Mastectomy, or removal of the breastsRemoving and resizing the nipples and areolae, as male nipples are usually smallerReplacing the nipples in a more masculine location, towards the outer edges of the chestContouring of the chest wall

Not all top surgery patients will need all procedure elements described above. Plastic surgeons use different approaches and techniques for top surgery, and different people have different body shapes and contouring concerns.

However, it is important to be clear that top surgery is not an elective surgery. Top surgery is a medically necessary procedure for individuals who experience gender dysphoria related to their chest.

The sole indication for top surgery is gender dysphoria. This is generally coded as an F64.* diagnosis. Gender dysphoria is when a person experiences psychological distress because their body does not reflect their internal sense of themselves.

In this article, we are solely discussing top surgery for transmasculine individuals, not transfeminine breast augmentation.

Top surgery is appropriate for individuals assigned female at birth who have a non-binary or male gender identity and experience dysphoria related to the size and/or shape of their chest.

Criteria

Access to top surgery is generally regulated by the World Professional Association of Transgender Health’s Standards of Care (WPATH). These standards are followed by most insurance companies to determine coverage. In general, for someone to access top surgery, they are expected to meet the following criteria:

Diagnosis of gender dysphoriaCapacity to make a fully informed decision and to consent for treatmentIf significant medical or mental health concerns are present, they must be reasonably well controlled.

One referral is needed for masculinizing chest surgery per WPATH. It is usually to confirm the diagnosis of gender dysphoria so it is often from a mental health provider or can be from the PCP or doctor providing hormones.

The letter requirement for top surgery is considered to be a form of gatekeeping by many individuals in the transgender community, as similar letters are not required for similar surgeries among cisgender individuals.

This may indeed be the case, but they also provide documentation of the requirements for surgery, which may not be easily measurable by a consulting surgeon.

Tests and Labs

In general, there are no specific tests or labs required for top surgery. However, some surgeons may require a cotinine test for individuals who have a history of nicotine use. This is because top surgery involves a free-flap transfer (removing and replacing the nipples), and nicotine in the system can compromise blood flow and make complications more likely.

In contrast, for gender affirming chest reconstruction, the documentation is around gender dysphoria, rather than any physical characteristics or discomfort.

Different surgeons have different requirements around when individuals have to stop using nicotine prior to surgery and for how long they have to stay nicotine free after surgery.

Individuals with other health conditions may require clearance related to those specific conditions prior to surgery. Your top surgeon may ask you to get a note from any specialists who you see on a regular basis in order to clear you for surgery. You may also be asked to see a specialist, such as a cardiologist, if you have a history of certain medical problems but no ongoing care.

A Word From Verywell

Top surgery is a medically necessary procedure to address gender dysphoria in transmasculine people. It has been shown to have substantial benefits for health and wellbeing. Although not all transmasculine individuals are interested in top surgery, those who want it can experience significant benefits.

As scar appearance can be linked to patient satisfaction with top surgery, many surgeons are particularly cautious around the timing of this procedure.

If you take any systemic acne medication it is important to discuss this with your surgeon prior to scheduling your procedure. It is also good to discuss your use of any topical medications for acne on your chest. You should also let your surgeon know if you use other products for chest rashes or skin breakdown.

The major expected downsides of top surgery are loss of nipple sensation and inability to chest feed (breastfeed) should a person become pregnant. (Although there are reports of individuals able to chest feed after certain types of top surgery, this ability should not be assumed.)

There are some transmasculine individuals who think of top surgery not as a way to get rid of gender dysphoria but to increase gender euphoria. Gender euphoria is the idea of being excited and happy that the body you are in reflects your gender identity.

Some people see gender euphoria as a less pathologizing framework than gender dysphoria for looking at gender surgeries and other forms of gender affirmation. However, realistically, gender euphoria and gender dysphoria describe different experiences and either or both may feel more relevant to any given individual.