Living with a physical body that does not match your true gender is an uncomfortable way to exist and interact. Masculinizing chest surgery or “top surgery” provides transgender men the opportunity to present as their most authentic self by removing unwanted breast tissue. Along with hormone therapy, it is often one of the first steps trans men choose to make in their transition journey.
A number of surgical techniques may be utilized to accomplish breast tissue removal and masculine chest contouring. Dr. Everett develops a customized treatment plan for each patient to ensure the results are natural and satisfying.
The double incision technique provides ideal masculine contouring for patients with a larger chest, excess skin or breast tissue laxity. In this procedure, a sizable ellipse of skin is excised at or near the lower breast crease and the underlying tissue is removed. The incision is placed so that it accentuates the pectoralis muscle fold, and when it has healed, the scar resembles a natural shadow under the muscle. Another incision is made to remove the nipple and areola, which are resized if necessary and then replaced as a free nipple graft into a more anatomically masculine position. The nipple typically does not retain sensation.
The double incision technique is the most powerful and reliable approach to chest masculinization. Although it involves sensation loss and the most extensive scarring, it is preferred by many patients because of the personalization of areola size and position it allows, and its effectiveness in achieving a flat and tight chest. In our practice, we have found that most insurance plans cover double incision top surgery.
The periareolar technique involves two concentric circular incisions. One is made around the edge of the areola to remove breast tissue. The second, slightly larger incision is made to remove the “donut” ring of tissue between the two incisions. The nipple and areola may be resized. The skin is then pulled taut toward the center (similar to the effect of pulling a drawstring bag closed) and reattached to the areola. A periareolar incision typically retains some nipple and areola sensation and can achieve good results for patients without a significant amount of excess skin or breast tissue laxity.
In the keyhole technique, breast tissue removal is accomplished through a small, semicircular incision around the lower border of the areola. The keyhole incision offers significantly reduced scarring and nipple and areola sensations are largely retained. However, a relatively limited number of patients are good candidates for this approach. A typical candidate for this type of masculinizing chest surgery has a small chest, good skin elasticity and a nipple position that does not require adjustment. The keyhole technique is not recommended for patients with excess skin or a larger amount of breast tissue.
The inverted T or anchor incision is similar to the standard technique used in most breast reduction surgeries. The incision circles around the areola, continues vertically down to the bottom of the breast, then extends horizontally around the inframammary fold where the breast meets the chest wall. The inverted T technique is an option for patients with larger chests and low skin elasticity, who are hoping to retain at least some areola and nipple sensation. Because some tissue must be left behind to supply blood to the nipple-areolar complex, it cannot achieve the same level of flatness as the double incision.
Liposuction may be combined with any of the above techniques to obtain a more thorough transformation. It is rarely used alone for chest masculinization. However, for patients who have a very small amount of breast tissue and naturally small areolas, liposuction by itself may be able to provide a satisfactory male chest contour. The primary advantage of this method is that scarring is minimal. Liposuction to masculinize the chest only requires a small incision through which a cannula can be inserted to remove the fat and breast tissue. In most cases, liposuction is more effective as a complementary procedure than the sole approach.
At Marc Everett MD, we understand that many trans men see top surgery as a vital component of their transition. We are proud to offer our gender-affirming procedures in a respectful, welcoming environment where all patients are treated with the utmost understanding, attention and professionalism. If you are considering chest masculinization surgery, we invite you to schedule a consultation with board-certified NYC plastic surgeon Dr. Marc Everett at one of our two convenient locations in Manhattan and Queens.