Top surgery can come in two forms; breast augmentation or masculinizing chest reconstruction, Both surgeries combat gender dysphoria in transgender men and women.
Breast augmentation for transgender women
Breast augmentation for transgender women, also known as feminizing augmentation mammoplasty, is the insertion of breast implants. The implants can be underneath (sub-muscular) or above (Sub-glandular) the natural muscle and tissue. These implants can either be silicone or saline and are sized and shaped to best match the body type. Silicone implants appear more natural and are the preferred method for transgender women. Though the incision needs to be larger for these implants, leading to more post-surgery scarring. The surgery itself includes one of three sites for surgical incision:
Peri-areolar incision: an incision around the areola.
Inframammary Incision: an incision at the bottom of the breast.
Transaxially incision: an incision underneath the armpit.
Before surgery, it is vital to meet with a behavioral health specialist to obtain a letter of referral; this may include well-documented gender dysphoria. Many surgeons also suggest hormone replacement therapy (HRT) up to 12 months before surgery. HRT results in nipple and breast growth; this extra tissue makes the placement of breasts more natural and has overall better results. It’s also advised to quit smoking two weeks before surgery and continue through six weeks post-surgery. Smoking hinders the healing process, and may cause improper healing. Finally, this is usually a single-day procedure, and patients will need assistance getting home.
These procedures are safe. though possible complications may include: hematoma (blood pooling under the skin), changes in feeling, firming of breast and scar tissue, and the potential for leaking or rupturing of the implant. Though, only about 1-2% of implants rupture each year (The Trans Center, 2019).
Post-surgery soreness and swelling for the first few weeks are normal and expected. Scars will fade though not totally, visibility of scars will vary depending on how your body heals. A compression bra should be worn for the first few weeks after surgery. Also, limit upper body exercise for several weeks as it can displace the breast implant. The care team will provide information on dressing changes and keeping the wound clean.
Masculinizing chest reconstruction
Masculinizing chest surgery is the removal of breast tissue, also known as a Double mastectomy. The technique used is dependent on the size of the breast. Smaller breasts may not need the nipples and areola to be resized and or moved, where larger breasts may have nipples and areola removed. If the nipples and areolas don’t need to be moved, they will stay sensitive, and the scarring will be minimal. Larger breasts may have their nipples and areolas remove, resized, and grafted into position; Leaving the area more scarred and losing some sensation in the nipples. If the nipples and areolas need to be moved, surgeons either use a double incision with nipple grafts, or an inverted-T; both are shown in pictures below. Some opt to have their nipples are areolas removed, especially if at risk for breast cancer. If the nipples and areolas get removed, they can be tattooed back on for a cosmetic look. Liposuction has also been used during this procedure for excessive fat tissue in the breast. Regardless of where you are in hormone replacement therapy the procedures are the same.
Images provided by: Ftm top surgery – double incision top surgery 2021.
With the expense of surgery and limitation of age, many are not able to access surgical options. When surgical options are not available, chest binders help the chest appear flat. Chest binding does help with gender dysphoria. However, over time the compressed skin losses elasticity. Loss of elasticity can negatively affect the surgery. If planning to bind and get surgery, do so as little as possible and communicate with the care team. More information about binders can be found on our Binder Safety and Usage page. It is also important to quit smoking up to 3 months before surgery and continue for up to 6 months after. Smoking hinders the healing process and can lengthen recovery time.
After surgery, the breast tissue will be sore and swollen. Side effects are limited though, keep in mind to limit upper body movement, watch for a build-up of blood or clear fluid in the wound, and keep the surgical site clean. The care team will give further instructions specific to the needs of the patient.
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