Top Surgery

Reconstructive chest surgery, commonly referred to as ‘top surgery’ is typically sought by trans people who were presumed female at birth (PFAB), including men and non-binary people, to remove breast tissue and sculpt the chest into a pectoral form.

While binding is an effective form of flattening chest tissue, it can cause pain, and respiratory and skin complications when used inappropriately or over long periods of time. Top surgery can improve physical and psychological health and wellbeing outcomes for those who seek it. For many people, this is the only surgery undertaken.

There’s no right or wrong way to be or embody your gender, regardless of your surgical status. Not all trans people want, seek or can have surgery, and being trans doesn’t necessitate surgery either. Find out more about that here.

Information and resources to assist clinicians learn more about top surgery can be found here.

The Standards of Care - 7th Ed (SoC7) is published by the World Professional Association for Transgender Health (WPATH) and offers guidance to clinicians working with trans patients all over the world, including criteria and recommended referral pathways for those seeking particular medical and surgical interventions.

The SoC7 does not specify an order by which surgeries should occur, if sought at all, and are guidelines, not legislated requirements.

WPATH state that top surgery is “not merely another set of elective procedures” and that “reported quality of life was higher for patients who had undergone breast/chest surgery than for those who had not.”

In Australia, top surgeons will need a readiness referral from a mental health provider stating that you are able to consent, and that the intervention is right for you. Find out more about readiness referrals here.

There are several kinds of surgical options, and the procedures chosen will depend on the surgeon’s expertise as well as your body and needs.

Double incision top surgery with nipple grafts

Also known as a bilateral subcutaneous mastectomy with nipple grafts, this procedure is typically recommended for people with larger chests and bodies. This procedure is usually an inpatient surgery that takes between 3 and 4 hours for the surgeon to complete.

In this procedure, the nipples are removed, typically decreased in size, and positioned on the chest for a more masculine appearance. This specific procedure often results in decreased nipple sensation and more significant scarring, which often fades over time.

Periareolar top surgery

Also known as a peri or circumareolar, this procedure is typically recommended for people with smaller chests and bodies. This procedure is usually an inpatient surgery that takes between 3 and 5 hours to complete.

Most people are able to maintain most or all of their nipple sensation after recovery — though the large majority of people experience decreased nipple sensation in the days immediately after surgery. While periareolar top surgery provides you with less visible and less significant scarring, people may require a revision to achieve a completely flat chest.

Keyhole top surgery

This procedure is typically only recommended for people with very small chests and tight chest skin. No excess skin is removed during keyhole top surgery, so few people are good candidates. This procedure is typically an inpatient surgery that takes between 1.5 and 3 hours.

This procedure results in very little visible scarring and preserves nipple sensation, but doesn’t provide the opportunity for the nipple to be repositioned on the chest

Inverted-T top surgery

Similar to Double incision top surgery, but the nipple is reduced in size and re-positioned by doing an additional vertical incision from the bottom of the areola to the horizontal incision along the pectoral muscle. With this surgery, the nipple stalk and nerve are not severed and so the nipple retains blood supply and sensation.

No nipple top surgery

This procedure involves removing the entirety of the nipple and areola from the chest, followed by 3D tattooing of the nipple. Note that the tattoo may require touching up over time as the ink fades.

Many of us need to wait years before being able to undertake surgical interventions. It can sometimes feel that everything you’ve been doing in life has led to this very specific moment. That’s a lot of pressure, and it often comes with a hefty price, that isn’t always financial.

Our families and friends may not get it, and it might be tough to get enough time off work to recover properly. Make sure you surround yourself with supportive peers and allies, and try to be gentle with yourself. Even if you sometimes doubt yourself, which is really normal, you will get through it.

Hospital

You may spend between 1-7 nights in hospital, this often depends on if you have private health insurance to cover the hospital stay, if not you’ll typically be able to leave the hospital the day of or after the surgery.

When you leave the hospital you will need to be signed out by a responsible person. They’ll need to be able to get you home or to wherever you’ll be recovering.

After your top surgery, your chest will be taped, and a surgical binder will be used to minimise swelling. Drains, which are small, thin tubes, may temporarily be placed to help drain any excess fluid or blood.

Follow up care

You will be required to wear a surgical binder for some weeks after surgery, depending on the type of surgery undertaken, the size of your chest and how your body is recovering. You will be given specific instructions for how to care for the surgery site by your surgeon, including medications to apply topically or take orally to help with healing. You can expect a number of follow up appointments with your surgeon as you heal. This may include being aspirated by the surgeon to remove any excess fluid.

Recovery from top surgery can take up to eight weeks. You’ll likely need to restrict movement as you heal. Keep the binder on and channel your inner T-Rex, try not to reach, push, pull, or carry anything heavier than 2kg for the first few weeks. This will improve recovery and reduce scarring. A good thing to consider is avoiding anything that might cause you to break a sweat.

Rest, stay hydrated and take good care of yourself, it can be helpful to ask friends and other allies check in and it’s ok to ask for extra help when you need it. Refer to peer networks or a mental health professional, as needed.

Scars are worn like a badge of honour by some people, and others prefer minimal scarring. Using 100% silicone lube twice a day on the surgery site goes a long way to reduce scars and can be really beneficial in establishing a new relationship with a new part of your body.

Even if a surgical outcome is affirming, it can still be confronting. It is great to feel excited, but also very normal to feel overwhelmed, uncomfortable, to grieve, and to take time to become used to your body again. This isn’t an indication that you have made a mistake, or regret your decision, but a normal part of reconnecting with how your body appears and functions. Sensation will change over time, and you will learn this for yourself over time.

Holistic body work such as lymphatic drainage massage can also be helpful after surgery. Gentle massage toward the direction of your armpits may be helpful.

Top surgery can cost between $4,000 - $18,000 out of pocket, depending on the technique and surgeon.

It is possible to get a Medicare benefit for your anaesthetist, surgeon, surgical assistant, and pathology. In addition, some private health insurers cover your hospital stay, and a portion of surgeon, assistant, and anaesthetist fees. Ask your surgeon for the MBS Item Number they use (often 45240 x2, though sometimes 1519, 45451 x 2, or 31524 x2) and check in with Medicare or your insurer, if you have one. For more information about accessing compassionate release of superannuation, go to our Superannuation page.

Top surgery is available in Australia.

The Australian Professional Association for Trans Health hosts a provider list of their members. It includes surgeons in Australia and is available here.

All surgeries carry some risk, including complications, infection, blood clots, and rarely death. It’s important to ask your surgeon about possible risks and how to avoid them.

While some surgeons in Australia will only perform top surgery for people aged 18 years and over, there are some surgeons who will perform top surgery for people who are 16 years and over. Parental consent, alongside the coordinated care of a multidisciplinary team (as available) is required for top surgery for anyone under 18 years old.

If you are under 18, it is advised that you and your carer or guardian contact your preferred surgeons asking if they will perform the surgery now, and what their referral requirements area, or if they prefer to wait until you are over 18.

For more information about your legal and medical rights while under 18, go to our Under 18s page.