Gender-affirming chest surgery · New York and New Jersey
Top Surgery
Top surgery removes chest tissue and reshapes the chest. There is more than one way to do it, and the right one depends on your body and on what you want from surgery. Dr. Steven Ovadia is a board certified plastic surgeon with fellowship training in gender-affirming surgery at Johns Hopkins, with offices in New York City and New Jersey.
Goals
The goals of top surgery are different for everyone
There is no single right result from top surgery. What matters is the result that is right for you. Most patients weigh some mix of these three goals.
As flat as possible
For many patients the priority is a chest that is as flat as it can be, with a smooth contour in clothing and without a shirt.
As masculine as possible
A masculine chest is more than a flat chest. It also comes from the contour of the chest, where the scars sit, and the size and position of the nipples and areolas.
Maintaining sensation
For some patients, keeping feeling in the nipples and chest matters most. That can point toward a technique that keeps the nipple attached, or toward nerve reinnervation.
These goals can pull in different directions. The technique that gives the flattest chest is not always the one that keeps the most sensation. Some patients want a smaller chest that is not completely flat, and some prefer a chest without nipples. At your consultation, you and Dr. Ovadia go over your goals and your anatomy to determine the optimal surgical plan.
Techniques
Top surgery techniques
The techniques differ in where the incisions are, how much skin can be removed, and what happens to the nipple and areola. Which ones are options for you depends on the size of your chest, how much your skin stretches and springs back, and your goals.
Gold lines show where the scars are.
How they compare
| Double incision | Keyhole | Periareolar | Radical reduction | |
|---|---|---|---|---|
| Often suited to | Medium or larger chests, or skin that has stretched | Small chests with firm, elastic skin | Small to medium chests with a little extra skin | Patients who want a much smaller chest that is not flat |
| Scars | One on each side, along the lower border of the chest muscle | Along the lower edge of the areola | Around the areola | Around the areola, down from it, and usually along the crease under the chest |
| Nipple and areola | Made smaller and placed as grafts, or not grafted back | Stay attached. Not moved | Stay attached. The areola can be made smaller | Stay attached. Moved to a higher position |
| Nipple sensation | Reduced in nipple grafts. Nerve reinnervation is an option | More likely to be maintained | More likely to be maintained | More likely to be maintained |
| Chest contour | The most skin can be removed, for a flat chest at most chest sizes | Flat, when the skin tightens well | Flat, when the skin tightens well | Much smaller, not flat |
These are general patterns. Chests and goals vary, and more than one technique can be a reasonable option for the same person.
Double incision
Double incision top surgery
Double incision is the most common technique for top surgery. It allows the most skin to be removed, so it can give a flat chest for patients with a medium or larger chest, or with skin that has stretched.
An incision is made on each side of the chest. The chest tissue and extra skin are removed, and the incisions are closed so that the scars sit along the lower border of the chest muscle. It can be done with or without free nipple grafts.
With free nipple grafts
The nipple and areola are removed, made smaller, and placed back on the chest as skin grafts, in a position that suits the new shape of the chest. This gives the most control over the size and position of the nipples. Because the grafts are separated from their nerves, feeling in the nipples is reduced. Nerve reinnervation is an option aimed at bringing it back.
Without nipple grafts
Some patients prefer a chest without nipples. The incisions are the same, and the nipples and areolas are not grafted back. There are no grafts to care for during healing. Some patients later choose nipple tattoos, and some choose nothing at all.
Sensation
Nerve reinnervation
In double incision surgery with free nipple grafts, the nerves that give feeling to the nipple are cut when the chest tissue is removed. Feeling in the chest skin often comes back gradually on its own, but the nipple grafts usually have much less feeling than before.
Nerve reinnervation is a technique aimed at bringing sensation back to the nipple grafts.
The nerves are found and kept
While the chest tissue is being removed, the sensory nerves that run from between the ribs toward the nipple are identified and preserved instead of being cut short.
The nerves are connected
The preserved nerves are brought to the new position of the nipple and connected beneath the graft. A nerve graft is sometimes used to bridge the distance.
Sensation returns over time
Nerves regrow slowly, about an inch a month. Feeling comes back gradually over months and can keep improving for a year or more.
Early studies have found better return of sensation in patients who had nerve reinnervation than in those who did not. No technique can guarantee sensation, and results vary from person to person. Dr. Ovadia goes over whether it is an option for you when planning your surgery.
Keyhole and periareolar
Keyhole and periareolar top surgery
These techniques use incisions at the areola only, so the scars are smaller and there is no scar across the chest. The nipple and areola stay attached to the tissue beneath them, which keeps their blood supply and helps maintain sensation.
Keyhole
A small incision is made along the lower edge of the areola, and the chest tissue is removed through it. No skin is removed, so the skin has to tighten on its own afterward. It is an option for a small chest with firm, elastic skin and nipples that are already in a good position.
Periareolar
An incision is made all the way around the areola, and a ring of skin around it is removed. This allows a small amount of skin to be taken out and the areola to be made smaller. It is an option for a small to medium chest with a little extra skin.
Because little or no skin is removed, these techniques depend on the skin tightening after surgery. They are not the right choice for a larger chest or for skin that has stretched. A touch-up procedure to refine the contour is more common after these techniques than after double incision.
Radical reduction
Radical reduction
Not everyone wants a completely flat chest. A radical reduction removes most of the chest tissue and leaves a small amount, for a chest that is much smaller but not flat.
It uses the techniques of a breast reduction. The nipple and areola stay attached to the tissue beneath them and are moved to a higher position without being removed, which helps maintain sensation. The scars go around the areola and down from it, and usually along the crease under the chest.
The trade-off is that the chest is not flat. Some tissue has to stay beneath the nipple to keep its blood supply.
Real results
Top surgery before and after
These are Dr. Ovadia's own patients. Each case notes how far out from surgery the "after" photo was taken. Swelling and scars keep improving for a year or more.
Before-and-after photographs
This section contains before and after photographs of real surgical procedures.
You must be 18 years or older to view this content.
Recovery
What to expect after surgery
Swelling and bruising are normal and expected
The chest is swollen and bruised at first. Swelling goes down gradually over the following weeks and months, and the final contour takes time to see.
Compression is important
You wear a compression garment after surgery. The compression helps prevent and minimize swelling and supports the chest while it heals.
Drains
Drains may be placed to keep fluid from collecting under the skin. If you have them, you are shown how to care for them at home.
Nipple grafts
If you have nipple grafts, a protective dressing is secured over each one while the graft heals in. Grafts often look dark or scabbed at first. This is expected, and their color evens out over the following months.
Walking, reaching, and lifting
Walking starts right away. Reaching overhead and heavy lifting are limited at first, so the incisions can heal without being pulled on.
Scars fade with time
Scars are red and firm at first. They soften and fade over a year or more. Dr. Ovadia goes over scar care with you once the incisions have healed.
Call the office right away if one side of your chest becomes much more swollen, tight, or painful than the other. Occasionally blood collects under the skin after surgery, which is called a hematoma. It is treatable, and it is best taken care of early.
Everyone heals differently. Dr. Ovadia reviews your recovery timeline with you, including when to return to work and exercise.
Insurance
Insurance coverage for top surgery
Many insurance plans cover gender-affirming top surgery when their criteria are met and it is a covered benefit of your policy. Each plan sets its own criteria, and plans commonly ask for a letter of support from a medical or mental health provider.
Every plan is different, and coverage is not guaranteed.
If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
Your surgeon
Board certified and double fellowship-trained
Dr. Ovadia is board certified by the American Board of Plastic Surgery. After his plastic surgery training he completed two fellowships: gender-affirming surgery at Johns Hopkins, and craniofacial and pediatric plastic surgery at UT Austin / Dell Children's Hospital.
He performs top surgery along with other gender-affirming procedures. He sees patients in New York City and in Jersey City and Millburn, New Jersey.
Questions
Common questions about top surgery
What is top surgery?
Top surgery is gender-affirming surgery of the chest. On this page it means surgery that removes chest tissue and reshapes the chest, also called chest masculinization or gender-affirming mastectomy. It is chosen by transgender men, non-binary people, and others who want a flatter chest.
Which top surgery technique is right for me?
It depends on the size of your chest, how much your skin stretches and springs back, and your goals: how flat you want your chest to be, how you want it to look, and how much maintaining sensation matters to you. At your consultation, you and Dr. Ovadia go over these together to determine the optimal surgical plan.
What is the difference between double incision and keyhole top surgery?
Double incision removes chest tissue and extra skin through an incision on each side of the chest, and the nipples are usually placed back as grafts. It can give a flat chest at most chest sizes. Keyhole removes tissue through a small incision at the lower edge of the areola. No skin is removed and the nipple stays attached, so it is an option only for a small chest with firm, elastic skin.
Can I have top surgery without nipples?
Yes. With double incision surgery, the nipples do not have to be grafted back. Some patients prefer a chest without nipples. Nipple tattoos are an option later for patients who want them.
Will I have feeling in my chest and nipples after top surgery?
It depends on the technique. Feeling in the chest skin often returns gradually over months. With keyhole, periareolar, and radical reduction surgery, the nipple stays attached and is more likely to keep feeling. With free nipple grafts, feeling in the nipples is reduced, and nerve reinnervation is an option aimed at restoring it. No technique can guarantee sensation.
What is nerve reinnervation?
Nerve reinnervation is a technique used with double incision top surgery and free nipple grafts. The sensory nerves that go to the nipple are preserved while the chest tissue is removed, then connected beneath the nipple graft so that feeling can return over time. Early studies have found better return of sensation with it than without it, but it does not guarantee sensation.
What is a radical reduction?
A radical reduction removes most of the chest tissue and leaves a small amount, for a chest that is much smaller but not completely flat. The nipple and areola stay attached and are moved to a higher position, which helps maintain sensation.
Do I need to be on testosterone to have top surgery?
No. Testosterone is not required for top surgery, and many patients have surgery without taking it.
What will my scars look like?
It depends on the technique. Double incision leaves a scar on each side along the lower border of the chest muscle. Keyhole and periareolar surgery leave scars at the edge of the areola. A radical reduction leaves scars around the areola, down from it, and usually along the crease under the chest. All scars are red and firm at first, and they soften and fade over a year or more.
Is top surgery covered by insurance?
It can be. Many insurance plans cover gender-affirming top surgery when their criteria are met and it is a covered benefit of your policy. Each plan sets its own criteria, and plans commonly ask for a letter of support. If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
Can I have a consultation without coming to the office?
Yes. Phone and video consultations are available, in addition to in-person visits in New York City, Jersey City, and Millburn, New Jersey.
Next step
Start with a consultation
Dr. Ovadia will examine you, listen to what you want from surgery, and go over which techniques are options for you. Together you determine the optimal surgical plan.
225 Broadway, Suite 3100, New York, NY
377 Jersey Ave, Suite 440, Jersey City, NJ
90 Millburn Ave, Suite 206, Millburn, NJ
Phone and video consultations available · info@ovadiaps.com