Transgender breast surgery is one of the most important part of gender affirmation. Patients with gender dysphoria often seek surgeries such as breast augmentation or mastectomy depending on their gender identities. Breast augmentation is the best approach for male to female while breast reduction, or partial mastectomies with nipple grafts, are options for female to male and female to non-binary transformation. The surgeries are tailored to each patients’ body and personal identities and aesthetics.

Transmasculine and non-binary breast surgeries (Female to Male) are usually performed under general anesthesia as an outpatient surgery center. There are several techniques.

Partial mastectomy through inframammary fold incision with Free Nipple Graft is performed if patients have medium to large sized breasts (full B or greater cup size), and/or sagging of the breasts. The breast is removed from the infra-mammary crease to above the areola and final scar is positioned along the edge of the pectoralis major which is the normal male chest fold. Liposuction may be used to remove fatty tissue near the armpits and to create the desired contour. The original nipples are reshape to a smaller size, and then are grafted on to the new breast mound as free nipple graft.

Periareolar Incision (purse string) method involves partial to circumferential incision around the areola.  The nipple is left attached via a central pedicle in order to preserve sensation and blood supply. The breast tissue is removed by direct excision, liposuction, or combination of both. The areola size is often reduced. The skin is the pulled toward the nipple, hence purse string technique. In this technique, the nipple can be repositioned to higher and more outward location.  There may be some puckering, depending on the diameter of the skin defect compared to the final nipple areola diameter. The scar puckering often resolves over several months after surgery.

There are a few anatomical keys in nipple areola complex repositioning int transmasculine breast surgery. The male nipple areola complex is slightly oval in the horizontal plane and most often is 27mm in longest width. Ideally the vertical location of the nipple areola complex is around 20cm from the Suprasternal Notch (base of the neck), and it is should be in the lower outer quadrant of the new chest mound.

For male to female patients, hormonal therapy usually increases patients’ breast size naturally, however the breasts are often small and cannot be proportional to their body.  Transfeminine breast surgery (Male to Female) is often performed to attain a more feminine chest. Most often, single stage breast augmentation is the best option. In rare occasions when the breast skin is too restricted (tight) for one stage implant, two stage tissue expander placement followed by exchange to implant may be indicated. Hormone may increase patients’ breast size naturally, however the breasts are often small and cannot be proportional to their body. 

Who are Candidates for Transgender Breast Surgery?

The best candidates are healthy people with realistic expectations of surgery. World Professional Association for Transgender Health (WPATH) provides standard criteria to guide health professionals to optimize patients medically prior to surgery. This requires pre-operative evaluation of a psychologist and a primary care physician. Patients who are optimized medically can proceed with surgical intervention with low overall risks.

How is Breast Affirmation surgery performed?

Breast augmentation and breast reduction are often performed under general anesthesia in an operating room. For male to female transformation, breast implants are often the best option. In rare occasion, patients may require two stages breast reconstruction with tissue expander followed by implants. For female to male patients, breast reduction is tailored to the patients’ body habitus. Sufficient reduction can be achieved through minimally invasive technique with periareolar excision and liposuction, or partial mastectomy and nipple grafting.

What is Recovery Like?

Downtime from surgery is between 1-2 weeks but some patients are able to return to work after a few days. Most patients can go home the same day after surgery. Moderate swelling and minor bruising is expected in the first week. Majority of the swelling will resolve by one month after surgery. Discomfort from swelling and pain along the incisions are the major complaints after surgery and gentle massage is recommended. Physical activity restriction is often 4-6 weeks after surgery.