Posted in: Our Experts, Procedural Information , Friday April 14, 2023

By: Dr. Noel B. Natoli

Q: Does insurance ever cover top surgery? What is the average cost of top surgery?

A: Fortunately, this is largely covered by insurance. Certain insurance plans do exclude these benefits, so it’s important to check with your carrier first. We do have patients that prefer to pay out-of-pocket for whatever reason – such as benefits excluding coverage, high deductibles, etc. Pricing does vary based on size- larger breasts and higher BMI mean longer operative times. 

Q: What is the typical age for top surgery?

A: Many insurance companies don’t cover top surgery before age 18, but that is starting to change as there is more support for this surgery in younger teens who’ve identified as transgender since their early teens or longer. I would say my typical patient is in their late teens to early 30s, but this is just in my practice. 

Q: Is top surgery risky?

A: Not particularly. Anytime we make a cut anywhere on the body, there is a small risk for infection, bleeding, scarring, asymmetry, or need for additional surgery. The risks don’t differ much from any other breast surgery. I do leave drains in the breast to prevent the risk of a collection of blood or fluid but they are removed promptly at the first visit which happens between days 5-7 after surgery. We use a lot of numbing medication which has a medication mixed in it (epinephrine) to cause vasoconstriction of the blood vessels and prevent bleeding. I have never found it necessary to transfuse a top surgery patient. We keep blood loss minimal even in heavy and large-breasted patients. 

Q: Can you feel your nipples after top surgery?

A: Sometimes, it just depends on the approach. In a larger breasted patient (larger than a B cup), I cannot offer preserved sensitivity. In smaller patients, I can leave the nipple attached which has a good chance of preserving sensitivity, however, even in this case it’s not a guarantee of sensitivity. In larger-breasted patients, often the priority is to be as flat as possible and we generally offer a free-nipple graft which means we remove the nipple, make the areola more oval (if the patient is seeking a more masculine look), we reduce the nipple in height (projection) and size, and then we replace the nipple in a slightly more lateral position and higher position typical of the male breast. Over time sensitivity does return and I have patients that want to shout out to the world that they can even feel their nipples. While it is true that you do get sensitivity back to the skin over months to years, there is not the same sensitivity as with a native nipple.

Q: What are the pre-requisites for top surgery?

A: Patients must have letters of medical clearance and mental health clearance from a mental health professional. I generally require these letters prior to consultation. Plenty of my patients do not see a counselor or psychiatrist regularly, but they still are required to get this letter. I do require a breast ultrasound prior to surgery as well and medical clearance which includes some basic labs. 

Q: Is top surgery reversible?

A: No. There are procedures that can be performed to rebuild a breast; or, in the case of a transgender female, implants can be removed and skin excess removed. However, I counsel patients that this is a permanent procedure and they should not undertake surgery unless they are prepared to live with their reconstruction for their lifetime. 

Q: Do I have to be on hormone therapy first to have top surgery?

A: It is not required to be on hormones prior to top surgery. However, if a transgender male has decided on his/their own to take hormones, then they must be first stable on testosterone for six month’s time. On the other hand, a transgender female who is seeking breast augmentation is recommended to be on estrogen or an estrogen derivative and possibly spironolactone for minimum of a year. This is because breast tissue takes a while to develop and it is best to maximize the natural hormone-associated breast growth prior to breast augmentation. 

Q: Is there a BMI requirement for top surgery?

A: No. I do recommend the use of medically-supervised weight loss medications or bariatric surgery in patients who are morbidly obese prior to top surgery. 

Q: What can I expect during a top surgery consultation? 

A: In general it’s a lot of getting to know you. We ask about your journey, how long you’ve been living trans, preferred pronouns and name, support network and who’s on your team (family, friends, mental health professionals), binding habits, medical problems, medications/allergies including steroid use, family history, psychological history (therapy, diagnoses, current/past counseling), social history (tobacco use, job status and how that will be affected by recovery, student status and how much time you need for recovery). We will do a full breast exam and take photos for insurance. We will review your ideal top surgery and what you are looking for in terms of results and aesthetic ideals. We will review timeline of insurance authorization, anticipated pre-op, operative course/ details of procedure, post-operative course and restrictions. And I will answer all the questions you have for me along the way!