Top Surgery (Chest Masculinization)

The aim of the top surgery is to grant a masculine look to the chest of patients that chose to undergo gender transitioning (trans men) procedures or neutral or non-binary patients. This chest-conformation change is reached performing three complementary steps in the same procedure:

  • Near-total mastectomy
  • Areola and nipple reconstruction
  • Liposuction above and on the side of the chest
  • Lipografting (optional) to create hypertrophy of the greater pectoral muscle

Whom is Top Surgery indicated for:

Masculinizing Mastectomy Surgery

In 90% of the cases, we perform Top Surgery in patients that use hormones (testosterone) and that are undergoing FTM transition, with this being one of the last steps.

After this procedure, it will no longer be necessary to use the binder. In 10% of the cases, we receive neutral or non-binary patients that chose not to use hormones and that do not want to have their breasts as a gender-defining criterion.

Several techniques have been described by several authors and we always take into account the best position to make the scar as less noticeable as possible. Thus, we do not use the inverted-T or flying-saucer techniques, since the scar is very visible. Consequently, we must consider the technique that removes as much mammary tissue as possible leaving a very acceptable scar.

For patients using testosterone, this will be easier, since the chest hair helps hide the scar.

Below, check out TWO ways of performing top surgery.

Horizontal Top Surgery (double incision)

This is the most used mastectomy because it works for medium and large breasts, allowing for the removal of a large amount of skin and mammary gland. It allows for a significant reduction of voluminous breasts. In other words, even if the breasts are large, we can achieve a flat and masculine chest with small areolas.

What is horizontal mastectomy?

We draw a large, horizontal skin fuse that will allow for the removal of a large amount of skin. This drawing runs closely along the base of the breast and includes the areola and nipple. These two will be removed in block, together with all the skin and gland.

Therefore, this technique allows for large volume reductions. After doing this, we remove more gland tissue from the upper part of the chest, right above the initial horizontal line. It’s common to use drains in this type of surgery.

The material removed varies a lot in weight and can reach up to 1.5 kg per side. We begin the internal absorbable sutures in several layers until we reach the skin. In the end, we either apply a special dressing that barely needs to be changed or the tape-glue, which will stay in place for 20 days. We will not use external stitches in the horizontal scar.

How are the areola and nipple reconstructed?

After removing the mammary volume, with an already flat chest, we will precisely calculate the position of the areolas, since the male areola is slightly more divergent than the female’s. We don’t use a standard measurement, we always calculate based on the width of each patient’s chest.

In thin patients with a narrow chest we use a measurement of 10 cm starting at the midline of the body. In patients with an average chest of about 11 cm this measurement starts in the center. In patients with a wide chest, we can use 12 or even 13 cm. After calculating all this, we will graft the nipple and areola.

It’s important to say that the male areola does not have the breast-feeding function, consequently being much smaller, and must have a maximum diameter between 15 and 25 mm. In the cases where the nipple is too big, we will also do the reduction either of its diameter, or projection (height), or both.

A special dressing called Brown’s dressing is used to protect this graft, since the areola and nipple tissue is very thin and delicate. Our areola or areola-and-nipple-grafting success rate is of nearly 100%.

It’s important to point out that since the nipple and areola have been disconnected from the body and grafted later, there will be a sensitivity loss in 100% of the cases. This loss of sensitivity is part of the technique and a few patients have reported a return of the sensitivity after a few months, but we advise you not to count on this.

Periareolar Top Surgery:

Indicated for small breast, it’s great advantage is that the areola and nipple don’t need to be removed in the beginning of the surgery, they will remain connected to the skin throughout the entire procedure. In this technique we have a very high sensitivity-return rate, of about 95%.

How is the Periareolar Mastectomy done?

Dr. Alexandre Charão will calculate how much skin and mammary tissue (gland) must be removed and will draw a sort of circle around the areola, hence the name “periareolar mastectomy.” The first step of the mastectomy surgery consists of the removal of as much of the gland as possible.

The second step is to mark how much skin will be left over and must be removed. After these two steps, we always perform a slight reduction of the areola, since men have a smaller areola than women.

In women, an areola must measure between 4 and 5 cm, and in men it should not exceed 2.5 mm.

If necessary, the nipple may be reduced in this step as well. After all these moments of the surgery, we begin the round-block suture: a circular suture that allows us to level the chest and close the entire skin area that was removed.

Why do we perform Chest Liposuction in some patients?

The main reason is that there is an extension of the breast in the direction of the axilla. To avoid having a large scar, we use liposuction to remove the contents without incisions. The other reason is small fat deposits that usually appear above and to the side of the breast and that will be visible after the mastectomy.

So that this fat does not call attention in the future, we already indicate liposuction as well. It’s important to mention that this is an optional procedure and will only be done if the person is interested in removing the fat build-up.

How is the Pectoral-Muscle hypertrophy?

We use the fat removed in the liposuction and inject it in the greater-pectoral muscle to achieve a better definition of the chest. Such procedure is optional and highly indicated for patients that workout a lot and already have a certain degree of muscle definition but want more hypertrophy. The use of testosterone will also help with the muscle and hypertrophy definition.

What is the recovery like?

All our patients receive two Physiotherapy sessions, with the first session done still at the hospital, that include: Lymphatic Drainage, Laser/LED and Taping. The patient is discharged the day after the surgery and the first post-op appointment will be 3 days later.

The recovery is usually a little more difficult in the first ten days, since it is a large surgery, but after that period the body reacts and the recovery becomes easier. We have not observed post-op pain in our patients.

Will the post-op be painful?

No, our patients do not mention pain, neither in the region of the mastectomy nor in the area of the liposuction, when it’s performed. There will always be an edema and a few bruised marks, therefore it will be necessary to use a post-op brace for two months.

When are the drains removed?

Our technique is in constant evolution and presently we are proud to say the drain is almost always removed in the first appointment following the hospital discharge. The removal of the drain is painless.

When will the stitches be removed?

Whenever possible, we use internal, absorbable stitches. That means you will barely have external stitches. One location where this is necessary is in the areola, in the horizontal mastectomy cases in which we always use a graft. In these cases, the stitches are removed 10 to 14 days after the surgery.

Will I have to change the dressing all the time?

No, we always use special dressings or the tape-glue called Dermabond Prineo. In both cases, you do NOT have to change the dressing.

When will I be recovered?

After 15 days, you will be able to do light activities, such as short walks. After a month, you will be able to do all basic daily activities like driving, working, and raising your arms. A few exercises will be allowed at this time. To do all exercises more intensely, we ask for 2 to 3 months. All patients receive a post-op booklet with detailed descriptions of these steps.

In a nut shell:

Our follow-up lasts 6 months and you will have a Whatsapp group to answer all your questions. Our team is composed of doctors, nurses and physiotherapists that will be with you throughout all the steps of the process. The recovery is reasonably smooth and we are a reference in top surgery, receiving patients throughout Brazil and abroad.

Our methods are constantly improving and we always bring some new benefit to our patients, such as less drain time and early return to the patient’s activities. The absence of pain and a very thin scar are also high points reported by our patients.

How to Undergo Top Surgery In Brazil?

Brazilian Plastic Surgery is very well-known around the globe. This started to happen with Dr. Ivo Pitanguy’s work, which raised the bar for modern plastic surgery worldwide.

At Dr. Alexandre Charão’s clinic, we have developed several protocols to improve our post-op outcomes and comfort. We were able to summarize years of experience in this site text.

Our patients come from many different countries around the world and all of them have reported the following advantages of undergoing the procedure in Brazil:

  1. high technical capacity
  2. lower cost
  3. friendlier experience in comparison to other countries
  4. complete team to facilitate a quick recovery
  5. safety in all steps

The next step for you to eliminate whatever is bothering you is to schedule an appointment
with Dr. Alexandre Charão.

This can be done in two ways:

After you get in touch, we will send you a link for the payment of the appointment, which
will be scheduled soon after.

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