From now until sometime in Spring 2023, we’ll be writing about gender affirming surgeries and procedures. We’re starting with bottom surgeries and will end with office visit procedures such as fillers and botox. Last week we talked about top surgery to add curves, and this week we’ll discuss top surgery to flatten the chest.
Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.
What Is Top Surgery To Flatten The Chest
The surgical procedure to flatten the chest is mastectomy.
A note on language use at QueerDoc:
We believe that there’s no one way to be trans. We also believe that there’s no one way to be masculine, feminine, or non-binary, and that what these terms mean has a lot of overlap for individual people. We use “angles” or “gettin’ square” to describe the body shape changes that are often associated with a testosterone-based hormonal milieu in the body. We also note that testosterone isn’t necessary to ‘get square.’
Other blogs about gettin’ square to check out:
Gettin’ Square The QueerDoc Way: Testosterone
Building a Broader Physique: Exercises for Angles
Resources:
Dr. Mosser’s Gender Confirmation Center has a ton of information on top surgery, including a guide on what to expect, a discussion of different techniques, and a whole section on non-binary top surgery options if you’re looking for a less traditionally squared-up chest. It also has an excellent section on body contouring.
Nice Pecs, Sib! What is Mastectomy?
Top Surgery for Getting Square is when breast tissue is removed to flatten the chest. Areolas and nipples may be resized and moved or removed altogether. The type of top surgery suitable for you depends on your goals, your pre-surgery shape and size, and your skin elasticity.
Unlike mastectomy for cancer, top surgery for chest flattening does not necessarily remove all breast tissue. Some may be left to provide the desired shape to the chest or be used to accentuate the lower line of the pectoral muscle.
The incisions used can also often be different. If you read our breast augmentation blog, you might remember the term inframammary fold. During BA, the inframammary fold may be moved down to accommodate more chest tissue. In flattening top surgery. the inframmamary fold may be moved up so there is a shorter distance between nipple and chest wall, and the shape changed to a straighter line, which can also accentuate the lower line of the pectoral muscle.
During surgery, nipples and areolas may be left alone, resized, and/or moved. Often, nipples are moved down the chest and out towards the sides of the body compared to the pre-operative chest. Some surgeons use a series of measurements to help decide where to place the nipples, some decide on final placement during surgery when they are able to see how different placements look, and some do both. (link to article) During your consultation, you’ll can bring pictures of what you want your chest to look like.
Top Surgery Incision Types
These are some of the more common incision patterns.
Periareolar Incision (Keyhole)
- Suitable for individuals with very little tissue to remove and very good skin elasticity.
- A half-circle incision is made at the bottom edge of the areola.
- No skin is removed.
- Nipples are not moved.
- Can preserve sensation.
Periareolar incision (Donut)
- Suitable for individuals with little tissue to remove and very good skin elasticity.
- A circular incision is made in the areola, which allows access to the tissue to be removed. A second circular incision is made further out, and the skin in between is removed. The skin edge is then drawn towards the areola and sutured.
- Minimal skin removal.
- Nipples are not moved.
- Can preserve sensation.
Lollipop
- Suitable for patients who have more skin to remove
- A circular incision around the areola, then a vertical incision down to the bottom of the chest tissue.
- Nipples are not moved.
- Can preserve sensation.
Double Incision
- Best suited for individuals with a moderate amount of tissue and skin to remove.
- Two incisions are made – one at the height of the bottom of the pec, and one along the lower edge of the chest tissue.
- These incisions may be curved along the line of the pectoralis muscle (the pecs.)
- Areolas and nipples are removed, resized, and repositioned as a skin graft.
- May lose nipple sensation.
Nipple-Sparing Double Incision
- Incisions are made in a curved wedge shape on the outer edges of the chest.
- Nipples are moved outwards and down due to the skin edge being moved towards the abdomen and side and sutured. Can preserve nipple sensation.
Buttonhole
- Incisions are similar to an inverted t surgery, but areolas and nipples are resized rather than removed and repositioned.
- Can preserve sensation.
Inverted T (Anchor)
- Buttonhole with an extra vertical incision underneath each nipple
- Suited for individuals with a greater amount of tissue and skin to remove.
- Three incisions: a circular incision around the areola, a curved horizontal one at the bottom edge of the chest tissue, and a vertical connecting incision.
- Can preserve sensation – tissue is removed around the nipple “pedicle,” then the skin is pulled towards the nipple and vertical incision.
Contouring
Body contouring using liposuction can be done during mastectomy. The chest, sides, back, flanks, and abdomen can be modified toward your goals.
When: Prep and Recovery for Mastectomy
Read our blogs on exercising before top surgery, returning to exercise after top surgery, and scar care!
There isn’t a lot of required physical prep before flattening top surgery.
You’ll have a consultation with your surgeon, get pre-op labs done, and a physical exam prior to surgery to confirm that your health is optimized for surgery and recovery. If you use nicotine, you’ll need to stop before surgery. If you have diabetes, your blood sugars will need to be well-controlled. Hormone use is not required before flattening top surgery. Our general surgery blog has more information about prep and recovery (it’s geared for bottom surgery, but much applies to top surgery as well.
You may be able to go home on the same day you have surgery. Some people stay one night in the hospital. You’ll likely be tired and sore for the first few days with restrictions on what you’re able to do, and may be required to have a support person. You’ll wear your bandages and a compression garment until your first post-op procedure (and you won’t be able to shower.) You’ll likely wear your compression vest for a couple of weeks. If you have drains, you may need help managing them until your first follow-up appointment.
Expect to be away from work for one to two weeks. You’ll have lifting restrictions for up to 8 weeks, and if you have a physical job, you may wish to arrange for modified job duties.
How: Insurance and Surgeon Requirements for Mastectomy
The new WPATH guidelines state that if a mental health assessment is required, only one letter is needed. Confirm with your insurance company and your surgeon what their current requirements are. You may also need a letter from your hormone prescriber. The WPATH hormone guidelines have also been updated. Six months of hormone treatment is recommended, except where hormones are medically not appropriate or hormones are not desired. Again, your insurance company or surgeon may not have updated their requirements to be inline with WPATH.
Your surgeon will require that have not used nicotine prior to surgery. If you have diabetes, your blood sugars will need to be well-controlled. Your may need to document that you have support and housing immediately after surgery.
Who: Finding a Surgeon for Mastectomy
Many plastic surgeons offer flattening top surgery. You are most likely to have a better experience and outcome with a surgeon who does a lot of gender affirming top surgeries.
How to find a surgeon (note – we’re most familiar with West Coast surgeons!)
- talk to others in the community
- gender care centers at academic institutions such as OSHU, UCSF, UW
- well-known private practices such as the Gender Confirmation Center, MozaicCare, Align Surgical, Crane Center, etc.
- FTMSurgery.net
- TransHealthCare.org
- findplasticsurgery.org
- WPATH Provider Directory
- OutCare Health
- The r/TransSurgeries wiki on Reddit
Citations
- Coleman, E., Radix, A. E., Bouman, W.P., Brown, G.R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F.L., Monstrey, S. J., Motmans, J., Nahata, L., … Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(S1), S1-S260. Appendix D.
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