Understanding the procedure
Having a clear understanding of the chest construction options available will help you make an informed choice.
Chest construction A gender-affirming, upper surgery that removes breast tissue and sculpts remaining tissue into a shape that is typically considered to be more masculine. surgery (also called top surgery Refers to some gender-affirming above-the-waist surgeries, including chest surgeries and breast surgeries. ) is a gender-affirming surgery that removes or reduces breast tissue and skin to make a flatter chest. It may involve changing the size or position of the nipples.
The goal is to have a chest with sensation, nipples with sensation (varies by technique), a fairly symmetrical chest with aesthetically pleasing contouring and minimal scarring (varies by technique).
If you’re considering chest construction, you can choose between the following options:
- Chest surgery (bilateral mastectomy A surgical procedure to remove one or both breasts. with contouring) — Removal and sculpting of chest tissue to create a flatter and more sculpted chest (view illustration).
- Chest reduction surgery – A procedure to minimize the amount of chest tissue present (view illustration).
These surgeries typically are done as outpatient surgery by a plastic surgeon. This means most people will not stay overnight in the hospital.
Surgical techniques
The two most common techniques used for chest construction are periareolar A surgical approach where an incision is made around the outer edge of the areola (the darker area surrounding the nipple) to access underlying tissues or perform procedures. and double incision A surgical technique used in gender-affirming chest surgery where two horizontal incisions are made along the bottom border of the pectoral muscles. Nipples may or may not be grafted onto the chest. . There are other techniques that may be used, such as keyhole A surgical approach where an incision is made around half the outer edge of the areola (the darker area surrounding the nipple) to access underlying tissues or perform procedures. . The most common technique for reduction is the Inverted-T (also called T-anchor).
The technique your surgeon uses will depend on several factors such as your existing cup size, skin elasticity and the position of your nipples.
Periareolar A surgical approach where an incision is made around the outer edge of the areola (the darker area surrounding the nipple) to access underlying tissues or perform procedures. is recommended for individuals with a B or C cup size and moderate to high levels of chest skin elasticity. There will usually be scarring around the nipples and areolas and some puckering around the incision. While sensation of the nipple and areola may be reduced, this technique is known to have less of an impact on sensation compared to double incision A surgical technique used in gender-affirming chest surgery where two horizontal incisions are made along the bottom border of the pectoral muscles. Nipples may or may not be grafted onto the chest. . This technique involves:
- Making a small incision around the outside of the areola.
- Making a second circular incision a few centimetres away from the first around the outside of the areola.
- Removing the doughnut shaped skin between the two incisions.
- Removing chest tissue with a scalpel or by using a combination of scalpel and liposuction A surgical technique for removing fat from under the skin by suction. .
- The areola or nipple may be reduced in size
- Suturing the skin together around the areola.
- Placing drains
Thin tubes placed in the body during surgery to remove excess fluid or blood.
(long thin tubing) along each chest incision to help drain off excess blood and fluid and prevent build up under the skin.
This technique is recommended for individuals with a C cup size (when skin elasticity is low) or a D+ cup size. Double incision A surgical technique used in gender-affirming chest surgery where two horizontal incisions are made along the bottom border of the pectoral muscles. Nipples may or may not be grafted onto the chest. involves:
- Making large incisions horizontally across the chest, usually below the nipple.
- Peeling back the skin and removing chest tissue and breast fat with a scalpel.
- Trimming excess chest skin and closing the incisions, leaving two scars below the pectoral muscle lines.
- Removing the nipple-areola complex
Area of the chest or breast that includes the nipple and the surrounding darker-colored area (the areola).
completely, trimming it to a smaller size and grafting it to the chest in a higher and more lateral position.
- Some people choose to forgo nipple grafts. This leaves the chest without nipples and areolas which may be a specific goal for some people. Some people choose to have nipples and areolas tattooed at a later date (see Medical Tattooing).
- Placing two drains Thin tubes placed in the body during surgery to remove excess fluid or blood. (long thin tubing) along each chest incision to help drain off excess blood and fluid and prevent build up under the skin.
This technique results in prominent scars, possible changes to the pigment of your areola and a complete loss of sensation in the nipples. You may be able to grow chest hair to cover the scars, or building your pectoral muscles may make the scars less noticeable. Some people choose to get tattoos over their scars.
Keyhole A surgical approach where an incision is made around half the outer edge of the areola (the darker area surrounding the nipple) to access underlying tissues or perform procedures. is recommended for individuals with a smaller cup size and a high level of chest skin elasticity. This technique results in a small scar on the lower part of the areola and nipples, which increases the chances of retaining sensation. It involves:
- Making a small incision along the bottom of the areola
- Removing chest tissue through the incision using a liposuction A surgical technique for removing fat from under the skin by suction. needle
- Closing the incision
The nipple is not usually resized or repositioned.
Inverted-T is a reduction procedure that is recommended for individuals with a medium or larger cup size who want to preserve as much nipple sensation as possible. This is done by keeping a bundle of blood vessels and nerves (called the nipple stalk) attached to the nipple-areola complex Area of the chest or breast that includes the nipple and the surrounding darker-colored area (the areola). (NAC). It is also an option that allows the patient to retain their nipple without a free nipple graft A surgical procedure in which one section of healthy skin is removed from a part of the body and used in another location (or in the same location in the case of nipple grafts). . This technique results in scars around the areola and nipples (from re-sizing), a vertical scar from the base of the NAC to the chest crease and horizontal scars along the chest crease. It is important to note that this procedure gives the patient the best chance at preserving chest and nipple sensation, but this is not a guaranteed outcome. It is likely there will be some numbness around the chest and nipples. It involves:
- Making incisions around the NAC to resize (but not remove) it
- Making a vertical incision from the NAC to the chest fold
- Making large incisions horizontally across the chest
- Peeling back the skin and removing chest tissue and breast fat with a scalpel
- Moving the NAC to a higher and more lateral position (this will depend on the length of the nipple stalk)
- Trimming excess chest skin and closing the incisions
- Placing two drains Thin tubes placed in the body during surgery to remove excess fluid or blood. (long thin tubing) along each chest incision to help drain off excess blood and fluid and prevent build up under the skin
This technique results in prominent scars, possible changes to the pigment of your areola and a change in sensation in the chest and nipples. You may be able to grow chest hair to cover the scars; or building your pectoral muscles may make the scars less noticeable. Some people choose to get tattoos over their scars.
Contouring the chest
A surgeon will typically spend time shaping (known as contouring) a person’s chest as part of one of these surgeries. The techniques a surgeon uses depend on the surgeon’s preference and your anatomy and will typically be discussed as part of your surgical consult.
- Resection A surgical technique where the surgeon cuts and removes tissue with a scalpel. This technique is common during chest construction. — cutting of tissue with a scalpel.
- Liposuction A surgical technique for removing fat from under the skin by suction. — removing tissue through suction. Some surgeons will offer to do liposuction to areas beyond the chest area (for example, in the underarm area) for a fee. If you are interested in this option, you can discuss this with your surgeon during your surgical consult.
Risks & complications
All medical interventions have potential risks and benefits. It’s important that you understand the risks of having surgery so you can decide whether the potential benefits outweigh the potential risk of surgical complications. This list is not intended to scare you or dissuade you from having surgery but rather to help you make an informed decision.
General risks associated with surgery
Anesthesia issues — Some people experience a negative reaction to anesthesia.
Cardiovascular issues — Such as blood loss, blood clots and artery blockages.
Hematoma — This is when blood collects in the surgical site, causing pain, swelling and redness. Drains Thin tubes placed in the body during surgery to remove excess fluid or blood. and compression bandages are used to prevent hematomas. Smaller hematomas can be sucked out, but larger ones require removal through surgery.
Seroma — This is when clear fluid accumulates in the surgical site. Your surgeon will manage this complication. The ways in which it might be managed include monitoring, clinical exam, ultrasound or possibly drainage.
Infection — This is when microorganisms such as bacteria get inside the body. Infection can occur at different locations such as the surgical site or bladder and are generally treated with antibiotics.
Abscess formation — This is a collection of pus caused by a bacterial infection. It can be treated with antibiotics or drained by the surgeon.
Wound separation — This is when there is a partial or complete opening of incisions along the sutures Sterile medical threads, also called stitches, used to close surgical incisions. .
Nerve damage and pain — There is a wide range of possible experiences related to how nerves heal after surgery. Some changes are short term and some are long term or permanent. Some changes are mild and inconvenient, while others are painful and distressing. Changes can include numbness, increased sensitivity, burning sensations and nerve displacement (sensation may feel like it’s occurring in one place but the stimulus is in another part of the body). Speak with your surgical team about any concerns you have about sensation or pain management.
Scarring — Scarring can be reduced by following your surgeon’s advice, which may include activity restrictions, avoiding sun, seeing a physiotherapist or massage therapist and doing massage exercises (if recommended). Severe scarring may require medical or surgical intervention.
Postoperative regret — Regret can happen for several reasons, such as experiencing significant complications or being dissatisfied with the outcome of surgery.
Risks specific to chest construction
If there are any complications that arise from your surgery, your surgical care team will help you understand and deal with them. These are some of the complications that are associated with chest construction A gender-affirming, upper surgery that removes breast tissue and sculpts remaining tissue into a shape that is typically considered to be more masculine. :
Contour irregularities — This is when a person’s chest isn’t the expected shape. Major contour irregularities can be corrected through liposuction A surgical technique for removing fat from under the skin by suction. , which is necessary in about 5–25 per cent of cases.
Decreased sensation — This is possible with keyhole A surgical approach where an incision is made around half the outer edge of the areola (the darker area surrounding the nipple) to access underlying tissues or perform procedures. and periareolar A surgical approach where an incision is made around the outer edge of the areola (the darker area surrounding the nipple) to access underlying tissues or perform procedures. surgeries. It’s an expected result of double incision A surgical technique used in gender-affirming chest surgery where two horizontal incisions are made along the bottom border of the pectoral muscles. Nipples may or may not be grafted onto the chest. surgery.
Nipple asymmetry — When the shape or location of the nipple on one side looks different than the other nipple. Some asymmetry is common; very noticeable asymmetry can be corrected through a surgical revision.
Nipple necrosis — A rare complication where the nipple, or part of it, falls off. If this happens within hours after surgery, saving the nipple may be possible; otherwise, the nipple may need to be replaced or reconstructed.
Important
This list of potential complications isn’t comprehensive so be sure to have a detailed discussion about complications when you consult with your surgeon before surgery.
This workbook contains worksheets, exercises and checklists related to chest construction
Contact our team of experienced health navigators for information about gender-affirming care in B.C.