Techniques & Incisions | Top Surgery Center of Connecticut

Female To Male (FTM) & Female To Nonbinary (FTN) Reconstruction Chest Surgery

FTM/N Techniques & Incisions

FTM/N Top Surgery involves removal or reduction of breast tissue to masculinize the chest wall of a transmasculine or non-binary individual, or to gender neutralize the chest wall for other non-binary individuals. When the presence of breast tissue contributes to gender dysphoria, FTM/N Top Surgery is highly effective at alleviating gender dysphoria and is considered are constructive chest surgery. After surgery, patients generally feel a sense of relief because the removal of the unwanted breast tissue allows them to feel more congruent with their inner sense of self and more comfortable in their bodies.

FTM/N Incisions

There are two main categories of FTM/N top surgery approaches, larger-incision approaches such as the double incision, and minimal-incisions approaches like the periareolar and keyhole approach. Other less common types of larger-incision approaches include the fishmouth, buttonhole, inverted-T, inframammary and lollipop incisions. Each procedure carries its own risk/benefit ratio and may be more appealing to you based on your primary surgical priorities and concerns. A thorough discussion with Dr. Chandler after evaluating your unique anatomy can help determine the best procedure for you.

The buttonhole and inverted-T are attempts to increase hope of preserving erotic nipple sensation, but will not guarantee nipple sensation and will result in a chest wall that is not as flat as possible. The fishmouth is unique in that it produces a scar that is non-anatomic in location. The inframammary incision involves an inferior horizontal scar that is similar to the double-incision but involves preservation of the nipple and is only indicated for patients with no extra skin (similar to the periareolar or keyhole, for patients that have a slightly larger amount of breast tissue).The lollipop incision is similar to the periareolar incision but includes a vertical incision from the inferior areola down to the inferior chest to allow for a small amount of skin excision from the inferior chest.

Choosing the Right Incision for Your Anatomy

When it comes to choosing your surgical approach, there are several options that will be discussed in-depth during your consultation. The approach chosen will depend on the volume of breast tissue required to be removed, the amount of extra skin present on your chest, your skin quality and elasticity and your individual preferences and goals. Nipple ptosis refers to the extent to which the nipple areola complex lies at or below the lower breast fold, which is representative of the amount of skin excess that is required to be removed. A physical

examination and measurements of your chest during your consultation will help determine whether you are a good candidate for a minimal-incision approach or a larger-incision approach. Dr. Chandler’s Top Surgery Anatomy video (link to YouTube video from the home page) can help you determine on your own which procedure you would best qualify for by showing you how you can measure your chest wall at home and determine the extent of nipple ptosis you have.

Once you figure out whether your anatomy is best for a larger-incision approach or a minimal-incision approach, there are multiple options available to you within each of these categories. For example, if you qualify for a minimal-incision approach, you can then decide whether you are satisfied with the size and shape of your nipple areola complex, or whether you would prefer a reduction in the diameter of your areola or the projection of your nipple. If you qualify for a larger-incision approach, you should then consider whether or not erotic nipple sensation is important to you and the extent of flatness you are willing to give up to maintain a hope at preserving nipple sensation. You should also consider your preferences regarding incision shape, incision location and nipple characteristics. Do you prefer a scar on the straighter side or a gentle curve? Do you like a contoured scar look that follows the chest muscles? Do you prefer nipples that are located close to your incision or do you prefer nipples located higher up? Do you want centrally or laterally located nipples? Do you like an oval or a circular nipple? These are all questions you will be able to discuss during your consultation and options you can think about before your surgery date.

See our decision tree to help you determine which FTM/N procedure is best for you.

Incision options include the following:

Keyhole Incision

A keyhole incision is ideal for patients with a small volume of breast tissue present, good skin elasticity and no nipple ptosis. This technique involves an incision at the junction of the areola (darker pigmented skin around the nipple) and lighter surrounding skin, usually along the inferior 180 degrees of the areola. The difference between the keyhole and the periareolar incision is that in the keyhole approach, the areola does not significantly change in size and shape and simply retracts against the chest wall as is. There is a very small amount of natural areola retraction that may result in a slightly smaller areola diameter.

Periareolar Incision

A periareolar incision is ideal for patients with a small volume of breast tissue present, good skin elasticity and minimal nipple ptosis, with an areola that is larger than the desired size. With this approach, the incision is carried all the way around the areola and the areola is reduced in diameter to create an aesthetically more pleasing size and/or shape. Only a small amount of extra skin is able to be removed with this approach.

Periareolar Incision

Minimal-scar approaches are beneficial in that they can result in a very flat chest, but are limited in the at they do not allow as much skin excision as in larger-scar approaches and they do not allow customizability of nipple position into a more lateral location if that is preferable.

Double Incision

The Double incision approach is the most commonly requested procedure for patients with extra skin or a large volume of breast tissue. This approach involves removal of breast tissue and skin through two incisions in a horizontal elliptical pattern, leaving a horizontal scar near the inferior chest border. Double incision surgery is the most effective technique for patients with excess skin to produce the flattest possible chest wall, and requires that the nipples be treated as “free nipple grafts”, meaning that the nipple areolas are removed, thinned out, reshaped and resized, and placed back on the chest wall in a new location. The areolas will become smaller and can be reshaped into an oval or a circle depending on your preference.

Inverted T (anchor) & Button hole Incisions

The inverted T (anchor) and buttonhole (anchor without the vertical component) incision patterns are also options for patients with extra skin or a large volume of breast tissue. These procedures involve a skin excision patternlike the Double Incision, but maintain the nipple attached to some underlying breast tissue ("the pedicle"), avoiding the need for a free nipple graft. The purpose of performing these procedures over the Double Incision is to provide some hope of maintaining nipple sensitivity, and these approaches will also maintain three-dimensional nipple volume and projection. However, retaining nipple sensitivity is not guaranteed and the unique downside to these procedures is that they will not result in a completely flat chest as in the Double Incision approach, which is an important consideration for many individuals.

Fishmouth incision

This approach may be selected by some non-binary patients because the horizontal incision ends up higher on the chest wall, close to the level of the nipple areola complex. With this approach, the nipple areola ends up positioned in line with the scar, away from natural anatomic chest wall boundaries. This non-anatomic incision location is preferred by some nonbinary individuals who prefer an incision that does not follow anatomic boundaries. In this approach, excess skin is able to be removed and the nipple areola may remain attached or maybe treated as a free nipple graft, depending on the level of chest flatness desired.

Lollipop Incision

The lollipop incision may be selected by patients who are on the cusp of qualifying for a minimal-scar approach, but who have a small amount of skin excess located at the inferior chest wall. This involves a scar around the nipple and straight down (in the shape of a lollipop)and allows for a small amount of skin excision from the inferior chest.

Liposuction

Patients who have a very small amount of breast tissue present and no skin excess may qualify for liposuction alone to remove the breast tissue. Liposuction is rarely performed alone because usually breast tissue is more glandular rather than fatty in composition, which is not easily removed via liposuction. However, if the breast tissue is more fatty in composition and small in volume, it is possible that liposuction would remove a significant amount of that tissue, and that with postoperative compression encouraging the skin to retract against the chest wall, a flat appearing chest wall would result. The amount of skin retraction is dependent on skin elasticity and is not entirely predictable, thus it is possible that a secondary procedure to remove skin through a periareolar approach may be necessary.

Liposuction is commonly performed in combination with the top surgery skin excision patterns listed above. Liposuction helps to remove excess fatty tissue, especially in the preaxilla (the area between where the breast tissue ends and the armpit), the lateral chest wall(lateral to where the breast tissue ends under the armpit)and sometimes in the middle of the chest over the sternum. This is very effective in removing fatty tissue outside the area of breast tissue. If performed in conjunction with top surgery, liposuction can be performed through the top surgery incisions, without creating any new incisions or scars.

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