Top surgery

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Illustration by Samuel Luke Art 

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 people, this is the only surgery undertaken.  

There’s no right or wrong way to be or embody your gender, regardless of your surgical status. 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 and resources to assist clinicians learn more about top surgery can be found on our page for clinicians. 

WPATH Standards of Care

The Standards of Care – 8th edition (SoC8) are published by the World Professional Association for Transgender Health (WPATH) and offers guidance to clinicians working with trans patients 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’.

In Australia, top surgeons may need a readiness referral from a mental health provider stating that you are able to consent, and that the intervention is right for you. Find out more about readiness referrals on this TransHub page. 

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. 

There are several kinds of surgical options, and the procedures chosen will depend on the surgeon’s expertise as well as your body and needs. 

Double-incision top surgery with nipple grafts 

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

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

Periareolar top surgery 

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

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

Keyhole top surgery 

This procedure is typically only recommended for people with very small chests and tight chest skin. No excess skin is removed during keyhole top surgery, so few people are good candidates. This procedure is typically an inpatient surgery that takes between 90 minutes 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 repositioned on the chest.

Inverted-T top surgery 

This procedure is similar to the 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, so 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 ink fades.

Recovery 

Many of us need to wait years before being able to undertake surgical interventions. It can sometimes feel that everything you’ve been doing in life has led to this very specific moment. That’s a lot of pressure, and it often comes with a hefty price — and not just a financial one. 

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Illustration by Samuel Luke Art 

Our families and friends may not get it, and it might be tough to get enough time off work to recover properly. Make sure you surround yourself with supportive peers and allies, and try to be gentle with yourself. Even if you sometimes doubt yourself, which is really normal, you will get through it. 

Hospital 

You may spend between one and seven nights in hospital. This often depends on whether you have private health insurance to cover the hospital stay. If not, you’ll typically be able to leave the hospital the day of or after the surgery. 

When you leave the hospital you will need to be signed out by a responsible person. They’ll need to be able to get you home or to the place you’ll be recovering. 

After your top surgery, your chest will be taped, and a surgical binder will be used to minimise swelling. Drains, which are small, thin tubes, may temporarily be placed to help drain any excess fluid or blood. 

Follow up care 

You will be required to wear a surgical binder for some weeks after surgery depending on the type of surgery undertaken, the size of your chest and how your body is recovering. You will be given specific instructions for how to care for the surgery site by your surgeon, including medications to apply topically or take orally to help with healing. You can expect a number of follow up appointments with your surgeon as you heal. This may include being aspirated by the surgeon to remove any excess fluid. 

Recovery from top surgery can take up to eight weeks. You’ll likely need to restrict movement as you heal. Keep the binder on and channel your inner T-Rex: try not to reach, push, pull, or carry anything heavier than two kilos for the first few weeks. This will improve recovery and reduce scarring. A good thing to consider is avoiding anything that might cause you to break a sweat.  

Rest, stay hydrated and take good care of yourself. It can be helpful to ask friends and other allies to check in —it’s ok to ask for extra help when you need it. Refer to peer networks or a mental health professional, as needed. 

Scars are worn like a badge of honour by some people, and others prefer minimal scarring. Using 100% silicone lube twice a day on the surgery site goes a long way in reducing scars and can be really beneficial in establishing a relationship with a new part of your body.  

Even if a surgical outcome is affirming, it can still be confronting. It is great to feel excited, but also very normal to feel overwhelmed or uncomfortable, to grieve, and to take time to become used to your body again. This isn’t an indication that you have made a mistake, or regret your decision, but a normal part of reconnecting with how your body appears and functions. Sensation will change over time, and you will learn this for yourself.  

Holistic body work such as lymphatic drainage massage can also be helpful after surgery. Gentle massage toward the direction of your armpits may be helpful. 

Top surgery recovery advice from community

We asked community members who have gone through top surgery if they have any tips. In their own words:

Clothing:

  • Wear button up shirts / jackets, or just hang out in the compression vest (lifting arms up to put on regular shirt is a no)
  • Wear tops that are easy to remove that don’t require you to lift your arms – so yeah, hoodies with a front zipper are great options. I pretty much lived in front-zip hoodies and loose fitting/comfy pants while recovering.
  • Wear slip-on shoes (I lived in slides)
  • Get a second compression vest if financially possible so they can be washed more regularly

Hygiene:

  • Get dry shampoo and baby wipes for no-shower days.
  • A shower stool can make showers more comfortable.
  • Use candles or room spray (even after a shower, healing tissue can be a bit on the smelly side).

Sleeping:

  • A wedge pillow was a life saver for me as I’m a back sleeper and laying fully down was painful
  • ALL the pillows. Sleeping on your back but slightly raised is often recommended especially in the first few weeks post top surgery, so I’d suggest propping yourself up on pillows so your upper body is a bit more elevated, plus having pillows on either side of the body/under each arm can help alleviate some discomfort too.

Meds:

  • Take pain meds early—don’t wait until it starts to hurt. It’s easier to keep pain under control than it is to treat it once it’s really hurting.
  • Using vitamin E oil for scar massages and eating oats to help skin regrowth.
  • Food & drinks
  • Doing a bunch of pre-surgery meal and snack prep and reorganising at home is going to really make things easier. Anything that you use regularly, move to an easy to reach level that won’t require raising your arms too high or bending down too much. This is especially important for anyone that isn’t going to have much help from other people while recovering.
  • Have prefilled water bottles.
  • Have juice boxes and candy if you’re feeling a bit faint and need a sugar hit
  • Have straws handy to help with drinking.

Mental health

  • I distracted myself in weeks ahead with cartoons (steven universe and adventure time) and distracting myself again after surgery and sleeping as much as humanly possible when the pain relief was working.
  • People can experience a bit of a mental health slump after having any kind of operation, since the body is depleted and expending a lot of energy to heal, which can make people feel extra vulnerable. It is really important to go as gently with yourself as possible, and have things in place post-surgery that help you feel more stable (time with friends, watching comfort shows etc.), with the understanding that the low mood isn’t a sign that you shouldn’t have had surgery, but rather a very common physiological response.

Other things:

  • A small pillow to put between the seatbelt and chest when travelling in a car.
  • Have someone stay with you to help you with daily activities if you can.

Costs 

Top surgery can cost between $4,000 and $18,000 out of pocket, depending on the technique and surgeon. 

It is possible to get a Medicare benefit for your anaesthetist, surgeon, surgical assistant, and pathology. In addition, some private health insurers cover your hospital stay, and a portion of surgeon, assistant, and anaesthetist fees. Ask your surgeon for the MBS Item Number they use (often 45240 x2, though sometimes 1519, 45451 x 2, or 31524 x2) and check in with Medicare or your insurer, if you have one. For more information about accessing compassionate release of superannuation, go to our superannuation page. 

Locations 

Top surgery is available in Australia. 

The Australian Professional Association for Trans Health (AusPATH) hosts a provider list of their members. It includes surgeons in Australia and is available here. 

Risks 

All surgeries carry some risk, including complications, infection, blood clots, and rarely death. It’s important to ask your surgeon about possible risks and how to avoid them. 

Under 18s 

While some surgeons in Australia will only perform top surgery for people aged 18 years and over, there are some surgeons who will perform top surgery for people who are 16 years and over. Parental consent, alongside the coordinated care of a multidisciplinary team (as available) is required for top surgery for anyone under 18 years old. 

If you are under 18, it is advised that you and your carer or guardian contact your preferred surgeons asking if they will perform the surgery now, and what their referral requirements area, or if they prefer to wait until you are over 18.  

For more information about your legal and medical rights while under 18, go to our Under 18s page. 

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