Transmasculine and nonbinary individuals have a number of personal decisions to make about their gender presentation. If you would prefer a flatter or masculine appearing chest, an important choice is how to pursue this goal.
For some, chest binding is a long-term or permanent solution to gender dysphoria. For others, the idea of having breast tissue permanently removed by undergoing top surgery is more appealing.
Different types of top surgery will work best on different people depending on their chest size. There are many options to choose from, distinguished by their incision type.
Some of the most common types of top surgery are double incision, peri-areolar, inverted-T, buttonhole, and keyhole top surgery. For those with a smaller chest size, keyhole top surgery is often performed because it only requires two tiny incisions that can be nearly invisible within a few months post-op.
If you or a loved one are considering keyhole top surgery, read on to learn all about the procedure and its recovery.
Keyhole Top Surgery
Keyhole top surgery is a gender-affirming procedure that removes breast tissue to create a flat, masculine looking chest. For transmasculine individuals or AFAB (assigned female at birth) nonbinary people, the surgery can greatly enhance body confidence.
The main reason to undergo the procedure is to feel more comfortable, both physically and psychologically. Most people who receive the surgery are pleased with the results.
The price of the surgery can vary substantially based on location, associated procedures (such as nipple reduction or liposuction), and your surgeon. Most top surgeries fall somewhere between $7,000 and $10,000. This figure includes the surgeon fee, as well as the anesthesiologist fee and the surgical center fee. However, you may also have to pay for related expenses, such as travel expenses or prescription meds.
If you’re lucky, your insurance may cover a big chunk of the price tag, but more often than not, this expense will be paid out-of-pocket.
Keyhole top surgery comes with a lot of benefits, such as a short recovery time and minimal scarring. However, it can be difficult to qualify for it.
Ideal Patients for Keyhole Top Surgery
Only about 5% (1 out of 20) people qualify for this particular surgery. Ideal patients for this type of chest construction are already small-chested, usually smaller than a B-cup. This is because the procedure does not remove skin along with breast tissue.
It also requires that the position of your nipples be roughly where you want them to be, because keyhole top surgery does not re-position them. In contrast, the double incision top surgery can re-position your nipples.
Skin elasticity is another important factor. Years of chest binding can reduce the elasticity of the skin, but binding should not greatly affect your chances of qualifying.
Ideal patients should also be in optimal health. Usually, weight will not impact your eligibility, although patients that qualify for this surgery tend to be naturally lean because this is a contributing factor to small chest size.
Your surgeon will discuss all of your options with you and let you know if you qualify for the procedure.
Pre-Op Preparation for Keyhole Top Surgery
Once you have your surgery date, you will need to make several preparations. Your surgeon will provide more detailed instructions, but in general, here are the actions you will need to take.
Before and after the surgery, you must stop all smoking and recreational drug use for about three weeks. In addition, do not drink alcohol for a week before or after. You will also need to avoid blood thinners prior to surgery, such as fish oil and NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen, acetaminophen, and Naproxen.
You’ll also want to incorporate a balanced diet and exercise to ensure your best possible health before surgery. Doing chest exercises is not required, but will help you achieve a more defined appearance post-operatively.
The night before surgery you will usually have to stop food and water intake somewhere between 10pm to 12am.
The Keyhole Procedure
The procedure uses a general anesthetic to put patients to sleep. In total, the procedure takes between one and a half to three hours to complete.
This top surgery procedure is one of the least invasive options available to patients, with only a small incision placed around half of each areola. An areola is the flat ring of pigmented skin that surrounds each nipple.
Your surgeon will create a small, partial incision around each areola and remove breast tissue through this hole. Some surgeons also perform liposuction during surgery to remove fat tissue and create a more uniform finished appearance.
While keyhole top surgery cannot reposition the nipples, the nipples can easily be reduced in size or shape if the patient prefers.
Finally, the surgeon places drains on each side of the chest and closes the incisions. The drain includes a small tube positioned under the skin to collect excess fluid. Fluid can accumulate post-operatively because tissue layers get separated during top surgery, leaving a pocket where it can collect. This is not ideal because this makes it more difficult for the tissue layers to heal back together, which is why drains are used.
Your drains will exit through a small incision underneath your armpit, where they will collect fluid into a small pouch.
Occasionally, surgeons, such as Dr. Sidhbh Gallagher in Miami, perform top surgery procedures using a drain-free approach. With this approach, the surgeon places a few “quilting” stiches to connect the tissues layers together before closing the patient up at the end of surgery. This approach prevents excess fluid from accumulating between the tissue layers, eliminating the need for drains.
The final result after keyhole top surgery is a smooth and flat chest with a masculine appearance. It is rare, but you may need to have a second surgery to correct cosmetic issues or complications.
Recovery after Keyhole Top Surgery
You will feel some pain after surgery, along with slight bruising or swelling, but this is easily managed by medication. Your chest may feel numb, but full sensation generally returns within a few weeks to months.
As mentioned, you will usually have medical drains under each arm collecting fluids and blood. These remain in place for about a week, during which time you will empty the reservoirs multiple times a day. Your surgeon will remove these drains at your post-op appointment, which is usually scheduled for 6-7 days post-surgery, depending on your surgeon’s schedule.
It is advisable to wear a compression binder constantly for at least four weeks to accelerate healing. This will also aid in minimizing scars.
Of course, you will need a friend or family member to aid you during your surgery aftercare. However, you should be able to return to your own home (or hotel or Airbnb) on the same day of surgery.
For a few days, you must limit your activity to simple walking, but you should be able to return to work and do simple exercises after 7-10 days. You can start driving after you get your drains removed, have stopped your prescription pain meds, and can handle making sudden moves with the driver’s wheel.
After six to eight weeks, weight restrictions lift and you will be able to return to your normal life. Surgeons will give more detailed recovery information and instructions on a case-by-case basis.
Scarring is minimal with this type of top surgery. Only a thin scar underneath (or along the outside of) the areola remains. After several months, this small incision will become nearly unnoticeable.
Your Path to Keyhole Top Surgery
For many nonbinary and trans people, top surgery is an exciting step on the path toward gender alignment and confirmation. If you think keyhole top surgery is right for you, then talk to your surgeon about your options. They can help you weigh the risks and benefits in order to determine the best option for your unique body and goals.
There’s plenty more to learn about top surgery. If you still have unanswered questions, ask them in the comments below.