Gender-Confirming Top Surgery

In the realm of gender-affirming healthcare, chest reconstruction surgery, often called top surgery, offers a path to greater comfort and self-expression for many individuals. This can include transgender and non-binary people seeking a chest that aligns with their identity, but it can also extend to others who experience discomfort or dysphoria with their chest.

Gender-Confirming Top Surgery

FTM top surgery and MTF top surgery offer distinct pathways for achieving chest alignment with gender identity. FTM top surgery prioritizes creating a flat, masculine appearance. Surgeons achieve this by removing breast tissue and reshaping the chest wall. In contrast, MTF top surgery focuses on building a more feminine chest shape and size. This is usually done through implant placement or fat grafting techniques. While the procedures differ, they both share the potential to significantly improve a person’s comfort and confidence in their own body.

There are two main categories:

Gender Confirming Top Surgery

What Our Clients Think

Frequently Asked Questions

How do I know which type of breast augmentation I should have? (MTF)

Hormone therapy is the first option for breast augmentation, and it will add some volume to the breasts, but probably not enough to achieve the feminine shape and contour you seek. Breast augmentation with Dr. Reuben& Dr. Moores can follow two paths: direct augmentation with implants, or augmentation broken into two stages.

Direct augmentation is performed on an outpatient basis and it generally takes about one hour. The surgeon makes an incision either around the areola, or at the location of the future lower breast crease for larger implants. He then forms a pocket in the breast tissue, usually behind the pectoral muscle, to hold the implant. The implant is inserted on one breast and then the other. The surgeon checks symmetry and position, and he closes the incisions.

If hormone therapy did not result in enough breast development to adequately hold the implants, the surgeon will have to perform a two-step augmentation. First, he places what are called tissue expanders into pockets he forms in the breast tissue. These expanders are placed where your implants will eventually be. These expanders are then gradually filled with saline solution. Over time the amount of saline is increased to enlarge the expander. This continues to stretch the skin and support tissues to create space for the implants. When the stretching is complete, the expanders are removed, and then replaces them with breast implants.

Should I have saline or silicone implants? (MTF)

Implants are all made with a silicone shell. They are filled with either sterile saline solution or silicone gel. Today’s silicone is much more cohesive than in the past, meaning it tends to adhere to itself and stay within the shell, even if the shell develops a leak or ruptures. Silicone feels more natural. The thickest form of silicone is known as highly cohesive, and this is used for “gummy bear” implants, which don’t leak any silicone even if cut in half.

Saline implants have a more fluid feel. They can be placed through smaller incisions, as they are filled once placed into the breast pocket. Saline implants placed atop the pectoral muscle have a chance of rippling, which can be seen on the outer breast skin. If a saline implant ruptures, the body simply absorbs the saltwater, but the implant shell will still need to be removed and replaced.

What factors can affect the appearance of my breasts? (MTF)

As mentioned above, you’ll need to decide between silicone and saline implants. Saline can sometimes ripple or even show the implant edge if the implants aren’t covered with enough tissue. This isn’t generally a problem with silicone implants.

You’ll need to consider the projection or profile of your implants. High profile implants have more projection from a smaller base than a low or medium profile implant. Dr. Reuben will work with you so you can see how different profile types look on your chest.

You’ll need to decide if you want Dr. Reuben to place the implants above or beneath the pectoral muscle. Submuscular placement provides more coverage for the implants and creates a gentler slope, which may appear more natural.

Can I get MTF breast augmentation if I have never been on estrogen?

While it is not mandatory to have estrogen prior to this surgery, Dr. Reuben usually recommends patients be on feminizing hormone therapy for at least one year prior to having surgery. This will maximize your results because the estrogen will trigger your breasts and nipples to grow on their own prior to adding the volume of the implants. It’s recommended to allow a full 18 months for your breasts to develop fully through the hormones.

What are the risks involved with MTF breast augmentation?

These are relatively low risk procedures with Dr. Reuben, but there are potential complications:

  • Capsular contracture — Scar tissue forms around all implants, but in some cases, it continues to grow beyond the norm. This begins to squeeze the implant and causes pain in the breast. When this happens, surgery is necessary to replace the implant and remove the “capsule” of excess scar tissue.
  • Implant rupture
  • Asymmetry between the breasts
  • Breast pain
  • Changes in breast and nipple sensation

Do I need to be on testosterone to get FTM top surgery?

It is not required to be on testosterone to have FTM top surgery. Although if you are seeking to get insurance coverage, you will need to have one year of hormone therapy prior to this surgery.

One benefit of being on testosterone prior to surgery is that it will help you develop larger chest muscles, which will give Dr. Reuben more contour to work with, and this can improve the aesthetic results of your surgery.

Am I a candidate for FTM top surgery?

Our surgeons follow the World Professional Association for Transgender Health (WPATH) Standards of Care for FTM top surgery. This is the criteria set by the WPATH:

  • Persistent, well-documented gender dysphoria
  • Capacity to make a fully informed decision and to consent for treatment
  • Be of the age of majority in the country of surgery
  • Significant medical or health concerns, if present, must be reasonable well controlled at the time of surgery

What are the risks associated with FTM top surgery?

This is major surgery, and it carries the risks inherent in all surgeries: reaction to anesthesia, infection, poor incision healing, and the like. Specific to FTM top surgery, these are the specific complications:

  • Reduced nipple sensation
  • Potential loss of nipple graft (if it was necessary)
  • Excessive scarring
  • Need for revision surgery (usually due to “dog ears” or issues with nipple symmetry or appearance)

What is recovery like after FTM top surgery?

These are outpatient procedures. When you return home, your chest will be wrapped in Ace bandages initially. You’ll be able to remove these in a few days and you’ll then need to switch to compression garments, sometimes called binders. These play an important role in healing, as they limit the swelling and bruising. Plus, they hold the surgical areas firmly in place, supporting the intended chest contours. These will be worn for up to 6 weeks after your surgery, but your doctor will discuss this timeline with you.

These are not overly painful recoveries. You’ll have prescription pain medication, but many patients feel over-the-counter options handle the discomfort. If you have a desk job, you’ll be able to return to work in 1-2 weeks. If you have a physically demanding job, you’ll need probably 4-6 weeks off.

As for exercise, you can return to light activity such as walking almost immediately. Strenuous exercise, particularly anything involving the chest, will need to wait for probably at least 8 weeks. Weightlifters need to be cautious about heavy chest workouts — avoiding them for 3 months — so not to stretch your incision scars.

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