Female-to-male (FTM) top surgery is a general term for gender-affirming surgical procedures that masculinize the chest area for transgender people who were assigned female at birth and who also have dysphoria about their chest. They may identify as transgender men, masculine-leaning, gender neutral or non-binary, or be elsewhere on the spectrum of gender identity. The surgery is designed to remove breast tissue and create a flat, masculine chest appearance so people feel more comfortable with their bodies.
Top surgery entails a range of surgical techniques. The aim is to give people a chest shape and appearance that affirms their gender identity. When considering top surgery, it is important to choose a surgeon who has training and vast experience in gender-affirming surgery.
Dr. Ginger Xu is a Board-certified plastic surgeon who has helped many transgender people align the appearance of their chests and bodies with their gender identity. Dr. Xu trained in aesthetic plastic surgery at Harvard where she gained specific expertise in transgender top surgery. She is now based in the San Francisco Bay area.
Dr. Xu embraces the responsibility of transforming her patients’ appearance to reflect their inner values and sense of self. She seeks to create natural results and give her patients the emotional relief and comfort of having physical features ultimately aligning with their unique identity.
Also known as masculinizing chest surgery or subcutaneous mastectomy, this type of surgery aims to remove the signs of a female-appearing chest to better align with gender identity and relieve dysphoria.
This involves removing breast tissue and skin to create a flat, masculine-looking chest. A range of procedures can be used to achieve this goal (see below), each with its own features around:
- Location of incisions
- Extent of scarring
- Amount of skin and breast tissue removed
- Ability to reshape the nipple and areola
- Retention of nipple sensation
- Recovery process
- Need for additional procedures
A good surgeon who listens to your vision for your body and who has experience in all the techniques is best able to match their surgical approach with your goals and body type.
People who are good candidates for FTM top surgery:
- Are in good physical health
- Are in good emotional health
- Have stable body weight – significant changes in body weight after surgery can affect the results
- Are close to healthy body weight – although being overweight does not exclude you from surgery
- Are non-smokers or have quit smoking at least six weeks before surgery
- Understand why they want to have a masculine chest
- Are able to provide a referral letter from a mental health professional
A range of procedures is available to help you reach your goals of having a masculine chest. The best way to learn about which approach can help you is to make an appointment with Dr. Xu. During the consultation, Dr. Xu will listen to your goals, examine your body and recommend an approach that best suits your needs.
The limitations and benefits of different techniques are described below:
Liposuction is rarely used alone because it can only produce a satisfactory male chest contour in people who have a very small amount of breast tissue and naturally small and masculine nipples and areolas. Liposuction is more typically used in combination with other techniques to fine-tune the appearance.
Liposuction to masculinize the chest involves making a small incision through which the surgeon can suction out the fat and breast tissue. The main advantage of this method is that scarring is minimal.
The keyhole approach can remove slightly more breast tissue than liposuction, but it does not remove any excess skin so it is best for people with very small breasts and tight chest skin.
The procedure involves the surgeon making an incision around the lower border of the areola (keyhole) to remove breast tissue and fat. The scar is partially camouflaged along the border of the areola and nipple sensation is usually retained. It is typically done in combination with liposuction.
Additional surgery may be needed if excess skin or breast tissue remains after healing or if the transition near the outer borders of the chest is not smooth.
The circumareolar approach is recommended for people with small chests who have a small amount of skin excess, as this technique can address a bit more tissue than the keyhole method. Two circular incisions are made, which allow a donut-shaped piece of skin to be removed to reduce the size of the areola. This method is derived from the “Benelli-style” technique and can also be described as a “concentric circle mastectomy with an areola reduction.” It allows for areola reduction and some skin tightening. The outer incision is larger than the keyhole and thus enables better access for the surgeon to remove tissue and excess skin.
The final scar is around the entire circumference of the areola and is partially camouflaged by the new border of the areola. This method can be combined with liposuction.
Nipple sensation is often decreased immediately after surgery, but sensation usually returns with time.
Possible issues with this technique include:
- Skin wrinkling or bunching after areola reduction – can cause fullness rather than a smooth profile
- Spreading or thickening of the areola scar – more likely for larger changes in areola size
Dr. Xu performs a nuanced surgical procedure that involves an incision around the areola (circumareolar approach) plus an additional incision extending from this circle, which removes any remaining excess skin in the shape of a wedge. This results in an additional scar that appears like a dart extending from the circular scar around the areola. The design and direction of the additional incision varies by person, and is customized to enable optimal tissue and skin removal depending on your individual anatomy. This is a good approach for people with a moderate amount of breast skin and tissue, who may not require the double-incision technique.
The double-incision mastectomy is the most powerful and reliable approach to masculinizing the chest. It gives the surgeon maximal control over reshaping the chest skin, and unlimited access to removing all the breast tissue. It consistently creates a smooth chest contour and enables the optimal tightening of chest skin.
Two incisions are made: one above the areola and one along the breast fold. All of the intervening skin and breast tissue is removed, and the incisions are brought together to create one final horizontal scar along the lower chest. The surgeon aims to position the final scar along the pectoralis muscle fold, which is a natural shadow on a masculine chest.
This method involves detaching the nipple and areola as a free nipple graft to enable repositioning and reducing its size to give a more masculine appearance. Only the top layer of the skin of the nipple-areola complex is removed and transplanted to a new location. As a result, the structure of the final nipple graft is different from before surgery and is typically flat. Because the nipples are totally detached from the underlying blood and nerve supply in this process, the body must rely on the ingrowth of new vessels to give this tissue new life and allow the nipple graft to ultimately survive the transplantation process. New nerve connections may also re-establish, but typically the new nipples do not retain sensation.
Dr. Xu performs a specialized technique which is based on the traditional double-incision mastectomy with the free nipple-graft method (see above) but seeks to avoid some of the disadvantages of the free nipple graft such as:
- Possible complete loss of nipple if blood flow is not re-established
- Possible pigment loss and mottled coloration due to loss of, or shock to, pigment cells
- Loss of nipple sensation
- Flattening and loss of original nipple architecture
This specialized technique still uses double-incisions, but the nipple-areola complex is kept partially attached on a small wedge of tissue containing blood vessels and nerves called a dermal pedicle. The nipple-areola complex is then repositioned by bringing it through a new opening created higher up on the chest skin like a “buttonhole.”
This method preserves some of the original attachments of the nipple-areola complex to its blood and nerve supply. So the nipple-areola complex is more likely to retain sensation and its original structure after healing.
Possible drawbacks with this method include:
- Fullness or bulging caused by the dermal pedicle
- Higher risk of bleeding
- Possible partial loss of nipple tissue
Dr. Xu has extensive experience with all forms of top surgeries. Through her specialized training and vast experience working with transgender people, she has developed variations on the established techniques and continues to evolve and improve the existing procedures.
You and your surgeon must communicate and work together so you have a good understanding of the recommended process. Dr. Xu will arm you with the knowledge to understand the factors affecting your top surgery and recommend the best approach to suit your pre-existing anatomy, goals, and values.
It is important that you have a realistic understanding of:
- How your chest will look after surgery
- Where your nipples will be positioned
- The limitations of the surgery
- Any short- and long-term side effects such as scarring
- Any possible complications
- The potential need for more surgery
The level of scarring depends on the technique used, with each technique creating scars depending on the position and extent of the incisions. But scarring is also impacted by:
- Your skin type
- Your genetics
- Your healing potential
- The tension placed on the wound after surgery
- Your level of physical activity
Dr. Xu will let you know what precautions you should take after surgery to minimize scarring. In general, scars do not disappear but will fade with time. If you are not happy with your scarring, speak with Dr. Xu about whether scar revision procedures can help.
For double-incision mastectomy, you will have a long horizontal scar along the lower chest. The goal of the surgeon is to place this scar along the natural position of the pectoralis muscle fold, but the exact location will depend on your anatomy.
You will also have small scars around the border of the free nipple graft, which is camouflaged well along the transition between the pigment of the areola and the rest of the chest skin.
Dr. Xu can explain the likely location of scars after she has reviewed your needs and recommended a surgical approach.
“Dog ears” are skin bulges at the corners of the incisions. This rarely occurs in Dr. Xu’s patients. The corners of incisions in a double incision mastectomy are usually tucked in, but the formation of dog ears depends on your size, pre-existing anatomy and the condition of your skin. If this occurs, a small skin revision procedure can be easily performed.
Nipple and areola tattooing can help to smooth out any color irregularities in the nipple graft and improve the overall appearance of the nipple and areola.
A free nipple graft is a part of the traditional double-incision surgical approach (see above). The top layer of the nipple-areola complex skin is fully detached from the chest and transplanted to a more masculine position higher up and more lateral on the chest. During this detachment, the nerves, blood vessels, and milk ducts are cut and this results in loss of sensation in the nipple, flattening of the original nipple architecture, and possible nipple graft loss if your body does not re-establish blood flow to the tissue.
This is a popular method. When a double-incision approach is recommended for people with larger breasts, a free nipple graft is typically needed.
The size of the areola is always decreased in free nipple grafts and can be easily decreased with a circumareolar procedure.
The core nipple tissue can also be reduced to suit individual preference.
Most approaches to FTM top surgery can include techniques to decrease the size of the nipples or areolas so they look more masculine. The approach used will depend upon your body type and your goals.
The level of nipple sensation after FTM top surgery depends upon the technique used. Techniques suitable for small chests will usually preserve nipple sensation (see above).
Sensation will be lost when a free nipple graft is used as part of the double-incision approach for larger chests. It is important for each individual to weigh the benefit of having a superior and more masculinized chest appearance against the loss of nipple sensation.
Ideal candidates for FTM top surgery have close to healthy body weight and stable body weight. This is because any significant changes in body weight after surgery can change the appearance of the chest.
Although healthy body weight is ideal, being overweight does not exclude you from surgery. You should understand that your surgeon will have to recommend a surgical approach that suits your body type and if overweight, you may have the risk of additional complications such as:
- Wound healing problems
- Wound separation
- Fat necrosis
- “Dog ears”
- Dissatisfaction with final aesthetics
- Deep vein thrombosis (DVTs) – blood clots
- Pneumonia and respiratory issues after surgery
- Changes in the appearance of the chest if you lose or gain weight after the surgery
Smoking significantly impairs the ability of the body to heal wounds, which may result in infection, large wounds breaking open during the recovery process, as well as nipple tissue death and loss. This can result in permanent tissue loss, distorted scarring, or a disfigured appearance that may be difficult or impossible to fully correct later.
It is critical that candidates for FTM top surgery stop smoking at least six weeks before surgery and should not smoke during recovery and wound healing. This is an essential requirement for free nipple grafts. All skin grafts have more complex healing requirements and smoking could result in the death of the nipple and areola graft, with few options for reconstruction afterward.
The ability of the skin to heal is dependent upon a range of factors including genetic predisposition and age. Some people are more likely to develop a keloid scar, which is a raised scar that continues to thicken after healing. People of some ethnic backgrounds have a higher risk of forming a keloid scar.
People with darker areolas have a risk of less pigmentation or mottled coloring in a healing nipple graft. The color takes time to return, but sometimes the coloring remains mottled. Nipple and areola tattooing is a simple procedure that can help to camouflage any variations in pigmentation if this becomes an issue.
During a consultation for FTM top surgery, you should inform your plastic surgeon if you have any family history of breast cancer (including the presence of the BRCA gene) or if you have an increased risk of breast cancer.
A higher breast cancer risk can affect the surgical approach recommended. The surgeon may need to be more aggressive in removing all possible breast tissue, and this can make the result less aesthetically pleasing.
After your FTM top surgery, you should consult with a breast surgeon regarding proper breast cancer screenings.
After FTM top surgery, some breast tissue usually remains on the chest to create a better contour. For this reason, you should continue to be aware of the possible risk for breast cancer and undergo screenings mostly by breast exams, with targeted work-up in accordance with recommendations by a Breast Surgeon.
Liposuction for FTM top surgery is a technique available to remove very small amounts of breast tissue, although it is rarely used alone. It is often used in combination with other approaches to fine-tune the results.
Liposuction can also be used as an adjunct to help better shape the chest, by removing unwanted fat deposits in areas such as:
- The outer region of the chest – liposuction of “side rolls” for overall chest contouring
- Axillary fullness – liposuction of armpit fullness or rolls
- Back – liposuction of fat from back rolls
- Abdomen – liposuction in this area can be done alone or as part of a tummy tuck
- Hips and lower body – to help create a more masculine overall appearance
Yes! Transgender body contouring gives a more masculine appearance to the whole body and can be performed at the same time as FTM top surgery. Read more about FTM body contouring here.
Dr. Xu understands the responsibility of transforming your appearance to better reflect your identity and build self-esteem. Her top priority is understanding your vision and desires.
Once Dr. Xu has performed a detailed assessment and examined your body,, she will use her artistic sense and technical expertise to recommend a surgical approach that will best suit your goals.
During a consultation, Dr. Xu will explain:
- The different types of FTM top surgery techniques
- Which options will best achieve your needs
- What types of incisions will be needed
- How much scarring you can expect
- How other surgeries (eg. liposuction and body contouring) can fulfill your vision for your future body
- Any potential need for further surgeries
- Potential complications or side effects – loss of nipple sensation
- What to do during the recovery period
Once you and Dr. Xu have agreed on an approach to your surgery, Dr. Xu will book your surgery time and give you instructions on what to do before and after your surgery.
Dr. Xu will also let you know which medications you should and should not take prior to your surgery and what to do on the day of your surgery. It is important to stop smoking at least 6 weeks prior to surgery.
You may need to get a blood test or undergo additional workup depending on your medical history. Dr. Xu may also correspond with your primary care doctor to ensure you are in an optimal state of health prior to surgery.
In the weeks before surgery, recommendations to help you prepare include:
- Making sure you get enough sleep and rest
- Eating a healthy diet with adequate protein and nutrition
- Exercising or engaging in physical activity to strengthen your body
- Maintaining a positive state of mind
- Prioritizing your well-being and reducing stress levels
Dr. Xu also recommends that transgender men build up their chest muscles prior to surgery. Defined chest muscles help to guide the surgeon during surgery to give the best possible aesthetic results.
It is essential that you feel comfortable about your upcoming procedure and fully understand the process. Dr. Xu encourages her patients to ask any questions about their surgery or recovery.
Transgender men do not need to stop testosterone therapy before FTM top surgery.
FTM top surgery alone can be completed within three to four hours and after an hour or two of recovery, you will be able to go home the day of surgery. If top surgery is combined with other procedures, the surgery will take longer.
Dr. Xu will give you specific recovery instructions that you should follow to improve healing for the best possible appearance of your masculinized chest.
The recovery time will depend on the techniques used. After your top surgery, you will feel mild to moderate discomfort. The amount of pain you feel depends on a number of factors such as:
- The type of technique used
- Whether you have had other surgeries completed at the same time
- Your age
- Your health before the surgery
Prescription pain medications might be needed for the first few days. After this time, any pain should be relieved with over-the-counter or non-opioid medications.
The need for drains is dependent on the technique used as well as individual risk factors. Dr. Xu will review this with you at the time of consultation.
If drains were inserted, these will usually be removed after one week. Recovery can take up to six to eight weeks and you must wear a compression vest. During this time, you should avoid lifting any heavy items. Once bruising and tenderness have gone, you can return to normal light activities. Most people can return to work after two weeks, but strenuous exercise should be avoided for eight weeks. Ask Dr. Xu when you can return to the full range of activities.
If you have had a combination of surgeries, Dr. Xu can advise you of any additional recovery needs.
During the early stages of recovery, follow these tips to optimize your results:
- Wear your compression vest as instructed – to decrease swelling and the risk of fluid collections
- Take pain-relieving medication as instructed
- Do not shower or get your incisions wet – use baby wipes until the dressings are removed and you get the go-ahead from your doctor
- Only carry or lift very light weights and do not lift your arms above shoulder level or over your head – especially in the early weeks after surgery
- Avoid strenuous exercise – ask your doctor when you can return to full activity
- Do not smoke or drink alcohol – both affect wound healing
- Use scar treatments – ask Dr. Xu about scar treatments to use once your dressings have been removed
Your risk for complications will depend on the specific technique used and Dr. Xu will make you aware of these before you have surgery. The risk of some common complications (such as infection, bleeding, and wound separation) can be decreased by following your doctor’s post-surgery instructions.
Potential complications after FTM top surgery include:
- Bleeding or hematoma (a collection of blood)
- Seroma (fluid collection) requiring drainage procedures later
- Wound separation or breakdown
- Temporary or permanent loss of nipple sensation
- Reduced or changed nipple sensation
- Loss of a nipple graft
- Unfavorable scarring
- Chronic pain
- Suture irritation or extrusion
- Fat necrosis
- Minor asymmetry
The cost of FTM top surgery depends on which techniques are most suitable for your situation. The best way to understand the costs of top surgery is to schedule a consultation with Dr. Xu, during which a customized plan will be developed and the surgical costs reviewed. Dr. Xu will advise you of a surgical plan as well as the related costs.