Top surgery refers to all surgical interventions aimed at masculinizing or feminizing the chest. For transmasculine individuals, it consists of a mastectomy with masculine chest reconstruction. For transfeminine individuals, it generally involves breast augmentation. This intervention is part of gender-affirming care and addresses a medical indication in individuals experiencing gender dysphoria affecting the chest.
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Medical indications and eligibility criteria for top surgery
Top surgery is indicated for individuals diagnosed with persistent gender dysphoria affecting the chest. Eligibility criteria follow the international WPATH (World Professional Association for Transgender Health) Standards of Care, version 8.
General criteria
- Persistent and well-documented gender dysphoria
- Capacity to make a fully informed decision and consent to treatment
- Age of majority (18 years in Belgium)
- Stable mental health
For adolescents under 18, Belgian regulations require comprehensive multidisciplinary evaluations, parental consent, and approval from care teams. International WPATH recommendations mention a minimum age of 15 for mastectomies, but these recommendations do not constitute legal authorization—each country applies its own legislation and decisions are made on a case-by-case basis.
Belgian specificities
In Belgium, two specialized multidisciplinary centers (Gender Teams) exist in Ghent and Liège. The pathway begins with psychological follow-up. These teams offer coordinated care with interventions partially covered by INAMI (mandatory insurance), with co-payments remaining the patient's responsibility.
In the transmasculine context, top surgery is medically based on subcutaneous mastectomy, the term used for medical coding and reimbursement by health insurance providers.
Unlike genital surgeries, hormone therapy is generally not a strict prerequisite for transmasculine top surgery, although it may be recommended depending on individual circumstances.
Principle and functioning of transmasculine surgery
Transmasculine top surgery aims to create a masculine chest contour. The intervention is based on removing glandular breast tissue through subcutaneous mastectomy. The surgeon removes breast tissue while preserving underlying structures as much as possible, then reshapes the chest to achieve a flat appearance with defined pectoral contours.
Preoperative evaluation
The choice of technique depends on:
- Volume and density of breast tissue
- Skin elasticity and quality
- Position of the inframammary fold
- Overall body morphology
- Patient's aesthetic goals
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Top surgery techniques: double incision, periareolar and keyhole mastectomy
A comparative study of 490 patients showed no significant difference in complication or revision rates between periareolar and double incision techniques, indicating that both approaches are safe with appropriate patient selection.
Double incision with free nipple graft
Most frequently used technique (approximately 80-85% of cases according to national data).
Procedure: Horizontal incisions along the lower pectoral muscle. Breast tissue and excess skin are removed. The nipple-areolar complex is harvested, reduced in size if necessary, and repositioned as a free graft.
Indications: Moderate to large breast volume, breast ptosis, limited skin elasticity.
Advantages: Maximum control over nipple positioning and size, predictable results, applicable to all body types.
Considerations: Visible horizontal scars, possible reduction or loss of nipple sensation (nerves are severed during free grafting).
Periareolar technique
Procedure: Two concentric circular incisions around the areola. Breast tissue is removed through these incisions, excess skin is excised, then skin is tightened toward the center.
Indications: Small breast volume (cup A-B) and good skin elasticity.
Advantages: Less visible scars (around the areola), possibility of partially preserving nipple sensation.
Limitations: Does not allow removal of significant excess skin, risk of skin rippling if elasticity is insufficient.
Keyhole technique
Procedure: Small incision at the lower border of the areola to remove breast tissue without removing excess skin.
Indications: Very small breast volume and excellent skin elasticity. Approximately 5-10% of patients are eligible.
Advantages: Minimal scarring, rapid recovery, sensation preservation.
Limitations: Very restrictive selection, not suitable if excess skin present.
Other approaches such as inverted-T technique or buttonhole technique may be used for specific cases, particularly to preserve nerve sensation.
Top surgery procedure: what to expect during the intervention
Preparation
Smoking cessation at least 3 weeks before the intervention (smoking compromises vascularization and significantly increases the risk of complications, particularly nipple graft necrosis).
Low-sodium diet (approximately 1500 mg/day) recommended 2 weeks before and after to reduce postoperative edema.
Operative procedure
Duration: 2 to 4 hours depending on technique and complexity.Anesthesia: General.Hospitalization: Generally outpatient (same-day discharge). Hospitalizations of 1 to 2 days may be necessary depending on hospital protocols.
Temporary surgical drains are usually placed to prevent fluid accumulation. They are generally removed within 1 to 2 weeks.
Top surgery recovery timeline and healing process
First week
Most uncomfortable phase. Edema, bruising, and chest discomfort present. Mandatory compression garment wear. Drains in place.
Restrictions: Avoid raising arms above shoulders, lift nothing heavier than 2-3 kg, short walks encouraged but no exercise increasing heart rate.
First postoperative appointment during this week for evaluation and possible drain removal.
Weeks 2-3
Edema and bruising decrease. Mobility improves. Light daily activities possible.
Restrictions: Avoid lifting more than 11 kg, keep arms below shoulder level.
Weeks 4-6
Return to work possible around 1-2 weeks (if non-physical), more demanding activities around 3-4 weeks.
At 6 weeks: Authorization generally given to resume physical exercise, including upper body weightlifting, pending surgeon approval.
3-6 months
Scars continue to improve and lighten. Residual edema resolves. Final results become apparent.
Long-term results
A longitudinal follow-up study of a patient cohort evaluated up to 40 years after intervention demonstrated chest body congruence scores ranging from 84.2 to 96.2 out of 100. Mental health benefits persist decades after the intervention, with significant reduction in suicidal ideation and resolution of mental health comorbidities secondary to gender dysphoria. Regret rates reported in scientific literature are very low.
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Top surgery effectiveness and patient satisfaction rates
Scientific data converge toward positive results. A Danish study reported that approximately 96% of patients were satisfied or very satisfied with the overall cosmetic result. Research also shows that complications do not significantly decrease overall satisfaction with top surgery—psychological benefits and body congruence appear to prevail over temporary technical difficulties.
Documented benefits include:
- Improved body image
- Reduced gender dysphoria
- Increased quality of life and self-esteem
- Improved daily functioning
- Reduced depressive and anxiety symptoms
One study showed that 23 of 90 transmasculine patients experienced persistent postoperative pain, but approximately 90% of these experienced only mild to moderate pain, with none having constant pain.
Top surgery complications and risks for transmasculine patients
Like any surgical intervention, top surgery carries risks. A study of 679 patients reported an overall complication rate of approximately 18% and a reoperation rate of approximately 11%, with these rates decreasing with surgeon experience.
Common complications
Hematoma and seroma: Collection of blood or fluid under the skin. May require drainage. Incidence generally below 5%.
Wound dehiscence: Partial reopening of incisions. Generally minor and managed with local care.
Sensation changes: Nipple and chest skin sensation may be reduced, increased (hypersensitivity), or absent, particularly after free nipple grafting.
Asymmetry or contour irregularities: May require minor surgical revisions.
Less common complications
Infection: Rare with prophylactic antibiotic therapy. Incidence below 1% in elective procedures.
Nipple necrosis: Partial or total loss of nipple graft due to vascularization failure. More frequent in smokers.
Post-mastectomy pain syndrome: Chronic pain related to nerve irritation. May last up to 6 months but generally resolves in 3-6 weeks. Scar massage and appropriate mobility exercises may help.
Dog ears: Excess tissue protrusions at scar ends, near armpits. More common with significant tissue removal or less elastic skin. May require minor correction.
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Risk factors
A national analysis identified certain demographic and medical variables as predictors of 30-day postoperative complications, notably diabetes. Obesity has not been associated with increased complications according to several studies, although patients with high BMI may present technical challenges.
Top surgery costs and health insurance reimbursement in Belgium
Important: The pricing information below is indicative, non-contractual, and may vary depending on hospital, surgeon, technique employed, and your health insurance provider. The amounts mentioned are provided for informational purposes and do not constitute a coverage guarantee.
Estimated cost of subcutaneous mastectomy
The total cost of subcutaneous mastectomy in Belgium is not standardized. Prices can vary significantly depending on provider and hospital structure.
Hospitalization: Generally 1 to 2 days.Work incapacity: Variable depending on professional activity.
Health insurance reimbursement
According to publicly available information from the Christian Mutual Insurance (data provided for informational purposes):
- Health insurance may cover approximately 90% of costs related to subcutaneous mastectomy for transgender individuals.
- The remaining 10% corresponds to co-payments and any supplementary fees.
- It is imperative to verify with your surgeon and mutual insurance advisor the exact amount that will be your responsibility.
Attention: This information concerns a specific mutual insurance provider. Reimbursement conditions may differ depending on your insurance organization (socialist, liberal, neutral mutuals, etc.). Contact your own mutual insurance provider directly to know your exact coverage.
General conditions:
- The intervention must be performed in Belgium
- The pathway must meet mandatory insurance criteria
- Conditions may vary depending on your status (BIM, third-party payment, etc.)
- Some hospitals or surgeons charge supplementary fees that are not reimbursed
Reimbursement does not systematically cover all ancillary costs (multiple preoperative consultations, specific complementary examinations, postoperative compression materials). Request a detailed quote before the intervention.
Contraindications and precautions for top surgery
Absolute contraindications
- Unstable medical conditions compromising anesthetic safety
- Uncontrolled coagulation disorders
- Active infection
Relative contraindications
- Active smoking (cessation required minimum 3 weeks before and after)
- Unstable mental health requiring prior treatment
- Unrealistic expectations regarding results
- Non-optimized chronic medical conditions (poorly controlled diabetes, hypertension)
Patients must disclose all medications. Anticoagulants and non-steroidal anti-inflammatory drugs (NSAIDs) must generally be discontinued before intervention to reduce hemorrhagic risk.
Frequently asked questions about top surgery
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