Gender-Affirming Surgery (Top Surgery)

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Gender-affirming surgery is a collection of surgical procedures for adults ages 18 and older diagnosed with gender dysphoria. The operations are often referred to as “top surgery" and "bottom surgery.” Duke Health offers several top surgery options to transgender, gender-diverse, nonbinary, and gender-nonconforming adults who want their appearance to align with their internal identity. If, after a consultation with our doctors, you decide to pursue top surgery, we work toward a positive outcome that improves your physical, emotional, and psychological well-being.

What You Should Know About Gender-Affirming Surgery

Choosing to pursue gender-affirming surgery is an individual, personal decision. You’ll want to consider how it will change your quality of life and how it will help you achieve your goals.

Gender Dysphoria
One important step is understanding how much you are affected by gender dysphoria, a diagnosis that the American Psychiatric Association defines as a conflict between your physical or assigned gender and the gender with which you identify. 

Candidates for Top Surgery
To be a candidate for top surgery, you must:

  • Be 18 or older
  • Be in good health without illness or a condition that can increase your risk of surgical complications
  • Have a BMI under 35
  • Provide a clearance letter from your mental health or primary care provider stating you have gender dysphoria and you have been living in your assigned gender for at least 12 months

Top Surgery Costs
Some private insurance plans will cover transgender surgery when it is used to address a diagnosis of gender dysphoria. Check with your insurance plan to determine your coverage.

Understanding Which Top Surgery Is Right for You
There are several approaches to transgender surgery. We will review these with you during your initial consultation and make a recommendation based on your physical exam and medical history.

You May Have Scars
Your surgeon will use the natural contours of your breasts to minimize scarring as much as possible. In some cases, depending on your breast size and weight, a small bunching of tissue may result in scars known as “dog ears” following mastectomy. These can be corrected later with revision surgery.

Understand the Risks
Top surgery carries the same risks as other standard surgeries. These include the risk of bleeding and infection and risks associated with general anesthesia. Your doctor will discuss these risks with you if surgery is recommended.

Initial Consultation and Tests

Consultation and Exam
Your first step will be an in-person consultation. Our providers spend time meeting with you, evaluating your anatomy, answering your questions, and determining if this surgery will help you achieve your goals.

Your surgeon will review your family history, general health status, lifestyle habits such as smoking, previous operations, any medications you may be taking, and conditions that can put you at risk for surgery.

Measurements, Photographs, Tests
Your breasts will be measured and assessed for size and shape, and photographs may be taken for your medical record. Before treatment is recommended, you will also undergo one or more of the following tests.

  • Blood tests may be necessary to evaluate your hormone levels. Pre-surgical testing also requires several blood tests to assess your liver and kidney function and to determine if you have a previously undetected infection, blood disorder, or anemia.
  • A mammogram may be performed to look for any underlying breast abnormalities. Additional imaging, including ultrasound and MRI, may also be requested.

Recommending Treatment
Based on these findings, your surgeon will recommend an approach to surgery. She will discuss the expected outcome, potential risks and complications, and your post-operation recovery. Alternatively, your surgeon may recommend that you lose weight, quit smoking, or discontinue medication before surgery to ensure you experience the best possible outcome.

If You Take Hormone Therapy
Some gender-affirming hormone therapy, such as testosterone, can be continued if you pursue transgender surgery. Others, such as anti-estrogen therapy, may be stopped. Your surgeon will explain what you need to do to prepare for surgery.

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Top Surgeries

Chest Reconstruction - Mastectomy, Breast Reduction

We use different approaches to remove breast tissue and contour breasts to appear more masculine. The right approach depends on your anatomy and the size of your breasts. Techniques for medium to large breasts include nipple-sparing, double incision, buttonhole, and inverted-T incision. Keyhole and peri-areolar techniques may be used for smaller breasts or for those with good skin elasticity. Your surgeon will discuss your options with you after your physical exam and consultation.

Breast Augmentation

There are also many different approaches to breast augmentation, including the use of implants and fat grafting. We can also combine breast augmentation with body contouring, liposuction, and neurotoxin injections such as Botox injections and dermal fillers.

The Procedure Length

On average, top surgery takes about two to three hours and is performed under general anesthesia in an outpatient ambulatory surgery center. In some case, an overnight stay may be required. Sometimes a second procedure is needed to further tighten skin and achieve optimal cosmetic results.


Your chest will be wrapped in bandages, and a compression chest vest or surgical bra will be worn after the procedure. Drains will be required after mastectomy but not after breast augmentation. Initial recovery takes about one week. It may take three to six months for all swelling to subside and scars to fade.

Consistently Ranked Among the Nation’s Best Hospitals

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 9 pediatric specialties by U.S. News & World Report for 2023–2024.

Why Choose Duke

You'll Work With a Plastic Surgeon Experienced in Gender Affirmation Surgery
Our plastic surgeon has worked with many individuals seeking gender confirmation surgery. She is fellowship trained in body contouring, which means she has completed additional training in procedures that improve the body shape. Our surgeon is also a member of the World Professional Association for Transgender Health (WPATH), a nonprofit organization working to standardize and improve transgender care.

Duke Health Is Committed to the LGBTQ+ Community
Duke Health values diversity and has taken many steps to show its commitment to eliminating discrimination, promoting equality, and standing beside our lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community. Duke University Hospital, Duke Regional Hospital, and Duke Raleigh Hospital are recognized as LGBTQ+ Healthcare Equality Leaders by the Human Rights Campaign Foundation for perfect scores across areas of patient-centered care, support services, and inclusive health insurance policies for LGBTQ+ patients.

This page was medically reviewed on 05/22/2023