TOP SURGERY

Transmen with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.

By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola needs not to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.

For transmen with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return.

Men with transsexualism require the surgical procedure of ‘male chest reconstruction’. This is not the same as a mastectomy.

Mastectomy is a medical term used to describe the excision of skin, nipples, breast tissue, fat, and muscle in cancer patients. A total removal of the nipples, underlying muscle and fat is a radical mastectomy. A mastectomy by itself usually results in a concave appearance, no nipples and more obtrusive scars. Removal of breast tissue, even in men who develop breast cancer, does not result in a masculine shaped chest.

A male chest reconstruction will result with incisions and reconstruction intended to result in a contoured, male looking chest. The operation usually takes 3 to 4 hours and requires a general anaesthetic. Excess skin and mammary glands are removed through incisions in the chest. Fat is also removed, leaving the right amounts in the right places for a male appearing chest.

Depending on the size and shape of your chest, your surgeon might also remove the nipples. They are sometimes sutured (sewn) back on individually. Drains are placed on either side of the chest and left in place for several days to a week to drain excess fluid from the surgical site. The sutures (stitches) are removed about a week after your surgery.

Usually you'll need to wear a binder for a time after the surgery to keep fluid from collecting under the skin. This post-surgical compression also assists the skin to adhere to the new position against your chest wall. It will take your body 3-4 weeks or more to recover from the anaesthetic as well as the surgery itself.
Your surgeon will usually advise you to not lift anything or work out for a number of weeks after the surgery. Ask your surgeon for advice when you can get back to your normal lifting or working out. Scarring usually looks the worst at about six weeks due to the formation of scar tissue. Scars are often itchy, due to healing. From six weeks to six months, the scars gradually flatten and pale.

Your surgeon may need to make further modifications. Sometimes there are 'dog ears' (excess skin at the end of the incision), or one side of your chest may appear to have slightly more remaining tissue than the other side. The majority of undergo at least one revision (sometimes more).

It can take up to 9-12 months for the surgical results to settle down before you can really tell how things will look for the rest of your life. This all depends on your age and general state of health.

TYPES OF TOP SURGERY

NOTE ON SMOKING –
Smoking can significantly affect the outcome of your surgery. Smoking reduces the amount of oxygen available to the cells for healing.
Smoking shrinks small blood vessels (vasoconstriction), which then reduces the amount of red blood cells (haemoglobin) available to your body and interferes with the release of oxygen (fuel your cells need) to your cells.
The use of nicotine gum and patches interferes with healing in the same way as nicotine in cigarettes.
Smoking reduces the ability of your heart and lungs to recover quickly from the effects of surgery and it causes a further narrowing of blood vessels which can cause a decrease or obstruction in the blood supply (ischemia) of the tissue, poor healing, bad scars, or actual loss of tissue.

QUESTIONS TO ASK YOUR SURGEON –
Ask questions about scars, pleating, skin thickness, skin elasticity, and final shape. Look for fine detail work in the suturing at the areola.
Look for consistency and some kind of artistry or pride in the work.

BOOST YOUR OUTCOMES –
Aim to be as fit and healthy as you can leading up to surgery.
Quit smoking.
Work-out before your surgery. Getting your chest as developed as possible will help your surgeon. It makes it easier for your surgeon with contouring, nipple placement, and scar placement.
Plan to rest at least four to five months after surgery, before you return to working out, lifting weights or hard physical exercise.