dr Merten is an active member of ANZPATH and WPATH
FTM top surgery is one step that can be involved in the process of gender transition. It aims to contour the chest such that it has a more masculine appearance.
Other benefits include:
- Improved confidence and self esteem
- Reduced social and/or physical dysphoria
- No need for breast strapping
I understand certain criteria needs to be met for this surgery?
Special criteria need to be met to even consider FTM top surgery. This includes, but is not limited to:
- Single letter of referral from a qualified mental health professional
- Persistent, well-documented gender identity disorder
- Capacity to make a fully informed decision and to consent for treatment
- Age of majority (18 years of age or older)
- If significant medical or mental health concerns are present, they must be reasonably well controlled
- You must not be smoking for at least 6 weeks before and after this surgery.
Masculinising hormone therapy is not a pre-requisite to qualifying for a mastectomy, however if you are starting testosterone Dr Merten recommends waiting at least 6 months for physical changes to stabilise.
What is the difference between the types of mastectomies?
The two main types of procedures are:
- Subcutaneous Mastectomy:
This is where the nipple and areolar are not removed, but instead lifted up and the breast tissue accessed and removed from beneath. This option only works well for smaller breasts where there is minimal skin excess, and the skin is good quality. If there is no excess skin and the nipple position or areolar diameter don’t need to be reduced, then the incision is only made along the bottom of the areolar (“Keyhole Top Surgery”), and as such, scarring is minimal. More commonly, either the skin also needs to be tightened, the nipple lifted, and/or the areolar circle size made smaller, or then the incision is made around the entire areolar (“Peri-areolar Top Surgery”)
- Total Mastectomy with Nipple/Areolar Reconstruction:
Often known as the “double incision” mastectomy, this technique is usually required for moderate to large breasts, when there is a larger amount of excess skin and drooping of the breasts. First, the nipple and areolar are prepared. In a “graft” procedure, they are removed, and put aside for the next part of the operation. If a “pedicled” technique is suitable, this is surgically created and protected while the rest of the operation proceeds. Next, the breast tissue is removed and the chest contoured by making an incision under the pectoralis muscle, and extending towards the armpit, with the aim of the final scars sitting in the male shadow line of the chest muscle. Once the ideal chest contour has been achieved, the nipple/areolar tissues that were put aside are sewn back onto the chest as skin grafts, in the ideal position and size for a masculine chest, or in the “pedicle” technique, holes are cut in the new position, and the internally-connected areolar brought through and inset into position.
The Consultation Process: What to Expect
During your consultation, Dr. Merten will ask you a variety of questions covering everything from your current health situation to details about the physical outcomes you desire. Be prepared to talk about current medications, allergies and any past or current medical treatments.
An examination of your breasts will be done to check for abnormalities, lumps and asymmetries of the breast or nipple. An assessment of your breast size, shape, positioning and any differences between your breasts is done and several measurements taken. Your expectations and concerns will be discussed.
Based on your history and examination, your best options for female to male chest surgery are determined and discussed with you. Photographs of your breasts will be taken as part of this consultation, to allow for planning of the surgery and to assess results following your surgery. These will be kept strictly confidential between Dr. Merten and his staff.
You will also discuss the recovery process and any potential complications that could arise. At any time, you are encouraged to ask any questions that you may have.
Your second consultation will further deal with your operation choices and reiterate the possible problems and complications with reference to your specific case.
The Procedure: What Does it Involve?
The procedure will vary depending on the type of mastectomy undertaken.
In general, incisions are made such that mammary glands and fatty tissue can be removed. Note that the muscles of the chest are not altered. Excess chest skin, and nipples and areola are grafted to a new position if required. Drains will be inserted to remove any excess fluid/blood.
Will I need to be hospitalised for the procedure?
Female to Male Chest Surgery is performed in hospital, under general anaesthetic, and takes up to 4 hours. It usually requires an overnight stay in hospital. All surgeries are performed in fully accredited facilities ensuring your safety.
What is recovery like?
Advancements in anaesthesia over recent years has meant more comfort for patients – less pain with minimal post operative sedation and nausea and a quick recovery to “feeling normal.” The anaesthetists are highly skilled and experienced in modern techniques and devoted to keeping you comfortable.
Naturally you may feel “woozy” as the anaesthetic wears off. You may feel some soreness, swelling or discomfort, but this is quite natural. You may also feel tired after surgery, but this and the soreness is normal and will last only a short while.
Drains will be removed the next day used to assist in healing and reduce swelling. Dressings will be placed over your incisions as well as nipples if you had a nipple graft. A chest garment will be used to assist further in reducing swelling and bruising and aid in final contour.
Results: What and When?
Your breasts heal over a period of time after chest surgery. Initially there will be some swelling and bruising, and your breasts may look larger and fuller than the final result. Most of the swelling subsides over the first week or two, and will resolve by about 6 weeks. After 8 weeks, we recommend the use of a Scar Management Cream, available for purchase at the clinic. This is to be gently massaged in the incision line twice daily. The friction of massage helps in the maturation and fading of any scars.
Swelling will generally fully subside after 3 months.
When can I resume day-to-day activities?
In most cases, you can resume normal activities within one weeks time.
Strenuous activity and sporting activities should be avoided for at least 4-6 weeks post surgery. If you are keen to keep fit, easy walking is permitted, at a level that is comfortable to you.
What complications can arise from the procedure?
As with any surgical procedure, there are potential risks and complications. These include:
- Bruising, bleeding, haematoma formation
- Anaesthetic problems
- Deep Vein thrombosis
Risks and complications specific to Female to Male Chest Surgery include:
- Nipple Malposition
- Nipple Necrosis
- Altered nipple sensation
- Breast Asymmetry
- “Dog ears”
- Unfavourable Cosmetic Result
The potential risks and complications of the surgery will be discussed with you in detail at your preoperative consultations.
Will this procedure leave scars?
Given incisions are made, there is a potential for scarring. There are different techniques however to minimise scarring and whenever possible, Dr. Merten utilises your natural nipple areola lines. For larger breasts, or where the skin quality is stretched and damaged, then usually a scar is also required in the fold beneath your breast. Muscle development in the area as well as growth of chest hair can assist in camouflaging potential scars.
We aim to achieve scars of superior quality and minimal length; however your personal anatomy and healing pattern are ultimately responsible. Dr. Merten will discuss the various types of reduction with you and help you to choose the one most appropriate to your problem and in line with your goals and expectations.
What else should I consider before having this surgery?
To understand what is reasonable to expect from the surgery, it is a good idea to look at before and after photos. This will give you a good perspective of what results other patients have achieved through Dr. Merten’s work. Some other factors to consider are;
- Are you happy with your body weight or do you intend to lose weight in the future?
- Do you have a preconceived idea of how you would like your chest to look?
- Have you considered the effects of surgery on sensation of the chest and nipples?
- Have you considered the prospect of scarring on your chest?
Do you have any more questions?
Please feel free to contact us with any additional questions that you might have about this procedure. Our team will be happy to address any concerns that you may have.
Surgical Animation Video