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In our increasingly anti-trans environment, it can be difficult to find affirming, inclusive information related to gender-affirming care. But if you know people who have had top surgery or have ever browsed an online group of people sharing photos of their first day wearing a favorite shirt with their new flat chest, you know that the possibility of gender euphoria is out there. That’s why SELF set out to create a guide for anyone curious about top surgery or how to pursue it. We talked to plastic surgeons who provide masculinizing top surgery, and dug into the research and information that will help you understand the procedure more comprehensively. Below, you’ll find lots of information, from surgical techniques and the insurance approvals process to surgery prep and recovery.
What is top surgery?
Top surgery is a gender-affirming surgical procedure that flattens and “masculinizes” the chest, according to the American Society of Plastic Surgeons. People who get this surgery—often transgender, transmasculine, and/or nonbinary folks—are looking to surgically alter their chests to better fit their gender. Unlike a mastectomy, which typically entails removing as much of the breast tissue as possible to prevent or remove cancer, top surgery can involve chest contouring and customizing the placement and appearance of the nipples.
There are several different types of techniques for top surgery—and there are several factors, including chest size, skin elasticity, and whether the person wants to preserve nipple sensation—that a surgeon considers when recommending one for a specific person. Common top surgery techniques include:
- Double incision: The chest skin is opened along two horizontal incisions. The nipple and areola (the pigmented skin around the nipple) are removed and, then, if the person wants to keep their nipples, reattached, often after being resized.
- Periareolar: An incision is made around the border of the areola and a second, larger concentric circle incision is made to remove excess skin.
- Keyhole: A small incision is made along the bottom of the areola and excess tissue is removed through this incision, but skin cannot be removed with this technique.
To learn more and get a sense of what the results might look like, check out the different kinds of techniques and their results, along with illustrations, here.
Will my insurance cover top surgery?
According to double board-certified plastic surgeon Jared Liebman, MD, attending physician at Plastic and Aesthetic Surgery at Einstein Healthcare Network in Philadelphia, it’s becoming more common for insurance to cover top surgery, which can cost anywhere from $5,000 to $10,000 out of pocket.
To find out what your insurance coverage may look like for gender-affirming top surgery, you’ll need to review your coverage documentation. (You can contact your provider by phone to ask specific questions and verify the information.)
If you have a private insurance plan, such as through an employer or Healthcare.gov, your plan documents should include in-network providers who can perform the surgery, and one may offer partial coverage for an out-of-network provider. If you go this route, you might be billed directly and will then need to seek reimbursement through your insurance company.
If you have Medicaid, it’s possible your surgery will be covered, but it depends on where you live. (You can see if Medicaid in your state covers transition-related care here.) As of 2014, Medicare covers medical transition-related surgery.
What if I don’t have health insurance?
Not everyone seeking top surgery has insurance or can get their carrier to cover their surgery. According to a recent report from the Centers for Disease Control and Prevention (CDC), 31.6 million—that’s almost 10%—of people in the US were uninsured in 2020. Additionally, transgender people face higher unemployment and poverty rates compared to cisgender people which makes them more likely to be un- or underinsured.
If you fall into that category, one option is to seek out community funding to cover the cost of the procedure, as well as related costs like transportation and meals while you recover. There are grants you can apply for, such as Point of Pride’s Annual Trans Surgery Fund, the Jim Collins Foundation grant, and others. Another option, though no one should have to do this, is raising money for your surgery using crowdfunding.
For help with insurance, check out the legal resources compiled by T4T Caregiving, which includes services that help people get their gender-affirming treatments covered.
Does my top surgery need to be “approved” in some way?
Between barriers to gender-affirming care (caused by stigma, lack of provider awareness, and other systemic issues) and the administrative process of getting any medical care covered by insurance, pursuing top surgery can seem frustratingly complex. The gatekeeping around who should be allowed to receive gender-affirming care is detrimental and actively prevents people from getting the treatments they need. With that in mind, familiarizing yourself with what’s ahead and knowing how to access resources and required paperwork will demystify the process and make it more accessible. Let’s get into it.
First, you should know a few things about WPATH: The World Professional Association for Transgender Health is a professional organization made up of clinicians and researchers working in medicine, psychology, law, social work, counseling, psychotherapy, nursing, and other disciplines dedicated to understanding and treating gender dysphoria. They publish a comprehensive document called the Standards of Care (SOC) that contains clinical guidance for health care professionals who treat transgender and gender-diverse people. Loren Schechter, MD, medical director of the Gender Affirmation Surgery Program at Rush University Medical Center serves on WPATH’s executive committee. He tells SELF that the SOC are intended to be used to “help provide a framework” for how health care providers should offer gender-affirming treatment.
One thing the SOC do is make recommendations for what criteria a person should meet before being approved for gender-affirming care, like hormone therapy or surgery. Over the years, WPATH criteria have been criticized by trans and gender-diverse people because of the barriers it can pose to getting treatment. And even though, as Dr. Schechter explains, health care providers and insurance companies are not required to follow the SOC, many do use them for guidance. As a result, your surgeon’s office may require you to meet some (or all) of the criteria for surgery established by the SOC. Unfortunately, many surgeons will not move forward without documentation that certain criteria have been met (typically in the form of a letter from another doctor or a therapist or other mental or behavioral health provider).
According to the latest update to the SOC (SOC 8, which was released in September 2022), criteria include “marked and sustained” gender incongruence, an understanding of the effects of gender-affirming surgery, identifying and ruling out other possible causes of “apparent gender incongruence,” the ability to consent to surgery, and more. You can see the full list here, but keep in mind that the most important thing to determine is what, specifically, from these guidelines your doctor and insurance company (if applicable) will require in order to have your surgery approved.
Some folks have affirming primary care providers and/or therapists who will happily write a letter to a surgeon and/or insurance company as needed stating that a person meets all the criteria for gender-affirming surgery. Others may not have access to health care providers at all, let alone affirming ones. And other providers require you receive specific treatment (like therapy, for example), before they’ll write the letter, and that might not be something you can afford. The good news is that there are some resources that can help fill this gap. The Gender-Affirming Letter Access Project (GALAP) is a group of transgender, nonbinary, and allied mental health providers working to increase access to free letters for trans and gender-diverse people who need them. GALAP’s directory can help you find a provider who has signed GALAP’s pledge that they’ll provide free, accessible documentation and don’t believe in institutional gatekeeping for trans and gender-diverse people.
How do I find a good surgeon?
First, make sure that any prospective surgeons are board certified in plastic surgery and meet the rest of the criteria listed by the American Society of Plastic Surgeons. Dr. Liebman also recommends choosing a surgeon who has experience not just as a plastic surgeon but with top surgery specifically, who he says “have the best toolbox for multiple different types of procedures to accomplish top surgery.”
Of course, everyone’s situation will be a little different when it comes to finding the right surgeon. If you live in a big city, especially one with a teaching university, there might be several board-certified surgeons to choose from in your area. If you live in a more rural area, you may have fewer to choose from or will need to travel for your surgery.
Beyond ensuring a surgeon has the minimum training and certifications, pay close attention to the overall vibe: Consider the surgeon’s bedside manner and personality; whether the staff seems to be trained to provide affirming care (using the right pronouns, avoiding misgendering, etc.); and whether it’s difficult to get an appointment or get the front desk folks on the phone. You’ll be able to get a sense of some of these when you make an appointment for a consultation, which is generally the first step in pursuing top surgery.
You can also get a sense of what different surgeons and their offices are like using directories like TopSurgery.net or TransHealthcare.org or asking for recommendations online. Online groups (try searching Facebook, Reddit, etc. with terms like “top surgery,” “ftm top surgery,” “non-binary top surgery,” etc.) and any IRL groups will likely help you access tons of useful information, not only about a given surgeon’s technical skills, but also about what it’s like to be their patient. One important piece of information to pursue is how much experience the office has getting pre-authorization from insurance companies to get your surgery covered. Some offices have staff that are especially adept at handling getting gender-affirming treatments covered by insurance, and that can be an incredibly valuable resource.
What should I talk to my surgeon about?
The American Society of Plastic Surgeons (ASPS) has a handy list of questions to ask prospective top surgeons. Give it a read before your consultations and write down any questions that apply to you. For example, if you smoke cigarettes, ask your surgeon if they’ll require you to quit smoking (and using nicotine generally). Many—but not all—surgeons will require patients to quit smoking cigarettes before surgery (as recommended by the ASPS) because nicotine can interfere with wound healing.
Other things you may want to ask about:
Even though BMI has long been found to be an inadequate tool for measuring health that leads to stigma and creates barriers to care, some surgeons won’t operate unless a patient is under a certain BMI. This is the case despite the fact that top surgery has been shown to be a safe procedure for people at higher weights. The good news is that not all providers use BMI as a precondition for surgery; if this is something you’re concerned about, be sure to ask the doctor about their policies.
If you have any health conditions, talk to your surgeon about how those may impact your surgery and recovery. Once again, every surgeon will have different requirements and preferences in this regard, and having certain health conditions doesn’t necessarily disqualify you from surgery. Some surgeons may just want to operate in a hospital versus a surgery center, or require that the health care providers helping you manage your conditions sign off on the surgery in advance.
According to the American Society for Plastic Surgeons, top surgery comes with the risk of potential complications, though Dr. Schecter says that it’s “quite uncommon.” Some of the ones to be aware of—and which come with almost any surgery—include bleeding, infection, poor healing of incisions, and reaction to anesthesia. Be sure to ask your surgeon what kinds of complications, if any, can be anticipated and how they’d be handled if they do happen.
If your surgery involves nipple grafts, which is when the surgeon removes the nipple and then resizes and repositions it, you may experience some numbness or irregularities in their shape or pigment after healing. Dr. Schechter says. He says that sensation may be regained over time, and adds that problems during healing can often be treated with topical scar care. In some instances, your surgeon may recommend a surgical revision sometime in the future to improve an aesthetic irregularity after healing.
Anyone who’s had trouble getting a callback or an appointment in time knows how frustrating it is to not be able to reach your doctor, and that’s not something you should have to deal with after surgery. Ask your surgeon about how many follow-up appointments will be scheduled in advance, as well as how to contact their office in the event of a question after surgery and in an emergency. Be sure to get a sense of how they handle concerns after hours, too. For example, Dr. Liebman’s office makes use of an encrypted email system that allows patients to send photos along with any questions they have. That way he can quickly take a look and determine if the patient should be seen in person. You may want to consider a surgeon whose office has a similar setup, or at least one who gives patients their cell phone number so they can be reached more easily. Here are a few specific things to ask:
- If I’m traveling for surgery, how long am I required to remain in the area after my procedure? What do you recommend that I pack to travel safely and comfortably?
- When can I safely shower after surgery? Is there anything I should be mindful of while bathing?
- What are some signs that my recovery is going well? Are there any red flags I should keep in mind?
- What should I look for to make sure that my wounds are healing properly? What are some signs of potential infection that I should look out for?
- Will you be prescribing pain management medications? If so, how can I deal with the side effects, like constipation, they may cause?
Planning for recovery and aftercare
Every surgeon will have their own guidelines for recovery, and your instructions will also likely vary based on factors that are individual to you. But one thing you can expect is that your doctor will want you to take things very easy while you recover.
Surgery recovery requires a pretty serious commitment to downtime, so it’s important to take that into account when scheduling your procedure. And because you’ll probably need to make changes and arrangements to your work and home life, try not to wait until the last minute to get it figured out.
Dr. Liebman recommends his patients take two weeks off of work. From there, continue to take it pretty easy for another couple of weeks. “I ask my patients to commit to one month of downtime after surgery,” Dr. Liebman says. “To me, downtime just means a conscious and intentional change in your routine.” He tells patients that while he doesn’t want them lying in bed day after day for their whole recovery, the activity they do should be slow and light.
Dr. Schecter says that people who work at desks can often expect to return to work in two or three weeks, but those whose jobs require physical labor—like lifting things or operating heavy machinery—should expect to either be told to take longer off of work, or request that their employer modify their duties in the weeks following surgery. Most people can expect to return to their normal activities unrestricted after about six weeks, Dr. Schechter says. Vib Gonzalez, coordinator of TGNB Perioperative Care and Services at the Callen-Lorde Community Health Center in New York City, recommends folks with more physically demanding jobs—where someone is lifting, pushing, or pulling objects, for example—take four weeks off from work if possible. (Most surgeons will require you to not lift your arms overhead for a period of days or weeks while you’re recovering.)
Beyond just time off work, also think about how you’ll adjust responsibilities at home like cooking, cleaning, caring for kids, elders, and pets. You may also need to think about your lifestyle; for example, do you typically ride your bike or take public transportation to get around town? Your surgeon might recommend other options like rideshares or having a friend drive you. (Dr. Schechter does not recommend taking public transportation in the days following surgery because of how much you can get jostled around.)
Once you have a timeline of your surgery and recovery figured out, you can start to map out your care coordination.
To get started, think about what domestic duties you need to complete on a weekly and monthly basis: cleaning, doing laundry, grocery shopping, meal prepping/cooking, pet care, and so on.
Some of the things you’ll need done while you’re recovering can be taken care of in advance—making bulk meals ahead of time, getting a ton of laundry done, moving anything you need from high shelves to lower surfaces, etc. But other things, like walking your dog or running errands and maybe even getting dressed and undressed, will likely require the help of someone else. If you don’t have a friend or family member nearby who can help, check out T4T Caregiving, a network of trans caregivers who provide support while you recover.
Lots of surgeons use drains to help with proper healing after top surgery. During the procedure, the surgeon will place two tubes, one in each incision site. These tubes attach to plastic bulbs; over the course of recovery, blood and excess bodily fluids will drain into the bulbs. Dr. Schechter says that patients (or their caregivers) will be expected to detach the bulbs and empty them a couple of times a day, keeping track of how much fluid is draining. At your post-surgery checkup(s), your provider will decide when it’s time to remove them; how long after surgery the drains generally depends on the surgeon’s recommendations as well as how long it takes for the fluid to drain. Dr. Schechter says that for the overwhelming majority of his patients, the drains won’t be removed before day five or six post-surgery, and rarely stay in longer than eight or nine days.
Most surgeons also recommend people wear compression garments after top surgery to reduce swelling during recovery. Dr. Schechter has his patients use ACE wrap or a Velcro binder to “apply gentle pressure to the chest to help prevent fluid from accumulating under the skin.” Your doctor’s office may also provide the garment they want you to wear during recovery (this is something you can ask about during your consultation). If not, there are also medical manufacturers who make specific post-operative garments. Ask your surgeon what their requirements are for a post-surgery binder and if they can recommend a reputable brand or retailer.
Whether you’ll need to wear a binder after surgery and for how long will depend on your surgeon’s guidance. Typically, Dr. Schechter recommends his patients wear a compression binder for three weeks, taking it off only to shower. Keep in mind that post-surgery binders are looser and gentler than binding intended to flatten the chest. If your skin gets irritated from compression binding, Dr. Schechter recommends placing some dry gauze underneath the garment to help prevent chafing.
If you talk to other people who have had top surgery or search any online forum, you’ll find tons of tips for things to have on hand while you recover. (And, of course, your surgeon will be able to make recommendations, too.)
Here are a few things people who have had top surgery often recommend:
- Shirts that open in the front and have pockets for drains (Google something like “mastectomy recovery shirts” to find these, and just know that many of these products are marketed to people who have had cancer-related mastectomies.)
- Pillows (like a wedge, body, or “husband”) that will prop you up in bed and help you stay comfortable, as well as sit up and stand without relying on your arms
- Reusable straws for drinking without having to lift a cup
- Throat lozenges for post-surgery sore throats (during the procedure, your throat will be intubated and can hurt afterward)
- Products for scar and nipple care (your surgeon will recommend specific ones)
- Whatever you need to stay cozy and occupied while you rest (blankets, soft socks, shows to stream, video games, etc.)
You may have to buy some of this stuff new, but if you’re strapped for cash, it’s worth asking around in groups and forums to see if people have items to pass on from their own surgeries.
“Most patients will wake up from surgery and perhaps describe somewhat of a burning sensation to their chest,” Dr. Liebman says. “Then it’s generally just a crampy, uncomfortable, kind of swollen inflammation type of discomfort that should last for about three or four days.”
Dr. Liebman recommends people manage post-operative pain with over-the-counter meds like ibuprofen or acetaminophen whenever possible, and use prescription-strength pain relievers, such as oxycodone, only when necessary. Of course, you should speak with your surgeon about their approach to pain management and find out what kind of pain you can expect and what medications they prescribe and recommend. Dr. Liebman also recommends using ice packs on your chest for the first few days after surgery and heating pads after day four of recovery.
Pursuing, finally getting, and recovering from top surgery can be a pretty fraught process, filled with all kinds of emotional ups and downs. But there are so many stories out there from people who have gotten top surgery and, as a result, experience a newfound sense of comfort and peace about their chests, not to mention some much-needed gender euphoria. With the right coordination, planning, and preparation, you can find yourself on a path that feels good for you.
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