Inverted-T Top Surgery

Inverted-T top surgery is a type of chest reconstruction top surgery, formerly FTM top surgery, that involves incision that looks like an upside down letter “T” which allows for more skin tissue removal. In this article, we compare the inverted-T with the double incision top surgery method in terms of chest fullness, customization of areola and incision location, and nipple sensation post top surgery. Deciding on which procedure to pursue may depend on your body type and goals and ultimately, a discussion with your surgeon would be the best approach in choosing your gender affirming surgery.

The Inverted-T Incision

During an inverted-T procedure,  the tissue attached to the nipple and areola keeps its blood supply along with a very thin sheet of tissue.  This tissue is called a “pedicle,” and it goes all the way down to the lowest part of the chest area and keeps blood supplied to the nipple and areola. While we hope nerves are also traveling within this pedicle, we won’t know how much nipple sensation, if any, was maintained until after surgery.

After the creation of the pedicle, the rest of the skin is folded around the pedicle and the excess is removed. As a result, there is an incision around the areola, a horizontal incision at the lower part of the chest, and a vertical incision connecting these two incisions—it looks like an upside down, or inverted, letter “T,” which is where this procedure’s name comes from.  What’s left over is the incision around the areola which comes from the areola down to the lower chest, and then a curved incision across the lower chest area. Buttonhole is similar to inverted-T in every way, except not as much skin is removed, and therefore the small vertical incision can be omitted from the buttonhole procedure. We tend to choose the inverted T procedure when patients wish to have a shape of the chest with more of a ‘teardrop style’ or ‘breast shaped’ appearance, while buttonhole is used when a more moundlike shape is the goal.

T-Anchor vs. Double Incision Techniques

Using the inverted-T method means the nipple and areola do not need to be placed as a free nipple graft, as it does with double incision.  Because of this, inverted-T may result in a better chance of maintaining pre-surgery levels of nipple sensation, though this outcome is not certain.

It is important to remember inverted-T involves an extra incision in the central chest area in the vertical region between the areola and the inferior incision. It is also important to be aware that this procedure may involve retaining more volume or fullness in the chest as a result of  the pedicle  left behind to keep the nipple and areola alive.

In addition, the lower curvature of the incision is not as customizable by the surgeon because it has to be located in the lower chest fold. The surgeon cannot customize the horizontal location of the areola as much as they can with the double incision approach.

Deciding Between Inverted-T and Double Incision 

If maintaining a high level of nipple sensitivity is your priority, you may want to consider the inverted-T or buttonhole  approach. However, it’s important to remember that retention of sensation is not guaranteed.

If you want to maintain a chest that is as flat as possible, or it is important for you to have a completely customized placement of the nipple or the incision, then the traditional double incision technique may be the best procedure to choose.

Here’s a video explaining Dr. Mosser’s perspective on the inverted-T technique.  Most of this applies to the buttonhole technique as well: