Elective cosmetic mastectomy, or “top surgery”, is a procedure designed to remove unwanted breast tissue in order to create a more masculine chest appearance. Alongside hormone therapy, top surgery is typically one of the first steps for patients who are transitioning from female to male; this may also be the only surgical procedure undergone by many transmen. Patients who opt for cosmetic mastectomy can expect to experience a number of benefits, including a greater congruence between their outside appearance and experienced gender, improved self-esteem and self-image, and an increased ability to blend-in society as a man.
There are a number of surgical techniques that may be utilized to accomplish the desired breast tissue removal. The most common technique is called a “bilateral mastectomy with free nipple grafts.” This technique allows for the removal of essentially all of the breast tissue (including milk ducts) and excess skin, along with proper placement and downsizing of the nipples. This technique is utilized most frequently because the majority of patients present with a combination of excess skin and a naturally low nipple position.
The peri-areolar, or “keyhole”, technique consists of breast tissue removal through a small incision around the nipple. This technique carries the advantage of significantly reduced scarring. However, a relatively small number of patients are considered good candidates for this procedure. The suitable candidate for this type of mastectomy is typically the young, slim patient with a small amount of breast tissue, no excess skin, and a nipple position that does not require modification. Your surgeon at ICTC will perform a physical examination and work with you to choose the best mastectomy technique for your anatomy and unique needs.
Some patients have inquired about the possibility of using a “pedicled” technique to preserve sensation to the nipple; however, this technique is often unsuccessful in maintaining nipple sensation. We generally do not recommend this technique for transmen because it necessitates leaving a fair amount of breast tissue and does not result in an optimal male chest appearance.
Patients who have a very large amount of breast tissue or chest wall fat tissue may benefit from combining lateral chest wall liposuction with their mastectomy. The decision as to whether or not this is needed will be made at the time of the consultation, or as determined by pre-operative photos in the case of our out-of-town patients.
While patients at ICTC are usually very happy with the outcome of their procedure, it is important to have realistic expectations going into surgery. While top surgery can help you to gain a more traditionally masculine appearance, your chest may not look “perfect” following surgery. Swelling and bruising are to be expected after mastectomy, so final results may not be evident right away. Ultimately, your results will depend on the specific mastectomy technique used, along with your individual anatomy and body characteristics. Your surgeon will work with you to ensure that you obtain the very best possible results. Additionally, performing weight-training exercises to build muscle mass both before surgery and after recovery can enhance your results.
Patients who have undergone top surgery often wonder if their breasts will “grow back” if they gain weight. Because this procedure removes the actual breast tissue (rather than just fat tissue), patients would have to gain a substantial amount of weight for the chest to recover a feminine appearance. Keep in mind that the results of top surgery are considered permanent and are not reversible.
As with any surgery, there are potential complications associated with cosmetic mastectomy. However, this is considered a very safe procedure, and most patients feel that the benefits outweigh the risks. Possible complications include bruising, swelling, nausea and vomiting, blood clots, infection, seroma (i.e., fluid build-up), and poor reaction to the anesthesia. Top surgery is generally performed under general anesthesia, which means that you’ll be asleep during the procedure. It is common to experience diminished nipple sensation post-surgery, but typically patients do retain some sensation and most transmen actually report increased sexual satisfaction following their procedure (likely due to enhanced body confidence).
A pre-operative appointment will typically be scheduled one week prior to surgery for local patients, and one to two days prior to surgery for out-of-town patients. It is essential that our office staff have all your health information at the time of scheduling in order to determine if any special requirements are needed (such as lab work or medical clearance). In addition, we follow the WPATH guidelines for transgender care, which means that a letter from your therapist is required prior to surgery. Patients who are over fifty years of age and those with significant underlying medical problems are required to obtain a medical clearance.
Out-of-town patients generally arrive two days before surgery. Please inquire with our office regarding area hotel accommodations, as we do work with a number of hotels to provide special pricing to our patients. The pre-operative visit is scheduled the day before surgery. At that time you will receive all necessary instructions, undergo the full nursing workup for surgery, and be examined by your surgeon. This is an ideal time to ask any specific questions you might have about the procedure itself. It is also important to have a support person with you at the time of your pre-op visit. This person will help in assimilating the extensive amount of information and instructions given to you, and will typically be the person staying with you after surgery.
A special dressing will stay on the nipple graft for one week, but drainage tubes are no longer needed for this procedure. We have developed meticulous quilting techniques designed to reattach the skin flaps to the chest wall, thus eliminating the need for uncomfortable drain tubes. Postoperative discomfort is typically mild to moderate and is controlled by pain medication. Arm use should be restricted during the first week. This includes driving, lifting, or reaching. At one week normal daily activities may be resumed; vigorous exercise and weight-lifting can be resumed at 6-8 weeks post-surgery. Scars are permanent, but they should fade gradually over the first year after surgery; do not tan incisions during this time period. Your surgeon can also provide you with instructions on techniques to speed the scar healing process.
The staff at ICTC understands that each patient has his own unique needs and expectations, which is why we take an individualized, patient-centered approach to gender transition services. During the preoperative consultation, your surgeon will take the time to discuss and understand your goals for gender transition. Additionally, he’ll thoroughly explain each procedure and answer any questions you might have. We want you to feel comfortable and happy with your decision to pursue top surgery with us, so please do not hesitate to let us know how we can be of assistance.
At the International Center for Transgender Care, we understand that top surgery is a vital component of the female to male transition process. Because this procedure is so important, it is paramount to choose a surgeon with specialized knowledge and skill. Our board-certified surgeons have more than 20 years of experience treating transgender patients. We are proud to offer all of our services in a respectful, welcoming environment at our world-class surgical center in Dallas, Texas. We look forward to assisting you in achieving the very best possible results for your mastectomy procedure. Contact us today to schedule a consultation at (972) 543-2477.