Following hormonal treatment, the next step is usually top surgery (chest surgery). There are many different methods for performing this surgery, and is often determined by the results you want, and the size of your breasts. Your therapist will be able to put you in contact with a surgeon.

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The options for chest surgery include: keyhole, drawstring, pie wedge, and double incision.

Keyhole and drawstring techniques
The keyhole and drawstring techniques are for people with very small breasts (A-cup size). When performing a keyhole procedure, the surgeon makes an incision around the areolar ring, inserts a liposuction device, and vacuums out the fatty tissue comprising the breast. With this technique, the mammary glands are usually left intact.

Drawbacks are that small deposits of fatty tissue may remain in the chest or the finished areola may be too large in comparison with the typical male chest. Advantages are little or no apparent scarring, and retention of nipple sensation.

The drawstring technique entails lifting the areolar ring away without disconnecting the nerves, and suctioning the breast and fatty tissue. Excess skin is trimmed and then pulled toward the centre of the opening, and the nipple is reattached covering the opening. Disadvantages are the same as for keyhole, and the nipple placement may be unnaturally low on the chest.

Pie wedge technique
The pie wedge technique creates a scar from the outer edge of each nipple towards the underarm, or sometimes straight down from the nipple. Usually this procedure is done with small to medium breasts. Many FTMs are dissatisfied with the appearance of the scars because they are so symmetrical and obviously breast-related.

Double incision technique
The double incision technique is the most common. Each breast is opened horizontally across the chest below the nipple. Breast and fatty tissue is cut and scraped away. The top skin panel is then brought down smooth and the skin is trimmed and sutured to the lower panel at the incision. The nipples are removed, resized to make them more masculine-looking, and grafted back onto the chest in the appropriate place. Disadvantages are loss of nipple sensation and scarring, though some nipple sensation may return over a period of months or years.

A hysterectomy is often undergone, in order to remove all high risk cells that could become cancerous due to testosterone intake. 
 

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