Gynecomastia surgery, also known as male breast reduction, is a procedure that removes breast tissue to create a flatter chest. For transgender men (FTM) who are assigned female at birth, FTM top surgery is a type of chest masculinization surgery that can involve breast tissue removal, reshaping nipples and contouring the chest to create a more masculine chest.

Who may benefit from top surgery?

Transgender and nonbinary people may choose top surgery as part of their gender affirmation treatment. Top surgery can be part of a person’s affirmation surgery plan to address gender dysphoria, which occurs when gender identity does not correspond to sex assigned at birth.

Gender affirmation surgery, including chest masculinization or chest feminization procedures, can improve well-being in patients who:

• Have ongoing and documented gender dysphoria.
• Have the legal and mental ability to make responsible medical decisions for themselves.
• Are successfully addressing other mental and physical health concerns.

Chest masculinization surgery

To give you a flatter chest, breast tissue will need to be removed. We might also need to move and shrink your areolas. Here are some key points to consider with regards to the procedure:

• Breast tissue removal: This can be done with a double incision mastectomy, which involves making two horizontal incisions across the chest, or with keyhole top surgery, which involves making a small incision along the areola. The amount of tissue removed depends on the size of the breasts.
• Nipple and areola repositioning: The nipples and areolas can be moved and reshaped to create a more masculine appearance.
• Liposuction: For smaller breasts, liposuction can be used to remove fat without making many incisions. 

The best surgical approach for FTM top surgery depends on factors like breast size, skin elasticity, and body type. Before surgery, you should discuss the procedure with your surgeon and follow your healthcare team’s instructions, which may include changing medications, stopping nicotine use, and making dietary changes. You should also give informed consent, as masculinizing surgery can cause physical changes that are not reversible. 

Dr. Ishoo often performs chest masculinization surgery on patients who are young, have small to medium size breast tissue with minimal skin excess and good skin quality. Dr. Ishoo will make a tiny nick in the armpits that allows liposuction to remove fat. He will then make a cut along the lower half of the areola and extract breast tissue through this opening. Afterwards, he’ll suture the area to tighten your skin around your areolas The areola and nipple may be made slightly smaller before closing the incision. This is the Keyhole Top Surgery for Chest Masculinization (Periareolar)

Pros

• The surgery leaves a less obvious scar along the border of the areola (the area of darker skin around the nipple)
• The procedure results in a very flat chest contour

Cons

• Drains are placed after surgery.
• You may experience diminished or absent nipple sensation.
• Inability for surgeon to reposition nipples or reduce the size of the areolas significantly.

What to Expect from Recovery

You’ll need someone to stay with you that first night in case you need assistance. In fact, we recommend you have someone with you for a day or two. For the first couple of days you will rest most of the time, so having someone prepare a meal or two, take care of pets, and perform small tasks is a big help.

For a few weeks post-op, there will be some swelling and bruising. You can help keep these at bay by maintaining a low heart rate and blood pressure. You will probably experience light to moderate discomfort at first. Most people use prescription medication for a day or two, then switch to OTC pain relievers.

After a few days of rest, you can resume light activity at home. You should plan to be away from work for at least a week. If you have a strenuous job, you will want to take a little more time off. And activities such as lifting weight or aerobic exercise should wait a few weeks.

Your new shape will emerge over time. You’ll notice some change right away, but swelling takes a while to disappear completely and your skin will also need some time to fully tighten. Do not feel discouraged if you don’t see the ultimate sleeker appearance you have been anticipating for a few weeks. If you are waiting to determine whether you might need additional skin reduction, you’ll need to be patient for a few months. Similarly, scars continue to fade for several months.

During the post-op period, you will see Dr. Ishoo a few times so he can check your progress. You and he can determine if any further measures would be beneficial. For instance, if a scar looks prominent to you, a simple injection can often help smooth it out.

Top Surgery Risks

Any surgery carries the possibility of complications. Most of them are familiar to you. Among the most common are infection, hematoma (blood buildup), seroma (fluid buildup), and excess swelling. Blood clots and tissue loss rarely occur. The majority of complications resolve themselves or are easily treated.

Specific Risks of FTM Top Surgery

• Adverse scarring: The periareolar procedure leaves minimal visible scars along the lower curve of the areolas that fade over time and become thin, light lines. The scarring process is inherently unpredictable, however, and it’s possible you could end up with scars that are bumpy or wider than expected. If so, they can be treated with injections or minor surgical repair if desired.
• Loss of sensation: Most nerve endings generally reattach during the healing process. Some patients find sensation is permanently diminished, either in spots or in a more widespread manner. The more extensive your incisions, the higher the risk.
• Regret: Patients undergoing female to male surgery occasionally ask what will happen if they regret the decision to have a breast reduction. While it’s theoretically possible to use breast implants to rebuild a chest, just as it is for women who undergo mastectomy for cancer treatment, you should consider FTM top surgery to be permanent. Results from a revision procedure would never give you the look you had prior to surgery.

Can my breasts grow back?

Finally, let’s tackle this one big myth—the idea that, for masculinizing or FTM top surgery, your breasts will grow back, especially if you go off or don’t take testosterone. It’s simply not true.

Whether you get a periareolar or double incision mastectomy, your surgeon is removing up to 95% of your breast tissue. Assuming your body has finished maturing by the time you have surgery, you’re not going to experience any more breast growth because 1) your breasts were already done growing and 2) most of that tissue is gone now. If you’re a younger patient, you should consult with your surgeon about any possible breast development that may not have happened yet, but in general, any change is likely to be minimal at best.

What can happen is that if you gain weight any time after surgery, you may develop some fat in your chest. If you’re not on testosterone, it’s possible that your fat distribution could favor your chest. While this might make your chest appear slightly larger, you’re not going to re-develop full breasts. 

At the Boston Gynecomastia Specialists, we are here to help get you going in the right direction. Schedule an individualized in-person consultation today to meet with our doctors.