What Type of Top Surgery Would you Need?

What Type of Top Surgery Would you Need?

By: Peter Buggert | Last Reviewed: 10/12/19 Last Updated: 10/12/19

We understand that the word “breast” can cause feelings of dysphoria, and for that I am extremely sympathetic, but for the sake of clarity in what is a medical text, there is no good substitute for the term. This article should not be substituted for medical advice and I am not a medical professional. Content warning: talk of surgery and female anatomy.

There are multiple different kinds of top surgery, and the only way to really know what kind you will get is by having a consultation with a top surgeon. However, for many this is not possible. Not knowing what type of surgery you may get and what type of scar pattern or recovery to expect can be rather stressful. This guide is meant to give you a general idea of what kinds of top surgery you may qualify for.

First we would like to show you a few charts that summarize the general way that surgeons make the decision on what type of surgery to use.

Image Description.: a flow chart, four options on top that flow through a few questions leading to five options on bottom. Title: Skin Envelope. First option: Small, A Cup, Grade 1 ptosis good skin elasticity without nipple reduction means semicircular method, good skin elasticity with nipple reduction means ransareolar method, moderate to poor skin elasticity means concentric circular method. Second option: Medium, B Cup, Grade 1 to 2 ptosis, good skin elasticity means concentric circular method, moderate to poor skin elasticity and will accept free nipple graft means free nipple graft method, moderate to poor skin elasticity and will not accept free nipple graft means extended concentric method. Third option: Large C cup, grade 2 ptosis, good to moderate skin elasticity and will accept free nipple graft mean free nipple graft method, good to moderate elasticity and will not accept free nipple graft means extended concentric method, poor skin elasticity mens free nipple graft method. Fourth Option: very large, grade 2 or 3 ptosis only option is free nipple graft method. End Image Description.
A flow chart that uses breast size, grade of ptosis, and skin elasticity to determine what type of top surgery is most likely the best, retrieved from the journal of Plastic and Reconstructive Surgery, click here to see source. FNG means Free Nipple Graft. Semicircular is commonly called Keyhole, Concentric Circular is commonly called periareolar, Extended Concentric is commonly called Fishmouth, and Free Nipple Graft method is commonly called Double Incision.
Begin Image Description. A flow chart. Title: Which FtM/FtN Top Surgery is Right for Me? Subtitle: For More information visit www.genderconfirmation.com. Flow chart first box: Is nipple sensation or chest flatness and tightness most important? If chest flatness and tightness is most important then the double incision method is best. Double incision also allows for the most control over nipple location. If nipple sensation is most important move to second box. Second Box: What is the infrabreast angle? If less than 110 degrees then Inverted T, Buttonhole, Lollipop, or Fishmouth method is best. These techniques also keep your 3D nipple shape. If infrabreast angle is 110-135 degrees than the periareolar method is best. If the Infrabreast angle is more than 135 degrees then keyhole method is best. End image description.
A flow chart from the Gender Confirmation Center created by gender confirmation surgeon Dr. Scott Mosser. Note that if you have small breasts but don’t care about nipple sensation you may not have enough skin to qualify for double incision.
Begin Image Description. A photo showing the three infrabreast angles mentioned in the above image with pictures of breasts with light and dark skin. Bodies are shown at about a 23 degree angle with the arms down. First panel is greater than 135 degrees. Shows a very small breast with small nipples pointing forward. Second panel is showing an infrabreast angle of 110 to 135 degrees. A medium chest with slightly larger nipples that are pointing slightly down. The third image is demonstrating an infrabreast angle of less than 110 degrees. shows a large saggier breast with larger nipples pointing downward. End image description.
A picture showing the different infra-breast angles, also from the Gender Confirmation Center. Click here to see Dr. Mosser’s page on figuring out your top surgery type.

The decision about what method to use is primarily decided by the physical aspects of the patient, but a good doctor will also take into account the patient’s wishes and concerns. The main determining physical factors as seen in the charts are breast size, breast shape, the general sagginess of the breasts (ptosis), skin elasticity, and nipple/areola size. Generally, the larger the breast is the riskier, more invasive, and more expensive a surgery will be. Top surgery has a relatively low risk of life threatening complications occurring during surgery no matter the method, although complications during healing are more common with some methods than others.

First you will need to know your cup size. Most people already know their cup size, but if you don’t there are many guides to figuring it out online. Your cup size depends on the ratio of the distance around your chest below the breast to the distance around your chest on top of the breast. Generally, an A cup is about the size of a lemon, a B cup an orange, C cup a grapefruit, and D cup a cantaloupe, but like I said it’s a ratio of your body size to your breast so an obese person could have a larger breast but still technically be an A cup. There are also sizes above and below A-D.

Second you will need to look at the sagginess of your breasts. Ptosis, in this case, is referring to how low the breast hangs, a lower breast with a higher degree of ptosis will have a smaller infra breast angle. This is figured out by taking a picture of the chest (similar to the angle shown above) and comparing the position of the nipple and areola with the inframammary crease (the line where the bottom of the breast meets the chest wall). It is very commonly believed that binding and testosterone causes sagging of the breasts. The larger the breast is the more common ptosis is as there is more tissue to be pulled down by gravity. Ptosis is measured by comparing the nipple placement and general tissue distribution with the lowest point of the inframammary crease. You can test this yourself using the “pencil test” which just means you line a pencil up where the lowest part of your breast meets your chest and then look at yourself in the mirror from the side. It should be noted that these classifications aren’t always easily fit inside of, you may be between grades or one side may be worse than the other.

Begin image description. A sketch showing six torsos from the side, all with breasts demonstrating different degrees of ptosis using the pencil test. End image description.
A picture showing the grades of ptosis relative to the inframammary crease.
  • Normal breasts have a nipple that points forward and sits above the inframammary crease.
  • Grade I describes mild ptosis where the nipple is at or near the lowest point of the inframammary fold and sits above most of the lower breast tissue.
  • Grade II describes moderate ptosis where the nipple is located below the inframammary fold, but is still higher than most of the breast tissue.
  • Grade III describes advanced ptosis where the nipple is well below the inframammary fold and sits at the lowest point of the breast.
  • Pseudoptosis is where the nipple is located either around or above the inframammary fold but the lower half of the breast sags below the fold.
  • Parenchymal Maldistribution describes an unusual shape usually caused by a deformity featuring a high inframammary crease, low nipple, and a lack of lower breast tissue.

The next physical characteristic is your skin elasticity, also called your skin turgor. Top surgery removes a lot of tissue very quickly, and that can leave you with extra skin if it isn’t removed. Healthy skin with high elasticity will slowly tighten back up if there is not to much of it, but a lot of extra skin or skin with low elasticity may leave a patient with rather upsetting results. Your skin will naturally lose elasticity as you age, usually noticeable changes in elasticity are noticed around 40 years old. Pre-existing conditions and smoking can also decrease elasticity. The best things that you can do to maintain your skin elasticity is to maintain a healthy BMI with proper diet and exercise, stay hydrated, and practice good skin care. Hydration is especially important with elasticity. To check your elasticity is rather simple. Just pinch and raise up about a centimeter section of your skin (usually done on the back of the hand) and release. If it springs back almost immediately your elasticity is good. If it takes a second or longer you have poor elasticity. This test is also used to check for dehydration, so if you have bad results it is a good idea to spend a day focusing on proper hydration and attempting the test again.

Image Description. Title: The Dehydration Pinch Test. Body: For a quick and easy way to decipher if you're dehydrated, try out the pinch test (also known as the skin turgor test). Lightly pinch some skin on the back of your hand and pull it up about one centimeter before letting go. If you're not dehydrated, the skin will spring back into its regular position almost immediately. If it takes a few seconds to settle back down, you may be dehydrated. End Image Description.
A picture showing how to do a skin turgor test to check skin elasticity. In this case it is talking about using the test to check for dehydration, but it is still the same test used for skin elasticity. Click here to read the source article.

The last physical characteristic is your nipple and areola size and placement. The average male has much smaller nipples and areolas than a female. The average female areola is about 38mm (and can even be larger than 100mm) where as the average male usually falls around 22mm to 28mm. The nipple itself is also smaller in men, usually just a few cubic millimeters when erect, whereas females are typically around a cubic centimeter when erect. Males nipples are also usually positioned further apart than females at about 21 cm between them, although this is a difficult thing to measure as males are typically larger than females, and female’s breast tissue is movable. When it comes to nipple and areola size and how it affects surgery, usually it is a little bit more of the patients choice as to what they want done. There is no major medical reason to resize the nipple or really even have nipples after a mastectomy, it’s a purely aesthetic choice. Nipple and areola size doesn’t matter as much in double incision surgery as they will have to be removed and grafted back on. It matters the most in small chested individuals who will not need a nipple graft, therefor have to make the decision of getting an areola or nipple reduction. In most cases it is possible to get revisions on the nipple and areola if you are unhappy with them after they heal.

On to the factors that you have some control over. A good doctor will take into account what you want and balance it with what he believes is best for you. If you want keyhole surgery, but you have a D cup chest, the doctor should obviously not do keyhole surgery as the results will be very poor. On the other hand if you are a good candidate for both buttonhole and double incision surgery, a good doctor will make sure your understand the risks and benefits of each and let you make that decision. Your body is your own and you shouldn’t be afraid to speak up about what you want and to advocate for your own health, at the same time you need to listen to your doctor as they are the expert. A doctor patient relationship is very important and if you don’t feel good about a surgeon do not be afraid to find a new one. You have a say in what you want, but you aren’t a professional.

Each method has their own pros and cons that have to be weighed, both by you and your surgeon to make a final decision on which method to use.

Surgery TypeProsCons
Keyhole (semicircular) Works on A cup or less.Minimal scarring, scar is hidden around areola,
Heals easier, usually maintain full nipple sensation, practically the same as gynecomastia surgery.
Does not resize the areola, does not move the nipple location, can leave extra skin, only works with very small breasts and good elasticity, requires drains, may not get chest skin tight, small hole for operation to be performed out of (difficult for surgeon).
Transareolar
Works on A cup or less.
Minimal scarring, heals easier, nipple reduction can be achieved at same time. Does not resize the areola, does not move the nipple location, can leave extra skin, only works with very small breasts with good elasticity, requires drains, may not make chest skin tight, uncommon procedure, scar cuts through the areola.
Periareolar (concentric circular, doughnut)
Works on A to B cup.
Scars are hidden,
No nipple graft, resizes the areola, removes extra skin, usually retains full nipple sensation, may not need as good of skin elasticity.
Does not move the nipple location, needs a relatively small breast, won’t work if there is not enough skin, risk of wrinkling due to purse string suture, high rate of revisions, difficult to achieve uniformity, difficult for the surgeon, usually requires drains.
Lollipop
Works on B to C cup.
Removes even more skin, good for people between peri and double incision, resizes areolas, avoids nipple grafts, smaller scars than double incision, may work with less elasticity, may or may not require drains.Uncommonly done (surgeon might not have experience), larger scar, more visible scar placement, usually requires drains, does not move nipple location, very few people have the right characteristics to qualify for this surgery.
Fishmouth (extended concentric circular)
Works on B to D cup.
Resizes areola, doesn’t use nipple graft, nipple usually has rather good sensation compared to other techniques, better flatness and tightness than inverted-T, removes extra skin, works below a D cup, large hole for removal, doesn’t usually require drains but are recommended.Uncommonly done (surgeon might not have experience), very visible unnatural scar, doesn’t work well for small breasts very large breasts or low nipples, don’t have much control over nipple placement.
Buttonhole
Works on C to D cup.
Resizes areola, attempt at maintaining nipple sensation, doesn’t use nipple graft, all scars can be hidden by chest contour, removes extra skin, doesn’t usually require drains but they are recommended.Long visible scars, can cause wrinkles, don’t have control over nipple placement, can have problems with wrinkling and extra tissue, can’t be done with small breasts or large breasts with low nipples.
Inverted T (Anchor)
Works on C to D cup.
Attempts at maintaining nipple sensation, doesn’t use nipple graft, resizes areola, majority of scars are hidden by chest contour, removes extra skin, doesn’t usually require drains but are recommended.Visible scar coming down from the nipple, can’t be done on very small or very large breasts with low nipples, a lot of scars, most commonly done of the large chest types other than double incision, don’t have much control over nipple placement, leaves some tissue behind to retain nipple sensation so there will not be a totally flat chest.
Double Incision
Works above a B cup.
Makes a very flat and tight chest, works on the majority of people, moves the nipple into the masculine position, resizes the areola, scars are hidden in natural chest contour, the most common type of surgery (any top surgeon is very familiar with the technique), very wide opening for surgery, drains are usually not required but recommended.Requires free nipple graft (if nipples are wanted), large scars, body can reject nipple graft or lose part of it, usually takes the longest to heal from, may never recover sensation in the nipples, does not work for small chests.

References and Resources for more Information:

Beckenstein, M. S., Windle, B. H., & Stroup, R. T. (1996, January). Anatomical parameters for nipple position and areolar diameter in males. Retrieved October 13, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/8722981.

  • A study that looked at the size and position of male nipples and areolas.

Grift, T. C. V. D., Elfering, L., Bouman, M.-B., Buncamper, M. E., & Mullender, M. G. (2017). Surgical Indications and Outcomes of Mastectomy in Transmen. Plastic and Reconstructive Surgery140(3). doi: 10.1097/prs.0000000000003607. https://www.ncbi.nlm.nih.gov/pubmed/28841608

  • A study that assessed the results of different methods of top surgery done on transmen.

Live Surgery of Transgender Ftm/Non-Binary Periareolar Top Surgery Performed by Dr. Mosser. (2019). Retrieved from https://www.youtube.com/watch?v=wOoT4OjhqXU&t=486s

  • A video of Dr. Mosser performing periareolar top surgery where he mentions the ideal nipple diameter being about 22 mm. Warning age restricted video, graphic surgical content. His website also has articles that go more into depth on each different surgery type.

Mosser, S. (n.d.). The Mosser Method – FTM Chest Surgery Types. Retrieved October 12, 2019, from https://www.genderconfirmation.com/which-surgery-is-for-me/.

  • An article by Dr. Mosser explaining how he makes the decision on the best method to use for each individual’s top surgery.

Ptosis (breasts). (2019, September 24). Retrieved October 12, 2019, from https://en.wikipedia.org/wiki/Ptosis_(breasts).

  • A wikipedia article on breast ptosis.

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