Top Surgery: Female to Male Gender Reassignment Surgery

Understanding Top Surgery To Reconstruct the Breasts

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“Top surgery” is the term most often used to describe a bilateral mastectomy performed as part of a female to male sex reassignment surgery.  The mastectomy is a procedure where one (unilateral) or both (bilateral) breasts are removed.  One of the most common surgeries in the United States, the surgery is typically performed as a cancer treatment or to prevent cancer in high risk women.  For transgender individuals, the procedure is a chest masculinization surgery, which minimizes feminine traits.

Where women who have a mastectomy due to cancer often opt to have reconstructive surgery with implants to replace the removed tissue, transgender patients are seeking to have removal of breast tissue with a cosmetic result.  

Why Top Surgery?

In most patients, testosterone therapy starts prior to surgery, which leads to a more masculine appearance.  Unfortunately, testosterone does not result in a reduction of breast size, and if pectoral muscles increase in size during the therapy the breast may be more pronounced.  Breast binders are often used to minimize the feminine appearance of the breasts, but for those with large breasts, it can be challenging to maintain a masculine appearance. 

More importantly, many transgender individuals feel a strong need to have their external features match the gender that they self identify with.  Top surgery, along with other types of gender reassignment surgery, are meant to make the body match the mind, rather than forcing the mind to match a body that feels wrong.

How Is Top Surgery Different From a Typical Mastectomy?

The goal of top surgery is different than that of the typical mastectomy, and is a far less common procedure.  Finding a surgeon with experience performing top surgery and the techniques used to minimize scarring is important for obtaining a “realistic” appearance.

 

The goal of the traditional bilateral mastectomy is to remove any tissue that is cancerous or may become cancerous in the future, and may include the removal of chest muscle.  Lymph nodes in the armpit are often removed as part of a mastectomy, which is not done during top surgery unless the individual has a need that dictates that the lymph nodes should be removed.  This virtually eliminates the risk of the arm swelling that some women experience after surgery.

The goal of top surgery is to obtain a more masculine appearance, which requires a different technique to maintain chest wall muscle while minimizing the breast tissue.  In addition to the bilateral mastectomy, some patients opt for chest contouring during the procedure or in a subsequent procedure, in order to have a more masculine chest silhouette.  

Top surgery may be done using a "keyhole" minimally invasive technique that attempts to hide scarring in the nipple, or the open technique that uses an incision under the breast.

  For cosmetic purposes, the keyhole technique has far less noticeable scars after healing, but the keyhole technique is typically only utilized for patients with B cup or smaller breasts.  Nipple grafting may or may not be necessary, depending on the size of the breasts, the surgical technique used and other factors. 

Scarring After Top Surgery

There are many techniques used by plastic surgeons to minimize scarring that are appropriate after top surgery, as the scars can be notable when shirtless and may detract from the appearance of natural male breast/chest tissue.  While your surgeon may have multiple options available to minimize scarring, eating a healthful diet, avoiding tanning of the surgical area during healing, good incision care and smoking cessation will contribute greatly to scar minimization.

Breast Cancer and Top Surgery

There is little research, if any, into top surgery patients developing breast cancer in the future.  For individuals with BRCA 1 or BRCA 2 genes or a strong family history of breast cancer, some female patients who want to be aggressive in their treatment are choosing to have bilateral mastectomy to reduce the risk of breast cancer.  For the transgender individual with a family history of breast cancer, a serious conversation with the surgeon may be in order to help minimize any cancer risk. 

Only your surgeon can advise you on whether you will have any tissue remaining that would make mammograms or ultrasound advisable in the future, or your personal level of breast cancer risk. 

Paying For Top Surgery

Unlike the bilateral mastectomy, which is paid for in full for women with cancer, top surgery is often excluded from coverage by insurance companies as it is considered a cosmetic surgery.  While more insurance companies are covering sex reassignment procedures, they are currently in the minority, leaving the patient responsible for cost of the procedure.  

Paying for surgery out of pocket can be very expensive, leading some patients to negotiate payment plans, use credit cards, use crowd funding techniques and other methods of payment.  Many save for years in order to pay for the surgeries that they require.

Safe Top Surgery

It cannot be stressed enough that it is absolutely essential that the choice of surgeon should be driven by a need safety and surgical skill.  A surgeon board certified in plastic surgery is an absolute must for a safe surgery with a good outcome.  The transgender community has long been the victim of charlatans, black market and back alley “surgeons”--imposters claiming to be surgeons who botch surgeries leading to scarring, infection and even death.

Safe surgery will be done in a professional environment, with a licensed anesthesia provider providing general anesthesia, by a board certified plastic surgeon.  It won’t be done after hours, in a dirty room or at the home of the surgeon.  It may take longer to save enough money for safe surgery, but the risks of cheap surgery are too great to even consider an alternative.  Traveling out of the country for surgery, regardless of type of procedure being sought, should be approached with great caution.

Sources:

Sex Reassignment Surgery in the Female to Male Transexual.  Seminars in Plastic Surgery. Accessed May, 2014. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312187/

Transgender Surgery Types for FTM Top Surgery. Charles Garramone, MD. Accessed May, 2014. http://drgarramone.com/surgery-types/

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