Insurance companies who cover top surgery generally follow WPATH guidelines, which are as

follows:

1. Living as your identified gender for at least one year
2. You are able to make informed decisions and consent for treatment
3. Your other medical and mental health conditions, if present, are well controlled
4. Age >18 years old OR >15 years old with one year of hormone therapy (for age 15 -18 this is recommended but may not be required depending on the individual case)

The three most common surgical techniques are the double incision, the periareolar approach and the keyhole approach. These incision patterns are explained below. There are many other types of incision patterns, including the fishmouth technique, the buttonhole technique, the inverted-T incision and the inframammary incision. The buttonhole and inverted-Tare attempts to increase hope of preserving some nipple sensation, but will not guarantee nipple sensation and will result in a chest wall that is not as flat as possible. The fishmouth is unique in that it produces a scar that is nonanatomic in location. The inframammary incision involves an inferior horizontal incision that appears similar to the double-incision technique, but involves preservation of the nipple and is only indicated for patients with no extra skin(similar to the periareolar or keyhole, for patients that have a slightly larger amount of breast tissue).

Double incision top surgery means that breast tissue is removed along with skin in a horizontal elliptical incision pattern, leaving a scar along the inferior chest border. Double incision surgery is the most effective technique that will give you the flattest possible chest wall but requires that the nipples be treated as “free nipple grafts”. There are various options that are customizable in terms of scar shape. Some patients prefer to have the straightest possible scar, while others prefer a more curved or contoured scar appearance.

“Free nipple grafts” means that the nipple areolas are removed, thinned out, reshaped and resized, and placed back on the chest wall as a free nipple graft, similar to a skin graft procedure. The areolas will become smaller and can be reshaped into an oval or a circle depending on your preference. The nipple areolas can be placed slightly lateral on the chest wall for a more masculine appearance or can be placed centrally on the chest wall for a more gender fluid appearance. The shape and location of the nipple areolas is fully customizable, and we can discuss your preferences at your consultation.

As free nipple grafts, the nipple areolas will be 100% numb right after surgery and will require extra care with ointment and moisturization until they adapt to be like the rest of your skin. The grafts go through a special healing process that involves a yellow bolster dressing that is sutured over the nipples for one week after surgery. The purpose of this dressing is to provide an environment of “no friction” so that the grafts can heal without being disturbed. Over the first 2-3 days after surgery, the grafts survive by absorbing oxygen and nutrients from the surrounding skin of your chest wall. During this time, small blood vessels from your chest wall will align themselves with empty vessels in the graft, and these vessels will start to grow into each other, allowing the graft to survive without absorbing fluid. It is important that the vessels are allowed to grow into each other without friction, so they don’t get disrupted in the healing process. The bolster dressings are very securely sutured over the grafts and it is very unlikely for anything to disrupt this healing process with the dressings in place. For this reason, you should not remove your dressing at all in the first week after surgery.

In the majority of patients with free nipple grafts, “protective sensation” will return after many months. Nerve regeneration takes a very long time, but over a long time it is likely that nerves will grow into your grafts and allow you to feel the grafts. However, you will never regain “erotic sensation” to the nipples. Instead, they will likely feel like the skin of your neck or your shoulder. This is not a guarantee, and there is still a chance of complete numbness, however, some sensation is likely to return.

Periareolar and Keyhole top surgery means that breast tissue is removed through a small scar that is located along the border of the colored areolar skin. In Periareolar top surgery, the scar goes all the way around the areola and the areola is reduced in size and/or shape. In Keyhole top surgery, the scar goes only along the inferior 180 degrees of this colored areolar border and the breast tissue is all removed through this scar. The only difference between these two procedures is that in keyhole top surgery, the areola does not change at all in size or shape and simply retracts as is against the chest wall. These minimal-scar approaches may only be performed in patients with no extra skin, because only a very minimal amount of skin is able to be removed to without causing unnatural pleating on the chest wall. The amount of breast tissue should also be relatively small. These procedures will result in a flat chest, but do not allow customizability of nipple position. The nipple areolas will retract where they are on the chest wall and cannot be moved laterally.

Unfortunately, even though the nipples are left attached, there is not a better chance of retaining erotic nipple sensation after periareolar or keyhole top surgery compared to double incision, because many of the nerve endings to the nipple areolas are coming up through the breast tissue that is required to be removed. It is almost a guarantee that your nipple areolas will be numb after surgery. However, the same rules apply to nerve regeneration over time. It is likely that you will regain protective (noterotic) nipple sensation over many months after surgery, although this is not a guarantee.

It is important to note that top surgery is different from a “prophylactic mastectomy”. Top surgery will remove about 95% of breast tissue, but about 5% of breast tissue will remain on the chest wall, and this is done on purpose. The reason we purposely leave this tissue behind is that if we were to remove every cell of breast tissue, you would be left with a skeletonized, deformed appearance to the chest wall. The goal of top surgery is a flat, uniform, aesthetic appearing chest wall. Because the pectoralis major muscle ends in an oblique fashion laterally on your chest, there may need to be some additional tissue left lateral to where this muscle ends in order to prevent a concavity or depression in this area.

What this means is that you are not 100% out of the woods in terms of breast cancer screening. What we know is that top surgery will significantly reduce your risk of breast cancer, because breast reduction surgery significantly reduces this risk, but we do not have guidelines at this point as to what type of screening you should undergo. When it is time for you to consider this(~age 40 or older),you should have a conversation with your doctor about what, if any, screening you may need. You will probably NOT be able to have traditional mammograms because you won’t have enough tissue to compress. If you discover later in life that you have a higher risk of breast cancer than you originally thought, you may need MRIs or more thorough clinical screening with a breast cancer specialist.

If you would like to explore your candidacy for a prophylactic mastectomy procedure, which would be done by a breast surgeon, it is possible to have this procedure and to have top surgery at the same time. We can recommend a breast surgeon and a genetics counselor so that you can be evaluated prior to top surgery. If you end up being a candidate for this procedure, we can potentially perform fat grafting to help fill in any contour deficiencies that would result. It is likely that you would require several stages of fat grafting in order to achieve a flat, uniform chest wall similar to a top surgery result.

bleeding is really referring to what is called a “hematoma”, which means that blood collects under the skin and requires another operation to drain the blood on an urgent basis, and can sometimes require a blood transfusion. This is very rare, but if it happened it would usually happen within 24-48 hours after surgery and would require are turn trip to the operating room. This would be temporarily annoying but ultimately should not affect long term results. The risk of hematoma is estimated at less than 5%. It is possible that you may be taking supplements, vitamins or medications that you may not know increase risk of bleeding. Please be sure to inform your surgeon of everything that goes into your body on a regular basis, because many off-label supplements can have ingredients that increase risk of bleeding, for example fish oil, acai berries, garlic, ginseng, ginger, vitamin E (which exists in some almond milks), and MANY others. We will ask that you stop any vitamins and supplements that are not absolutely required for2-4 weeks prior to surgery and for 2 weeks after. You should also avoid aspirin, NSAIDs/ibuprofen or other anti-inflammatory medications. Blood thinning supplements may be beneficial for long-term health, but they are terrible to take just before or after surgery.

This is extremely rare but you could potentially develop an infection of the skin or nipples requiring antibiotics, drainage, additional surgery or hospitalization. Patients undergoing double incision top surgery will have antibiotics for one week, and patients without free nipple grafts (peri/keyhole) will have antibiotics for only a few days.

This means a fluid collection under the skin of the chest that in frequently develops. This could lead to infection or poor contour and may require additional procedures for drainage of fluid. To avoid seromas we use one drain on each side, and the drains remain in place for one week. The nurses at the hospital will show you how to care for the drains after surgery. You can also go on YouTube and search for “JP drain stripping”, “JP drain care” and “how to empty a JP drain” and you will find many helpful videos on the subject that will make you feel much more comfortable dealing with drains after surgery or you can view Dr. Chandler’s educational video on Drains and Top Surgery. The drains should be emptied about twice a day for a few days after surgery and then once a day after that, and stripped twice a day. Stripping the drains is important to keep the fluid moving through the drains so they don’t get clogged.

This means that you could develop a depression or asymmetry of the contour along the chest wall. While this is unusual, you may notice small contour asymmetries when you compare both sides closely.

These refer to areas of pinpoint fullness at the lateral aspect of your scars. The scars end laterally under your armpit on the lateral chest wall. This is very uncommon, however if dog ears do occur, they may improve with time as swelling resolved. If they don’t resolve, they can usually be easily corrected with a small procedure under local anesthesia. If you have fullness of your lateral chest wall prior to surgery (excess fatty tissue or skin folds lateral to where the breast tissue ends), this will not necessarily change after top surgery and treatment of these areas may benefit from liposuction. These areas may become more obvious in appearance after top surgery if untreated.

It is possible that one scar or nipple areola may end up slightly asymmetric compared to the other side. Some chest asymmetry naturally occurs in most individuals. Differences in terms of chest and nipple shape, size, or symmetry may also occur after surgery. Additional surgery may be necessary to revise asymmetry after a top surgery.

Wound disruption or delayed wound healing is possible. Some areas of the chest skin or nipple region may not heal normally and may take a long time to heal. Areas of poor healing may require frequent dressing changes or further surgery to remove the non-healed tissue. Individuals who have decreased blood supply to chest tissue from past surgery or radiation therapy may be at increased risk for delayed wound healing and poor surgical outcome. Smokers have a greater risk of skin loss and wound healing complications.

Poor scarring refers to hypertrophic or keloid scarring, which is usually related to genetics, or widened scarring. Widened scars can be prevented by limiting the amount that you raise your elbow over the level of your shoulder. You should try to keep your elbow at or below the level of your shoulder for 6 months after surgery (e.g. Raising your hand, reaching up high). You may need to adjust things in your house, and lower items down if you have items up high on shelves where you can’t reach them easily. You are allowed to touch your head and wash your hair, but try to limit raising any higher than this as much as possible.

Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. You may be disappointed with the results of top surgery. Asymmetry in nipple location, unanticipated chest shape, wound disruption, poor healing, and loss of sensation may occur after surgery. Unsatisfactory surgical scar location or visible deformities at the ends of the incisions (dog ears) may occur. Liposuction may be necessary to thin tissue that is out side of the normal surgical location for top surgery. It may be necessary to perform additional surgery to attempt to improve your results.

There are many variable conditions that may influence the long-term result of top surgery. Should complications occur, additional surgery or other treatments may be necessary. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. In some situations, it may not be possible to achieve optimal results with a single surgical procedure. Often insurance will not cover revision surgery. If you request a revision that is reasonable and within one year of your surgery date, there will be no charge to you for the surgeon’s fee involved in that revision. You would be responsible for the anesthesia and facility fees involved in that revision procedure, if necessary.

In rare cases, local allergies to tape, suture material and glues, blood products, topical preparations or injected agents have been reported. While extremely unlikely, serious systemic reactions including shock (anaphylaxis) may occur in response to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.

This refers to a blood clot in your leg that could travel to your lung and could be very serious and even life-threatening. This is extremely rare but there is some risk to this when you are under anesthesia, because the blood flow in your legs slows down. To prevent this, it is VERY IMPORTANT TO WALK AFTER SURGERY (see the “What needs to be done after surgery” section).

Complications of anesthesia are extremely rare, but there are risks of under going anesthesia including death that the Anesthesiologist will go over with you on the morning of surgery. The anesthesiologists we work with are very experienced and we have never had one of our patients have a complication from anesthesia before.

We perform top surgery at Norwalk Hospital in Norwalk and St. Vincent’s Medical Center in Bridge port. Depending on the surgery schedule, your procedure may be located at one or the other. If you prefer one hospital over the other you can request it.

• The surgery is outpatient surgery, so you go home the same day.
• You should plan to arrive at the hospital 2 hours before your scheduled surgery time.
• You should leave all valuables at home on the morning of surgery, but bring a photo ID and insurance card.
• You will report to the main lobby patient registration desk at the facility where your surgery is scheduled.
• The facility will call you usually one business day before surgery to go over these details and to verify the time that you should plan to arrive.
• One visitor is permitted to be with you in the preoperative area and in second stage recovery (about one hour after you are finished with surgery).
• You will need someone to drive you home after surgery (Uber or cab are not allowed).
• See our Preoperative Care Guide for more information about how to prepare for surgery day.

In the operating room, generally there will be a Scrub Nurse (the one who is in charge of the sterile instruments and assists in passing instruments to Dr. Chandler), a Circulating Nurse (who is in charge of providing materials within the room that are needed for the case), a Physician’s Assistant (who will help assist Dr. Chandler during surgery), and the Anesthesiologist. There may also be other staff such as a medical student or physician’s assistant student who observe surgery and are there to learn.

Your first postop visit will be one week after surgery. The following visit schedule will depend on your healing process, but usually occurs two weeks after the first visit followed by another visit in one month, three months, six months and one year.

If you are older than 40 years old, we require a mammogram within 1 year. Please have a copy faxed to us at 203-423-0124. If you are younger than 40 years old you do not need a mammogram.

Therapist or other mental health provider note of support – please have your therapist use our template to write their letter. If you do not have a therapist, we can recommend one that we use frequently. See page 1 of this FAQ sheet for more details.

No smoking nicotine or marijuana x 4 weeks and stay away from second-hand smoke or other nicotine products(see previous page)

Appointment with your primary care physician for preoperative clearance and blood work within 60 days of surgery. They will also do any other indicated testing they feel is indicated. We ask for the blood work to detect for any undiagnosed bleeding disorders, which we do pick up on occasion. Please let us know WHEN AND WHERE your appointment is so that we can send your doctor a note with the blood work and preoperative clearance that we need. We prefer to do this close to your appointment date so the paperwork doesn’t get lost.

COVID vaccination card copy or COVID test. If you are fully vaccinated, we only need a copy of your card, which you can email to us or provide to us on the day of your consultation. If you are not vaccinated, you will need to have a COVID test performed within 3 days prior to surgery if at Norwalk Hospital or 5-6 days prior to surgery if at St.Vincent’s Medical Center. The test needs to be done AT the hospital where your surgery is scheduled. If your surgery is at Norwalk, alternative testing sites are Danbury Hospital and Vassar in Poughkeepsie. If your second dose of the vaccine is performed too close to your surgery date (within 14 days), you will also need a COVID test.

No aspirin/ibuprofen/NSAIDs or other blood thinners x 2-4weeks prior to surgery.

No vitamins other than a standard multivitamin, and NO herbal supplements (especially fish oil and vitamin E).We will provide you with a full list of medications to avoid before surgery and will discuss with you if there are any specific medications or vitamins in your regimen that you should avoid.

Nothing to eat or drink after midnight the night prior to surgery. Small sips of water with medications are ok. Stay hydrated before surgery and eat a big dinner the night before your surgery.

From the pharmacy, you should purchase Bacitracin Ointment, Aquaphor and Tylenol. Optional pharmacy items include Chapstick(for dry lips), throat lozenges(for sore throat after anesthesia), tums or Maalox(for a sensitive stomach, Colace and Senna (for constipation). Provide us with your pharmacy information so we may call in your prescription medications before your surgery date.

• No strenuous activity or heavy lifting (nothing greater than 5 lbs) for 4 weeks after surgery. It is important that the surgical incisions are not subjected to excessive force, swelling or friction while they are healing. This includes exercising, fast-paced or power-walking, heavy stairs, hills, or mile long walking because you do NOT want to do anything that may increase your heart rate. When your heart rate goes up, your blood pressure goes up and blood flow increases to the areas that are healing, which can cause excess swelling and increase risk of fluid collections. Your healing tissues are especially prone to this excess fluid production.
• If you perform strenuous activity or heavy lifting at work, this should be limited for 4weeks after surgery. You may return to light duty or to an office job or school at 1.5 weeks after surgery. If you are not able to perform light duty at your workplace, we recommend taking the full 4 weeks off after surgery.
• You should not engage in intimate relations (sex) after surgery for4 weeks. Increased activity of any kind can cause bleeding or swelling.
• To prevent blood clots (DVT/PE), it is VERY IMPORTANT TO WALK AFTER SURGERY. This is REQUIRED at least one time on the same night as your surgery AND at least three times a day thereafter. What I mean is leisurely walking, like walking around your living room or taking a few laps around your bed room at a very slow pace, just something to get your legs moving. Having someone give you a leg massage also helps. When you are resting in bed or on the couch during recovery, you should move and fidget your knees and ankles around–anything that promotes blood flow through your legs and improves circulation is good. It is important to note that this does NOT mean you should do any strenuous walking as mentioned above. There is a BALANCE–slow, leisurely paced walking is important but avoid anything that could break a sweat or make your heart race.
• Stay hydrated and well nourished.

• You will take antibiotics for3-7 days after surgery, depending on if you have free nipple grafts (7days) or not (3 days). The first dose should be taken on the night of surgery.
• You will take pain medication as needed (oxycodone or Tylenol).Try to avoid Motrin or ibuprofen, because these medications can cause bleeding. Some patients do not take any of the oxycodone, some take it for a few days, some take it only at night before bed for a few nights. Everyone is different. You can break the pill in half if it makes you feel loopy. You can take the oxycodone WITH Tylenol and that is called Percocet. Tylenol and oxycodone together have a synergistic action so they work better together. You may take 1 gram of Tylenol at a time, but no more than 3 grams per day (follow the instructions on the label). Sometimes Tylenol comes in 500 mg, so you can take two of those at a time. Sometimes they come in 1 gram, so you would only take one of those. You should only take the pain medication if you are in pain. Do not take it before you have pain. The oxycodone can make you constipated if you take too much of it.
• If you are constipated, you can take an over-the-counter stool softener (Colace 100 mg twice daily and Senna 17.2 mg at night).
• You may have a scopolamine patch behind one ear (it looks like a circular band aid). This is sometimes placed before surgery to reduce nausea and is usually left in place when you go home. DO NOT LEAVE THIS PATCH IN PLACE. Take it off as soon as possible after you get home and are starting to eat without nausea. DO NOT leave it on for longer than24 hours after surgery. After you remove it, throw it in the garbage and wash your hands thoroughly because you don’t want to get the medication in the patch in your eyes.

• You will wake up with a compression wrap around your chest and two drains. This wrap should stay on for3 weeks. If you had double incision surgery, NO ONE TOUCHES THEDRESSINGIN THE FIRST WEEK except Dr. Chandler at your first postoperative visit. Try to sleep on your back and make sure nothing bumps your chest or rubs near your nipples. Shower only below the waist and wash your hair in a sink. The entire chest dressing should remain clean and dry. If you had periareolar or keyhole surgery, you may shower at 48 hours and replace the compression wrap (you will need a second pair of hands todo this).
• After 7-10 days, all patients will be allowed to shower. When you shower, turn your back to the water and let the water and soap run over you from behind. If you have nipple grafts, know that they are still very fragile and should not be rubbed at all. They should be gently patted dry after the shower. You will then perform your nipple graft dressings with bacitracin ointment and a nonstick dressing that will be provided to you. Most patients at this point should replace the compression wrap. Occasionally inpatients with a large BMI we may elect not to continue the compression wrap after your first postoperative visit because the wrap may slip which can cause friction on the fragile grafts. If you feel that your compression wrap is shifting or slipping, notify Dr. Chandler immediately and we may remove the compression wrap altogether.
• If you would like to purchase your own compression wrap, you can buy one for about$70 on Amazon (search LIPOELASTIC MTmS Comfort–Medical Post OP Gynecomastia Compression Vest). This can easily be taken on and off by yourself with a zipper in the front. Most patients elect not to do this because it is only required for a short period of time,
• After 3 weeks, nipple grafts will require moisturization with Aquaphor once a day to once every other day (usually done at night before bed so the ointment doesn’t get on your clothes during the day). Over time, you will notice this is required less frequently until one day it is not required at all as the grafts will stay moist on their own like normal skin. You do not need any dressing after this point.

The drains should be emptied 2x/day for a few days then 1x/day after that and stripped2x/day. Usually, you will have both drains removed at your first postoperative visit. If you have nipple grafts, the dressings over the nipple grafts will also be removed. Where the drains were removed, bacitracin and a band aid will be placed. You can change this daily with new bacitracin and a new band aid until the drain holes have closed up. This usually takes 2-3 days.

• After 4 weeks post-surgery, you do not need to do anything to your scars. If you choose to, silicone therapy (scar away or another brand) is a good way to care for your scars–follow the instructions on the box. Scar away can be purchased at CVS or Amazon. Silicone tape is the best form of Scar away. The tape is placed on the scars for 12 hour per day for 3 months. This helps the scars stay flat.
• If you had double incision top surgery, for 6 months after surgery, you should try to avoid raising your arms above your head (“raised hand”)–you should try to keep your elbow at or below the level of your shoulder to prevent your scars from widening. You can wash your hair and touch everywhere on your body. It is really about trying not to raise your arm up high. This is recommended but not required.