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:
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.
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 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/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 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.