Top surgery is a gender-affirming procedure that reshapes the chest to better match a person’s gender identity. It includes both chest masculinization (removing breast tissue to create a flatter, more traditionally masculine chest) and chest feminization (augmenting the chest with implants or reshaping existing tissue for a more traditionally feminine contour). The term is used almost exclusively in the context of transgender and nonbinary healthcare.
If you searched for the TOPS System, an FDA-approved spinal implant, that’s a different procedure entirely. It’s covered at the end of this article.
Chest Masculinization Techniques
Chest masculinization is the more commonly discussed form of top surgery. The goal is to remove breast tissue and reshape the chest so it appears flat or contoured along the pectoral muscles. Three main techniques exist, and the right one depends largely on how much tissue needs to be removed and how elastic your skin is.
Double Incision Mastectomy
This is the most widely used technique worldwide and works for all body shapes and sizes. The surgeon makes two horizontal incisions across the chest, following the natural line of the pectoral muscles, then removes the breast tissue through those openings. The nipples are typically resized and repositioned as free grafts to sit naturally on the new chest contour. Because the incisions are long, this method does leave visible horizontal scars, though they fade over time and sit along the muscle line. It’s the go-to option for people with moderate to large amounts of chest tissue.
Keyhole (Periareolar) Surgery
For people with very small chests and excellent skin elasticity, keyhole surgery offers a less invasive alternative. The surgeon makes a small cut along the lower edge of the areola and removes breast tissue through that opening. The areola and nipple may be slightly reduced in size before the incision is closed. Scarring is minimal compared to the double incision approach. However, eligibility is strict: you need both a very small amount of tissue and skin that will naturally retract and tighten after the tissue is removed. Without that elasticity, the remaining skin can look loose or uneven.
Buttonhole Technique
The buttonhole method is a middle ground for people who want a more masculine chest but also want to preserve nipple sensation. Rather than removing the nipple and repositioning it as a graft, the surgeon keeps the nipple attached to a stalk of tissue that includes the nerves responsible for feeling. The trade-off is that this stalk leaves a small amount of bulk in the chest area, so the result may not be as completely flat as a double incision. It’s best suited for people who prioritize sensation over the flattest possible contour.
Chest Feminization Techniques
Chest feminization typically involves breast augmentation. A surgeon places a gel or liquid-filled implant into a pocket behind the breast tissue or beneath the pectoral muscle, centering each implant under the nipple. The procedure is similar to cosmetic breast augmentation performed on cisgender women, though the surgical considerations can differ because of chest wall structure and skin characteristics shaped by testosterone.
For patients who want a subtler result, gender-affirming breast reduction is also an option. This involves removing some tissue through a longer incision while keeping the nipple and its nerves intact on a tissue stalk. The surgeon then shapes the remaining tissue into a rounder, slightly feminine profile. The final scar is anchor-shaped, with lines running beneath and vertically below the breast.
Insurance Coverage and Requirements
Coverage varies significantly between insurers. A study evaluating 57 major U.S. insurance companies found that 96% covered chest masculinization, while only 68% covered breast augmentation for chest feminization. That gap is substantial and reflects ongoing disparities in how these procedures are classified.
The requirements for approval also vary widely. No single criterion was universally required across all insurers. Common prerequisites include one or two letters from mental health professionals, a period of living in your identified gender role, and in some cases, a course of hormone therapy before surgery. Hormone therapy requirements were far more common for chest feminization policies (90%) than for chest masculinization (21%). Only 4% of companies used criteria consistent with the World Professional Association for Transgender Health (WPATH) guidelines, meaning most insurers impose additional hurdles beyond what clinical experts recommend.
Recovery After Top Surgery
Recovery timelines depend on the technique used. Keyhole procedures generally involve a shorter healing period than double incision surgery because less tissue is disrupted. Across techniques, most people can expect to return to light daily activities like housework within four to six weeks. Driving is typically restricted for the first two to four weeks, and car rides should be kept under 30 minutes during that window to limit strain on the chest.
If your job is primarily desk work, returning after four to six weeks is common. Jobs involving light physical labor may require three to six months off. Heavy physical labor may not be possible in the same capacity afterward, at least for a significant recovery period. Strenuous exercise, including jogging, cycling, and weight lifting, is off-limits until your surgeon clears you. Walking is encouraged from the start, gradually increasing distance each day.
Surgical drains are often placed during the procedure to prevent fluid buildup and are removed within the first week or two. Compression garments are standard for several weeks to support healing and help the skin conform to the new chest shape.
The TOPS System: A Spinal Implant
If you were searching for “TOPS surgery” in the context of back or spine treatment, you’re likely looking for the TOPS System, an FDA-approved spinal implant designed as an alternative to spinal fusion. The name stands for Total Posterior Spine System.
The TOPS System treats a specific combination of lower back conditions: mild vertebral slippage (Grade I spondylolisthesis) combined with moderate to severe narrowing of the spinal canal, occurring at one level between the L3 and L5 vertebrae. It’s approved for adults between 35 and 80 years old. The device attaches to the spine using screws and sits in the back of the vertebral column, supporting body weight while allowing the two vertebrae to move relative to each other. That’s the key difference from fusion, which locks the vertebrae together permanently.
How It Compares to Spinal Fusion
In clinical trials, the TOPS System outperformed traditional fusion on several measures. At two years, 94% of TOPS patients reported meaningful improvement in disability scores compared to 77% of fusion patients. Pain reduction was also more pronounced: 84% of TOPS patients reported significant improvement in back pain versus 62% in the fusion group. Younger patients (under 65) with the TOPS device reported significantly less leg pain at both one and two years after surgery.
The mobility advantage is straightforward. Because fusion eliminates movement at the treated level, patients lose flexibility in that segment permanently. The TOPS group preserved significantly more range of motion, including side-to-side bending, at both one and two years. Reoperation rates were also lower in the TOPS group (about 8%) compared to fusion (about 13%) at two years, though the difference wasn’t statistically significant.
Recovery from TOPS surgery follows a similar trajectory to fusion recovery in terms of general timelines, since both involve spinal decompression and hardware placement. Light activities resume within four to six weeks, with a gradual return to more demanding tasks over the following months.