Top surgery

Top surgery is a phrase used in the transgender community to mean a variety of kinds of gender-validating surgeries that can be done on the chest or breasts. This is as opposed to bottom surgery, which is any kind of gender-validating done on the reproductive organs or genitals. As with any kind of transgender people, some nonbinary people seek top surgery, some prefer not to. Top surgery is an option that a person can take on their transition path only if they personally want or need it. There are three main kinds of top surgery: making the breasts larger (breast augmentation), making the breasts smaller (breast reduction), or removing the breasts (mastectomy). It is each nonbinary person's own choice to get one of these, or none of these.

This page is written to use anatomically correct and yet gender-neutral language everywhere possible. This includes calling the surgery patient the "patient" or "person," rather than "woman" or "man," and calling the patient by "they" pronouns.

Breast augmentation
See main article: breast augmentation.

Some transgender and/or nonbinary people want to have breasts. For people who are developing breasts without having to take any hormone therapy, breasts can continue to grow during puberty until about the mid-20s. For people who take estrogen hormone therapy, this causes the exact same kind of breast development as happens naturally for women, just not necessarily at the same age. If either of these processes has finished, and the person still wants to have larger breasts than what they have, then they have a variety of options, non-surgical and surgical. They can temporarily make their breasts look larger by wearing a more supportive bra, a push-up bra, or padded bra. They can wear breast prostheses, also called fake breasts. For people who want to permanently make their breasts larger, then they have the option to get breast augmentation surgery.

There are several things one has to take into account when looking for breast augmentation surgery options:
 * Type of implant: there are two types of implants: silicone implants and saline (i.e. saltwater) implants. While silicone feels and looks more natural, it also requires bigger incisions, which means bigger scars.
 * Shape: the shape of the implant can be round or like a teardrop. Round implants are the most popular choice, because they are symmetrical and rotation is not a problem. However, teardrop implants can give a more natural look.
 * Incision location: there are three ways to insert an implant: through a periareolar incision around your areola, an inframammary incision just below your chest muscle or a transaxillary incision through your armpit. With silicone implants, an inframammary incision is normally the best choice, as they are inserted fully inflated. With a saltwater implant there are more possible choices.

Mastectomy or masculine chest reconstruction
See main article: mastectomy.

Some transgender and/or nonbinary people want or prefer to have a flat, masculine chest. For transgender children and teens, going on a prescription medicine called puberty blockers can postpone or pause puberty, which prevents or reduces the amount of breast growth they would have. The effects of puberty blockers are temporary, so breast growth will resume whenever the person stops taking that medicine. For people who have already had breast growth, going on hormone therapy such as testosterone may reduce breast size just a little bit, if at all, but it does not get rid of breasts. There are also nonbinary people who go on estrogen hormone therapy in order to get other body changes that they want, but who do not want breasts. Wearing a well-fitted sports bra or binder can reduce how large the breasts look, and temporarily make a flat, masculine chest shape. The only way to permanently get rid of breasts is through surgery. Surgery to take away the entire breast is called mastectomy. For transgender people, mastectomy is also called masculine chest reconstruction, to emphasize that they don't see it as a loss, but as fixing a problem.

Mastectomy for trans people is not as painful or traumatic as mastectomy to remove breast cancer or lumps, because the latter usually has to remove lymph nodes. For trans people, mastectomy is a short, single-stage procedure done under general anesthesia at a cosmetic surgery clinic or hospital. The patient goes home the same day. The recovery process depends on which method for mastectomy the patient had.

These are a few of the different methods for mastectomy. These options vary depending on what is possible or best for that patient's anatomy. They also vary from one surgeon to the next, since each has a specialty or a preferred method.
 * Double incision with free nipple grafts. In this surgery, both the breast tissue and the nipples are removed. Then, nipples are reconstructed in a typically male position. This usually causes loss of sensation in the nipples and the areolae.
 * Inverted-T or T-Anchor: This surgery is similar to the previous one, but the nipple is not removed, which means that the person is much more likely to still have nipple sensation. The nipple stays attached to the body with a piece of skin, and moved higher up on the chest after the breast volume is taken away. This creates a scar on each breast shaped like an upside down capital letter T, with a long horizontal scar below the pectoral muscle, and a vertical scar going up from the middle of that to the nipple.
 * Peri-areolar. In this surgery, the surgeon makes two incisions around the areolae in order to remove the breast tissue. Scarring is minimal, but it often requires further revision surgeries to reduce puckering from extra skin. Only people with medium to small chests are eligible.
 * Keyhole. A semi-circular incision is made under the areola, and the breast tissue is removed through it. Otherwise it is similar to peri-areolar.

Preventing breasts from developing
Some transgender and/or nonbinary people who have not yet developed any breasts already know that they do not want to have any. If they can prevent their breasts from developing in the first place, then they will not have to get surgery to remove them. If someone knows that developing breasts would be a significant source of distress (gender dysphoria), then preventing breast development can be better for their longterm mental health.
 * Breast ironing is a non-surgical procedure that attempts to destroy the breast bud, so that breasts cannot develop. This is mostly practiced in Cameroon and can lead to scarring, breast cancer, infection, severe fever, cysts, asymmetrical breast development, and the inability to breastfeed.
 * For children and teens, puberty blockers can postpone or temporarily stop the development of breasts for as long as they are on that therapy.
 * For people who are on the female-to-male spectrum, or whose bodies do not naturally produce much testosterone: taking testosterone or otherwise being on a masculinizing hormone therapy can prevent or temporarily stop the development of breasts, for as long as they are on that therapy.
 * For people on the male-to-female spectrum, or people whose bodies do not naturally produce much estrogen, some types of feminizing hormone therapy make it possible for someone to have a feminine appearance without developing breasts.

Breast reduction
Some transgender and/or nonbinary people have larger breasts than they want. If the temporary methods such as sports bras and binders do not meet their needs, then they may prefer to get surgery to reduce the size of their breasts. The variety of methods for breast reduction are very similar to those for mastectomy described above. Larger breasts or those that need to go down more sizes will be reduced by the T-anchor method. Breasts that only need to be a little smaller can be reduced by the peri-areolar or keyhole method.

Breast reduction is also commonly sought by binary men and women who seek a smaller breast area for a variety of reasons.

Nipple reconstruction
One rare complication of breast surgery is that some or all of the aureola or nipple skin can die during recovery. This leaves a blank, scarred, or pitted area of skin. This can happen to one or both nipples. A person can help prevent nipple loss by choosing a proficient surgeon, choosing a surgical method that keeps the nipple attached during the entire surgical process, and quitting smoking. Nipple loss is more common in mastectomy and masculine chest reconstruction, in which the nipple has been removed, divided, reshaped, and grafted back on during surgery. In masculine chest reconstruction, the nipple is also divided and reshaped, in order to make the nipples smaller and placed higher on the chest. Nipple loss can also happen to people who have had surgery to treat breast cancer, in which case it is not always possible to save the nipple.

For people who have lost one or both nipples, some non-surgical options to restore them include nipple tattooing, which recreates the color, but not the three-dimensional shape. Although nipple tattooing is considered a medical tattoo, patients get aesthetically better and more realistic results by going to a professional tattoo artist than by having a doctor do the tattoo. Some artists offer nipple tattoos for free for breast cancer survivors. Another non-surgical option is a nipple prosthesis, a realistic fake nipple temporarily glued to the skin. Many prosthetic nipples are sold for women who survived breast cancer. There are also ones such as GenderMender prosthetic nipples for men, women, and nonbinary people, which are available in over 200 custom skin tones, and in smaller sizes that can look more appropriate on a masculine chest. Nipple reconstruction surgery recreates the three-dimensional shape of the nipple. Sometimes it uses a piece of skin from another part of the body to help create a raised shape. Any of these treatments for nipple loss can help cover scars that might have come from breast surgery.

Nipple free
Some transgender and/or nonbinary people do not want to have nipples. They can choose to have their nipples removed, possibly as part of a breast reduction, mastectomy, or masculine chest reconstruction. This can create a smooth chest with no nipples. Other people who got a mastectomy or masculine chest reconstruction did not value nipple sensation, but wanted to look like they have nipples, so they chose to have their nipples removed during that mastectomy or masculine chest reconstruction, with the plan that later they would get nipple tattooing, to create the appearance of nipples. If a mastectomy or masculine chest reconstruction is nipple free, then this can involve fewer incisions and scars, which can make recovery a little bit easier. For people who are at a higher risk of losing a nipple after surgery if it is grafted back on, such as smokers, going nipple free gets rid of the risk of the possibility of worse scarring if the patient happens to lose a nipple after surgery.

One point of confusion involved in this is that surgeons-- and patients who describe their experiences with having surgery, such as on sites like TransBucket-- use the phrase "no nipple grafts" to mean two different things. They can use "no nipple grafts" to mean someone who chose to have their nipples removed and not grafted back on. Or they can use "no nipple grafts" to mean a mastectomy or masculine chest reconstruction in which the nipples were kept, and stayed attached to the body the whole time, instead of being removed and grafted back on.