Top Surgery

Cost

Insurance will sometimes cover this procedure. In cases where insurance does not cover, the cost ranges from $6500-$7500

Who Is a Good Candidate?

While hormone treatment is not required prior to this surgery, treatment with testosterone for >12 months can shrink breast size and turn fibrous breast tissue more fatty. Hormone treatment can also help build up the underlying pectoralis muscles, which helps the plastic surgeon contour the chest optimally. Often, hormonal treatment alone is not sufficient to give a more male contour chest, and other factors such as nipple placement go into making a more masculine appearing chest. From a functional standpoint as well, patients wearing chest binders also encounter a multitude of functional issues including rashes and chafing.

There are 3 main procedures for top surgery (and many combinations thereof): liposuction alone, a keyhole procedure, or double incision mastectomy. Liposuction alone is ideal for patients who have a very small amount of breast tissue and very little excess skin. The keyhole procedure is ideal for patients who have small breasts, not a lot of extra skin, but enough tissue and fibrous tissue that is not firm enough to be amenable to liposuction alone.  The advantage of liposuction alone or the keyhole incision +/- liposuction is that the scars hide well in the inframammary fold and areolas, however it does not allow complete nipple relocation. The double incision procedure is more ideal for patients who have enough breast tissue and skin to perform basically an amputation of the breast and placement of the nipple in more lower and lateral position via free nipple skin graft. The incisions end up around the nipple and in the inframammary fold. The double incision procedure has the advantages of removing all excess breast tissue and completely reshaping the chest and moving the nipple. The disadvantage is that the incisions are larger and more visible, drains are necessary post operatively and the nipple will no longer have sensation. 

The Procedure

The procedure is done under general anesthesia at an outpatient ambulatory surgery facility. The procedure takes about 1 hour for a less involved surgery (such as liposuction alone or a keyhole incision), and takes around 2 hours for more extensive reshaping procedures such as a double incision mastectomy. Liposuction is done through 3-4 mm incisions well hidden in the underfold of the breast, and in the areola for keyhole surgery. If only liposuction or a keyhole incision is made, there is no need for a drain. In contrast, for the double incision procedure, one drain per side is needed and they usually stay in for 1-3 weeks depending on the drain output. For the double incision, a non-stick bolster dressing is sutured to the skin to facilitate take of the free nipple skin graft, which is sutured back in place. This bolster dressing stays in place for 5-7 days. All incisions are closed with dissolvable sutures and skin glue, and outer dressings consist of padding and an ACE wrap for compression. 

Recovery 

Recovery is different for liposuction and the keyhole incisions than it is for the double incision procedures. For the keyhole incision procedure or liposuction, patients are wrapped in compressive ACE wrap with gauze padding, and permitted to remove this in 48 hours and shower. After that, either the ACE wrap is worn 24/7 for 4-6 weeks. All incisions are closed with dissolvable sutures and skin glue, so there is no need to remove any sutures or staples.

For the double incision procedure, non-stick bolsters consisting on antibacterial vaseline gauze are sutured to the skin to help press down the nipple skin graft and allow it to heal. Patients are seen in clinic anywhere from 5-7 days after surgery for removal of this bolster. The fresh skin graft must be cared for meticulously and kept dry for approximately 2 weeks after surgery. During this time, patients may shower from the waist down only. Showering may occur with drains in place. With the free nipple graft, the outer layer of skin which contains pigment may slough off, and this color will slowly come back over several months and will reappear as spots of color that grow larger and coalesce. 

For all surgeries, patients should avoid any overhead reaching for 2 weeks after surgery, and avoid lifting anything more than 5 lbs or high end exercise or activities for 4-6 weeks after surgery. Patients can usually drive after 1 week or when they are off prescription pain medications. Those with desk jobs may consider going back after 2 weeks if they can avoid heavy lifting, and those with jobs involving heavy lifting should plan to take the full 4-6 weeks off.