Before my top surgery I did lots of research. It mostly consisted of browsing piles of pictures of people’s chests, picking apart the subtle nuances of each, and drawing conclusions to ultimately inform my decision. I get quite a few requests to share my thought process for analyzing these results.

Given my experience, I’m going to focus on DI procedures, though some things are relevant for others. If you aren’t familiar with the various options for FTM Top Surgery, or male chest reconstruction, you can read up on that here: http://www.ftmguide.org/chest.html. I refrained from using other people’s pictures, so for illustrative purpose I instead included rough sketches from a layperson’s understanding.

Hopefully you’ll take away something useful.

Natural Look

My top priority when deciding on a surgeon was consistent, aesthetically pleasing results. What do I mean by that? A chest that looks natural, and avoids that surgically-altered feel (as much as possible, of course); a chest that I would have, were I an average guy.

Specifically, I focused on:

• Contour
• Incisions: neatness, position and shape
• Nipples: position and shape
• Technique
• Details

Time

Before we start, one important thing to keep in mind while looking at people’s results is time. My chest didn’t fully settle until 6-8 months post-op. Most people post pictures fresh out of the OR, or 1 week after, or even 3 months after. That is still too early to accurately gauge how the chest will look like in the long term, though of course there are a few things that are fairly obvious from the start. Whenever possible, look for 6+ month post-op pictures. Or at least try to mentally compensate.

Body Type

In general, I tried to look for pictures of people who shared my body type, skin color, age, musculature, etc. Specifically I sought out people who were not on T, especially before the surgery, but also after (which is a bit harder to find). Although everybody’s body is different, this is one rule of thumb to better predict how your chest will look on your body. Additionally, it’s a good sign when a surgeon has great results on people of all body types.

DI Techniques

For the double incision procedure (DI), there is one common technique, and several variations. The biggest difference is usually the style of incisions and the treatment of nipples.

DI with Free Nipple Grafts

When I first learned about DI with Free Nipple Grafts, I thought the “free” meant gratis, cost-free, as if the surgeon was being nice and throwing in the nipples as an extra. What it actually means is that the nipples are “free-floating” in a way. Basically, the surgeon cuts off the nipples, does the chest work, and then – literally – staples them on top of the skin.

Given this, the nipples are vulnerable to infection, necrosis, and even loss. There is also concern for losing or regaining nipple sensitivity, and while it helps to have a more experienced surgeon here, there’s always more of a risk with a graft.

Another little known fact is that, over time, the nipples stretch horizontally with your skin. This means that if the surgeon originally leaves circular nipples, they will stretch out to be ovals. Thus, a surgeon who is aware of this will leave slightly oval nipples, so they eventually settle into a circular shape.

T-Anchor

Also known as inverted-T technique, since the scars look like an inverted T, this is a derivative of the regular breast reduction procedure, and it includes an extra vertical incision. Being a year post-op, this line has completely faded and is barely noticeable, so that shouldn’t be anything to worry about.

Personally the way the skin is stretched out looks slightly different compared to a regular DI. Basically, because there are three incision points, rather than two, the skin isn’t “pulled” as much and doesn’t look stretched out.

Usually the nipple is never detached from the nipple stalk, or pedicle. (The “pedicle technique” is sometimes done with regular DI’s and not just T-anchor, but it’s not as frequent.) This means its blood supply is never cut off, and it’s a “living” nipple as opposed to a graft. In theory this is also better for retaining nipple sensitivity. To me it seems the nipple has less of that pasted on look that can occur with some grafts.

Nipples

I’ve already talked about the treatment of nipples discussing the various procedures above, such as grafts and pedicles. Note that some people opt for no nipples, and either tattoo them later on, or just prefer to be without them. Whatever your preferences, noticing the nipples can hint at a surgeon’s other abilities. Here are other things to look for.

Size and Shape

Depending on your original chest and your surgeon, you may opt to reshape the nipples in some way. The most common is to resize the areola, since male ones tend to be smaller. Another is to trim the actual nipples, though often this will be done in a subsequent revision so as not to risk losing the nipples, especially if it is a graft.

In general, look for circular nipples, and ones that are re-sized to your preference. But when browsing pictures, be aware that the person may still be awaiting a revision to further shape the nipples.

Positioning

On a male chest the nipples are higher than on female breasts. A few surgeons tend to position the nipple way too high on the chest, while there’s one surgeon who will always place them too far out on the sides, closer to the armpits than to the center of the pec. For the most part, I looked out for symmetry and centered-ness. Stare at a chest and see if the nipples “feel” off somehow – sometimes they do. Other times they just look like they belong, as if they are in the exact spot they should be. To get a better sense of this, you can also look at bio-male chests.

Infections

Probability-wise infections are bound to happen, especially with grafts. Often it depends more on the person’s body than with the surgeon’s skill, but quick mental tallies should alert you when there’s an anomaly. I kept an eye out for the general track record of each particular surgeon regarding infection rates, potential recovery and healing, as well as the surgeon’s post-op care and attention to it.

Incisions

Some scars look very neat and straight, and fade nicely afterwards. I attribute this to clean incisions. Watch out for surgeons who leave jagged and crooked scars. As you might know, my scars got hypertrophic, which is unrelated to the surgeon, and that’s why they don’t look as neat or as healed. There are a number of surgeons who do a consistently excellent job in this area.

Positioning and Shape

There is great variety on the positioning and shape of incisions. Some surgeons will do straight horizontal incisions, others will do curved “smiley” ones, and all variations in between. Some incisions are aligned with the armpit, while others are closer to the lower bicep fold. Some extend to the center of the chest, with both sides almost touching in the middle, while others leave space in between.

And then there is the nipple position relative to the incision, as pointed out before, where the nipple can be almost touching the incision line, or way high up, or simply a few inches above.

Where an incision will look best can depend on your individual body, and of course on your own preferences. But surgeons have distinct cutting patterns that you can pick up on, and from there you can choose which is a better fit for what you want.

For my tastes, correctly positioned incisions contour the natural pec muscle line. This means slightly curved lines aligned near the mid-bicep, as if cupping it with your hand, and the nipple a few inches above that in the center of the pec. While other styles generally heal nicely as well, this was an important personal preference.

Contour

Contour to me means that the pecs look, well… like pecs, and not like stretched out pancakes. A few surgeons seem to take out too much, even taking out muscle, which you can never build back up. This results in an unusually flat or even concave or sunken-in chest. Other surgeons take out too little, though that is easier to fix in a revision afterwards.

The general rule is to leave in about 10% tissue for chest lift and shaping. And never ever take out the muscle. My theory is that a lot of FTMs make up for poor contouring with T – their muscles fill out this area and compensate for the flatness. Without T, you rely purely on what the surgeon gives you. Thus contour was very important to me.

Now remember what I mentioned before – the chest takes 6+ months to de-swell and de-compress to its actual size and shape. The fresh-out-of-surgery pictures often depict a very puffy chest, and are not the best indicator of contour.

Other

While those are the basic guidelines I watched out for, the devil can be in the details.

Sensation

Overall sensitivity and feeling are another preoccupation, and obviously you can’t gather this from the pictures. A lot of people I met mentioned that certain areas of their chest were numb, even years post-op. Note that it can take from 6-12 months to fully recover sensation in the chest area. A year post-op, I now feel everything on my entire chest, even on the scars. There are no weird numb patches as far as I know.

Details

There are other details that can indicate careful work. For instance, “dogears” are the little excess skin flaps on the sides next to the incisions. These are a common complaint of your average DI, but there are a handful of surgeons that are quite skilled at avoiding this now. But again, remember – it takes time for the swelling to go down, and what may look like dogears could simply be puffiness. As always, take into account how long post-op the picture was taken.

In general, take note of naturalness, symmetry and overall “look and feel” of the chest. What impression do you get when you first see it?

Misc

There is lots of non-surgery stuff to look out for as well. Take into account the experience the surgeon has performing this specific procedure (though be weary of going for the “popular” option without doing your research first). Where the surgery is performed, in a hospital or a clinic, might influence your decision as well. Find out how complications are handled, and whether the surgeon is responsive and attentive to post-operative care. In case you ever want to change any of your legal documents to male, ask whether the surgeon provides an official letter for this, namely stating that you have undergone gender reassignment surgery. Moreover, requirements such as being male-identified, being on hormones, or having a therapists’ letter, are now becoming unnecessary barriers for surgery, which a lot of surgeons are bypassing altogether.

Ask

The last piece of wise advice I will leave you with is: ASK.

You can ask me about anything, or check out the resources section. People who post their pictures are usually quite friendly and open about their surgery, and are happy to point you in the right direction. Ask the surgeon about their experience, requirements, and other information. Always always ask.

Thoughts?

And of course, I love comments. Is there anything that stood out as personally important for you? Something you don’t quite understand? Have a different opinion on something? I especially welcome people sharing their experiences, either from a pre-op researching perspective or post-op reflections.

Hopefully you’ve found this guide helpful.