Gender Affirmation Tops Surgery

Ready to proceed with gender affirmation surgery?

Top surgery is the most common insurance-covered surgery for gender affirmation. After clearance from a suitably qualified psych provider, and after being on hormones for a couple of years, it may be the right time to get Top surgery. Below we discuss some tips on both male-to-female top surgery and female-to-male keyhole and double incision surgeries. 

You are welcome to come in for a consultation with Dr. Gill, who headed the gender affirmation program during her time at Kaiser Permanente in Sacramento, California.

Top surgery refers to surgery of the chest area done in support of gender affirmation. This is one of the most common surgeries done for gender affirmation. As terminology for gender affirmation is a sensitive matter and may change, please make allowances for any errors made on our part. We will refer to trans-female as those desiring female shaped breasts, and trans-male for those desiring a flatter more male shaped chest area, and mean no disrespect to non-binary or other designations in the gender affirmation community. 

Dr. Gill is experienced in face and chest gender affirmation work but does not perform genital gender affirmation procedures. At Pulsar Health, we only operate on adults for gender affirmation surgery. We also require recent clearance from a psychological evaluation to make sure that this is a good time to undergo surgery, with enough lifestyle stability and support. We also obtain breast imaging, usually an ultrasound, before doing breast surgery and may need lab tests. Nicotine exposure must be stopped three months before and at least two months after surgery, in order to avoid healing complications that could have permanent negative consequences, such as the loss of a nipple.

Male to female top surgery usually involves placement of a breast implant after a couple of years of hormone therapy. Here are some tips to get the most out of the procedure:

• Hormones for male-to-female transition and maintenance usually help increase the breast tissue. Many times, just the hormones produce a sufficient expansion of the breast. If more fullness is required, typically we proceed with a breast implant, although fat grafting can be considered (see below). 
• The size and shape of the breast implant needs to be carefully selected. As trans-females can have a wider base width of the chest than the average cis-female, a bigger implant is often needed for adequate projection. The maximum volume of breast implants in the United States for non-custom implants is 800cc. That is the largest "off the shelf" size in silicone implants, but if a saline implant is used, it can be overfilled significantly to create a fuller look. 
• The decision of "under the muscle" or "over the muscle" and other implant considerations, such as monitoring and possible complications, is discussed in detail in the website section "Breast Resizing: Going Bigger" so please look there for more details on implants. Over the muscle (subglandular) breast augmentations can be done awake at Pulsar Health, without needing general anesthesia.
• Fat grafting can be done with or without a breast implant to increase fullness. Half the fat goes away as it does not manage to get enough of a blood supply. It is better to repeat the procedure than put a lot of fat in in one go to the breast area. Fat grafting can be done awake with numbing medicine, and consider if you want fat placed in the facial cheeks or buttock area to create a more rounded shape there. Please see our section "Buttock Enhancement" for more details.
• Hair reduction with laser may be helpful if hair is dark colored on the chest.

Female to male top surgery is usually done via the double incision technique but if the breasts are quite small and the skin is elastic, it can be done successfully via the keyhole technique. Again, here are some tips worth bearing in mind:

• The keyhole technique is similar to cis-male gynecomastia surgery in focusing on removing the excess breast gland and, if necessary, a small amount of skin. The skin excision around the nipple areolar complex can enhance flattening of the chest contour. 
• Skin quality is important in that we are relying more on skin elasticity in the keyhole technique for a final fabulous aesthetic. Binding the breasts over a period of time can result in injury to the skin, which shows up as stretch marks or unusual blood vessels, that can compromise the ability of the skin to contract down and heal nicely. 
• The shape of the nipple areolar complex (NAC) in trans-male clients is adjusted to make it a more horizontal elliptical shape rather than the classically circular shape in a female breast. Sensation to the NAC is usually retained in a keyhole approach, but it may vary after the surgery.
• For a double-incision top surgery, a lot of skin and a much larger amount of breast tissue can be removed than with the keyhole approach. The first of the double incisions is made along the original infra-mammary fold (IMF) and angled upwards in a straighter line on the outer sides to replicate the appearance of developed pectoralis muscles. The second incision in the double incision is usually just above the original nipple position. From here, the skin and underlying fatty tissue, with or without some breast tissue depending on the thickness of the chest wall, is surgically developed as a "flap", and the remaining "excess" tissue removed. The two incisions are then sewn together. We try to avoid vertical scars but if your nipple areolar complex (NAC) is originally positioned high up on the chest wall, it may be necessary. A free nipple graft is placed, and a bolster tied to secure it. A drain is usually required, and we do recommend use of compressive garments such as a vest.
• If you are trying to keep nipple sensation, a modified approach can be done where the NAC remains attached to a "pedicle" of breast tissue. This can be a bulkier result than a classic double incision top surgery, and nipple sensation retention is not guaranteed.
• It is very important to avoid nicotine exposure as it can result in partial or complete loss of the nipple areolar complex as well as other problems with wound healing. 
• Cosmetic procedures, such as truncal liposuction, can be done to further augment your appearance. We can do lipo-sculpting on a case-by-case basis. If insurance is covering the top surgery, they may not permit doing a cosmetic procedure at the same time, in which case the liposuction can be done later. Please see the section on "Liposuction love handles & more" for more details on liposuction.

If you are unsure which procedure would be a good fit for you, you are welcome to come in for a consultation and we can discuss your options. Other services at Pulsar Health may also be helpful for you, such as lasers treatments, facials, or peels. Simply let us know what you are looking for, and we will do our best to help you.