Top surgery is a procedure that reshapes the chest to match a person’s gender identity. For transgender men and nonbinary people, this typically means removing breast tissue to create a flatter, more masculine chest. For transgender women and nonbinary people, it means breast augmentation to create a more feminine chest. Both fall under the umbrella of gender-affirming surgery, and the specific technique used depends on a person’s body, goals, and anatomy.
Masculinizing Chest Surgery
Masculinizing top surgery removes breast tissue and reshapes the chest wall. In many cases, the nipples are also resized and repositioned. The goal is a flat, natural-looking chest contour. There are several techniques, and the right one depends largely on breast size and skin elasticity.
Double incision with free nipple graft is the most common approach for people with medium to large breasts or significant skin laxity. The surgeon makes two horizontal incisions across the chest, removes the breast tissue, trims excess skin, and then grafts the nipples back onto the chest in a new position. This technique gives the surgeon the most control over the final shape and nipple placement, but it does leave visible horizontal scars across the chest. Because the nipples are fully detached and reattached, sensation in them is typically lost, though some partial feeling may return over time.
Periareolar (or semicircular) techniques work best for people with smaller breasts and good skin elasticity. The incision follows the edge of the areola, resulting in less visible scarring. The tradeoff is that the surgeon has less control over the final contour and nipple position. Since the nipple stays partially attached, there’s a better chance of preserving some sensation.
Keyhole is the least invasive option, reserved for people with very small breasts and firm skin. A small incision is made along the lower edge of the areola, and tissue is removed through it. Scarring is minimal. Revision rates for keyhole are comparable to those for double incision (roughly 10 to 14%), though the reasons for revision differ. Keyhole revisions tend to address contour issues, while double incision revisions more often involve nipple-related touch-ups.
Feminizing Chest Surgery
Feminizing top surgery is a breast augmentation procedure. For transgender women, hormone therapy often produces some breast development, but many people want additional volume or a shape that feels more proportional to their body. Surgery can address that gap.
Most feminizing procedures use silicone gel implants, which come in a range of profiles from low to extra full. Silicone tends to be preferred over saline because the gel creates a more natural feel, and modern highly cohesive (“gummy bear”) options hold their shape well. In one large surgical series, about 65% of patients received cohesive silicone implants, with moderate and low-plus profiles being the most popular choices.
Implant placement matters, and it differs from what’s typical in cosmetic breast augmentation for cisgender women. Because transgender women generally have less native breast tissue, surgeons place the implant above the chest muscle (subglandular) in roughly 80% of cases. This avoids a problem called animation deformity, where the implant visibly shifts every time the chest muscle flexes. A smaller number of patients receive subfascial placement, which sits just beneath a thin tissue layer for a bit more coverage.
Some patients also need additional contouring during surgery. About a third of patients in one academic study had scoring of the mammary gland, a technique that loosens tight breast tissue to allow the implant to sit more naturally. This is especially useful when hormone therapy has produced tubular or asymmetric breast growth.
Recovery Timeline
The first week after masculinizing top surgery is the most restrictive. Most patients go home the same day or the next morning with surgical drains in place to prevent fluid buildup. If drainage output is low, the drains come out at the one-week follow-up.
For the first three weeks, you’re limited to lifting no more than five pounds, roughly the weight of a half gallon of milk. Reaching overhead is off-limits. At three weeks, light activity can gradually resume, but nothing over 25 pounds and no upper-body weight training. You should also avoid raising your arms above shoulder level for the first six weeks.
Most people return to full physical activity, including exercise, around the six-week mark. But healing continues well beyond that point. The final chest contour takes six months to a year to fully settle. Scars continue to mature for about 12 months, and nipple graft pigmentation can take just as long to reach its final shade.
Recovery from feminizing surgery follows a similar general arc: limited activity for the first few weeks, gradual return to exercise over four to six weeks, and several months for the implants to settle into their final position as swelling resolves.
Risks and Complications
Top surgery is considered safe, but like any operation, it carries risks. The most common complications are hematoma (a pocket of blood under the skin) and seroma (a pocket of clear fluid). Seroma is particularly common after any procedure involving tissue removal, with rates in mastectomy-type procedures reported as high as 15 to 85% depending on the study, though most are small and resolve on their own or with a simple office drainage.
For masculinizing surgery specifically, nipple graft complications are a concern with the double incision technique. Partial graft loss, where a portion of the nipple doesn’t take, is uncommon but possible. Hypopigmentation, where the nipple heals lighter than the surrounding skin, is more frequent. Infection, poor scarring, and chest contour irregularities that require revision are other possibilities.
Feminizing surgery carries the standard risks of any implant-based procedure: capsular contracture (where scar tissue tightens around the implant), implant malposition, and the eventual need for implant replacement, since implants are not lifetime devices.
Sensation Changes
One of the most common questions about masculinizing top surgery is whether you’ll retain chest and nipple sensation. The honest answer is that sensation changes are very likely, at least temporarily. Numbness or reduced feeling across the chest and armpits is normal in the early months and gradually improves as nerves regenerate.
Permanent changes in nipple sensation are possible, particularly with the double incision technique, where the nipple is fully detached. Free nipple grafts generally lose sensation and full projection. Periareolar and keyhole techniques, which keep the nipple partially connected to its nerve and blood supply, offer a better chance of preserving feeling, though there are no guarantees. UCSF lists possible loss of nipple sensation as a disclosed risk for all masculinizing techniques.
Cost and Insurance
Out-of-pocket costs for masculinizing top surgery typically range from $3,000 to $10,000. Feminizing surgery falls in a similar range, roughly $5,000 to $10,000, though costs can be higher depending on body size, desired breast size, and implant choice. These figures usually don’t include the facility fee or anesthesiologist fee, which add to the total.
Insurance coverage has expanded significantly in recent years. Many private insurers and state Medicaid programs now cover gender-affirming top surgery, though requirements vary. Some insurers require documentation of persistent gender dysphoria, a certain duration of hormone therapy, or letters from mental health providers. The specifics depend entirely on your plan, so checking with your insurer before scheduling is the practical first step.