An Expert Guide with Dr Omar Tillo
Gender-affirming top surgery is something that many trans masculine and non-binary people consider as part of their transition. It is also one of the surgical topics we are asked about most at Gender Plus. So we invited our contributor, Dr Omar Tillo, Medical Director and Senior Plastic Surgeon at CREO Gender in London, to answer some of the most frequently asked questions - from available techniques to what scars might look like, to how long recovery takes and what the associated risks are.
What does top surgery involve?
Masculinising top surgery creates a flatter chest by removing breast tissue and, where needed, excess skin and fat. The nipples and areola may also be resized or repositioned. According to Dr Tillo, removing tissue is only part of the process, the wider goal is to carefully contour the chest so the results are more aligned with an individual's gender identity and importantly, in proportion with the rest of the body.
Choosing a technique
There are three main techniques available, and the right one depends on factors such as the patient’s anatomy and their goals, rather than on any one being better than the others.
Double incision is the most common technique and is usually considered for medium or larger chests, especially where there is loose skin as well as breast tissue. The scars are longer, but it gives the most control over chest shape and nipple position.
Periareolar surgery is mainly for smaller chests with less excess skin. The incision runs around the edge of the areola, so the scar can blend into the natural change in colour.
Keyhole surgery may be an option for people with a very small chest and good skin elasticity.
In any consultation, the surgeon will assess chest size, skin quality, nipple position and the amount of tissue present, which will inform their recommended approach. Some people also benefit from liposuction to refine the contour. Pectoral implants for increased definition are also an option, once the chest has settled.
Dr Tillo is clear that scar size alone should not drive the decision: "I would rather recommend the right operation with a longer scar than choose a smaller scar that does not give you the chest shape you want."
Do I need to be taking testosterone?
No, and this often surprises people. You do not need to be taking testosterone or any other hormone therapy to have top surgery. If you are taking hormones, you do not need to stop them because you are having surgery. Instead, Dr Tillo looks at the whole picture: your health, your medical history, where you are in your transition and what you want surgery to achieve.
Am I ready for top surgery?
The surgical consultation provides an opportunity to discuss your physical and mental health, medical history, any medications you may be taking and what you want surgery to achieve. Consultations are also an excellent opportunity to ask as many questions as you wish. Prepare ahead of time so you walk into the room with a clear idea of what you want to know.
Patients must be over 18 and have a professional diagnosis of gender incongruence.
Two other points that are worth knowing:
BMI requirements for surgery vary between providers and depend on several factors, including hospital policies, anaesthetic protocols, available facilities and individual patient risk assessments. Dr Tillo generally recommends that patients are at or close to their target, stable weight before surgery to optimise outcomes and minimise complications.
Top surgery does not completely remove the future risk of breast cancer, so it is still important to be aware of your chest and see a doctor if you notice anything unusual.
Surgery and recovery
On the day of surgery, you meet your surgeon again to ask any final questions and have your chest marked. The operation is done under general anaesthetic and normally takes two to three hours. You will need a responsible adult to take you home and stay with you for the first 24 hours.
Your chest will look flatter straight away, though swelling, bruising and soreness are normal. Everyone heals differently, but a typical timeline looks like this:
Around 1 week: light activity or working from home
Around 3 weeks: returning to the office, driving and using public transport
Around 6 weeks: more strenuous exercise and some sport
Around 6 months: the final result becomes much clearer
Scars and risks
All surgery leaves a scar. Keyhole and periareolar scars are smaller while double incision leaves longer scars across the lower chest - these are the scars most commonly associated with top surgery.
Incisions can be planned along the natural contours of the chest, and scars usually fade and mature over time. As Dr Tillo puts it, "no surgeon can promise that a scar will become invisible."
Like any operation, top surgery carries risks. These include bleeding, infection, fluid build-up, delayed healing, changes in nipple sensation, nipple loss, asymmetry and noticeable scarring. Any surgeon should discuss these with you clearly at your consultation. Because top surgery is permanent, it matters that you feel confident it is the right decision for you so make sure you do your research.
Before you decide
The most important thing is that you feel ready and understand both what surgery can achieve and its limits. If you are exploring top surgery, these questions can be useful to bring to any consultation:
Which technique do you recommend for my chest, and why?
What are my scars likely to look like?
Which risks are most relevant to me?
How will recovery fit around my work and daily life?
Would any additional procedures help, and are they necessary?
Dr Tillo describes his role as bringing surgical expertise to a shared conversation, recognising, in his words, that "you are the expert in your own experience." Whatever you decide, a good consultation should leave you clearer about your options, not under pressure to choose one.
If you have questions about whether surgery is right for you, the Gender Plus team can help you think through your options.
About Dr Omar Tillo
Dr Omar Tillo is Medical Director and Senior Plastic Surgeon at CREO Gender in London, where he specialises in gender-affirming body contouring for trans+ patients.
