Male-to-female (MTF) top surgery is a general term for the feminization of the chest area for transgender people who were assigned male at birth. They may identify as transgender women, feminine-leaning, or be elsewhere on the spectrum of gender identity, but in all cases they feel dysphoria regarding their chest.
Also known as feminizing mammaplasty or transgender breast augmentation, this type of gender-affirming surgery aims to relieve dysphoria by creating a feminine chest appearance, typically with breast implants or fat grafting. For trans women who already have modest breast tissue, surgery can help increase the size of the breasts and create a more feminine contour.
When looking for a surgeon, it is important to choose one who is well-trained and familiar with the nuances of breast augmentation in trans women. The chest anatomy of trans women is different from that of cis women. This makes it critical that you work with a surgeon with the knowledge base and the skill set required to give you the best results possible.
Dr. Ginger Xu is a Board-certified plastic surgeon who has helped many trans women achieve greater self-confidence through feminizing breast augmentation. Dr. Xu received specialty training in aesthetic plastic surgery at Harvard where she also gained particular proficiency in top surgery for transgender patients. 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 that give her patients the emotional relief and comfort of having physical features ultimately aligning with their unique identity.
Feminizing chest surgery aims to create the appearance of a convincingly feminine chest with a full, maturely developed breast shape that is in proportion to the rest of the body.
A good surgeon who listens to your vision for your body and who has experience in gender-affirming techniques and breast implants is best able to match their surgical approach with your goals and body type.
Choosing an experienced surgeon with a sense of artistry is an important first step to ensure your breasts and body have the feminine contours you desire. Your ability to communicate with your surgeon is essential and you should make sure your surgeon understands your needs.
During a consultation, Dr. Xu will discuss all the factors to think about when choosing an approach for your surgery including:
- Type of implant – silicone or saline
- The shape of the implant – including dimensions and projection
- Size of the implant
- Plane of the implant placement
- The firmness of the implant
- Placement of incisions
People who are good candidates for MTF top surgery:
- Are in good physical health
- Are in good emotional health
- Have been on hormone therapy for at least one year
- Have a stabilized breast size after hormone therapy
- 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 feminine chest
- Are able to provide a referral letter from a mental health professional
The techniques for MTF top surgery are similar to breast augmentation for cis women. To create a feminine chest, plastic surgeons can use:
- Breast implants – either silicone-filled or saline-filled (see options below)
- Fat grafting
Breast implants are typically used for MTF top surgery. Although the technology for fat transfer has evolved and the survival of fat cells has improved, fat grafting is not a widely used technique. The technique involves:
- Adequate liposuction of fat from the abdomen or other areas
- Transfer of this fat to the breast
In many cases, people having MTF breast augmentation do not have enough fat to transfer to the chest to give a reliable result. The ability to use this technique depends on the person’s body, the distribution, and availability of fat and the desired breast size.
The pre-existing anatomy of trans women is not the same as that for cis women and this can affect the choices and approaches to breast augmentation surgery. Dr. Xu can discuss all of the options available to give you the best results based on your body type and your goals.
Transgender women typically have the following differences:
- Smaller nipples and areolas (together called the nipple-areola complex)
- Nipples and breast footprint are generally set wider apart on the chest
- Breast fold may be constricted, high, or not well-defined
- Less breast volume overall in comparison to the rest of the body frame
- Less developed breast shape – breast may appear more like a breast bud that is not fully formed, rather than a mature tear-drop shaped breast typical of cis women
The chest muscle is usually thicker in trans women and this affects the choice of implant placement under or on top of the chest muscle. If the implant is placed under the chest muscle, transgender women may have a higher risk of:
- More pain after surgery
- “Animation deformity” – the movement of the implant and related movement of the skin and nipple
- Implants being pushed down or bottoming out with heavy lifting or vigorous use of the chest muscle
Some transgender women may wish to have a very large implant but their skin cannot initially stretch enough to accommodate the implant. If this is the case, a series of surgeries may be needed with the placement of progressively larger implants until you reach your desired size. Trans women can also have a more tuberous breast shape and a herniated nipple-areola complex. These can be addressed with cosmetic nipple surgery such as areola reduction.
You and your surgeon must communicate and work together so you have a good understanding of the process that will give you the results you desire. The goal of a good surgeon should be to arm you with the knowledge you need to make the best decisions about your breast augmentation.
Dr. Xu can help you understand how different implants will affect the final look you will achieve.
It is important you have a realistic understanding of:
- How your breasts will look after surgery
- Limitations of the surgery
- The differences between saline implants and silicone implants
- Any short- and long-term effects – such as the potential need for more surgery
- Any possible complications
The choice of implant and surgical technique will depend on a number of factors including:
- The condition of your skin and how much it can stretch to accommodate an implant
- Your overall body type and how the implant will fit with your frame
- How much fat you have in the upper chest – can affect the implant transition zone
- Whether the implant will be placed under or on top of the chest muscle (pectoral muscle)
Dr. Xu encourages open and honest communication about your body, your lifestyle and what you want for the future. Photos of your desired look can help her understand your needs. Your medical history is also important, including any information about medical conditions.
Things to discuss with Dr. Xu include:
- Why you want the surgery
- Your future lifestyle goals
- What appearance you hope to achieve – for example, a natural look or a more voluminous look
- What sort of breast shape or form you would like
Breast implants are medical devices with an outer silicone shell that can be either smooth or textured. They can be either round or “anatomic” tear-drop shaped, and can be filled with:
- Saline – smaller incisions needed, but rupture causes immediate deflation, less natural look and feel
- Silicone gel – gives a more authentic feel and is more robust
- A new type of silicone gel – called “gummy bear implants”, which hold their shape better
Anatomically shaped implants only come as textured implants, which have been linked to Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL – see below). Dr. Xu never uses textured implants for this reason. Dr. Xu only uses smooth implants, which have not been linked to this condition.
Options for the placement of incisions are:
- Around the nipple (periareolar) – where the nipple border can help to hide the scar
- Under the breast fold (inframammary) – gives the easiest access for placing implants and the scars are almost invisible
- In the armpit (transaxillary) – the scar is hidden under the arms, but this is only an option for saline implants because of more restricted access and view for the surgeon
During hormone therapy for transgender women, the breasts will naturally increase in size. The breast size will settle after approximately one year. Some trans women are happy with the results attained with hormone therapy, but others would like a more convincing feminine look for their chest. This may be achieved by an increase in breast size and/or an improvement in breast shape.
Dr. Xu uses different approaches to help you choose your breast size including:
- Discussing your goals and vision for your body
- Trying “sizers” in the office – breast molds in various sizes that you can wear under your clothes
- Looking at “before and after” photos
- Her sense of artistry regarding what looks best on your particular body and frame
- Her technical experience of what can be safely achieved
The positioning of any scars depends on where the incisions are made during surgery. Most scarring is out of sight or well hidden, especially when the incisions are under the breast.
Scars will initially appear red or pink and slightly raised until they begin to heal and become less noticeable over time. Scars will heal at different rates (up to 18 months) depending on your age, skin tone and exposure to the sun.
Depending on the condition of your chest and skin, implants can be placed either:
- Over the chest muscle – faster recovery time, less discomfort and fills loose skin more effectively
- Under the chest muscle – more natural appearance in the upper chest, less risk of rippling or hardening of the tissue around the implant but a greater chance of problems with the pectoral muscle in physically active people
The best placement option for each person depends on many factors, especially your body type.
In thin trans women, implants placed on top of the muscle might be more easily seen through the skin, so placement under the pectoral muscle might be the preferred option.
On the other hand, very active or muscular women with sufficient fat to camouflage the implant might be better off with the implant placed over the muscle. This avoids the need to cut the chest muscle to place the implant.
Another disadvantage of placing implants under the chest muscle is that vigorous use of the chest muscles in physically active women can cause obvious movement of the implants and also lead to downward implant migration over time.
It is best to wait until your breast growth and size has stabilized after at least one year of hormone therapy.
Hot Topic for Trans Women: Can My Breasts Be Brought Closer Together to Create More Cleavage After Breast Augmentation?
To an extent, breast augmentation can help to create natural-looking feminine cleavage. However, implants are centered under the nipple where the breast tissue normally lies, and because the nipples and breasts of transgender women are set more widely apart than the breasts of cis women, there is a limit to how close your implants can be placed during surgery.
Placing implants too close to the middle of the chest while the nipples are far apart would result in abnormal-looking breasts with nipples too far off towards the sides. Because of these limitations, you might need the assistance of a bra to bring the breasts closer together and create the appearance of cleavage.
As a side-note, it is important for trans women to have a realistic understanding that there is great variation in breast shapes and sizes in cis women, and there is no real “standard,” only what may have been idealized in the media. There can sometimes be unhealthy notions of what a woman “should” look like based on marketing and images created with digital or physical enhancements.
Breast implant manufacturers in the US have warranties. For the latest details, ask your surgeon or search the manufacturer’s website:
- Allergan® Natrelle® ConfidencePlus® Warranty Program and Natrelle® ConfidencePlus® Premier Breast Implant Warranty
- Mentor® – Saline-filled Breast Implants Warranty and MemoryGel® Breast Implants Warranty
- Sientra® – Platinum20TM Limited Warranty and Lifetime Product Replacement Program
Both liposuction and body contouring can be performed at the same time as top surgery, with facial feminization surgery as another option to consider.
Liposuction can be used as an adjunct during breast surgery to help better shape the areas around the breasts, by removing unwanted fat deposits in areas such as:
- The outer region of the chest – liposuction of “side rolls” to better accentuate breast shape
- Axillary fullness – liposuction of armpit fullness or rolls
Liposuction can also be performed to the remainder of the body to create more feminine body contours. Fat removed during liposuction can even be used to augment the feminine appearance of the hips and buttocks. Areas of the body that can be contoured with liposuction and fat grafting include:
- 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 overall feminine appearance
Dr. Xu understands the responsibility of transforming a person’s appearance to better reflect their identity and build self-esteem. Her top priority is understanding your vision and desires. During a consultation, Dr. Xu will explain:
- The different types of saline and silicone implants
- Implant sizes and shapes
- Options for incision placement
- Placement of implants over or under the chest muscle
- Special considerations in trans women
- The need for further operations
- Potential complications
Once she has examined your body, breasts, and chest, she will use her artistic sense to recommend an approach to your surgery that will suit your identity and vision for your body.
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
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.
Usually, it is recommended you stop estrogen-based hormone therapy two weeks before surgery. This is to reduce the risk of potentially dangerous blood clots developing in your legs and lungs. But this is a personal choice that depends on how you weigh-up the potential risks with how you will be affected if you stop taking hormones.
Dr. Xu can further discuss with you the options and implications of remaining on hormone therapy during breast augmentation.
Recovery typically takes approximately two weeks. During this time, you should avoid lifting any heavy items. Once bruising and tenderness have gone, you can return to normal activities. Most clients can return to work after a week, but strenuous exercise should be avoided for four to six weeks.
After your surgery, you will feel mild to moderate discomfort. The amount of pain you feel depends on a number of factors such as:
- Where the implant is placed – for example, the pain might be more noticeable if the breast implants are under the chest muscle
- Size of the implant and the degree of skin stretch
- 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.
During the early stages of recovery, follow these tips to improve your results:
- Wear your surgical bra as instructed – to decrease swelling and prevent fluid formation
- Take pain-relieving medication as instructed
- Use ice packs – to decrease swelling, bruising and pain
- 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 to enter water
- Only carry or lift very light weights and do not lift your arms 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
Once the recovery period has ended, if you develop any tightness or pain related to breast implants, if your breasts start to appear distorted or deformed over time, or if you experience any problems at all related to breast implants, you should consult a plastic surgeon. The list below covers some of the possible complications of breast implants:
Implant migration or malposition is caused when the implant moves with gravity downwards or laterally, with the implants than in the wrong position. If this happens only in one breast, it can cause asymmetry. Surgery will be needed to correct this.
Capsular contracture is the formation of scar tissue around the implant. The scar thickens and hardens over time. This can squeeze the implant and increase firmness, leading to poor positioning of the implant (malposition) and pain. The implant is typically pulled in an upward direction, higher up on the chest.
Stretched skin can be caused by implants that are too large.
Implant leakage or rupture can occur with either saline or silicone breast implants. For saline implants, the ruptured or leaking implant will lead to deflation. Salt occurs naturally in the body so the saline from the implant will be absorbed and eliminated. You will need surgery to remove the deflated implant and insert a new one.
Leaking silicone implants are more difficult to detect as the leaked silicone gel often stays in the “pocket” holding the breast implant. Sometimes, the silicone leaks out of the pocket and can be felt around the edges of the implant. You should see your surgeon if you feel any irregularities. If the implant has leaked or ruptured, you will need surgery to remove the old implant and insert a new one.
Infections after surgery can appear within a few days and up to two weeks. Surgeons take precautions to reduce the risk of infections such as giving you antibiotics before, during and after surgery. If you do get an infection, most can be treated with antibiotics. On rare occasions, the breast implant will have to be removed and can be replaced later after the infection clears.
Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare and highly treatable type of lymphoma that can develop around breast implants. This is a relatively new disease entity that the medical community continues to learn more about as additional data unfolds with time. If you have questions, Dr. Xu can review the latest updates and safety advice with you in detail at the time of consultation. At this stage, BIA-ALCL is only associated with textured surfaces and this is why Dr. Xu does not use implants with textured surfaces.
Breast implants are medical devices and manufacturers and surgeons are constantly working to provide better results for people wanting their first breast augmentation or breast augmentation revision.
There have been dramatic improvements in the past few decades, and even in recent years, as newer generations of silicone are being developed and released on to the market. This has resulted in improved outcomes and improved device longevity. The gel is also more cohesive and less likely to migrate in scenarios of implant rupture or leak. Newer implants also have improved elasticity, shell strength, and a variety of other characteristics that make them feel more natural and life-like.
Even with the latest advancements to implant technology, it is important to understand that breast implants are not guaranteed to last a lifetime. While newer generations of implants are more robust than older models, future surgery may still be needed to replace an implant if a rupture or leaking develops. After the placement of breast implants, it is a good idea to have regular breast exams to check the condition of your implants.
Saline implant rupture would result in obvious deflation and a change in the size of the affected breast. But silicone breast implant rupture is often “silent” and undetectable by the woman or even by a physical exam. In this scenario, an MRI is a useful tool that can detect silent rupture. Currently, the Food and Drug Administration (FDA) recommends MRI screening for silent rupture three years after receiving a silicone implant and every two years afterward.
During the recovery time, you might feel more or less nipple sensation, but that will usually resolve. In rare cases, people lose sensation in their nipples.
Combination surgeries are more complex and will cost more. The best way to understand the costs of surgery is to schedule a consultation with Dr. Xu — a Board-certified plastic surgeon with a high level of technical training and vast experience in gender-affirming surgery necessary to help people achieve their aesthetic goals.
Many people are unaware of the range of techniques available to help them achieve their goals for a feminine body. Dr. Xu will listen to your vision for your body and discuss the surgical options that can best create the results you want, and that ultimately reflects your true inner self.