Chest flattening (top surgery) is a procedure done for people assigned female at birth (AFAB), as part of a medical transition process.
Top surgery can be done in several techniques, depending on the preference of the patient and the abilities of the surgeon.
Top surgery is a procedure that can be done through several routes: privately, through the Committee for Gender Reassignment (completely subsidized), and in some cases through the HMOs (partially subsidized, depending on the HMO. The approval is individual and there is no guarantee for HMO funding).
Usually, the goal of the procedure is to create a chest with a “masculine” appearance, that is, a flat chest with small nipples. Note that sometimes, mostly for non-binary people, the desired result is not a “masculine” chest.
Top surgery can be performed as part of gender reassignment for trans men, non-binary people, and cis women, as well as cis men suffering from gynecomastia1https://www.nhs.uk/common-health-questions/mens-health/what-is-gynaecomastia/ (growth of breast tissue in cisgender men). The goal of top surgery is to reduce gender dysphoria that the person experiences and to align their outward appearance with the gender they identify with.
It is not necessary to go through other medical processes to undergo top surgery, but many trans men undergo it after beginning hormonal treatment as HRT is often more accessible, and may also help shrink the breasts and allow for top surgery using other techniques.
Note that top surgery is similar in character to breast reduction surgeries or mastectomies done as a result of breast cancer, but the techniques used are different, and the results in terms of appearance, sensation, and satisfaction are different.2https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635198/
Studies show that most trans men who underwent top surgery are satisfied with the result of their surgery, and only 1% experienced regret after the surgery.3https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8726650/
Note that generally it is not necessary to stop testosterone treatment before the surgery, but some surgeons will request that you do so.
It is necessary to stop smoking about a month before the procedure and for about a month afterward, to avoid complications.
Your surgeon will instruct you about which medications you should take before the surgery.
If you are interested in becoming pregnant in the future, consult with your surgeon. Note that pregnancy can cause the growth of breast tissue if there is any remaining, so it is best to make sure that none remains. Additionally, after top surgery, you will not be able to breastfeed (depending on the type of surgery you choose).
Existing Surgery Types
There are different types of top surgery performed with different techniques. Not all people can undergo all types of surgeries, as it can depend on various factors such as chest size and structure. It is important to consult with a surgeon to determine the most suitable type of surgery.
You can view surgery results from Israel on the Israeli surgery results website. You can also search for results in the Trans Health Facebook group, on Reddit, or the Transbucket website.
The most common surgeries performed in the country are peri-areolar, double incision, and keyhole.
The goal of top surgery is to create results that suit you, which is not necessarily the chest appearance of a cisgender man. Many non-binary people choose to completely remove their nipples, to reduce breast size instead of entirely removing them, or to choose a surgery type where the scars aren’t “hidden” underneath the chest muscles.
Note that in each of the surgery types, it is possible to perform reduction of the nipple tip as well.
The main procedure types are:4https://www.topsurgery.net/procedures/
- Double incision5https://www.topsurgery.net/procedures/double-incision-top-surgery.htm surgery – the most common surgery method. It is possible in almost all cases and all chest sizes. The procedure includes the removal of the nipples, reduction of their size (depending on the surgeon’s preference), and creation of two incisions underneath the chest muscles while removing breast tissue and excess skin. At the end, the incisions are closed and the nipples are returned to the preferred location.
In most cases, sensation does not fully return to the nipples, as they are fully removed from the chest during the procedure.
After the surgery, there will remain two scars under the chest muscles, as well as scars around the nipples.- Pros – an option of reducing the size and moving the nipple location, an option of fully removing the nipple, a method that can be used for most people, very flat results, option of leaving breast tissue or fat for a result that is not completely flat.
- Cons – significant scarring, the chance of fully or partially losing sensation in the nipples.
- Buttonhole6https://www.topsurgery.net/procedures/buttonhole-technique-top-surgery.htm surgery – a less common surgery and is similar to the double incision method. In this method the nipples are not removed from the chest, a “hole” is made in the preferred location and the nipples are put through the hole – like a clothing button.
This method raises the chances of sensation remaining in the nipples but can cause a slightly swollen appearance in the nipple area and is not fully flat, as not all tissue is removed.
After the surgery, there will remain two scars under the chest muscles, as well as scars around the nipples, similar to the double incision method.- Pros – a high chance of sensation remaining in the nipples, an option of reducing the size and moving the nipple location, a method that can be used for most people, very flat results, an option of leaving breast tissue or fat for a result that is not completely flat.
- Cons – significant scarring, the chance of the chest not being fully flat.
- Peri-areolar7https://www.topsurgery.net/procedures/peri-areolar-top-surgery.htm surgery – a surgery performed in people with a relatively small chest, usually up to a B cup size. The option of doing this surgery depends on chest structure and skin elasticity as well, therefore not all people can undergo it.
This method includes an incision around the nipple (and reduction of its size if necessary), an additional incision a larger distance from the nipple, removal of breast tissue and excess skin, and closure of the incision (similar to the closure of a drawstring bag).
Full sensation can remain in the nipples, as the nerves are not severed during the procedure. There will remain scars around the nipple after surgery.
The nipple location is not changed, so the nipples may be lower on the chest than those of cisgender men.- Pros – high chance of sensation remaining in the nipples, minimal scarring, an option of reducing nipple size, an option of leaving breast tissue or fat for a result that is not completely flat.
- Cons – nipple location cannot be significantly changed, suitable only for those with a small chest, suitable chest structure and high skin elasticity, the chance of the chest not being fully flat.
- Keyhole8https://www.topsurgery.net/procedures/keyhole-top-surgery.htm surgery – a surgery suitable only for those with a very small chest, usually A cup size. In this method as well, the option of doing this surgery depends on chest structure and skin elasticity, so it is not suitable for everyone.
This method includes one incision below the nipple, removal of breast tissue and excess skin, and closure of the incision.
Full sensation can remain in the nipples, as the nerves are not severed during the procedure.
After the surgery, there will remain scars underneath the nipples. Usually, the scars are very small and not easily visible after recovery.
The nipple location is not changed, so the nipples may be lower on the chest than those of cisgender men.- Pros – high chance of sensation remaining in the nipples, minimal scarring.
- Cons – nipple location cannot be significantly changed, suitable only for those with a small chest, suitable chest structure and high skin elasticity, the chance of the chest not being fully flat.
- Minimal scarring9https://www.topsurgery.net/procedures/minimal-scar-top-surgery.htm surgery – a surgery performed on people with a very small chest, usually A cup size. In this method as well, the option of doing this surgery depends on chest structure and skin elasticity, so it is not suitable for everyone.
This method includes an incision under the nipple and on the side of the chest on both sides. Usually, the scars are very small and not easily visible after recovery.
The nipple location is not changed, so the nipples may be lower on the chest than those of cisgender men.- Pros – high chance of sensation remaining in the nipples, minimal scarring.
- Cons – nipple location cannot be significantly changed, suitable only for those with a small chest, suitable chest structure and high skin elasticity, the chance of the chest not being fully flat.
- T-anchor10https://www.topsurgery.net/procedures/inverted-t-anchor-top-surgery.htm surgery – a less common surgery. This method is similar to breast reduction surgeries and is performed less often on trans people but is a possibility that exists.
This method is possible for almost all chest sizes.
It includes an incision around the nipple, under the chest muscle, and between the muscle line and nipple. Then the nipple can be moved or reduced in size if needed, breast tissue and excess skin are removed and the incisions are closed.
Full sensation can remain in the nipples, as the nerves are not severed during the procedure.
After the surgery, there will remain scars around the nipples, under the chest muscles, and between the muscle and nipple, on both sides.- Pros – high chance of sensation remaining in the nipples, an option of reducing the size and moving the nipple location, a method that can be used for most people, very flat results, an option of leaving breast tissue or fat for a result that is not completely flat.
- Cons – significant scarring.
- Fish-mouth11https://www.topsurgery.net/procedures/inverted-t-anchor-top-surgery.htm surgery – a less common surgery. This method is possible for almost all chest sizes. This method is done mostly by non-binary people.
It includes an incision around the nipple and on either side of it, reduction of nipple size and moving their location if needed, removal of breast tissue and excess skin, and closure of the incisions.
Full sensation can remain in the nipples, as the nerves are not severed during the procedure.
After the surgery, there will remain scars around the nipples and on either side of the nipples, on top of the chest muscle and not underneath it.- Pros – high chance of sensation remaining in the nipples, an option of reducing the size and moving the nipple location, a method that can be used for most people.
- Cons – significant scarring, and an unnatural nipple location for cisgender men.
Recovery and Scar Appearance
The recovery process from top surgery depends on the type of procedure. Usually, returning to daily routine will take between two weeks to two months, and returning to physical activity will take between two months and half a year.
After the incisions are healed, it is recommended to use silicone cream or tape to avoid prominent scarring and to improve the scars’ appearance.
The surgeon will provide instructions about medications and scar care during recovery.
To improve scar appearance, you can use various creams and oils and medical tattoos. A medical tattoo can improve the color of the scars, or even create nipples with a 3D look (in cases where there were complications or if the nipples were removed).
It is recommended to go to a lymphatic physiotherapist, which is the recommended type of physical therapy after top surgery (breast removal or enlargement). It can help reduce pain, fluid retention and swelling, scar care, and help return to full range of motion.
Physical therapy after surgery is a service that is provided by your HMO, it is recommended for anyone undergoing top surgery to consult with one of the professionals on the attached list, and they can also help coordinate care through your HMO if they do not work with them.
List of trans-friendly lymphatic therapists. The list was updated at the beginning of 2023.
Surgeons and Surgery Funding in Israel
Top surgery can be done privately (and pay on your own for the procedure or use private health insurance. For reading about using private health insurance), via the HMOs without going through the Committee for Gender Reassignment (it is possible to receive partial funding or full funding if the surgery is included in your HMO complementary insurance), or via the public healthcare system with full HMO funding with approval from the Committee for Gender Reassignment.
It is recommended to consult with multiple doctors. A consultation will usually cost a few hundred shekels, and you can use private insurance, if you have it, for reimbursement.
Some of the private doctors will provide consultation at a reduced rate through arrangements with your HMO.
Funding for consultation with doctors in the public health sector can be received with a Form 17 from your HMO.
List of doctors who perform the surgery (this is not a full list; it is recommended to do further research):
- Dr. Alon Liran
- Through the Committee for Gender Reassignment
- Operates at Sheba-Tel Hashomer Hospital
- Privately
- 3 Hanehoshet St, Building B, 3rd floor
- Website
- Phone – 054-4607139
- Email – alonliranmd@gmail.com
- Through the Committee for Gender Reassignment
- Dr. Udi Arad
- Through the Committee for Gender Reassignment
- Operates at Ichilov Hospital
- Privately
- 5 Habarzel St, 1st floor, Tel Aviv
- 4 Hagavish St, Titanium building, 2nd floor, Netanya
- Website
- Phone – 058-51001123
- Email – Dr@udiarad.com
- Through the Committee for Gender Reassignment
- Dr. Yoram Wolf
- Through the Committee for Gender Reassignment
- Operates at Sheba-Tel Hashomer Hospital, Hillel Yaffe Hospital
- Privately
- 11 Habarzel St, Building A, 5th floor, Tel Aviv
- Website
- Phone – 077-2318957
- Email – drwolfcl.mail@gmail.com
- Through the Committee for Gender Reassignment
- Dr. Yaakov Frand and Dr. Rivi Haiat
- Through the Committee for Gender Reassignment
- Operate at Wolfson Hospital (Keshet Clinic)
- Through the Committee for Gender Reassignment
- Dr. Avry Raveh
- Privately
- Shekel Tower, 2 Tashah St, Tel aviv
- Website
- Phone – 052-9708697
- Email – clinic@drraveh.com
- Maccabi
- Privately
- Dr. Ran Talisman
- Privately
- 1 Zeitlin St, Tel Aviv
- Phone – 03-6090660
- Privately
- Dr. Lior Heller
- Privately and also possible through the committee
- 9a Habarzel St, Tel Aviv
- Phone – 03-9195779
- Privately and also possible through the committee