Comparing FTM Top Surgery Procedures and Choosing the Right Procedure for You

The Mosser Method: Know Your Options

Chest type for FTM periareolar incision

A wide (obtuse) infrabreast angle

An acute (narrow) infrabreast angle

The procedure that’s right for you has a lot to do with the amount of extra skin and chest tissue (your soon-to-be former breast) you have. Patients with minimal skin and tissue can do well with a keyhole incision approach, with no skin removal. Other patients with more skin require a purse-string (circumareolar / periareolar / purse-string) or fishmouth / extended wedge approach. More skin and tissue means your best and only option will be the Double-incision or Inverted T approaches. These are procedures where maximal skin can be removed.

Many patients ask me how they can figure out where their body lies on the spectrum of skin and tissue in order to figure out what incisions will be available to them. If you’re trying to figure out whether you a good candidate for a minimal incision procedure, or whether a longer incision is the best method for achieving the masculine chest you desire, please read on…

I’ve created a simple guide to help you answer this question, based primarily on what I will call the “inframammary angle,” which is the angle that the lower breast area makes with the chest. It’s a good way to measure relevant aspects of your body like skin elasticity, amount of breast tissue and amount of excess skin to understand which procedure might be best for you. You might be able to make these observations without taking a photo of your chest, but if you’d like to analyze a photo of yourself, here are some guidelines:

How to take the photo of your chest:

To observe and measure the angle of your lower chest tissue/breast area, you will need to take a photo of your chest taking two important things into account:

  • The camera must be at the same height as the lower chest. If the photo is either shot from above the chest (looking down) or below the chest (looking up), the angle will not be captured accurately in the photograph.
  • The photo is taken with the body at a 45-degree angle to the camera. Stand or sit up straight, and face a direction that is 45 degrees (diagonally) off to the side of the camera. This is the only way to capture the profile of the actual chest/breast tissue.

Got it? Ok, now here are a couple examples of the angle we are looking for:

In this case, that angle below the breast/chest is clearly visible as long as the person being photographed is facing diagonally relative to the camera. Ok now, let’s go through some possibilities and discuss what they mean for the surgeries available to you.

The Mosser Method:

First case: your infrabreast angle is greater than 145 degrees

Chest type for FTM keyhole incision

Here there is relatively minimal breast tissue and skin. Also, there’s not a lot of “projection” (how far the areola and nipple are positioned out forward from the chest due to them sitting on prominent breast tissue). Projection can lead to hanging skin when that volume of tissue is gone. In this case, minimal skin removal techniques work well. Within the “Greater than 135 degrees” category, patients with very good skin/very little tissue can use the Keyhole approach. Patients with a bit more tissue may need to use the Periareolar/Circumareolar (donut) approach.

Second case: your infrabreast angle is from 110-145 degrees

Chest type for FTM periareolar incision

If your angle is about 110 degrees (just a bit wider than a right angle) or more, you are in the middle ground of having too much extra skin for a Keyhole incision, but perhaps not so much that a Double-incision is needed. For many of these patients, a purse-string/donut (also called Circumareolar) incision is a possibility. Others with a bit more excess skin may be able to have a donut-type incision with some additional wedges of skin removed nearby the areolas (the Fishmouth incision). However, these approaches may result in either a pleating-pattern of wrinkles around the areolas, or final scars that originate directly out from the areolas and are therefore not in anatomic positions. An alternative incision for patients in this category is the Lollipop techinique, which involves an incision around the areola, and a vertical scar running down from it.  In my practice, some patients in this category ultimately decide to have a Double-incision procedure even though other options are available, because the Double-incision is the most reliable way to get a flat, tight chest.

Third case: your infrabreast angle is less than 90 degrees

Most FTM surgical patients have enough extra skin and chest tissue that they have at least some degree of overhang of the lower breast tissue. These patients have an infrabreast angle of less than 90 degrees. Virtually all of these patients require extensive skin removal to get a good result, and therefore will require either a Double-incision approach (with nipple grafting), an Inverted-T approach, or the newer Buttonhole  approach which is similar to an Inverted-T but there is no vertical incision involved. The decision between Double-incision and Inverted-T/Buttonhole is a matter of preference with regards to how the nipple/areola is handled and the amount of control a patient wishes to have over how much breast tissue is removed. More information is available regarding the actual procedures involved by clicking this link.

You might ask, what about infrabreast angles of 90-110 degrees?  Most patients in this category are best served by having one of the more aggressive skin removal procedures cited just above.  However, some patients in this range have really good skin elasticity and there’s a chance that the Periareolar approach would work.  In this case, a consultation with Dr. Mosser would be necessary to identify the best procedure for you.

In terms of nipple sensation, patients who choose the Double-incision technique do not have nipple numbness.  Those patients still have sensation in their nipples, similar to the sensation in the skin of their upper chest before surgery.   If a patient is hoping to maintain the heightened sensitivity of the nipples they have before surgery, then the Keyhole, Periareolar, Lollipop, Inverted T and Buttonhole incision types can sometimes accomplish this goal.

Stated another way, here’s a decision tree that might help you decide what FTM top surgery procedure is the best one for you:

Choosing the right FTM Chest Surgery

To download a PDF version of this image please click here.

So there you have it! Once you have a sense as to which category your body fits into in terms of chest shape and therefore extra skin, you will understand which procedure may be the best option for you. Take a good quality photo, then pay attention to the infrabreast angle and you’ll quickly know which options are the ones you should focus on as being right for you.