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Types of top Surgeries

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Double Incision, with FNG

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

Best fit: individuals with medium to larger chests and/or those who 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 areolas are removed, resized/reshaped, and grafted back onto the chest to their new location
  • Placement of drains, 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
  • Swelling, firmness, color changes, and scar maturation can continue for up to 18 months
  • Areola/nipple scars heal in approximately two to four weeks
    • Scabbing will generally look worse than it is.
    • Scab can form over the entire area and come off in pieces or one large piece
  • Scars will go from deep red/pink to a lighter pink in 2 to 18 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 visible along the lower 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, areolas and nipples to their new and final location. This does require removing the nipples from their blood supply. Partial or complete nipple-graft loss is an uncommon but recognized complication. Individual risk depends on factors such as surgical technique, blood supply, nicotine exposure, health conditions, and postoperative healing. Your surgeon can explain their complication rates and your individual risk.

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 graft, 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 nipples 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, color, and appearance 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 that scar care is effective.

Periareolar Incision

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

Best Fit: individuals with smaller chests, smaller nipples and areolas, and who require less excess skin removal

Procedure:

  • Two circular, donut-like incisions around each areola
    • The first is around the areola and has diameter of approximately 22 mm
    • The 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 the 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
  • Swelling, firmness, color changes, and scar maturation can continue for up to 18 months
  • Areola/nipple scars heal in approximately two to four weeks
    • Scabbing will generally look worse than it is
    • Purse-string sutures can leave jagged or ripple pattern scar
    • Scab can form over the entire area and come off in pieces or one large piece
  • Scars will go from deep red/pink to a lighter pink in 2 to 18 months with proper aftercare
  • Scar care for healed incision (see Recovery and Scar Care)

Periareolar Overview:

Periareolar incision 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 nipples is kept intact, reducing the level of invasiveness and increasing sensation preservation.

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. Periareolar surgery is generally considered for people with a smaller amount of chest tissue and good skin elasticity. Eligibility cannot be determined by chest size alone; nipple position, skin elasticity, body proportions, goals, and the surgeon’s technique also influence the recommendation.

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 stitch suture. Though the two circles might not align perfectly, the healed result generally does not have a 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 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 who require excess-skin removal and desire to retain sensation in the areola/nipple complex

Procedure:

  • Two bilateral incisions below the pectoral muscle, where excess skin and tissue can be excised
  • The nerve complex is preserved through dissection
  • A free nipple graft, in which the nipples and areolas are removed, resized or reshaped, and grafted onto the chest in their new locations. The nerve complex is then rejoined to the underside of the nipple graft.
  • Diagonal incision from lateral incision to the areola/nipple incision
  • Placement of drains, 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 and 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
  • 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 more common double incision top surgery could be of interest. Some surgeons offer techniques intended to preserve or restore nipple sensation by maintaining a nerve-containing tissue connection or by performing nerve reconstruction. These techniques are not available in every practice, and preserved or restored sensation cannot be guaranteed. Ask the surgeon which technique they use, whether you are a candidate, and what sensory outcomes they typically observe.

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 have reduced sensation after neurotization, in part from the mass of tissues being excised to flatten the chest contour.

Double Incision, without FNG

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

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

Procedure:

  • Two bilateral incisions below the pectoral muscle, where excess skin and tissue can be excised
  • Placement of drains, 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 FNG Overview:

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

Also known as: ‘Hockey-Stick Incision’

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, 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 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 Incision

Also known as: ‘Keyhole’ or ‘Semi-Circular Areola Incision’

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, 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:

  • 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.

Center-Joining Incision

Also known as: ‘Joining Incision’ or ‘Single Lateral Incision’

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

Procedure:

  • Two, lateral incisions, joining in the center 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, 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:

  • 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
  • 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)

Center-Joining Incision Overview:

This procedure can provide the patient with the maximal amount of excess tissue excision. The joining of the scars at the center might not be ideal for the patients who are concerned with hiding scars, but with scar care, can be minimized with time.

Fishmouth Incision

Best Fit: individuals who desire a non-traditional scar

Procedure:

  • Two lateral incisions, across the center of the chest, circling around the areola/nipple complex (NAC)
  • Non-traditional scars located along the lateral plane of the nipples, not under pectoral muscles
  • Placement of drains, 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:

  • Fishmouth 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)

Fishmouth Overview:

This procedure results in a unique scar pattern and equally unique scar healing process. The incisions circling the nipple/areola complex (NAC) allows for resizing without complete removal, allowing for sensation preservation. The scar placement is not easily hidden, although their appearance will flatten and diminish with time. Fishmouth top surgery can be desirable for individuals who are interested in a unique scar pattern.

Lollipop Incision

Also known as: ‘Short-Scar with Periareolar’ or ‘Vertical-Scar with Periareolar’

Best Fit: individuals with smaller chests, require minimal skin removal

Procedure:

  • Two, vertical incisions with periareolar incisions
  • A deeper, slit-like incision allows for the removal of chest tissue
  • Liposuction, if needed, to remove excess tissue
  • Placement of drains, if needed

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:

  • Vertical/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
  • 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)

Lollipop Incision Overview:

This procedure is similar to periareolar incisions, with the addition of two short, vertical incisions extending down from the nipple/areola complex (NAC). This is ideal for periareolar candidates with a small amount of skin that needs to be removed to flatten the chest contour. Like traditional periareolar incisions, there is no ability to reposition the NAC.

Buttonhole Incision

Also known as: ‘Buttonhole with Double Incision’ or ‘Nipple-Sparing Double Incision’

Best Fit: individuals with larger chests, wanting to preserve nipple/areola sensation

Procedure:

  • Two, bilateral incisions with no Free Nipple Graft (FNG)
  • A deeper, slit-like incision allows for the removal of chest tissue
  • Liposuction, if needed, to remove excess tissue
  • Placement of drains, if needed

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
    • 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)

Buttonhole Incision Overview:

This procedure is like Inverted-T (Anchor) Incision, where the blood supply to the nipple/areola complex (NAC) is preserved. Buttonhole incision top surgery still has variable sensation preservation results. Because a peduncle of skin is used to maintain the blood supply during surgery, the result is often a visible area of remaining tissue that results in a visible area of chest tissue. This is generally not a desired masculinization outcome and will likely hide toned chest muscles from looking as defined as the results seen in Double Incision top surgeries. Further revision and surgeries might be required to remove excess fullness after Buttonhole Incision surgery for the appearance of a flat chest.

Inverted-T (Anchor) Incision

Also known as: ‘Inverted-T’ or ‘T-Anchor’

Best Fit: individuals with larger chests, wanting to preserve nipple/areola sensation

Procedure:

  • Two, bilateral incisions joining with two vertical incisions with no Free Nipple Graft (FNG)
  • A deeper, slit-like incision allows for the removal of chest tissue
  • Liposuction, if needed, to remove excess tissue
  • Placement of drains under incision, if needed

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
    • 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)

Inverted-T Incision Overview:

This top surgery option is best suited for individuals with a larger BMI, inelastic skin, and/or do not have an interest in a completely flat chest. Body size can influence incision placement, contour, and the amount of tissue or skin that may need to be addressed. However, BMI alone does not determine which procedure is appropriate. A surgeon should evaluate your anatomy, health, goals, and individual risk factors. Individuals with a larger BMI might want their new chest to match their body-type and want to avoid an indented-appearing chest that might come with the Double Incision method. The nipple/areola complex (NAC) can be moderately resized, while a peduncle is kept intact to aid in the preservation of the blood supply and nervous surrounding the area. For those who are not looking to have residual volume or fullness in their chest should avoid Inverted-T top surgery.

No-Nipple Procedures

Nipple-free, or “blank-slate,” top surgery involves removing the nipple-areola complexes (NACs) without grafting or reconstructing them. This option is generally chosen based on a person’s gender expression or desired aesthetic rather than medical necessity, and it has become increasingly visible within transgender and nonbinary communities.

Choosing not to retain or reconstruct the NACs eliminates nipple-graft-specific risks and aftercare, including the possibility of partial or complete graft loss. However, it does not eliminate the risks or recovery associated with top surgery itself. Overall recovery depends on factors such as the surgical technique, amount of tissue and skin removed, incision pattern, and individual healing.

Nipple-free top surgery is most commonly performed using a double-incision technique without free nipple grafts. After healing, some people choose medical tattooing to create the appearance of nipples, while others prefer to keep a completely nipple-free chest.

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