Transgender choices – Top surgery (F to M)

Posted on September 28, 2020

By: Dr. Asaf Yalif

When our Atlanta transgender patients come to our offices in Atlanta or Alpharetta for consultation on their transition choices we try to have a frank discussion about their options and how to maneuver them to achieve their desired gender aesthetic. In today’s blog we will discuss options for female to male transition. In a future blog we will address bottom surgery for both male to female and female to male. Recently we discussed top surgery for male to female. You can see that blog here.

For masculinization of the chest there are really only variations of one operation. All of them involve removing the breast tissue and extra skin present and creating a more masculine contour. In addition there are 2 options on how to handle the nipple areolar complex.

Mastectomy..? –

Removal of all the breast tissue is a mastectomy. This enables us to leave skin and subcutaneous tissues while removing the breast tissue from the chest. At the same time we remove the excess skin from the chest and can downsize the areola to be more masculine. There are options for incision placement. Classically a mastectomy will be performed through an incision on the face of the chest, and the areola can be located in the middle of it. We also have the option of using an infra-mammary fold incision to remove the breast and the excess skin. This is chosen a bit more frequently as the resultant scar rests where the pectoralis major muscle inserts into the ribs and where one expects to see a shadow on a male contoured chest. That being said, either incision is reasonable to remove the extra skin and breast.

The areola is oftentimes larger than one would like for a male contoured chest. We have the ability to make the areola smaller – usually around 18-22cm by measuring and downsizing the resultant nipple areolar complex. We also have 2 options for blood flow to the nipple and areola. We can remove the nipple and areola and then place it back on the chest as a free nipple graft, or we can retain some blood flow to the nipple with a pedicle (random blood supply). Free nipple grafting was the classical way to downsize the areola and locate it in a more favorable position. This does mean that the blood flow and nerve supply to the nipple is severed and blood flow needs to be similar to a skin graft – where it takes a few weeks for the nipple to “take” and for pigment changes to resolve. If we leave a pedicle (random blood supply) to the nipple then we can’t necessarily move the nipple quite as far as we would like, and we have added some thickness by retaining that blood supply so may not be completely flat, but then the nipple is supplied with blood flow throughout the process and there is less of a chance of necrosis (loss) of the nipple. In addition some nerves may survive with the pedicle and make sensation more normal to the nipple. We can discuss which is more reasonable for you during consultation. There are a number of factors involved, but you can keep more reliable blood flow and some sensation if you want to.

Implant?.. Fat transfer..?-

There are solid silicone implants available to make the male chest contour more muscular. These are solid silicone devices that can be placed along the border of the pectoralis major muscle and are secured to the fascia. They can be placed at the same time or at a separate procedure if the contour is not as masculine as we had hoped for.

We can also transfer fat back to the chest in a delayed fashion if the area appears too thin. This can happen when the subcutaneous tissue of the breast/chest is thin relative to other areas of the body.

We always have options to make the area more angular, thicker, or thinner, depending on what your desired aesthetic is.

Recovery –

Recovery from top surgery depends on which procedure you’ve chosen but there will be an incision on the chest Usually we glue this incision shut. Care for the incision is minimal. The nipple will either have similar dressings (if pedicled) or some form of a bolster dressing (if free nipple graft. The free nipple graft dressing comes off at one week and the glue dissolves over 10-21 days. There will be one drain on each side to help minimize the chance of a seroma and we remove them around 1-2 weeks depending on how much the output is. There will also be a compression garment for your chest to additionally help minimize the risk of a seroma. Once the drains come out things move rather quickly and within 6-8 weeks the swelling resolves. We ask you to wear a compression vest for 3-4 months, especially when you exercise.

Still have questions –

We are always happy to answer your questions online and in person. You can also call one of our offices at (404) 476-8774 (Alpharetta & Atlanta) to schedule an appointment.

As a Triple Board Certified Plastic Surgeon I make sure to spend significant time with you to help you realize your goals in transgender female to male chest masculinization. With my years of experience and technical expertise, I know that I am more than capable of providing you with a result that exceeds your expectations.