About transgender male/transmasculine “Top” Surgery
(Subcutaneous Mastectomy, Male chest contouring):
Dr. Esther Kim performs this procedure in the Division of Plastic Surgery at UCSF. Masculinizing “Top” surgery will shape the skin and tissue of your chest to match the contour of a male chest. There are many factors that Dr. Kim will discuss with you during your consultation. These factors include your current shape and size, body type, skin type, and nipple size and position. Dr. Kim is a proponent of “double incision” surgery with free nipple grafts. Most transmasculine patients with larger breasts are good candidates for a “double incision” chest surgery with free nipple grafts, where the lower scars are hidden under the lower border of the pectoralis muscle in the male chest. Depending on your chest dimensions, the nipple and areola is resized and new nipple positions are chosen to look more masculine. Patient with smaller breasts may also be candidate for either a periareolar incision subcutaneous mastectomy (“keyhole”). During your consultation, Dr. Kim will discuss what options are available and your expected postoperative result.
Dr. Kim can also use liposuction to help contour and create better definition in specific areas in the male chest. Please let Dr. Kim know if you are interested in this procedure. This added procedure is not usually covered by insurance.
Due to privacy and ethical considerations, we do not publish photos of our patients on our website. During your consultation, you will have the opportunity to view pre-operative and postoperative patient photographs.
Preparing for your initial consultation:
At UCSF, we want you to have the best possible result from your surgery with the greatest satisfaction. UCSF criteria for chest surgery are based on the World Professional Association for Transgender Health SOC (Standards of Care) 7th Edition, and are required by most insurance companies. Prior to scheduling your initial consultation, please send the following:
- Your insurance card and identification
- A completed Medication List and Plastic Surgery Intake Packet
- A completed UCSF Transgender Care Chest Surgery Patient Packet
- A UCSF Transgender Care Chest Surgery Medical Clearance Letter from your medical provider indicating that you are medically cleared and prepared for surgery, and capable of providing consent for surgery. In some cases, you may be asked to have a medical consultation at UCSF with Dr. Deutsch prior to scheduling your consult with the surgeon.
- If you are taking testosterone, documentation by your medical provider of how long you have been taking this medication.
- Documentation from your medical provider (may be included in the clearance letter) that your BMI(link is external) (body mass index) is less than 37 before scheduling your consultation. The reasons for this are twofold – to reduce the risk of general anesthesia and to give a better appearing final result.
- Due to insurance regulations, a Referral Letter from a licensed mental health professional is required for surgery. While this letter is not required before your initial pre-op consultation, it is recommended that you provide this in advance to help expedite your process toward surgery. This referral letter should meet WPATH criteria and include a discussion of the following:
- Persistent, well-documented gender dysphoria
- Capacity to make a fully informed decision and to consent for treatment
- Age of consent (18) or meeting the WPATH SOC 7th Edition criteria for adolescents
- Any significant medical or mental health concerns are reasonably well-controlled.
- Documentation of at least one year of current and consistent estrogen hormone therapy
- Your identifying characteristics
- Their psychosocial assessment of you, including diagnoses
- Duration of their relationship with you, including the type of evaluation, counseling, and therapy provided to date.
- An explanation that criteria for surgery are met, and the clinical rationale for supporting your request for surgery.
- A statement that you have given informed consent for chest surgery.
- A statement that your mental health provider is available to contact for care coordination, including their telephone number or email.
- If you are over 40 years old, a mammogram performed within the past year.
Referral letters and documentation should be e-mailed, faxed or mailed to:
UCSF Transgender Care Navigator
2356 Sutter St, 3rd Floor
San Francisco, CA 94143
TransCare@ucsf.edu(link sends e-mail)
How to prepare for the operation:
- Meet all necessary criteria for surgical treatment (see ‘Getting clearance from your doctor and/or therapist for Chest Surgery’ link).
- You may be asked to obtain additional medical or mental health clearance letters, which must be faxed to the office before your operation can be scheduled.
- A pharmacy and pharmacy plan in order to obtain postoperative medications.
- Schedule an appointment or phone appointment with the anesthesia PREPARE preoperative evaluation clinic.
- Two weeks before the operation:
- Make sure you eat a healthy balanced diet, get plenty of rest, and stay active.
- If you are a smoker, you should absolutely quit smoking two weeks before and six weeks after surgery to avoid poor wound healing and complications (or better yet, use this opportunity to quit forever!)
- PREPARE clinic will tell you which medications to stop taking and which to take.
- Make sure you have transportation to and from UCSF for your operation (most patients go home the next day after surgery)
- The night before surgery:
- Shower with antibacterial soap and hibiclens (chlorhexidine) scrub – this is available at most drugstores
- Make sure your home is well stocked with light food, beverages, and items that you will need are within reach without needing to lift your hands above your head or bending over.
- Make sure you pack your surgical garment or vest to bring with you to the hospital the morning of surgery.
- Plan to attend postoperative appointments, usually at 1 week, 2 weeks and 6 weeks from your operation.
- Supplies for after surgery:
- Compressive surgical garment or vest (if not available, ACE wraps will be provided)
- Silicone sheets or scar gel for after surgery
What to expect for your recovery:
- Your chest will be covered in a compressive surgical garment or vest over bandages. This must be kept on at all times, including while sleeping, until your first postoperative appointment.
- You will also have two drains coming out of your dressing. These drains and the compressive dressings are meant to prevent fluid from building up underneath your chest.
- As your incisions heal, you can expect some itching and shooting pains. This is normal healing.
- Plan to sleep on your back with several pillows to elevate the head of your bed. This is to lessen the amount of swelling you experience, which may worsen in the first few days after surgery before getting better. Plan to sleep on your back for the first 6 weeks after surgery while your chest heals.
- Don’t shower or get the dressings wet until you are seen at your first postoperative appointment. You will not be allowed to shower or get dressings wet for 2 weeks to protect the nipple grafts.
- Drains are usually removed at the first postoperative appointment. Compression vest is worn the second postoperative appointment.
- You will be sore and will need to rest for about a week after surgery. During this time, you may need someone to help you at home. We do want you to walk around the evening after surgery to prevent blood clots form forming in your legs.
- Avoid strenuous activity or lifting more than 5 pounds for two weeks after surgery.
- Scar Care:
- You can improve the appearance of your scars by using silicone sheets or scar gel on your incision, beginning two weeks after surgery. Your surgeon can advise you on which brands and size to purchase.
- Scars can be made more noticeable by sun exposure for up to one year after surgery. Make sure the scars are either covered, or apply a strong sunscreen to your scars.