Top surgery

This page provides a brief summary of a gender affirming top surgery and offers guidance to help you support your trans and gender diverse clients if they decide to undergo this surgical intervention. 

Reconstructive chest surgery, commonly referred to as ‘top surgery’ is typically sought by trans people who were presumed female at birth (PFAB), including trans men and non-binary people, to remove breast tissue and sculpt the chest into a typically ‘masculine’ pectoral form.  

While binding is an effective form of flattening chest tissue, it can cause pain and respiratory and skin complications when used inappropriately or over long periods of time. Top surgery can improve physical and psychological health and wellbeing outcomes for those who seek it. For many trans people, this is the only surgery undertaken.  

Not all trans people want, seek or can have surgery, and being trans doesn’t necessitate surgery either. Find out more about that on our ‘Am I trans enough?’ page. 

Information for community members about top surgery is available here. 

Standards of Care (SOC8)

The Standards of Care – 8th edition (SOC8) are published by the World Professional Association for Transgender Health (WPATH) and offer guidance to clinicians working with trans and gender diverse clients all over the world, including criteria and recommended referral pathways for those seeking particular medical and surgical interventions.  

The SOC8 do not specify an order by which surgeries should occur, if sought at all, and are guidelines, not legislated requirements.  

WPATH state that ‘the efficacy of top surgery has been demonstrated in multiple domains, including a consistent and direct increase in health-related quality of life, a significant decrease in gender dysphoria, and a consistent increase in satisfaction with body and appearance’.

Criteria for mastectomy and creation of a typically masculine chest in trans & gender diverse people: 

  1. Capacity to make a fully informed decision and to consent for treatment 
  2. Being assessed for risk factors associated with breast cancer prior to mastectomy
  3. Being informed about aftercare requirements, travel and accommodations, and the importance of postoperative follow-up
  4. Hormone therapy is not a prerequisite. 

What happens during top surgery

There are several kinds of surgical options, and the procedures chosen will depend on the surgeon’s expertise and the physical capacity and needs of the client. 

Double incision top surgery with nipple grafts

Also known as a bilateral subcutaneous mastectomy with nipple grafts, this procedure is typically recommended for trans and gender diverse people with larger chests and bodies. This procedure is usually an inpatient surgery that takes between three and four hours. 

In this procedure, the nipples are removed, typically decreased in size, and positioned on the chest for a typically more masculine appearance. This specific procedure often results in decreased nipple sensations and more significant scarring, which often fades over time. 

Periareolar top surgery

Also known as peri or circumareolar, this procedure is usually recommended for people with smaller chests and bodies. This procedure is usually an inpatient surgery that takes between three and five hours. 

Most are able to maintain most or all of their nipple sensations after recovery — though the large majority of people experience decreased nipple sensation in the days immediately after surgery. While periareolar top surgery provides less visible and less significant scarring, clients may require a revision to achieve a completely flat chest. 

Keyhole top surgery

This procedure is only recommended for clients with very small chests and tight chest skin. No excess skin is removed during keyhole top surgery, so few are good candidates. This procedure is typically an inpatient surgery that takes between one and three hours. 

This procedure results in very little visible scarring and preserves nipple sensation, but doesn’t provide the opportunity for the nipple to be re-positioned on the chest. 

Inverted-T top surgery

This procedure is similar to double-incision top surgery, but the nipple is reduced in size and re-positioned by doing an additional vertical incision from the bottom of the areola to the horizontal incision along the pectoral muscle. With this surgery, the nipple stalk and nerve are not severed and the nipple retains blood supply and sensation. 

No nipple top surgery

This procedure involves removing the entirety of the nipple and areola from the chest, followed by 3D tattooing of the nipple. Note that the tattoo may require touching up over time as the ink fades. 

Supporting your trans patient through surgery

Before surgery

At appointments in the lead up to surgery, your client might like to discuss their expectations and concerns, as well as their hopes and fears. It will be important to have an open conversation about what surgery can and cannot do. They may have been waiting many years for this particular surgery and feel that they have a lot riding on it. They may not be part of a supportive network or could be the centre of a thriving friendship circle. They might be clear about what they need from you, or really unsure.  

Although the SOC8 don’t mention it in their guidelines, some surgeons request that their clients be referred to a mental health professional for assessment to confirm readiness for surgery. 

Finding comprehensive, evidence-based information about gender affirming surgical processes can be a challenge, and so your client might benefit from your additional research, including contacting a specific surgeon, if requested, or connecting with other health professionals to better understand and explain the process, possible complications, risk factors and outcomes.  

It’s also likely that a person’s GP will be the first point of contact for any post-surgical care and complications, so having a sense of what might be happening, and being able to engage with additional clinician peer networks could prove advantageous.  

Surgery location 

If your patient is contemplating surgery in Australia, it is prudent to encourage them to obtain private health insurance when and if they can afford it. This will help cover some of the costs such as the hospital stay. Their surgeon will be able to provide the applicable MBS Item Numbers that can be checked with the health insurer.  

If a patient is considering having surgery overseas, they will very likely appreciate a discussion about the benefits and risks of travelling overseas for surgery. This can be complex, especially if the surgery they’re seeking is not performed, or widely available, in Australia.  

For some people, benefits can include cost saving, particularly if they’re not able to access private health insurance or Medicare in Australia, having greater choice of surgeons and being connected to a global community of trans people (we do a great job of offering comprehensive surgical reviews to the community).  

Risks tend to arise from a lack of access to post-surgical care, including being able to effectively, and efficiently treat complications. Additional complications can arise if the person is not able to take the requisite time off work or study and inadvertently damages the surgical site.  

Around surgery

Around the point of surgery, the surgeon and their staff will typically be supporting the patient through any fears and complications. 

Some surgeons require trans and gender diverse people to decrease hormones, particularly oestrogen, for a period of time in the lead up to, and immediately following, surgery. Your patient may want to discuss timeframes, expectations, and potential side effects from this.  

After surgery

Your patient will be required to wear a surgical binder for many weeks after surgery, depending on the type of surgery undertaken, the size of their chest and how their body is recovering. Many patients require additional aspiration to reduce fluid build up, and this is managed by the surgeon. Recovery from top surgery can take up to eight weeks. As well as providing regular post-surgical care for your patient, you might find yourself supporting them through learning how their body now functions and feels.  

Even if a surgical outcome is affirming for people, it can still require some getting used to. Discuss with your client that it is normal to feel excited, but also very valid to feel overwhelmed or uncomfortable, to grieve, and to take time to become used to their body again. This isn’t an indication that they have made a mistake, or regret their decision, but a normal part of reconnecting with how their body appears and functions. 

It can also be valuable to discuss how sensation may change, and what this might feel like. Having an honest conversation about how your patient will need to learn this for themselves over time can be helpful too. Refer to peer networks or a mental health professional, as needed. 

Some patients will find accessing physiotherapy, including receiving lymphatic drainage massage, a valuable part of surgery aftercare and comfort, and can be referred to an affirming physiotherapist.  

Others may seek scar treatments while others consider their scars a source of great pride.  

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