Female-to-Male (FTM) and Female-to-Nonbinary (FTN) top surgery is not a one size fits all approach. That is, there isn’t just one way that it is done no matter one’s preferences or anatomy.
Instead, there effectively are countless possibilities that can be considered and implemented in the planning and performance of FTM and FTN top surgery. This means that when undergoing this gender affirming surgery, the procedure can be highly customizable to meet your desires, needs and anatomy.
Procedure Choices for FTM and FTN Top Surgery
There are several distinct approaches available to address the dysphoria related to the breasts. Which procedure would be best for you would be determined by both you gender identity determinants, other preferences and your anatomy.
Do you want a flat chest?
Are you gender fluid or androgynous and want very small breasts as opposed to a flat chest?
Based on the above as well as your anatomy, you may have one or more procedure choices to select from. Of course, your plastic surgeon’s preferences will also affect this.
The available options for FTM and FTN top surgery are the:
- Double Incision Free Nipple Graft Mastectomy (photos A – D)
- Double Incision without Nipples Mastectomy (photos E and F)
- Concentric Circle/Peri-areola Mastectomy (photos G and H)
- Keyhole Mastectomy
- Inverted “T” Mastectomy
- Androgynous Breast Reduction
A.) FTM Double incision – before
B.) FTM Double incision – after
C.) FTN Double incision – before
D.) FTN after – larger areolas
E.) FTN Double incision without nipples – before
F.) FTN Double incision without nipples – after
G.) FTM Concentric circle – before
H.) FTM Concentric circle – after
For in depth information on these procedures, refer here.
Procedure Incision Design
Incision shape and design is flexible with the double incision mastectomy – with or without the nipple areola complexes. It can be curvilinear, more curved and elongated, straighter or straight. The option to have a straight incision is largely determined by your anatomy and specifically, your breast size. Sizable breasts will remove this as an option.
For individuals with a higher body mass index (BMI) and lateral chest wall rolls (skin and fat rolls on the sides of the chest, often extending to the back), the incisions need to be modified to take into account this contour issue. However, there still is some flexibility of the incision design.
The incisions for the keyhole and concentric circle approaches are fixed – being determined by your areolas. For the keyhole, the incision follows the border of the lower half of the areola whereas for the concentric circle it goes around the entire areola.
Nipple-Areola Complex Options
There are several general options related to the nipple-areola-complex issues in gender affirming top surgery to consider. Some of these have, in essence, unlimited permutations. However, this applies almost exclusively to the free nipple graft approaches.
These category choices include:
- Preserving the nipple-areola-complex versus no nipple-areola-complex
- Areola Size
- Areola shape
- Location of the nipple-areola- complex
- Nipple projection
Nipple versus No Nipple
In gender affirming top surgery, the majority of individuals pursing this procedure do want to have their nipples placed back on. However, there are many who do not want them at all. This latter choice is a more common on selected by gender nonbinary individuals as opposed to those who are transmasculine (photos E and F).
There is no right answer for this.
You do you!
Whatever feels and works best for you and your situation – do.
Areola Size
The areola size can be completely customized to fulfill your preferences. Do you want them masculinized in size (smaller), remain feminine appearing (larger) or somewhere between male and female in size (photos C and D).
What constitutes each is somewhat subjective and there is definitely significant overlap in these categories. Pick which category meets what you are seeking best.
Areola Shape
Do you want more round areolas or ones that are more elliptical in shape? This choice is more relevant to those seeking a more masculinized appearing chest but is appropriate for both FTM and FTN top surgery.
Location of the Nipple-Areola Complex
The nipples can be placed in a more masculine location (more lateral and lower), a typically female position or somewhere in between these – which leave a lot of latitude for location.
Nipple Projection
The projection of the nipple may be able to be reduced depending on certain factors. This can apply to all top surgery procedures where a nipple is present.
Lateral Chest Wall Rolls
Rolls of skin and fat are commonly present in individuals who are overweight and have a higher BMI. These extend from the breasts posteriorly along the chest wall laterally and may continue onto the back.
These rolls are not part of the breasts or an intrinsic part of the top surgery procedure in general. However, the incisions for the double incision approach and breast reduction can be modified in order to create a smoother, more natural interface extending from the breast to these fat rolls.
In a perfect world, you do not want to have these lateral chest wall rolls as they will detract from the overall body contour and harmony. If they are present, you do have options to consider as related to them. These include:
- Lose weight beforehand
- Do lateral chest wall lipectomy
- Don’t do lateral chest wall lipectomy
Losing weight can reduce the size of these chest wall rolls. In some situations, they actually may disappear with weight loss though this is not very common.
You can also choose to have these chest wall rolls surgically addressed – either at the same time as the top surgery or sometime later on. If you have a relatively high BMI and are planning to lose weight, it often makes more sense to have this procedure done later after losing the desired amount of weight as you will have a far superior long term result.
Of course, you can always decide that you don’t want to address these rolls of your chest. This can be for several reasons including financial or that they don’t bother you.
Pursuing Your Top Surgery
You have plenty of options to select from when seeking the chest that you want from gender affirming top surgery. Tailor it to your needs and goals.
Make it uniquely yours!
We can help you customize the chest that you are seeking. To schedule your consultation for gender affirming top surgery, you can either call us at the Arizona Center for Aesthetic Plastic Surgery at (480) 451-3000 or contact us by email.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
