Medically reviewed by Tuan A. Tran, M.D., M.B.A., F.A.C.S. | Written by Nhuhao Do on May 26th, 2021
The chest is one of the most obvious characteristics differentiating female from male. Not having the gender characteristics matching with one’s gender identity can be stressful and suppressing. For transgender and intersex people choosing to pursue gender confirmation surgery, chest reconstruction is the most popular and often the first gender affirming procedure they elect.
Transmen (female-to-male) and female to non-binary may elect to have a subcutaneous mastectomy to remove their natural breast tissue to achieve the firm and masculine chest they desired. Transwomen (male-to-female) may undergo a breast augmentation to enhance the size, shape and fullness of their breasts to achieve a more feminine figure.
Before the surgery
A good candidate for chest reconstruction is a healthy adult with realistic expectations of what the procedure can help them achieve along with the understanding of potential risks. Before proceeding with your surgery, your surgeon will go over an informed consent with you; you will be asked to provide a psychiatric evaluation; and other medical screening including, blood tests and electrocardiogram (EKG).
Leading up to your surgery, if you are taking hormone replacement therapy (HRT), you will be required to stop it for two weeks before surgery, and refrain for another two weeks after surgery. Be sure to discuss in detail with Dr. Tran about the any medications that you take regularly and any recreational drugs you may use. He will advise whether or not you will need to stop taking any of those medications before your surgery.
Procedure in Detail
Chest reconstruction in gender confirmation surgery is distinguished by two main categories, male-to-female and female-to-male.
For assigned male at birth (AMAB), chest reconstruction involves breast augmentation that is similar to the procedure for female looking to enhance their breast size, shape or volume. You can choose from various types and sizes of saline or silicone implants to best fit your body frame and achieve your desired results.
Implants are place either over (sub-glandular placement) or under (sub-muscular placement) the chest wall muscle. Placing the implant under the muscle can create a more natural look for those with minimal breast tissue. However, this method may require a longer recover period and higher pain tolerant.
In some cases, tissue expanders may be placed under the breast tissue for months prior to placing permanent implants to ensure the most optimal results. Other techniques such as fat transferring can also be done to achieve the best aesthetic outcome.
Dr. Tran will discuss with you in detail to determine the best method to your breast augmentation.
Fig. 1. Before and after results of breast augmentation with silicone implants performed by Dr. Tran on AMAB patient.
Top surgery for female-to-male or female to non-binary involves more than a mastectomy for the treatment of breast cancer. Subcutaneous mastectomy involves special techniques to contour and reduce the chest wall, as well as grafting the nipples and areola.
If your breast size is small, you might be able to have a subcutaneous nipple-sparing mastectomy. Where the incisions are made around the borders of the areolae. Breast tissue and excess skin are removed through the incisions. The remaining skin is the reattached at the border of the areola. This procedure can minimize scarring, reduce healing time and preserve sensation in the nipples.
If your breast size is larger, your surgeon might remove the nipples and areolas to resize and graft them back into position after moving the breast tissues and any excess skin. This causes more scarring and loss of sensation to the nipple. Non-erotic sensation typically returns in months to years.
If you know you have an increased risk for breast cancer, you might also choose to have your nipples and areolas completely removed and subsequent surgery or 3-D tattooing to recreate the appearance the nipples and areolas.
Fig. 2. Before and 3 weeks after subcutaneous mastectomy performed by Dr. Tran on female-to-male patient.
Healing time for chest reconstruction is varied in each patient and varied with the invasiveness of each procedure. An overview of recovery period for each procedure can be examined bellow. However, it is best to discuss with Dr. Tran and his team for more personal recommendation and in-depth post-op instructions.
Soreness and swelling are expected after surgery and for the next few weeks following. You will have two drains placed where your breasts were removed to drain any fluids that accumulate after surgery. It is important to keep a record of your drainage and present it to Dr. Tran at your post-operative appointment in 5-7 days after your surgery. At which point, he will remove the drain tubes. You will wear a compression bra for three weeks. To prevent the breast implants from displacing, limit upper body exercise and avoid lifting more than 10-15 lbs for at least 4 weeks after your surgery.
After surgery, your chest will remain in a compression wrap for several weeks. You will have two drains placed where your breasts were removed to drain any fluids that accumulate after surgery. It is important to keep a record of your drainage and present it to Dr. Tran at your post-operative appointment in 5-7 days after your surgery. At which point, he will remove the drain tubes. Avoid lifting more than 10-15 lbs for at least 4 weeks.
Top surgery can play an important role in relieving gender dysphoria for transgender men and women to significantly improve their quality of life.
Cost and Consultation
Many major medical insurances in California, including CalOptima, cover for chest reconstruction as part of gender confirmation surgery. If you have more questions or would like to schedule a free consultation with Dr. Tran, please contact us via our website, Tran Plastic mobile app or call us today at 714-839-8000.
Mayo Clinic Staff. (2019, October 4). Top surgery for transgender women. Mayo Clinic. Retrieved from https://www.mayoclinic.org/tests-procedures/top-surgery-for-transgender-women/about/pac-20470693
Mayo Clinic Staff. (2019, September 27). Top surgery for transgender men. Mayo Clinic. Retrieved from https://www.mayoclinic.org/tests-procedures/top-surgery-for-transgender-men/about/pac-20469462#:~:text=Top%20surgery%20for%20transgender%20men%20is%20a%20surgical%20procedure%20to,nipple%2Dsparing%20subcutaneous%20mastectomy).