Chest reconstruction, also known as top surgery, refers to any of various surgical procedures to reconstruct the chest by removing breast tissue or altering the nipples and areolae in order to mitigate gender dysphoria. Transgender men and non-binary people may pursue chest reconstruction as part of their transition and it is also used to treat cases of gynecomastia in cisgender men.
The removal of breast tissue in chest reconstruction is a type of mastectomy called a subcutaneous (under the skin) mastectomy. This type of mastectomy removes tissue from inside the breast (subcutaneous tissue), as well as excess skin. The surgeon then contours the chest, altering the size and position of the areolae and nipples as needed or as indicated by the patient.
Those undergoing chest reconstruction may opt to forgo nipple grafts, with the intent of having a completely blank, flat chest, or to have them tattooed on at a later date.
History
In 1942, British physician and author Michael Dillon underwent a chest masculinizing mastectomy as part of his transition to male. This would be among the first of Dillon's 13 gender-affirming surgeries. All were performed by Harold Gillies, a New Zealand plastic surgeon, who is sometimes referred to as "the father of modern plastic surgery." It is possible this was the first top surgery performed.
In the mid-1970s, Chicago surgeon Michael Brownstein (having graduated from UCSF) opened a plastic surgery practise in San Francisco. In 1978, Michael Brownstein conducted his first chest reconstructive surgery under the request of a FTM (Female to Male) identified as "John L." The surgery was successful, and shortly thereafter, "FTMs were 'flocking to him,' including some who had not had any so-called gender counseling." Brownstein continued to provide the plastic surgery until healthcare misconduct defense attorney Paul Walker contacted him, stating that he was violating the Standards of Care. Following this, Brownstein requested referrals from trans patients and Brownstein became known for his "outstanding results." Brownstein became a "world renowned" surgeon, with patients including Lou Sullivan in 1980Highleyman, Liz. "Who was Lou Sullivan?". Seattle Gay News. February 22, 2008. Archived from the original on November 4, 2015."Guide to the Louis Graydon Sullivan Papers, 1755-1991 (bulk 1961-1991)" . The Gay, Lesbian, Bisexual, Transgender Historical Society. San Francisco, 1999. Accessed November 4, 2015. and Chaz Bono in 2009. Brownstein retired in 2013, "after 35 years of serving the transgender and gender-non-conforming communities."
Since these first surgeries, surgical practice has evolved significantly. While early surgical procedures resembled breast reduction surgeries, these often fell short of transgender patients' masculinization goals. The shift toward subcutaneous mastectomy procedures has allowed for superior male chest contouring, and better management of excess skin.
Top surgery as gender affirming care In the U.S., the adoption of chest reconstruction as a commonly accessible part of gender transition is largely a 21st century phenomenon. A 2009 report by the Human Rights campaign cited a number of contemporaneous insurance policies with clauses explicitly excluding gender affirming care, as well as 2003 report that found that nearly a third of transgender people studied had experienced discrimination in obtaining healthcare, including in obtaining health insurance. Prior to the passage of the Affordable Care Act in 2010, gender dysphoria could be treated as a "pre-existing condition", for which insurance plans could deny coverage. Since then, coverage has varied significantly between states and between insurance plans.
In 2014, the Department of Health and Human Services overturned the ban on Medicare coverage for gender affirming surgeries. This likely accounted for the dramatic rise in top surgeries and gender affirming care consultations in general that immediately followed.
In 2019, a group of plastic surgeons issued a letter condemning insurance coverage denials for free nipple grafts, which had become more common. A 2020 analysis later found generally inconsistent coverage between different diagnostic codes for top surgery, multiple of which are often needed.
As of 2026, there are ongoing attempts by Republicans to limit access to gender affirming care, including surgeries, and a 2025 report by the AMA finds that 55% of patients seeking out gender affirming surgery in the past year were denied coverage.
Patients
Chest reconstruction surgery candidates desire a flat chest, which may or may not include masculinization. These candidates may include cisgender men with gynecomastia; transgender men who are medically transitioning and have chest dysphoria; and non-binary people with breasts.
In cisgender men, gynecomastia is a common breast deformity characterized by additional breast tissue, which may require surgical intervention. Causes of gynecomastia may vary but may include drug side effects or genetics.
In both cisgender men and people assigned female at birth with male, masculine, or non-binary genders, their breast tissue may cause gender dysphoria, or distress associated with the inconsistency between one's gender and one's physical appearance. Conversely, after surgery, patients may experience relief or joy from the appearance of their chest matching their gender, which is called gender euphoria. Chest reconstruction also removes the need for chest binding, which can be painful or inconvenient for some people, and can lead to chronic health issues if done frequently for a long period of time. For this reason, chest reconstruction is considered the primary gender-affirming surgery for transgender men, and is often the only surgical intervention they seek out.
In transgender patients in certain places, undergoing gender affirming surgery such as chest reconstruction may be necessary to change their gender on legal documents.
Indications
Transgender people Patients seeking chest reconstruction as part of their gender transition typically have to meet eligibility requirements related to the progress of their transition in order to get surgery. One common requirement is for the patient to have been on gender affirming hormone replacement therapy (HRT), in this case, testosterone for a sufficient length of time. Another common requirement is that patients have a letter of support from a mental health professional, confirming that the patient is in a sound state of mind to choose to have surgery and that surgery is in the best interest of the patient. Patients may also be required to have lived as their experienced gender (rather than their birth sex) for a certain length of time.
The World Professional Association for Transgender Health (WPATH)'s most recent clinical protocol, as of 2022, are that 6 months on HRT and no more than one letter from a qualified mental health professional be required for surgery. Previous recommendations required two letters of recommendation for gender-affirming surgery, at least one of which had to be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as gender dysphoria), who had known the patient for over a year.
In the United States, these requirements would come from the patient's health insurance. Not all insurance plans cover gender affirming surgery, and insurance coverage of it has improved over time. Multiple medical organizations, including the American Medical Association, the American Psychological Association, and the National Association of Social Workers have issued statements that failing to cover gender affirming surgeries is a form of discrimination.
Transgender minors Gender-affirming surgery is generally not performed on children under 18, though in rare cases may be performed on adolescents if health care providers agree there is an unusual benefit to doing so or risk to not performing it. Preferred treatments for children include puberty blockers and gender affirming hormone therapy, which reduces the need for future surgery by preventing breast growth.
Cisgender people Chest reconstruction surgery is not the primary treatment for gynecomastia in cisgender men, but is considered highly effective. For sufficiently severe gynecomastia that has persisted for longer than six months, primary treatment may involve treatment of underlying causes or medication with selective estrogen receptor modulators (SERMs) such as tamoxifen, raloxifene, and clomifene or aromatase inhibitors (AIs) such as anastrozole, though these are not currently approved for gynecomastia by the U.S. Food and Drug Administration.
In 2019, 24,123 male patients underwent surgical treatment for gynecomastia in the United States. Thirty-five percent of those patients were between the ages of 20 and 29, and 60% were younger than age 29 at the time of the operation. At an average surgeon's fee of $4,123, gynecomastia surgery was also the 11th most costly male cosmetic surgery of 2019.
Cisgender minors Gynecomastia is very common in adolescents, with incidence peaking around 13-14. However, in 75–90% of adolescents, it resolves on its own, and by age 17, only 10% will still have gynecomastia. As such, in adolescent males, it is recommended that surgery be postponed until puberty is completed.
Procedures
A variety of procedures may be used for chest masculinization, depending on the patient's native anatomy and goals for surgery. Unlike in typical mastectomy or breast reduction, many patients prioritize flatness or masculinization over the preservation of function or sensation. Thus, many surgical procedures for chest masculinization aim to optimize the removal of breast tissue and maximize control over the appearance of the nipple-areolar complex, while minimizing visible scarring.
Depending on the patient's chest size, the degree of excess skin, skin elasticity, and the position of the nipple-areolar complex (NAC), surgeons most commonly choose between three procedures: double incision with free nipple grafts, periareolar, and keyhole surgical approaches. However, many variants of these exist, depending on the patient's goals. This decision-making process is particularly relevant for transgender patients, who are more likely to have ptosis, excess skin, or skin of poor quality due to the binding of their breast tissue.
Double incision One of the most common chest reconstructive procedures, double incision involves an incision above and below the breast mass, the removal of the fatty and glandular tissue, and the closure of the skin. This method leaves scars along the bottom contour of the pectoral muscles, stretching from the underarms to the medial pectoral. Double incision is usually accompanied by free nipple grafts to make male-looking nipples, resulting in a second set of scars around the areola.
Double incision surgery is more common than other procedures because it can be performed on the widest range of breast sizes and on skin with poor elasticity, and particularly for patients with larger breasts, free nipple grafts may offer greater control over final appearance than other methods.
Free nipple grafts Free nipple grafts fully remove then reattach the areola. The areola and nipple are removed from the breast tissue, cutting away along the circumference and removing the top layer of flesh from the rest of the tissue. After the chest has been reconstructed, the nipples are grafted on, allowing for a more typical male nipple position. The areolae are often sized down as well as the nipples themselves, as female areolae are often larger in circumference and the nipples protrude farther. Some patients may also request specific shapes for the nipples that will be reattached.