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Surgery to alter the physical appearance of the chest may form part of the gender-affirming and/or the transition-related process where the individual seeks to either have breast augmentation surgery or remove their breasts to produce a flat chest.

One component of the gender-affirming or transition-related process may be to address the physical appearance of the chest through surgery. Top surgery may involve a breast enhancement primarily through the use of breast implants, or breast tissue removal which can help a person to produce a flat chest.

Surgery may be considered to help a person realign their gender expression or presentation with their true self.

At Avery, we welcome the opportunity to have an open conversation with you to understand the changes you are looking for with surgery. Our patients’ stories matter a great deal to us. You can discover some of our wonderful patients’ journeys here.

Wherever you are on your personal journey, we would like to assist you. Dr Avery will listen to your concerns and what you want to achieve with surgery. Dr Avery will assess your health and medical history to ensure any surgical procedure you are considering is a safe and appropriate choice for you.

Procedure

Female to male top surgery

Surgical considerations involve the removal of breast tissue to create a flat chest contour and adjustment of the nipple and areola complex, including its size and position on the chest, as appropriate for the altered chest contour.

The goal of this surgery is to create a chest contour and appearance consistent with gender identity. A female to male top surgery may help improving poor posture and/or pain and skin irritation from frequent firm binding of the chest and breasts.

There are generally three surgical options that are primarily influenced by breast size and the associated skin excess as well as the quality of the skin:

Limited incision top surgery

Often referred to as keyhole surgery, the removal of the breast tissue, similar to a mastectomy is performed through an incision along the outer border of the lower half of the areola.

If the areola size needs to be reduced, an incision around the whole circumference of the areola can be performed, either at the time of breast tissue removal or as a second procedure. This limited incision or single-incision surgery results in a scar at the border of the areola and the skin of the breast and may not be visible to others with a shirt off.

Double incision top surgery

For larger breasts where there is excess skin that needs to be removed in addition to the breast tissue, it is not possible to ‘hide’ the scar at the areola junction. In this case, an incision is usually made in the lower crease of the breast or the inframammary fold, through this incision the breast tissue is removed along with excess skin to create a flat chest contour.

The second incision relates to the areola and nipple complex which is removed, reduced if required, and replaced on the chest in an appropriate position. This technique is referred to as a nipple graft. The double incision top surgery results in a scar around the areola which may heal in a manner that is not very visible, and also a second generally longer scar on the lower part of the chest, curving up toward the armpit, that will generally be visible for some time with a shirt off. This scar may fade and become difficult to see over time, potentially hidden following significant hair growth that may occur with any hormone therapy.

Nipple and areola pedicle

In this procedure, the nipple and areola remain attached to the body on what is known as a pedicle of tissue that maintains blood supply and potential sensation to the nipple and areola. Skin is removed from the chest to an extent that the resultant scar cannot be hidden around the new areolar position and will generally be similar in size and location to that of the double incision technique. The main advantage of this technique if appropriate relates to nipple and areola sensation and blood supply.

Male to female top surgery

Chest surgery as part of the transition from male to female generally involves the use of silicone breast implants. These implants are commonly placed via an incision in the lower breast fold, to sit either in front or behind the pectoralis major chest muscle. Breast implants are foreign material and typically are not lifelong devices. The benefit of breast augmentation is often the alignment of physical appearance with gender identity. Detailed information regarding breast augmentation can be found here.

Regardless of the technique used, a number of potential risks exist with top surgery. Some of these risks are common to any surgical procedure such as bleeding, wound healing delay, deep vein thrombosis and surgical site infection. Others such as loss of nipple sensation, loss of the nipple (which may be partial or complete, due to inadequate blood supply) and an unsatisfactory cosmetic result or contour irregularities resulting in the need for further surgery are more specific to top surgery.

Consultation

There are two main pathways to a consultation with a Specialist Plastic Surgeon. Your GP or another health practitioner can make a referral to Dr Avery. Alternatively, it is possible to refer yourself for a consultation. This decision may be made after talking with family or friends or following your own research into plastic surgery and Dr Avery.

The purpose of your initial consultation with Dr Avery is to discuss both your concerns and your goals. It is an opportunity to openly communicate what you want to change, alleviate, improve, restore, enhance, or remove. We will discuss any concerns you may have about your potential surgery and its outcome. We will also collect information that is specific and tailored to you, to add to the knowledge you acquired through your research outside of the consultation process.

When you arrive at Avery, you will check in with our front-desk team and complete a medical history form, if not already completed. We encourage you to bring a supportive family member or friend who can remain with you throughout the consultation if you like, and be a sounding board during your decision-making process following the consultation.

The consultation with Dr Avery will include an examination of the area of your body that you are concerned with and considering changing. Our aim will be to determine if plastic surgery can achieve what you hope it will, and if so, what specific plastic surgery procedures will address your concerns and meet your expectations in a realistic way.

Plastic surgery procedures generally impact both physical appearance and your psychological response to the new changes in your body. Besides all the advantages of having plastic surgery, it is important to be fully aware of any potential limitations of the operation and how they apply to your unique situation. This includes possible complications and what can be done if these occur.

We will discuss what the surgery involves, how it relates to you specifically given your uniqueness and current state of health, what the possible risks of the surgery are, and then decide if having the surgery is a safe and appropriate choice for you as an individual.

After your consultation, our support team will be there to talk through any further questions you have, including the cost of the surgery.

At Avery, our goal is to ensure you are equipped with the knowledge needed for you to feel empowered throughout the decision-making process, surgery and post-surgery.

Top Surgery FAQs

How long do I have to stay in the hospital following surgery?

The length of your hospital stay will depend on the extent of the surgery and the help available to you at home. Most people having double incision top surgery will stay in the hospital for one or two nights. Some patients are able to go home the day of surgery if the pain is under control and they have an adult to stay with them the first night following surgery.

Will I have surgical drains after my top surgery?

Surgical drains are soft flexible silicone tubes that are placed within a cavity or space created via surgery. Surgical drains are used to help remove blood and fluid that leaks from body tissue following surgery. In addition to removing any blood and fluid (which may increase the risk of discomfort, infection or wound healing problems), surgical drains may also help a surgically created space collapse down and allow body tissues to stick to each other and aid the recovery process. Surgical drains may be used if there is a large potential space created, which happens in most cases of double incision top surgery and some cases of limited incision top surgery.

How much time off will I need to recover from my top surgery?

Recovering from surgery is a gradual process rather than a single point in time. In general, you will require two weeks off any work, focusing on resting and doing small amounts of activity only. After two weeks, depending on your comfort level and the demands of your job, you may be able to return to work and may feel comfortable enough to drive. By six weeks most people will have only minimal restrictions on activity if any, and any surgical wounds should require relatively minor care to help the scar obtain its optimal appearance.

Wounds from surgery of any sort can take up to 18 months to start fading.

When will I be able to exercise?

Simply walking is advised and is recommended during the first 2 weeks after surgery. An increase in activity is encouraged between 2-6 weeks, limiting this increase based on how your body feels and responds. From 6 weeks you can be mostly unrestricted with exercise but it may not be until 12 weeks following surgery that you feel you are back to pre-surgery fitness, or even improved from your pre-surgery fitness if physical symptoms and restrictions have been addressed with surgery.

Will I experience much pain and movement restriction post-op?

Pain following top surgery will vary depending on the extent of surgery. Pain immediately after surgery may be reduced by the use of local anaesthetic at the surgical site given during the surgery. The pain will also be managed with tablets or injections as required. Physical measures such as the dressings and supportive garments as well as limited movement and possibly ice packs will all help minimise any pain. Pain is usually well tolerated within a few days after surgery with all these measures. If your pain is increasing following surgery this is usually a sign that you may need a review to ensure your recovery is proceeding as expected.

Dressings and supportive garments will offer support to the wounds and the areas of your body that are still recovering. You will be also be advised to restrict excessive movement of the surgical area in the first two weeks after surgery. A good general rule throughout your recovery is if an increase in movement or activity does not increase any discomfort or swelling, then it is probably safe and this gradual progression back to ‘normal’ will be encouraged.