Top surgery for transgender women is a procedure transgender women might use to increase their breast size and improve the shape of their chests. It is also called feminizing breast surgery, breast augmentation, chest construction or breast mammoplasty. Top surgery for transgender women might involve placing breast implants or tissue expanders under breast tissue. In some cases fat is taken from other parts of your body (liposuction) and injected into your breasts. Both techniques might be used, if needed.
Top surgery for transgender women might be done as a step in the process of treating distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria). The procedure can help transgender women transition physically to their self-affirmed gender.
Why it's done
Transgender women who seek top surgery might experience distress due to a difference between experienced or expressed gender and gender assigned at birth (gender dysphoria).
While many transgender women use estrogen to stimulate breast growth, they might not feel that their resulting breast size is adequate. Some continue to wear external prostheses or padded bras. Others choose to have surgery to change the appearance of their chest. Transgender people relate to their bodies differently and need to make individual choices that best suit their needs.
Your doctor might recommend against top surgery if you have:
- Unmanaged mental health conditions
- Significant health conditions, such as heart or kidney disease, a bleeding disorder, or a history of blood clots in a deep vein (deep vein thrombosis) or in a lung (venous thromboembolism)
- Any condition that limits your ability to give your informed consent
Like any other type of major surgery, top surgery for transgender women poses a risk of bleeding, infection and an adverse reaction to anesthesia. Other complications might include:
- Scar tissue that distorts the shape of the breast implant (capsular contracture)
- Fluid accumulation beneath the skin (seroma)
- A solid swelling of clotted blood within your tissues (hematoma)
- Breast pain
- Asymmetry of the breasts or breast creases
- Implant displacement, leak or infection
- Dissatisfaction with appearance after surgery
Correcting these complications might require more surgery. Within 10 years of surgery, you might also need implant replacement.
How you prepare
Top surgery for transgender women is typically deferred until adulthood. Before top surgery, you'll meet with your plastic or reconstructive breast surgeon. Consult a surgeon who is board certified and experienced in this procedure. Your surgeon will describe your options and potential results. The surgeon will provide information on the anesthesia, the location of the operation and the kind of follow-up procedures that might be necessary. Follow your doctor's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking.
In addition, before you can have top surgery, you'll be required to meet certain criteria. To start, your doctor will evaluate your health to rule out or address any medical conditions that might affect or suggest against treatment. The evaluation might include:
- A review of your personal and family medical history
- A physical exam, including an assessment of your internal reproductive organs
- Lab tests measuring your lipids, blood sugar, blood count, liver enzymes and electrolytes
- A review of your immunizations
- Age- and sex-appropriate screenings
- Identification and management of tobacco use, drug use, alcohol use, HIV and other sexually transmitted infections
- Discussion about contraception and future fertility
Although giving your informed consent after a discussion about the risks and benefits of the procedure is an acceptable standard of care, most surgeons and insurance companies will require a mental health evaluation by a provider with expertise in transgender health. The evaluation might assess:
- Your gender identity and dysphoria
- The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
- Mood or other mental health concerns
- Sexual health concerns
- Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
- Protective factors such as social support from family, friends and peers
- Your goals, risks and expectations of treatment and your future care plans
Before having top surgery, most surgeons and insurance companies require obtaining one letter of support from a mental health provider competent in transgender health. He or she will determine that you meet the World Professional Association for Transgender Health (WPATH) standards of care criteria. The criteria state that you must:
- Have persistent, well-documented gender dysphoria
- Have the capacity to make a fully informed decision and to consent to treatment
- Be of legal age to make health care decisions in your country (age of majority or age 18 in the U.S.)
- Be managing any significant medical or mental health concerns
- Undergo hormone therapy as appropriate to your gender goals for a minimum of 12 months prior to feminizing breast surgery, unless you have a medical contraindication, or you're otherwise unable or unwilling to take hormones
The purpose of hormone therapy prior to breast augmentation is to maximize breast growth in order to help you obtain better results.
Since top surgery for transgender women will cause irreversible physical changes, you must give informed consent after thoroughly discussing:
- Social and legal implications
- Potential complications
- Procedure irreversibility
Health insurance might not cover surgical procedures considered cosmetic for the general population, even though these procedures might be essential to alleviating your gender dysphoria.
You might also consider talking to others who've had top surgery before taking this step. They can help you shape your expectations of what can be achieved and what personal and social problems you might experience during treatment.
What you can expect
Top surgery for transgender women is typically done as an outpatient procedure. You'll be given general anesthesia.
During the procedure
The principles of breast augmentation are similar for transgender women and cisgender women. But transgender women typically have broader chests, larger and thicker pectoral muscles, smaller and more lateral nipple and areola positioning, and shorter distances between their nipples and the creases under their breasts (inframammary). Because of their wider chest walls, transgender women often have a wide space between their breasts, even with use of larger implants.
During top surgery your surgeon can make incisions around the areola, near the armpit or at the level of the inframammary fold. Silicone or saline implants will be placed through the incision under breast tissue.
You'll have saline or silicone implants placed, based on your preference. When the implant is in place, the surgeon will close the incision — typically with stitches (sutures) — and bandage it with skin adhesive and surgical tape.
If feminizing hormones haven't made your breasts large enough, you might need an initial surgery to have devices called tissue expanders placed in front of your chest muscles. You'll visit your doctor every few weeks after surgery to have a small amount of saline injected into the tissue expanders. This will slowly stretch your chest skin and other tissues to make room for the implants. When your skin has been sufficiently stretched, you'll have another surgery to remove the expanders and place your implants.
After the procedure
You might need someone to accompany you home after surgery. Your surgeon might require that you stay locally for a few days.
Soreness and swelling are likely for a few weeks after surgery. Bruising is possible, too. Expect scars to fade over time but not disappear completely. You'll wear a compression bra for three weeks.
To decrease the risk of displacing a breast implant, limit upper body exercise for the first several weeks after surgery.
Top surgery for transgender women can play an important role in relieving gender dysphoria for transgender women.
Many transgender women report satisfaction after surgery, though some desire an even larger breast size and pursue further augmentation.