Chest Reconstruction Top Surgery After Breast Reduction

Often, patients ask us about the interaction between a traditional breast reduction and a gender-affirming chest reconstruction top surgery. Specifically, patients ask if having a breast reduction will affect a subsequent top surgery procedure to further flatten the chest, and if having the breast reduction will limit the options available to them if they decide to have top surgery. Here we will describe factors you may take into consideration such as the availability of minimal incision techniques like periareolar or keyhole top surgery, the potential joining of the incisions on the chest, and  the incision location options. If you have undergone breast reduction or are planning to have one, it is important to be aware of the implications discussed below prior to going through with your gender affirming surgery.

How does a prior breast reduction impact top surgery options?

  • It is common for excess skin to be removed during a typical breast reduction procedure. This impacts the incision types available for top surgery based on the following considerations.
  • First, the removal of skin during a breast reduction puts patients at risk for protrusions of excess skin, often called “dog ears,” in the outer chest area after top surgery. See Image A for a closer look at “dog ears.” In order to reduce the risk of dog ears appearing on the outer chest of patients who have had a breast reduction, our surgeons usually extend the incisions into the outer chest area to remove some of that excess skin. This means that top surgeries with minimal incisions–like keyhole or periareolar incisions–are usually no longer available to patients who have had a breast reduction.

 Top Surgery Dog Ears

  • Second, it is common for prior breast reduction patients to have excess skin in the central chest area. If present, this would likely require a single incision to be created during top surgery across the entire chest to avoid a bungee or ruffled skin appearance in the central chest area. This means that patients considering top surgery who have already had a breast reduction often may need longer incisions on the outer chest and joined incisions in the center of the chest. See Image B on the right for a clearer picture of what this central chest incision might look like.
Top Surgery Insicion Crosses Chest Line
  • Third, the actual location on the chest for the incisions will need to capture the extra tissue and the old scars left by the breast reduction procedure. This means that patients who have had a breast reduction before top surgery have less options for the location of their top surgery scars. Often, the top surgery incision location would be a bit lower than it would be otherwise. Most patients do not consider this slight restriction to be a major factor in their overall satisfaction after surgery.
  • Finally, it is most commonly the case that a second breast reduction (non-flattening) cannot be done after an initial reduction because of the likelihood of problems with blood supply to the nipples and areolas. Complete reduction (flattening) such as with a double incision procedure is possible with the limitations listed above, but if a second breast reduction is desired, then it would most likely require free nipple grafting as part of the procedure. This would preserve nipple survival but would have potential loss of erotic sensation.

In Summary 

Trans, nonbinary, and gender expansive folks who have undergone a breast reduction procedure can still have a subsequent gender-affirming chest reconstruction top surgery procedure, but should keep the following implications in mind:

  • Top surgeries with minimal incisions are usually no longer an option because incisions are usually lengthened in the outer chest to prevent “dog ears” from appearing.
  • The incisions are usually joined in the central chest area to prevent bungeed or ruffled skin in that area.
  • The incision location from the breast reduction procedure has an impact on the incision location for the subsequent top surgery, often making the top surgery incisions a bit lower than is common.
  • A second breast reduction after an initial reduction may be possible but would likely require a free nipple graft and therefore possible loss of erotic sensation.