Shedding the cocoon (top surgery, chest surgery)
Trans men often bind their chests—using bandages or adhesive tapes—to compress or conceal breast tissue. Sometimes this leads to skin injury, reflecting profound discomfort or even aversion toward one’s chest.
Hormone therapy has limited impact on breast size. For many trans men, the first—and often most important—operation is creating a masculine chest contour by means of subcutaneous mastectomy (SCM). This procedure can make it easier to live as a man and to experience one’s gender identity as affirmed. It is often followed by further external genital procedures, such as hysterectomy, metoidioplasty/phalloplasty, and implantation of an erectile prosthesis.
Procedures during transition
We recognize that for some transgender people, upper-chest surgery undertaken during transition may be the only surgical step. While mastectomies are performed in many centers in Poland, these are most often for breast disease in women or for gynecomastia in men; specialists may lack experience with chest surgery for trans men.
At Timeless Chirurgia Plastyczna, we use the newest and most effective methods, continually refined by our surgeons. For us, the primary goal of subcutaneous mastectomy is to achieve an aesthetic, masculine chest wall. We do this by removing all glandular breast tissue and excess skin, reducing and properly positioning the nipple–areola complex with sensory preservation whenever possible, and minimizing chest wall scarring.
Indications for subcutaneous mastectomy (SCM) follow the Standards of Care (SOC) of the World Professional Association for Transgender Health (WPATH).
- Criteria for mastectomy and creation of a masculine chest in trans men (and AFAB non-binary people):
- Persistent, well-documented gender dysphoria.
- Capacity to make a fully informed decision and provide consent for treatment.
- Age of majority in the given country (if younger, proceed according to the SOC for adolescents).
- Any significant medical or mental health concerns are reasonably well controlled.
Hormone therapy is not a prerequisite.
- Contraindications:
- Smoking.
(If the patient smokes, the surgeon will discuss the negative impact on skin quality, wound healing, vascularity, and the risk of necrosis, and will encourage smoking cessation.) - Health status that precludes general anesthesia.
- Untreated mental health conditions.
- Uncontrolled systemic diseases, e.g., diabetes, arterial hypertension.
Patient selection and preoperative planning. Eligibility for the appropriate type of surgery is based on a preoperative examination. We assess breast size and volume, the presence of excess skin, breast ptosis, the size and position of the nipple–areola complex, and skin elasticity. Between 2 and 3 weeks before surgery, hormone therapy is paused or switched to a transdermal route, depending on the patient’s status. Due to the number of available techniques, the difficulty of subcutaneous mastectomy (SCM) lies less in the procedure itself and more in choosing the optimal technique. Since our primary goal is to achieve an aesthetic, masculine chest wall, we have developed a dedicated algorithm that helps select the most appropriate option from five operative techniques for each patient.
Technika półkolista
The semicircular technique is essentially the same operation used to correct gynecomastia. It is useful for patients with smaller breasts. Its advantage is a small, well-concealed scar limited to the areola.
At Timeless Clinic, we combine this approach with liposuction. The main drawback is the relatively small operative window, which makes excision of breast tissue and vessel closure more challenging. We use this technique for removing small breasts with small areolae.
Technika przezotoczkowa
For patients with smaller breasts but large, prominent nipples, we use the transareolar technique. It allows for a greater reduction of the nipple. The resulting scar runs horizontally across the areola and around the upper portion of the nipple. At Timeless, we often combine this approach with liposuction.
An additional advantage is the ability to reduce the nipple size. The drawback is similar to the semicircular technique—excision of breast tissue and achieving hemostasis are more challenging. In addition, the transareolar scar is typically somewhat more visible.
Wokół brodawkowa technika kołowa
We use the concentric circular technique for medium-sized breasts or for smaller breasts with reduced skin elasticity. The resulting scar is limited to the areolar circumference. The concentric incision can be drawn as a circle or an ellipse, allowing removal of lax skin in the vertical or horizontal direction, as well as glandular tissue.
A permanent subcutaneous purse-string suture is then placed to set the desired areolar diameter (usually 25 mm). The advantages of this technique include the ability to reduce or reposition the areola when needed and to remove excess skin. It also provides good exposure for glandular excision and facilitates hemostasis. However, surgical experience is required to judge how much skin to remove. In people who train intensively, postoperative scar widening can occur; a revision may sometimes be necessary.
Rozszerzona wokółbrodawkowa technika kołowa
The extended circular technique is similar to the circumareolar round-block, but includes one or two additional triangular excisions of skin and subcutaneous tissue, which may be inferior and lateral or medial and lateral. These additional skin excisions provide greater access to the glandular tissue.
This technique is useful for correcting excess skin and wrinkling. As in the standard method, a permanent subcutaneous purse-string suture is placed to set the desired areolar diameter. The resulting scars encircle the areola, with horizontal extensions on the breast skin depending on the degree of excess skin. Advantages include wide exposure for glandular excision and hemostasis, areolar reduction and repositioning, and better tailoring of excess skin, which reduces periareolar puckering. The main drawback is that residual scars are no longer limited to the areola; therefore, surgeon experience is essential.
Technika przeszczepu brodawki
We recommend the nipple–areola graft technique for patients with large, ptotic (sagging) breasts. The areola is excised as a full-thickness skin graft, the breast tissue is amputated, and the areola is grafted into a new position on the chest wall.
Our preference is to place a horizontal incision 1–2 cm above the inframammary fold, then extend it upward laterally below the lateral border of the pectoralis major muscle. Incisions should not cross the midline. At this stage, we perform liposuction to ensure symmetrical contouring.
Regarding ideal nipple placement, we find that relying on absolute measurements can be misleading. In a typical patient, this corresponds to the fourth or fifth intercostal space. However, intraoperative assessment is paramount—we determine the final nipple position with the patient seated during surgery. The resulting scars will be linear and visible on the masculine chest, in addition to the periareolar scar.
The advantages of the nipple–areola graft technique include excellent exposure and faster excision of breast tissue, as well as the ability to reduce areolar size and reposition it. Disadvantages include very long residual scars, areolar pigment changes, and loss of sensation. For these reasons, we avoid this approach unless clearly indicated—that is, in cases of very large, significantly ptotic breast glands.
How we tailor the surgical technique to the patient
We aim to operate on patients as early as is appropriate—when the skin still has strong recoil properties and hormone therapy has slowed breast growth. A decision is possible once a diagnosis has been established. Such surgery can be performed in adolescents, provided there is parental consent and the young person’s own consent.
For chests with a small areola and good skin elasticity, the semicircular technique with liposuction is suitable. A gland with a hypertrophic nipple is removed using a through-the-nipple technique. Glands with moderate or poor elasticity—or a larger cup size (B, C) with mild ptosis—require a circumareolar (concentric) technique.
Breasts of moderate size (cups C–D with grade 1–2 ptosis) and poor skin elasticity will require an extended circumareolar technique. Finally, very large-volume glands (cup D–E or larger) with significant skin excess and little or no elasticity will most likely be treated with amputation and free nipple–areola grafting. This inevitably involves larger incisions and longer scars. This approach also corresponds to the “short-scar” concepts popular in breast reduction and mastopexy.
However, in our experience with this patient group, scar limitation yields clearly better results. Good skin elasticity leads to fewer incisions, fewer scars, and likely less periareolar puckering. We have observed that trans men are increasingly well-informed and discerning. We believe that an aesthetic result—though sometimes challenging to achieve and occasionally requiring revision—is key to restoring a patient’s healthy body image.
Postoperative complications
Performing a subcutaneous mastectomy is technically demanding, and—as with any surgery—complications can occur. The overall postoperative complication rate in our clinic is lower than in most other centers. Hematoma is a known potential complication; its frequency may be reduced when a free nipple–areola graft is used, though this approach leaves longer, more visible scars. Some complications may be associated with hematoma, including partial necrosis of the nipple–areola complex. Smaller hematomas can often be aspirated without surgery; however, in some situations surgical evacuation is required. Rare cases of partial or total nipple–areola necrosis may necessitate secondary nipple–areola reconstruction.
Despite a relatively low complication rate, in some patients—especially those with large, ptotic glands—we aim to further improve aesthetic outcomes. The possibility of an additional aesthetic revision is always discussed in advance. At times, we prefer a planned two-stage approach. In the first stage, we intentionally leave more skin to allow full recoil, thereby avoiding unsightly stretching of scars and the areola and often shortening the final scar length—depending on skin elasticity. The second stage removes any residual excess skin after the initial healing and refines the chest contour.
Breast cancer in trans men
Medical literature shows that a small amount of breast tissue can remain after prophylactic radical mastectomy, and even a carefully performed subcutaneous mastectomy (SCM) does not remove it completely. Timeless clinicians, drawing on extensive breast oncology experience, inform patients that very rare cases of breast cancer have been reported in trans men after bilateral mastectomy. Preserving the nipple–areola complex in SCM leaves a small amount of ductal tissue, which can undergo malignant transformation—especially with a family history of breast cancer.
At Timeless Chirurgia Plastyczna, we perform thorough preoperative breast assessment and take a detailed family history of cancer. Genetic testing for BRCA1/2 is performed, as well as preoperative breast MRI. After surgery, excised glandular tissue is examined by experienced pathologists, and the patient receives a report that should be kept. Lifelong follow-up is necessary.
Results
Chest masculinization surgery for trans men is a major surgical procedure. Recovery and the stabilization of chest appearance take time. It can take a year or longer for the final results to become visible. In some cases, minor additional procedures may be needed to correct asymmetry or other surgery-related issues, which can extend the overall recovery period. We observe that the vast majority of patients are very satisfied with their final results and experience profound relief after surgery.
Chest reconstruction for trans men is usually the first—and sometimes the only—surgical step. If you are considering surgery, it is important to have realistic expectations. This is a significant, often life-changing procedure, though accepting the final outcome may at times involve some compromise.
Timeless Chirurgia Plastyczna
- ul. Gen. Abrahama 18/322
03-982 Warszawa - pon-pt: 9:00-19:00
- tel. (+48) 508 713 484
- klinika@timeless.com.pl