FTM Top Surgery Comparison

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A comparison table of the details, risks, advantages and disadvantages of each of the three most common types of FTM chest reconstructive surgeries.

To see photos of many different people's surgery results, both for top surgery and many other transition-related surgeries, see http://transbucket.com/. Transbucket is particularly helpful both for comparing and contrasting different surgeons' work and learning about how much different surgeons, and different procedures, tend to cost.

Disclaimer: Individual results vary as widely as individual health, individual surgeon skill and care, and individual luck. The most important thing is for each of us to decide which chest characteristics are important to us, locate the most skilled and reliable surgeons for that procedure, and then discuss our individual options with those surgeons.

Generalized Chest Surgery Comparison
  Double Incision Peri-Areolar Keyhole
What is it also called? Bilateral mastectomy Subcutaneous mastectomy Subcutaneous mastectomy
What is it? Skin is opened in two incisions, along bottom of pecs, from center of chest out toward armpits. Almost all breast tissue is removed by scalpel. Nipples and areolae are removed, resized, and repositioned in a graft higher up on the chest. Minor liposuction sometimes used to contour fat at borders of surgical area/under arms. Incision is closed together at bottom of pecs line. Some surgeons will maintain original nipple/areola on stalk ("dermal pedicle") instead of grafting, to preserve nerve sensation. Ask surgeons about their techniques for nipple preservation if that's important to you. Skin is opened along entire circumference of areola. Skin is separated away from underlying breast tissue. Most of the breast tissue is removed by scalpel. Nipple nerve and blood supply is maintained on a stalk ("dermal pedicle"). Excess skin is trimmed from around circumference of areola in "doughnut" shape. Minor liposuction sometimes used to contour fat at borders of surgical area. Areola is resized, then skin reattached to areola at its border. Nipples can be reduced in revision if desired. Areola may be repositioned to a limited extent, depending on original chest size (i.e., amount of chest skin available). Skin is opened along bottom half of areola border. Most of the breast tissue and surrounding tissue is removed via liposuction through this small hole. Nipples may or may not be resized, but cannot be repositioned. Areola is not reduced; surrounding chest skin is not reduced.
Who is it for? Larger chests (B, C, D+).

Looser skin, more droop/sag/"ptosis".

Do you pass the pencil test? Stand up straight and place a pencil under one breast, parallel to the floor, as high up under the breast as it will go. Let go. Does the pencil stay put or fall to the floor? If it stays put (pass), you'll very likely need double incision. If it falls (fail), there may be a chance that peri-areolar or keyhole would give you good results.

A or small B.

Works well with moderate body fat, moderate to very elastic skin. Some sagging/droop of original chest OK; better result with least stretching/thinning of chest skin.

Fibrosity of breast tissue not an issue as tissue is not removed through liposuction needle.

Smallest chests (small/very small A has best result in this method).

Tightest skin, most elastic skin, least body fat. No sagging of chest ("ptosis").

Works best with smallest amounts of least-dense, least-fibrous breast tissue: glandular tissue must pass through liposuction needle.

What are the scars? Larger, more prominent scars; competent surgeons will place them along the underside of the pecs, following the natural contour of the chest. (Pec development is not necessary for a competent surgeon to know where your pecs are.) They will fade with time; how long that takes will depend on how your body heals. Look at other scars you have for some indication. Good scar care will go a long way towards helping them fade more quickly. Nearly invisible scarring at incision line around the border of the areola and skin. Nearly invisible scarring at incision line along bottom junction of areola and skin. Sometimes also adhesion scars/puckers under chest skin.
Will I need revisions (extra surgeries)? Revisions may be necessary. Usually to remove small amounts of breast tissue left near the armpits, or to repair dog-ears or small puckers in scar line. Revisions may be necessary. Usually to additionally contour underskin fat around surgical area, or reduce broadened scars or small pleats in scars. Nipples may be resized. Revisions may be necessary. Usually to remove chest skin and/or areolar tissue that has not shrunk close enough to the chest. Also to repair adhesion scars, or contour underskin fat around surgical area. Nipples may be resized.
What sensation might I have? Possibly less sensation in nipples, because they are removed and re-attached in the appropriate place and therefore the nerves will need to regrow. Better sensation likely if original nipples retained with "pedicled" procedure, instead of reconstructed with grafts. Good chance of sensation and normal erectile ability in nipples, because the nipples are not removed. Good chance of sensation and normal erectile ability in nipples, because the nipples are not removed.
Overall Pro/Con + Surgeon has much more control over chest contour, nipple size, and nipple placement, which are the three things that make a male chest.

+ Nipples are generally smaller, and in a higher position on chest, as is appropriate on a male chest.

+ Healed, well-placed/well-contoured scar hides well under pectoral muscle.

- Higher likelihood that some nipple sensation will be reduced.

- Scars are more visible in the short term than peri-areolar or keyhole scars.

+ Less prominent scarring, frequently invisible. Higher likelihood of good nipple sensation.

+ Less invasive surgery than keyhole, due to lack of significant liposuction damage to tissues; faster healing and less post-operative pain compared to keyhole. Good possible outcomes for A- or small B-sized individuals.

- Nipples and areolae may remain large and/or in a lower position on chest, compared to double-incision surgery.

- Procedure done poorly, or on too-large a chest, can leave loose skin or pleating in skin at skin/areola closure.

- Procedure as done by some doctors may retain more breast tissue than in double incision initially and possibly permanently.

+ Less prominent scarring, frequently invisible. Higher likelihood of good nipple sensation. Good possible outcomes for very small-chested individuals.

- For all but smallest "small A"-sized patients, significant risk of insufficient "shrinkage" of chest skin, leaving lumpy, deflated-looking or puckered surface, as no extra skin around areolae was removed.

- Risk of adhesion scars under upper chest skin. Areolae remain original size and at original position on chest.

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