In this guide17 sections
- Key Points
- What Are the Different Types of Top Surgery?
- How Do the Top Surgery Incision Types Compare?
- What Is Double Incision Top Surgery?
- What Is Nipple-Sparing Double Incision (Buttonhole) Top Surgery?
- What Is Inverted T (Anchor) Top Surgery?
- What Is Keyhole Top Surgery?
- What Is Periareolar Top Surgery?
- Keyhole vs Periareolar Top Surgery: What Is the Difference?
- Can You Have Top Surgery Without Nipples?
- Which Top Surgery Is Right for Me?
- What Is the Best Top Surgery Technique?
- What Disqualifies You From Top Surgery?
- Does Keyhole Top Surgery Heal Faster?
- Frequently Asked Questions
- FTM Top Surgery in London
- References
Key Points
- There are five main types of FTM top surgery: double incision with free nipple grafts, nipple-sparing double incision, inverted T, keyhole and periareolar. Top surgery without nipples is also an option.
- Your chest decides more than your preference. Chest size, how much the chest droops, skin elasticity and nipple position set which techniques can give you a flat, even result.
- Keyhole and periareolar are different operations. Keyhole removes no skin and suits small, firm chests. Periareolar removes a ring of skin around the areola and can make the areola smaller.
- There is a trade-off between scars and control. Smaller-incision techniques leave less scarring but have higher revision rates; double incision leaves longer scars but gives the most control over shape and nipple position.
- Nipple sensation depends on whether the nipple stays attached. Keyhole, periareolar, nipple-sparing double incision and inverted T keep it attached. Free nipple grafts reduce sensation.
- Your surgeon recommends, you decide. At consultation your surgeon examines your chest and explains which options suit you.
There are five main types of top surgery for trans men and non-binary people: double incision with free nipple grafts, nipple-sparing double incision, inverted T (anchor), keyhole and periareolar. Which one is right for you depends mainly on your chest size, how much your chest droops, how elastic your skin is, and how much you value keeping nipple sensation compared with having the flattest chest and the shortest scars. Some people also choose top surgery without nipples.
All five techniques remove breast tissue to create a flatter chest. They differ in where the incisions go, how much skin is removed and what happens to the nipple. This guide explains each type of FTM top surgery, compares their scars, sensation, drains and recovery, clears up the confusion between keyhole and periareolar surgery, and helps you work out which is right for you.
What Are the Different Types of Top Surgery?
Top surgery techniques fall into two groups. Double incision, nipple-sparing double incision and inverted T use longer incisions under the chest and remove excess skin. Keyhole and periareolar work through the edge of the areola and remove little or no skin.
The five types we offer are:
- Double incision with free nipple grafts: two incisions along the lower chest; nipples resized and replaced as grafts.
- Nipple-sparing double incision: the same incisions, but the nipple stays attached to a stalk of tissue (a pedicle). Also called buttonhole top surgery.
- Inverted T (anchor): an anchor-shaped incision that removes more skin while keeping the nipple attached.
- Keyhole: a short incision along the lower edge of the areola, with no skin removed.
- Periareolar: a ring of skin removed around the areola, which is made smaller.
You may see other names online: “T-anchor” means inverted T, and “peri”, “donut” and “circumareolar” usually mean periareolar. Liposuction is often added to smooth the side of the chest rather than used as a separate technique. Surgeons choose between these options mainly on chest volume, droop (ptosis), skin quality and nipple position[1].
How Do the Top Surgery Incision Types Compare?
All five are day cases under TIVA (total intravenous anaesthesia), with a compression binder worn for six weeks. The figures below are typical.
| Technique | Usually suits | Skin removed | Scars | Nipple | Nipple sensation | Drains |
|---|---|---|---|---|---|---|
| Double incision with free nipple grafts | Moderate to large chests, any droop | Yes, the most | Two horizontal scars along the lower chest, plus around the grafted nipples | Removed, resized and grafted | Usually permanently reduced | Not usually needed; if used, removed once fluid output drops |
| Nipple-sparing double incision | Moderate chests with good elasticity | Yes | Two horizontal scars along the lower chest | Kept attached on a pedicle | Most keep partial to full sensation | Not needed in most cases |
| Inverted T (anchor) | Larger chests or looser skin | Yes | Around the areola, a vertical line down and a horizontal line along the chest fold | Kept attached on a pedicle | More likely to be kept than with grafts | More often needed, for around a week |
| Keyhole | Small, firm chests, typically A or B cup | No | Along part of the lower edge of the areola | Stays in place, not resized | Usually preserved | Not routinely needed |
| Periareolar | Small chests, typically B cup or smaller, good elasticity | A ring around the areola | All the way around the areola | Kept attached; areola can be reduced | Most keep partial to full sensation | Sometimes, depending on the case |
What Is Double Incision Top Surgery?
Double incision top surgery with free nipple grafts is the most widely performed type of top surgery. Through two horizontal incisions along the lower border of the chest muscle, the breast tissue and excess skin are removed, often with liposuction to contour the side of the chest. The nipples are made smaller and placed back as free grafts in a masculine position.
It works for almost any chest, including larger chests with significant droop, and gives the most control over shape, scar position and nipple size and placement. The trade-offs are longer scars and sensation: grafting divides the nerves to the nipple, so feeling is usually reduced for good, although some light touch often returns.
The evidence on complications favours this technique. In a 2018 systematic review in the Annals of Plastic Surgery ↗, which pooled 2,138 operated breasts from eight studies, free nipple graft techniques had the lowest rate of early return to theatre for bleeding (4.8%) and fewer secondary operations (20.3%) than periareolar surgery (37.5%)[2]. These figures include small revisions, such as tidying a scar.
Graft loss is uncommon but more likely in people who smoke or vape nicotine. Our guide to the risk of losing a nipple after top surgery explains how grafts heal and what you can do to protect them.
What Is Nipple-Sparing Double Incision (Buttonhole) Top Surgery?
Nipple-sparing double incision top surgery, also called buttonhole top surgery, uses the same horizontal incisions along the lower chest as standard double incision. The difference is that the nipple and areola stay attached to a pedicle of tissue that carries their blood supply and some of their nerves, rather than being grafted.
It suits moderate chests with good skin elasticity. Most people keep partial to full nipple sensation, and the nipples keep their natural texture. The compromises are that the pedicle leaves a little more tissue behind the nipple, so the chest can be slightly less flat there, and there is less freedom to move the nipple. In a 2024 prospective study of 51 patients, nipple sensation was better preserved when the nipple stayed on a pedicle than when it was grafted[3]. Drains are not needed in most cases.
What Is Inverted T (Anchor) Top Surgery?
Inverted T top surgery, also called anchor or T-anchor top surgery, is the nipple-sparing option for larger chests or looser skin. It uses three incisions that together form an anchor shape: one around the areola, a short vertical line down from the areola to the chest fold, and a horizontal line along the fold. This allows more skin to be removed than with nipple-sparing double incision, while the nipple stays attached to its pedicle.
It suits a larger chest where keeping your own nipples, and a better chance of sensation, matters to you. In return, there is an extra vertical scar, drains are more often needed for around a week, and the pedicle can leave a little more fullness. Surgeons increasingly report that nipple preservation is possible across most chest sizes when the technique is matched to chest volume, droop and nipple position[4].
What Is Keyhole Top Surgery?
Keyhole top surgery removes breast tissue through a short incision along the lower edge of the areola, usually about a third to half of its circumference. Much of the tissue is removed with liposuction through the same incision. No skin is removed, and the nipple is not detached or resized, so it keeps its own blood and nerve supply.
It gives the smallest scar and the best chance of keeping nipple sensation, and drains are not routinely needed. The catch is that it only works for small chests, typically A or B cup, with firm, elastic skin, which has to shrink back flat on its own. On a chest that is too large or too loose, the result can be wrinkled or baggy skin that needs further surgery.
Limited-incision techniques such as keyhole and periareolar carry a higher risk of bleeding under the skin (haematoma) than double incision with free nipple grafts. A 2022 systematic review found that this was the factor most strongly linked with haematoma after top surgery, and that nicotine use also raised the risk[5].
What Is Periareolar Top Surgery?
Periareolar top surgery removes a ring of skin from around the areola. Your surgeon marks a smaller inner circle for the new areola and a larger outer circle, removes the skin between them, takes out the breast tissue through this opening, and then draws the outer edge in to meet the smaller areola, rather like closing a drawstring bag.
This tightens the skin a little and reduces the areola, which keyhole cannot do. The nipple stays attached, so most people keep partial to full sensation, and the scar sits at the areola edge where the colour change helps hide it. It typically suits chests of B cup or smaller with good elasticity and only a little excess skin.
The scar can stretch or look pleated in the early months, it is harder to make the chest completely even, and revision rates are higher than with double incision[2]. If you have more than a small amount of loose skin, double incision or inverted T usually gives a better result.
Keyhole vs Periareolar Top Surgery: What Is the Difference?
Keyhole and periareolar top surgery are often confused, but they are two different operations:
- Incision: keyhole uses a short cut along part of the lower edge of the areola. Periareolar goes all the way around the areola.
- Skin: keyhole removes no skin. Periareolar removes a ring of skin, which gives a small amount of tightening.
- Areola size: keyhole leaves the areola as it is. Periareolar makes the areola smaller.
- Who it suits: keyhole suits the smallest, firmest chests. Periareolar suits small chests that have slightly more skin or a larger areola.
- Scars: both leave scars at the areola edge, but the periareolar scar is a full circle and is more likely to widen or pucker.
Both keep the nipple attached, so both give a good chance of keeping sensation.
Can You Have Top Surgery Without Nipples?
Yes. Some people choose a smooth chest with no nipples, usually using the same incisions as double incision top surgery without replacing the nipples. In a 2024 study of 536 people having gender-affirming mastectomy, 13% chose not to have nipple grafts, and 98% of those surveyed were satisfied with that choice[6].
Non-binary people may want a flat chest without nipples, smaller or repositioned nipples, or a reduced rather than completely flat chest. Our non-binary top surgery page explains how these options are planned around what you want.
Which Top Surgery Is Right for Me?
The right technique gives you a chest you are happy with, with risks and scars you can accept. These questions help narrow it down:
- How large is your chest? A small, high, firm chest may suit keyhole or periareolar. Moderate chests usually suit double incision, with or without nipple grafts. Larger chests usually need double incision with grafts or inverted T.
- How much does your chest droop? If your nipple sits at or below the fold under your chest, a technique that removes skin will give a flatter result.
- How elastic is your skin? Stretch marks, weight loss or years of binding can reduce elasticity, making keyhole or periareolar less likely to work.
- How important is nipple sensation? If it matters most, ask about the nipple-sparing techniques. Our guide to nipple sensation after top surgery explains what to expect with each technique.
- How do you feel about scars? Double incision and inverted T scars are longer but usually fade well over 12 to 18 months. Keyhole and periareolar scars are shorter but carry a higher chance of revision. Our guide to top surgery scars covers how they heal and how to look after them.
- Do you want nipples, and where? For smaller nipples in a typical masculine position, or no nipples, double incision gives the most control.
It helps to rank what matters most to you before your consultation. Your surgeon will examine your chest and tell you which techniques are realistic; where more than one would work, the choice is yours.
What Is the Best Top Surgery Technique?
There is no single best technique, only the best match for your chest and priorities. A 2023 systematic review and meta-analysis in the Journal of Plastic, Reconstructive and Aesthetic Surgery ↗, covering 3,055 patients, found the lowest complication rates with double incision and free nipple grafts, followed by pedicled nipple-sparing techniques, with periareolar techniques having the most complications[7]. Patients who had periareolar surgery did report higher satisfaction scores, reflecting the appeal of smaller scars when the chest is suitable.
Longer-term satisfaction seems to depend more on getting the right technique for the chest than on the technique itself. In a 2024 study using the BODY-Q Chest questionnaire ↗ of 123 patients followed up for several years, satisfaction scores did not differ significantly between techniques, periareolar surgery was not linked with better satisfaction despite its smaller scars, and patients who needed more secondary corrections were less satisfied with their chests[8]. In practice, slightly longer scars are usually a better choice than a smaller-incision technique your chest does not suit.
What Disqualifies You From Top Surgery?
Few things rule top surgery out altogether, but some affect when you can have it or which technique is safe:
- Age: we offer top surgery to adults aged 18 and over only.
- Smoking and nicotine: stop all nicotine products, including vapes, for four weeks before and four weeks after surgery.
- Medicines: aspirin needs to be stopped two weeks before surgery, and your surgeon will check any other medicines you take.
- Uncontrolled health conditions: conditions such as poorly controlled diabetes need to be managed first.
You do not need a diagnosis, a GP referral or a WPATH letter to have top surgery with us. We recommend a two-week cooling-off period between consultation and surgery.
Does Keyhole Top Surgery Heal Faster?
A little. Keyhole, periareolar and nipple-sparing double incision usually allow a return to desk work after about a week, compared with one to two weeks after double incision with free nipple grafts. Physical jobs need longer.
Otherwise the milestones are the same. You go home the same day with a responsible adult, who stays with you for 24 hours. Your wound check is at day 7 to 10, strenuous exercise and heavy lifting wait until your surgeon review at six weeks, and you are assessed again at three months. Our FTM top surgery recovery guide sets out the full timeline.
Frequently Asked Questions
Do you lose your nipples with top surgery?
Not usually. With keyhole, periareolar, nipple-sparing double incision and inverted T surgery, your nipples stay attached to their own blood supply. With double incision and free nipple grafts, the nipples are removed, resized and placed back on the chest as grafts. A small number of people choose top surgery without nipples for a smooth chest.
What are the downsides of top surgery?
Every technique leaves scars, and some loss of chest and nipple sensation is common, especially after nipple grafts. Possible complications include bleeding under the skin, fluid collections, infection, small folds of skin at the scar ends (dog ears), uneven contour and graft problems. Some people need a minor revision, which is not usually done until nine to twelve months, once healing has settled.
Which top surgery has the least scarring?
Keyhole top surgery leaves the smallest scar, along part of the lower edge of the areola, followed by periareolar surgery with a scar all the way around the areola. Both are only suitable for small, firm chests. Double incision and inverted T leave longer scars, but they usually fade well over 12 to 18 months.
What cup size is suitable for periareolar top surgery?
Periareolar top surgery typically suits a B cup or smaller, with good skin elasticity and only a small amount of excess skin. Cup size is only a guide, as skin quality and droop matter just as much. With a larger chest or looser skin, double incision or inverted T usually gives a flatter result.
What is buttonhole top surgery?
Buttonhole top surgery is another name for nipple-sparing double incision. The breast tissue is removed through incisions along the lower chest, but the nipple stays attached to a pedicle of tissue and is brought out through a small opening in the new chest skin, rather than being removed and grafted. It suits moderate chests with good elasticity.
Is top surgery the same as a mastectomy?
Not quite. A mastectomy for breast cancer aims to remove as much breast tissue as possible. Top surgery is chest masculinisation: the surgeon removes most of the breast tissue but also shapes the chest, leaves an even layer of fat under the skin and positions the nipples to create a male or non-binary chest.
Should I get a breast reduction or top surgery?
It depends on the result you want. A breast reduction leaves smaller breasts with a breast shape. Top surgery creates a flat chest. Some non-binary people want something in between, such as a much smaller, flatter chest, and this can be planned with your surgeon at consultation.
FTM Top Surgery in London
FTM top surgery at Centre for Surgery is performed by GMC-registered surgeons at our CQC-regulated Baker Street hospital, rated Good overall by the CQC, for trans men and non-binary people aged 18 and over. We offer all five techniques, double incision with free nipple grafts, nipple-sparing double incision, inverted T, keyhole and periareolar, as well as top surgery without nipples, and your surgeon will recommend the options that suit your chest and your priorities. No diagnosis or referral letter is needed. The consultant who assesses you at consultation is the consultant who performs your surgery. Your initial consultation is £100, redeemable against the cost of surgery if you go ahead; our FTM top surgery cost guide explains what the price includes, and you can see real results in our top surgery before and after photos. Finance is available, subject to status.
Phone: 020 7993 4849 | Address: 95–97 Baker Street, Marylebone, London W1U 6RN
Contact us to schedule a consultation
References
- Singh A, Charipova K, Del Corral GA. Indications and surgical techniques for gender affirming mastectomy. Clinics in Plastic Surgery 2025. doi:10.1016/j.cps.2025.07.001 ↗
- Wilson SC, Morrison SD, Anzai L, et al. Masculinizing top surgery: a systematic review of techniques and outcomes. Annals of Plastic Surgery 2018;80(6):679–683. doi:10.1097/SAP.0000000000001354 ↗
- Kanlagna A, Oillic J, Verdier J, et al. Prospective assessment of the quality of life and nipple sensation after gender-affirming chest surgery. Journal of Plastic, Reconstructive and Aesthetic Surgery 2024. doi:10.1016/j.bjps.2024.05.022 ↗
- Tse T, Potter E, Armstrong K. Techniques for preserving the nipple areolar complex in chest masculinization for all chest sizes. Cureus 2025;17(3):e80757. doi:10.7759/cureus.80757 ↗
- Bekisz JM, Boyd CJ, Daar DA, et al. Hematoma following gender-affirming mastectomy: a systematic review of the evidence. Journal of Plastic, Reconstructive and Aesthetic Surgery 2022;75(9):3108–3121. doi:10.1016/j.bjps.2022.04.081 ↗
- Ferrin PC, Pua E, Isbester K, Peters BR. Factors affecting the choice to forgo nipple grafts in gender-affirming chest surgery. Annals of Plastic Surgery 2024;93(2):189–193. doi:10.1097/SAP.0000000000004004 ↗
- Zhu J, Wang E, Liu S, et al. Impact of surgical technique on outcome measures in chest masculinization: a systemic review and meta-analysis. Journal of Plastic, Reconstructive and Aesthetic Surgery 2023;87:109–116. doi:10.1016/j.bjps.2023.09.002 ↗
- Saarinen M, Suominen S, Sintonen H, et al. Patient-reported satisfaction and health-related quality of life after chest masculinization in transgender men using the BODY-Q Chest module and the 15D instrument. Journal of Plastic, Reconstructive and Aesthetic Surgery 2024;96:43–49. doi:10.1016/j.bjps.2024.07.006 ↗
Related Articles
- Nipple Sensation After Top Surgery: Will You Still Feel Your Nipples?
- Top Surgery Scars: How They Heal, Fade and Can Be Treated
- Can Your Nipples Fall Off After Top Surgery? Nipple Graft Loss Explained
- FTM Top Surgery Recovery and Aftercare
