# Chest reconstruction

Chest reconstruction, also known as top surgery, refers to any of various surgical procedures to reconstruct the chest by removing breast tissue or altering the nipples and areolae in order to mitigate gender dysphoria. Transgender men and non-binary people may pursue chest reconstruction as part of their transition, though it is also used to treat cases of gynecomastia in cisgender men.
The removal of breast tissue in chest reconstruction is a type of mastectomy called a subcutaneous (under the skin) mastectomy. This type of mastectomy removes tissue from inside the breast (subcutaneous tissue), as well as excess skin. The surgeon then contours the chest, altering the size and position of the areolae and nipples as needed or as indicated by the patient.
Those undergoing chest reconstruction may opt to forgo nipple grafts, with the intent of having a completely blank, flat chest, or, to have them tattooed on at a later date. Some patients may also request specific shapes for the nipples that will be reattached, such as hearts or stars; some surgeons may have no qualms with providing this service, while others may feel less skilled or experienced in creating 'non binary' top surgery chests.

## History

In 1942, British physician and author Michael Dillon underwent a chest masculinizing mastectomy as part of his transition to male. This would be among the first of Dillon's 13 gender-affirming surgeries. All were performed by Harold Gillies, a New Zealand plastic surgeon, who is sometimes referred to as "the father of modern plastic surgery." It is possible this was the first top surgery performed.
In the mid-1970s, Chicago surgeon Dr. Michael Brownstein (having graduated from UCSF) opened a plastic surgery practise in San Francisco. In 1978, Dr. Michael Brownstein conducted his first chest reconstructive surgery under the request of a FTM (Female to Male) identified as "John L." The surgery was successful, and shortly thereafter, "FTMs were 'flocking to him,' including some who had not had any so-called gender counseling." Brownstein continued to provide the plastic surgery until healthcare misconduct defense attorney Paul Walker contacted him, stating that he was violating the Standards of Care. Following this, Brownstein requested referrals from trans patients and Brownstein became known for his "outstanding results." Brownstein became a "world renowned" surgeon, with patients including Lou Sullivan in 1980 and Chaz Bono in 2009. Brownstein retired in 2013, "after 35 years of serving the transgender and gender-non-conforming communities."
In 2017, German model Benjamin Melzer called top surgery "the most important surgery for all trans men". It was one of the 11 surgeries he had during his own transition. Right after his healing process was over, Melzer went to a public pool and jumped into the water with just shorts on, which he described as "the best".
Canadian actor Elliot Page underwent the surgery circa March 2021; he stated, "It has completely transformed my life... [It's] not only life-changing but lifesaving."

## Patients

Chest reconstruction surgery candidates desire a flat chest, which may or may not include masculinization. These candidates may include cisgender men with gynecomastia; transgender men who are medically transitioning and have chest dysphoria; and non-binary people with breasts. All of the above listed may experience chest dysphoria and/or a desire to masculinize its size or shape.
Gynecomastia is a common breast deformity that can occur in cisgender men, which may require surgical intervention. Causes of gynecomastia may vary but may include drug side effects or genetics.
People assigned female at birth with male, masculine, or non-binary genders may experience gender dysphoria caused by their chest and/or gender euphoria after the surgical recovery.

## Procedures
### Inverted "T"

A transverse inframammary incision with free nipple areolar grafts may be one approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T).
The areola is trimmed to a pre-agreed-upon diameter and the nipple sectioned with a pie-shaped excision and reconstituted. There may be varying sensory loss because of nerve disruption.

### Double incision

One of the most common chest reconstructive procedures, double incision involves an incision above and below the breast mass, the removal of the fatty and glandular tissue, and the closure of the skin. This method leaves scars under the pectoral muscles, stretching from the underarms to the medial pectoral.
Double incision is usually accompanied by free nipple grafts to make male-looking nipples. The areola and nipple is removed from the breast tissue, cutting away along the circumference and removing the top layer of flesh from the rest of the tissue. After the chest has been reconstructed, the nipples are grafted on in the appropriate male position. The areolae are often sized down as well as the nipples themselves, as female areolae are often larger in circumference and the nipples protrude farther.
Nipple grafts are generally associated with double incision style chest reconstruction, but may be used in any reconstruction procedure if necessary.
With nipple grafts comes the possibility of rejection. In such cases, the nipple is often tattooed back on cosmetically or further surgical procedures may be applied.
Sensation may return to the grafted nipples over time. However, the procedure severs the nerves that go into the nipple-areola and recipients may experience complete or partial loss of sensation.

### Keyhole

To remove the glandular and fatty tissue which constitute the breast mass and the added skin that drapes the mass, there are three basic approaches.
For petite breasts, such as an A or a small B, a peri-areolar incision can be done. That is a circular incision around the areola, combined with an inner circular incision to remove some of the excess areola. Drawing the skin into the center will result in some puckering, but this often smooths out with time. There will be significant tension on the scar line, and to prevent spreading of the scar, a permanent fixation suture is needed. Leaving outer dermis (raw skin) underneath the marginalized areola helps in its survival.
The keyhole incision (i.e., skeleton key) augments the periareolar incision further by making a vertical closure underneath (lollipop), which results after the unwanted skin is pulled in from side to side and the excess is removed.
An anchor incision adds to that a transverse incision usually in the infra mammary fold to further remove excessive skin. Draping or blousing is not desirable. This is reserved for much larger breasts or topographically a larger surface area as seen in women with postpartum breast atrophy.
The nipple areolar complex may be supported by a pedicle which has the advantage of leaving some sensation and blood supply intact, but can have the disadvantage when the pedicle has sufficient bulk not to provide the flat look most FTM patients desire.

#### "Dog ear"

Occasionally, the side limbs may be quite long, and the expression doctors use is "chasing a dog ear" into the axilla (or underarm). A dog ear may occur when the skin at the edge or corner of an incision 'flows over,' when there is too much gathering, usually at an angle greater than 30 degrees. This usually becomes more apparent after several months of healing, and can be caused by things like weight gain (excess skin or fat changing the shape in areas like torso, hips, stomach, or buttocks, may also occur along the incision line), or due to 'poor surgical planning and execution.' Using a curved incision can reduce the chances of dog ears developing because it requires less gathering of skin to be done, but some patients dislike the appearance of the curved scar as it can mimic the appearance of breasts.
Not uncommonly, a surgeon may revise the incision lines after 3 or more months of settling shows some residual problem areas. Other revisions may include changing 'slight irregularities,' such as reshaping of the nipple that may have stretched 'out of shape' due to too much upper arm/over the head arm movement, or general 'overextension' during the healing process (which may also cause asymmetry), bulges or puckering (typically along incision lines), failed nipple graphs (which may result in one or both nipples 'failing' to 'take' to the patient's healing chest, or scarring patterns a patient may not be happy with.