The procedure that’s right for you has a lot to do with the amount of extra skin and chest tissue 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 chest area makes with the chest. It’s a good way to measure relevant aspects of your body like skin elasticity, amount of chest 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:
In order to observe and measure the angle of your lower chest tissue area, you will need to take a photo of your chest taking two important things into account:
The images above show the type and placement of the angle we are looking for. As you can see, that angle below the chest is clearly visible as long as the person being photographed is facing diagonally relative to the camera.
Let’s go through some possibilities and discuss what they mean with regards to surgeries available to you.
Here there is relatively minimal chest tissue, and also relatively minimal skin. Also, there’s not a lot of “projection” (projection means how far the areola & nipple are positioned out forward from the chest due to them sitting on prominent chest tissue). Projection can lead to hanging skin when all of that volume is gone. All of these things usually add up to the minimal skin removal techniques working well. Within the “Greater than 135 degrees” category, patients with very minimal skin / very little tissue can have the keyhole approach, and patients with a bit more tissue may need to have the periareolar / circumareolar (donut) approach.
An additional issue to be aware of, for patients considering the periareolar approach, is glandular ptosis, when the patient’s nipple and areola sit high on the chest, or when the area beneath the nipple bulges out beneath the nipple/areolar region, as illustrated to the left with shading. Because the person depicted in the image has an infrabreast angle of less than 90 degrees, they would not be eligible for a periareolar procedure, but the image is provided to illustrate glandular ptosis, which can occur in patients with an infrabreast angle of >135 degrees as well. This circumstance can make the final appearance of a peri procedure hard to predict, and sometimes unfavorable results, like bulges on the lower chest, can occur. Even patients without glandular ptosis can encounter issues with the peri approach, so it is important to weigh the risks and rewards of the procedure in order to make an informed decision.
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.
Most FTM/N surgical patients have enough extra skin and chest tissue that they have at least some degree of overhang of the lower chest 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 high skin elasticity, so 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/N top surgery procedure is the best one for you:
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 extra skin, you will understand which procedure may be the best option for you. Take a good quality photo, pay attention to the infrabreast angle, and you’ll quickly know which options are the ones you should focus on.