Top surgery (chest wall surgery)

What is top surgery?

Top surgery, also known as chest masculinisation surgery, FTM (female-to-male) top surgery, gender affirming mastectomy, or chest wall reconstruction, is a surgical procedure that removes breast tissue and reshapes the chest to create a flatter, firmer outlook. The aim is to reduce or eliminate the need for chest binding (flattening of the chest), improve comfort in clothing and support gender affirmation.

People may seek top surgery for several reasons, including:

• Gender dysphoria (a feeling of distress when their gender identity does not align with the sex they were assigned at birth) related to chest appearance
• Desire for a more masculine or non-feminine chest shape
• Physical discomfort from long-term chest binding
• Emotional or social distress linked to chest anatomy.

Top surgery is one of the most commonly performed gender affirming procedures worldwide and has been shown in research to significantly improve psychological wellbeing, body confidence and quality of life¹.

What are the different types of top surgery?

Your surgeon will recommend the most suitable technique based on your chest size, skin elasticity and personal goals.

Which type of top surgery is right for me?

Your surgeon will assess:

• Chest size and shape
• Skin elasticity
• Your goals for chest shape
• Your overall health
• Whether nipple grafting is appropriate.

Together, you’ll decide on the safest and most effective approach.

Who is suitable for top surgery?

Top surgery may be suitable for adults who:

• Have been assessed by a recognised Gender Identity Clinic (GIC) or gender specialist
• Experience gender dysphoria related to their chest
• Are in good general health and your weight is stable
• Understand the benefits, limitations and risks of surgery
• Have stable testosterone levels (if used).

Do I need a mental health assessment or letter?

Patients will need a surgical referral from a gender identity clinic (GIC), a gender specialist, or a qualified mental health professional confirming that top surgery is appropriate as part of their gender affirming care.

Do I need to be on hormone therapy?

No. Testosterone therapy is not required for top surgery, although some people choose to combine both as part of their transition.

What are the alternatives to top surgery?

Non-surgical options include:

• Chest binding
• Compression garments
• Targeted exercise to build pectoral muscles.

Surgical alternatives may include:

• Breast reduction

These may help in specific cases but do not achieve the same results as top surgery.

How can I prepare for top surgery?

To support a safe procedure and smooth recovery, your surgeon may advise you to:

• Maintain regular exercise and good fitness
• Stop smoking at least 6 weeks before surgery
• Avoid blood-thinning medications (e.g., aspirin) if advised
• Share any supplements, herbal remedies and weight management injections (e.g. Mounjaro) you take
• Optimise your diet with protein and vegetables
• Attend a pre-operative assessment to check your general health.

What happens on the day of surgery?

• You’ll meet your surgical and anaesthetic team, who will go through the plan and answer any final questions.
• Your surgeon will mark your chest to guide the procedure.
• You’ll be given a general anaesthetic, so you’ll be asleep throughout.
• The surgery typically takes 2 to 3 hours, depending on the technique.
• You’ll wake up in recovery wearing a compression binder to support healing.
• Pain is usually manageable with prescribed medication, and most people describe discomfort rather than severe pain.

What happens during top surgery?

Top surgery is tailored to each individual. Before your procedure, your surgeon will assess your chest size, skin elasticity and goals, and recommend the technique that will give you the safest and most natural-looking result.

Although the approach varies, top surgery usually aims to achieve two key outcomes:

1. Removal of all or most breast glandular tissue

The technique used depends on the amount of breast tissue and whether there is excess skin.

When there is no or minimal excess skin:

Surgeons remove the breast tissue through a hemi-areolar incision (a semi-circular cut along the lower edge of the areola).

• This approach leaves minimal scarring – usually a small curved scar under the areola and one or two 5 mm scars from the liposuction cannula.
• The final contour relies partly on the skin’s natural elasticity to shrink back to the chest wall.
• Skin tightening takes time, so although the chest will look flatter immediately, the final result may take several months to settle.

When excess skin needs to be removed:

If there is loose or excess skin, your surgeon may recommend one of two approaches:

i. Peri areolar technique
Suitable for small breasts with good skin elasticity.

• Excess skin is removed around the existing areola to tighten the chest skin.
• The areola is usually reduced in size.
• Scarring is limited to the areola border.

ii. Bilateral inframammary fold mastectomies with free nipple grafting (double incision)
This technique is used for moderate to large breasts.

• Incisions are made along the inframammary fold (the natural curvature forming the under section of the breast), following the lower border of the pectoralis major muscle (also known as “pecs” or chest muscles).
• Breast tissue and excess skin are removed.
• The wound is closed to create a straight line scar.
• The nipple areola complex is resized and repositioned as a free graft.

2. Resizing and repositioning the nipple areola complex

Most people choose to reduce the nipple areola complex to around 2–2.5 cm in diameter (roughly the size of a £1–£2 coin). This can be achieved in several ways:

i. As part of the peri-areolar technique:

• The nipple remains attached to its blood supply.
• This approach often preserves more sensation.

ii. Free nipple grafting:

• The nipple areola complex is removed and grafted into a new position on the chest wall.
• This is the most common method used during the double incision technique.
• If the nipple is large, the upper portion may occasionally necrose (die off), leaving a raw area that heals over several weeks.
• Once healed, the nipple is usually numb.

iii. Pedicled nipple technique:

• The nipple areola complex is left attached via a dermal “bridge” (pedicle), which maintains blood supply but usually not sensation.
• This can increase the chance of nipple survival but may leave extra bulk on the chest.
• Some patients may require a second procedure to reduce this bulk, so this method is used less frequently.

Important to note: The latter two techniques (free graft and pedicle) can reduce the areola diameter but cannot reduce nipple size. If nipple reduction is needed, it is usually safer to perform this as a small separate procedure under local anaesthetic. However, nipple height is often flattened during grafting, so additional reduction is rarely required.

How long does it take to recover after top surgery?

Most patients stay in the hospital for one night, though some may go home the same day, depending on the procedure and surgeon's preference.
Your first few days:

• You’ll go home wearing a compression binder, which helps reduce swelling and support the new chest contour.
• You’ll need someone to accompany you home.
• If you live far from the hospital, you may choose to stay locally for a night or two.

Driving and returning to daily life:

• Most people feel comfortable driving again after 4 weeks, once they can safely control the vehicle. Please make sure you check with your car insurance provider.
• Most people need 6 weeks off work, depending on your job. Your surgeon will be able to discuss with you the timeframe.
• You’ll have a follow-up appointment at 10 to 14 days, when wounds are usually healed.

Movement and activity:

• Sleeping on your side: Usually comfortable again after 2–3 weeks.
• Exercise and swimming: Light activity such as walking after 2 weeks; full exercise and swimming after 6 weeks.
• Compression vest: Your surgeon will advise how long to wear it, but many patients use it for several weeks.

Wound care and scarring:

• You’ll receive clear instructions for dressings and showering.
• Scars may remain pink for several months and mature over 12–18 months.
• Micropore taping, moisturising and gentle massage can help soften scars over time.

Important points to be aware of

• Changes in skin sensation are common – numbness or hypersensitivity usually improves gradually.
• Nipple shape and colour may change over time, and mild asymmetry is normal.
• Scarring varies by technique and individual healing.
• You will not be able to breastfeed after top surgery.
• Regret following top surgery is uncommon. However, as with any permanent surgical procedure, some patients may later experience regret or wish they had made a different decision.

Your surgeon will guide you on what to expect based on your specific procedure.

What are the risks and complications of top surgery?

Most people recover without complications, but all surgery carries some risk. These may include:

• Chest infection
• Bleeding
• Heart-related complications
• Stroke
• Deep vein thrombosis (DVT).

Top surgery specific risks include:

• Delayed wound healing
• Nipple tissue loss
• Asymmetry
• Reduced nipple sensation.

Your surgeon will discuss all risks with you during your consultation so you feel fully informed and comfortable to proceed.

How much does top surgery cost at Nuffield Health?

For pricing information, please contact your local hospital. The hospital or your healthcare team will give you a fixed all-inclusive price for the treatment following your initial consultation.

Sources:
1. https://pmc.ncbi.nlm.nih.gov/articles/PMC12333847/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC12133143/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC10066763/
4. https://www.researchgate.net/publication/350302671_Transgender_and_Gender-nonbinary_Patient_Satisfac...