What to Know About Top-Surgery Scars, According to Plastic Surgeons
Everyone deserves to feel confident in their skin. For many transgender men and nonbinary folks whose gender identity differs from the gender or sex labels they were assigned at birth, that might mean using binders to create the appearance of a flat chest or opting to undergo hormone therapy to develop more masculine features. However, another gender-affirming option is top surgery.
Female-to-male (FTM) top surgery is a procedure that involves removing breast tissue and excess skin or fat and repositioning the nipples to create a natural-looking, flat chest area. "Some [people] want a flat chest that is considered 'masculine,' while others want a radical reduction that maintains the shape of the breast but makes it significantly smaller and with no ptosis or droop," says Alexes Hazen, MD, plastic surgeon and clinical associate professor at NYU Langone Health. (Breast ptosis, also known as sagging, refers to when the breasts rest lower on the chest.)
While top surgery can be beneficial and gender confirming for those with access to it, like any surgery, it doesn't come without risks. In this instance, top-surgery scars are common and difficult to avoid. With that said, the visibility and prominence of scars can vary based on the type of surgery you get and the aftercare measures you take. To get a more comprehensive look into top-surgery scars, we asked plastic surgeons to break down this life-altering procedure and what you can expect after the surgery, from the scar size to the healing process.
Types of Top-Surgery Scars
Image Source: Keith Blechman of Blechman Plastic Surgery
The type of scars someone might experience post top surgery will vary based on the procedure and technique executed by the surgeon. "Chest-masculinization procedures usually fall into two main categories: double incision or periareolar," says Keith Blechman, MD, plastic surgeon at Blechman Plastic Surgery who specializes in breast reduction and breast-lift surgery.
A scar's size and visibility will also depend on the preferences discussed between the patient and doctor, as well as the size of the chest presurgery. "Double incision gets its name because one incision goes under the breast and one goes above the areola, forming an ellipse," Dr. Blechman says. "This approach is used to remove extra skin associated with large breasts." The double-incision approach (shown in the photo above) leaves a scar across the chest at the lower border of the pectoralis muscles.
The periareolar approach does not remove any skin, so it's usually used for patients with smaller breasts. "The scar resides along the lower border of the areola — it's very inconspicuous and virtually 'scarless,'" Dr. Blechman says. Another consideration to keep in mind is the initial size of the breasts: if someone has a large chest presurgery, their scars might be more visible than someone with a small chest.
What Happens to the Nipples After Top Surgery?
"The double-incision approach requires the nipples and areola to be removed and then sewn back on," Dr. Blechman says. "This is called a graft." That means the nipple will remain intact during surgery, but where the nipple is placed on the chest afterward will be determined by the surgeon based on individual preferences and the breast itself.
There is also the option to forego reapplying the nipples entirely, Dr. Hazen adds. In this case, the patient will only have the scar from the removal of the breast. That's an aspect to keep in mind when it comes to top-surgery scarring and how much of it patients are willing to tend to.
While it's uncommon, another risk of top surgery is the possibility of losing sensation in the nipple. According to the Gender Confirmation Center, those who smoke or have diabetes have an increased risk of nipple-graft failure. Ensuring you're going to a reputable surgeon with years of experience can help minimize that risk.
How Do You Lighten Scars From Top Surgery?
For many trans and nonbinary people, scars can often trigger feelings of gender dysphoria, which means you may be interested in learning how to treat or lighten top-surgery scars. First and foremost, what happens in terms of scarring is largely a result of what a surgeon does during the procedure.
"In many cases, we use dissolvable sutures and special surgical glue to help eliminate the need for sutures on the outside of the skin," double-board-certified plastic surgeon David Shafer, MD, FACS, says. "This helps reduce suture marks. The glue can also help reduce the tension on the incisions to help result in a thinner line for the final scar."
However, there are some tips that plastic surgeons suggest to patients when it comes to tending to scars postop. "Having a good, healthy, balanced diet is paramount to healing," Dr. Hazen says. "Not smoking or vaping is also critical." In some cases, laser treatment — such as V beam, which helps reduce redness and promotes healing — can be utilized. "Other treatments, such as microneedling, can also be helpful and can be used in all skin types," Dr. Shafer adds.
Additional products like medical-grade skin care and creams can help in wound healing. "One of my favorites is BioCorneum ($24), which has SPF and healing ingredients to help patients," Dr. Shafer says. Additionally, silicone scar sheeting can be helpful, especially if the incisions are raised or red. These work to increase hydration of the uppermost layer of the skin, which allows the skin to "breathe" and aid in producing softer and flatter scars.
This is why entertainer and trans man Peter Petrella, who underwent top surgery a few years ago, says he took his postop scar care very seriously.
"I was very meticulous and strict about my aftercare when it came to my scar-healing process," he tells POPSUGAR. "My surgeon gave me a product called Silagen, which I applied twice a day after my incisions closed to aid in the healing process." Silagen is a physician-exclusive silicone gel sheeting or silicone liquid gel that helps the skin heal and replace scar tissue faster than when left on its own.
Can You Tattoo Over Top-Surgery Scars?
The option to tattoo over top-surgery scars has become increasingly popular in recent years and should be done only once the incisions are completely healed. Depending on someone's goals postsurgery, tattooing can be used to camouflage scars or accentuate them. Petrella, for example, has gotten tattoos to draw attention away from the appearance of his top-surgery scars. He says he also plans on getting the scars completely covered in the future.
"After the incisions are completely healed, medical tattooing is helpful to camouflage any areas and help with symmetry, if needed, for the size and shape of the nipple-areola complex and reduce the appearance of the incisions," Dr. Shafer says.
When it comes to top surgery — and any medical procedure for that matter — it's important to talk to your doctor about what course of treatment is best for you. You'll want to go to a plastic surgeon who specializes in gender-affirmation surgery, like Dr. Hazen, Dr. Shafer, and Dr. Blechman. Your doctor is the only person who will have recommendations catered exactly to your needs, whether that's in terms of reducing the visibility of scars or managing postop pain and discomfort.