The Complete Guide

Last updated June 18th, 2024

WHAT IS TOP SURGERY?

When transgender individuals aim to have their external match their internal, generally a medical transition is a desired outcome. A medical transition can come in the form of hormone replacement therapy (HRT) and/or gender-affirming procedures, such as top surgery.

WHO CAN GET TOP SURGERY?

This is one of the most highly debated, and often politicized, topics in gender-affirming care. In a time where state legislation can influence an individual’s access to medical care, there is no one-size-fits-all answer.

Generally, if you are over the age of 18 and live in a state where there are not restrictions on gender-affirming care, you are a candidate for top surgery. Additional factors such as general health, age, BMI, psychological readiness, and history of previous surgery complications play a role in your eligibility for top surgery.

WHY TOP SURGERY?

Top surgery is desirable for individuals for personal, emotion, physics, and social reasons. Individuals suffering from gender dysphoria might not align to the image they see reflected in the mirror. Binders and binding tape can be a temporary solution while wearing clothing, but what about when you are at the beach, pool, or during intimate moments? We deserve to feel at home in our physical bodies, with or without clothing on.

HOW MUCH DOES TOP SURGERY COST?

There are two major avenues that influence your eligibility, and ultimately the cost: out-of-pocket private practice or health insurance.

Out-of-pocket private practice is exactly as it sounds; you will be responsible for paying for, or sometimes financing, the total cost of the surgery without using insurance. Generally, the total cost includes the plastic surgeon’s consult fee (some apply it to the cost of the proceed if you book with them, some don’t have a consult fee at all), the cost of the procedure, general anesthesia, the operating room fee (if in a hospital vs. in-office operating room), and all your post-operative appointments.

Health insurance is generally a more cost-effective avenue that allows for the same costs as above to be applied to your eligible plan, based on their parameters for coverage. The complexities of health insurance coverage and procedure approval is best assessed directly with the health insurance company, as coverages range even within plans from year-to-year.

In 2024, the average of top surgery for out-of-pocket private practices is estimated to cost between $11,000 and $17,000. Health insurance coverage can significantly lower the cost and sometimes defer the time which you are required to pay for any uncovered portion of the procedure.

WHAT IF I WANT TO INSURANCE TO COVER MY TOP SURGERY?

Going through health insurance will generally require more hoops to jump through before your coverage approval. Informed consent requires providers to give you information on the benefits, risks, and potential alternatives. Informed consent means you are making a well-educated decision about your top surgery.

Most, if not all, insurance companies require a support letter, or multiple letters, from a licensed therapist or mental health provider. Insurance companies look for very specific information to be present in these letters and not all mental health providers have experience writing letters that will be accepted through insurance. Seeking a letter-writer with experience in this area is integral to the process of approval. WPATH Standards of Care (SOC-8) have outlined the letter requirements. There are mental health individuals who can work with you specifically to write you your letter; meaning you do not necessarily need to use your primary therapist if they are not experienced in writing support letters.

Additional documentation, such as a referral letter, might be required if your chosen provider is out-of-network. A referral letter can be obtained from your primary care provider in preparation for insurance coverage approval. Overall, both the support letter(s) and referral letter will require diligent planning and time to obtain.

What are the different types of Top Surgery?

Double Incision with Free Nipple Grafts (FNG)

Also known as: ‘Bilateral Double Incision Mastectomy with FNG’

Best fit: individuals with larger chests and/or require excess skin removal

Procedure:

Two bilateral incisions below the pectoral muscle, where excess skin and tissue can be excised
Free nipple graft (FNG), where nipples and areola are removed, resized/reshaped, and grafted back onto the chest to their new location
Placement of drains in armpit area, if necessary

Post-operative:

Pain management medication as needed
Drains (if needed) stay in for approximately two weeks
Minimum two to four weeks restricted lifting and movement
Gradual increase in mobility
Numbness and bruising are likely to occur
Will require one or more post-operative visit(s) to redress wounds, remove drains, remove non-dissolvable sutures, and/or needle-drain excess fluid

Scarring:

Bilateral scars heal in approximately two to four weeks
Areola/nipple scars heal in approximately two to four weeks
- Scabbing will generally look worse than it is, scab can form over entire area and come off in pieces or one large scab
- Skin pigmentation may change
- Loss of nipple grafts are unlikely but may occur (see Complications and Concerns)
Scars will go from deep red/pink to a lighter pink in two to six months with proper aftercare
Scar care for healed incision (see Recovery and Scar Care)

Double Incision Overview:

Double incision with Free Nipple Grafts is a very popular top surgery procedure option and is well known for the large, bilateral scars visual along the pectoral line of the chest. While a popular option, this is one of the more invasive types of top surgery. It works well with individuals who want to achieve a flatter chest.

Free nipple grafts (FNG) allow for the surgeon to essentially “cut and paste” newly sized, and sometimes reshaped, areola and nipple to its new and final location. This does require removing the nipples from their blood supply, but losing a nipple is a highly unlikely outcome when performed by a skilled plastic surgeon.

This surgery is suited for individuals in most chest shapes and sizes. Patients with larger chests or with extra fat and skin are ideal candidates for double incision. This technique allows the plastic surgeon to perform a free nipple graph, make bilateral incisions, perform liposuction (if necessary), remove any extra skin and tissue, and position the nipples and areola more laterally.

The result is masculinizing the symmetry of the chest. Permanent removal of the nipple is an option, and they would simply not be removed or relocated back onto the chest after closing the bilateral incisions.

The bilateral scars are generally under the lower pectoral line and will slowly fade in thickness and color over time. For FNG, the scarring will look your whole nipple is scabbing over until the scabbing around the wound sloughs off. Diligent post-operative care, as informed by your plastic surgeon, helps ensure the healing process goes smoothly and scar care is effective.

Periareolar Incision

Also known as: ‘Donut’ or ‘Peri’ or ‘Circumareolar’

Best Fit: individuals with smaller chest, nipples/areola, and require less excess skin removal

Procedure:

Two circular, donut-like incisions around each areola
- One around the areola, diameter is approximately 22 mm
- Second is larger, allowing for skin excision
A deeper, slit-like incision allows for the removal of chest tissue
The donut is closed using a purse-string suture
Placement of drains under incision, if necessary

Post-operative:

Pain management medication as needed
Minimum two to four weeks restricted lifting and movement
Gradual increase in mobility
Numbness and bruising are likely to occur
Will require one or more post-operative visit(s) to redress wounds, remove non-dissolvable sutures, and/or needle-drain excess fluid

Scarring:

Circular scars heal in approximately two to four weeks
- Scabbing will generally look worse than it is, scab can form over entire area and come off in pieces or one large scab
- Skin pigmentation may change
- Purse-string sutures can leave jagged/ripple pattern (see Complications and Concerns)
Scars will go from deep red/pink to a lighter pink in two to six months with proper aftercare
Scar care for healed incision (see Recovery and Scar Care)

Periareolar Overview:

Periareolar incisions is another popular top surgery option and is best known for the donut-like, circular incisions around the areola. Like the double incision technique, periareolar incision does allow for some shaping and minimal relocation. The benefit is that the blood supply to the nipple is kept intact, reducing the level of invasiveness.

This surgery is ideal for patients with some excess skin to remove and are looking for a surgery where the nipple blood supply will be minimally interrupted. Patients with larger chests are not likely good candidates for periareolar incision surgery because only a small portion of excess skin and tissue can be effectively removed.

The first incision is around the areola, giving it a smaller circumference and allowing for reshaping. The second incision is around a second, larger circle and the outermost epidermis skin is removed. Through a second deeper incision, the plastic surgeon creates an opening where the chest tissue will be removed, using liposuction if necessary. Once enough tissue is removed, the two circular incisions are sutured together.

This procedure can pose a challenge as the smaller and larger diameter circles do not angularly match up, causing the surgeon to use a purse string stich suture. Though the two circles might not align perfectly, the healed result generally does not have noticeable nipple pattern that might be seen during the post-operative healing process.

The scars are hidden in the natural outline of the areola, making the healing process like less invasive than the bilateral incision technique.

Nerve-Preserving Double Incision

Also known as: ‘Sensation-Preserving Mastectomy’ or ‘Targeted Nipple Reinnervation (TNR)’

Best fit: individuals with larger chests and/or require excess skin removal, desire to keep sensation in the areola/nipple complex

Procedure:

Two bilateral incisions below the pectoral muscle, where excess skin and tissue can be excised
Nerve complex is preserved through dissection
Free nipple graft, where nipples and areola are removed, resized/reshaped, and grafted back onto the chest to their new location, nerve complex rejoined to underside of nipple graft
Diagonal incision from lateral incision to the areola/nipple incision
Placement of drains in armpit area, if necessary

Post-operative:

Pain management medication as needed
Drains (if needed) stay in for approximately two weeks
Minimum two to four weeks restricted lifting and movement
Gradual increase in mobility
Numbness and bruising are likely to occur
Will require one or more post-operative visit(s) to redress wounds, remove drains, remove non-dissolvable sutures, and/or needle-drain excess fluid

Scarring:

Bilateral /diagonal scars heal in approximately two to four weeks
Areola/nipple scars heal in approximately two to four weeks
- Scabbing will generally look worse than it is, scab can form over entire area and come off in pieces or one large scab
- Skin pigmentation may change
- Loss of nipple grafts are unlikely but may occur (see Complications and Concerns)
Scars will go from deep red/pink to a lighter pink in two to six months with proper aftercare
Scar care for healed incision (see Recovery and Scar Care)

Nerve-Preserving Double Incision Overview:

See above overview for Double Incision.

If you are concerned about maintaining sensation around your areola/nipple area, this alternative to the classic double incision top surgery could be of interest. It differs in the plastic surgeon’s technique of harvesting the nerves that innervate the nipple complex. In addition to free nipple graft, there will be an additional nerve graft that is returned to the nipple’s new placement.

This procedure requires a highly specialized provider that has experience in nerve grafting, which is not currently a common approach among gender-affirming surgical practitioners. The amount of preserved sensation is based on the level of sensation prior to surgery. Individuals with a higher BMI (>30) are likely to has reduced sensation after neurotization, in part from the mass of tissues being excised to create a flatter chest.

Double Incision, without Free Nipple Grafts (FNG)

Also known as: ‘Bilateral Double Incision Mastectomy’ or ‘Nipple-Sparing Double Incision’

Best fit: individuals with smaller to medium-size chests, smaller areola/nipple complexes

Procedure:

Two bilateral incisions below the pectoral muscle, where excess skin and tissue can be excised
Free nipple graft (FNG), where nipples and areola are removed, resized/reshaped, and grafted back onto the chest to their new location
Placement of drains in armpit area, if necessary

Post-operative:

Pain management medication as needed
Drains (if needed) stay in for approximately two weeks
Minimum two to four weeks restricted lifting and movement
Gradual increase in mobility
Numbness and bruising are likely to occur
Will require one or more post-operative visit(s) to redress wounds, remove drains, remove non-dissolvable sutures, and/or needle-drain excess fluid

Scarring:

Bilateral scars heal in approximately two to four weeks
Scars will go from deep red/pink to a lighter pink in two to six months with proper aftercare
Scar care for healed incision (see Recovery and Scar Care)

Double Incision, without Free Nipple Grafts (FNG) Overview:

See above overview for Double Incision, with Free Nipple Grafts (FNG)

Double incisions without free nipple grafts allows for the plastic surgeon to remove tissues through the lateral incisions while keeping the nipple complex intact, preserving nipple sensation. This top surgery method is best suited for individuals who are pleased with their areola/nipple size and location, as the procedure does not allow for resizing and only minimal relocation.

‘Hockey-Stick’ Double Incision with Free Nipple Grafts

Also known as: ‘Hockey-Stick Incisions’

Best fit: individuals who wish to maintain a muscular chest post-op and want to blend scars into natural pectoral line laterally

Procedure:

Two bilateral incisions below the pectoral muscle, where excess skin and tissue can be excised
Medial (towards middle) scars curve under pectoral line, laterally incision is angled up towards armpit
Free nipple graft (FNG), where nipples and areola are removed, resized/reshaped, and grafted back onto the chest to their new location
Placement of drains in armpit area, if necessary

Post-operative:

Pain management medication as needed
Drains (if needed) stay in for approximately two weeks
Minimum two to four weeks restricted lifting and movement
Gradual increase in mobility
Numbness and bruising are likely to occur
Will require one or more post-operative visit(s) to redress wounds, remove drains, remove non-dissolvable sutures, and/or needle-drain excess fluid

Scarring:

Bilateral scars heal in approximately two to four weeks
Scars will go from deep red/pink to a lighter pink in two to six months with proper aftercare
Scar care for healed incision (see Recovery and Scar Care)

Double Incision, without Free Nipple Grafts (FNG) Overview:

See above overview for Double Incision, with Free Nipple Grafts (FNG)

Hockey-stick double incisions are ideal if you are looking to blend the double incisions under a defined pectoral muscle.

Keyhole Incisions

Also known as: ‘Keyhole’

Best Fit: individuals with small chest, nipples/areola, and require no excess skin removal

Procedure:

Two, semi-circular incisions under each areola
- Half-moon shaped
A deeper, slit-like incision allows for the removal of chest tissue
Liposuction, if needed, to remove excess tissue
Placement of drains under incision

Post-operative:

Pain management medication as needed
Minimum two to four weeks restricted lifting and movement
Gradual increase in mobility
Numbness and bruising are likely to occur
Will require one or more post-operative visit(s) to redress wounds, remove non-dissolvable sutures, and/or needle-drain excess fluid

Scarring:

Semi-circular scars heal in approximately two to four weeks
- Scabbing will generally look worse than it is, scab can form over entire area and come off in pieces or one large scab
- Skin pigmentation may change
Scars will go from deep red/pink to a lighter pink in two to six months with proper aftercare
Scar care for healed incision (see Recovery and Scar Care)

Keyhole Overview:

Keyhole is top surgery option suited for only about 5% of top surgery candidates. It requires the candidate to have a low BMI, small chest, and small areola/nipples and requires no tissue removal. The benefit of keyhole is minimal scarring, a minimally invasive scarring, and faster recovery period.

Since nerves connection to the areola/nipples is never disrupted, there is a higher chance of preserving chest sensation. The minimal scarring can improve an individual’s satisfaction post-operative satisfaction.

Joining Incisions

Also known as: ‘Single Lateral Incision’

Best Fit: individuals with larger chest, requiring extensive skin removal

Procedure:

Two, lateral incisions, joining in the middle of the chest
A deeper, slit-like incision allows for the removal of chest tissue
Free nipple graft (FNG), where nipples and areola are removed, resized/reshaped, and grafted back onto the chest to their new location
Liposuction, if needed, to remove excess tissue
Placement of drains under incision

Post-operative:

Pain management medication as needed
Drains (if needed) stay in for approximately two weeks
Minimum two to four weeks restricted lifting and movement
Gradual increase in mobility
Numbness and bruising are likely to occur
Will require one or more post-operative visit(s) to redress wounds, remove drains, remove non-dissolvable sutures, and/or needle-drain excess fluid

Scarring:

Joining lateral scar heal in approximately two to four weeks
Areola/nipple scars heal in approximately two to four weeks
- Scabbing will generally look worse than it is, scab can form over entire area and come off in pieces or one large scab
- Skin pigmentation may change
- Loss of nipple grafts are unlikely but may occur (see Complications and Concerns)
Scars will go from deep red/pink to a lighter pink in two to six months with proper aftercare
Scar care for healed incision (see Recovery and Scar Care)