Non-Binary Top Surgery

In order to understand what non-binary is let’s start with basic, most commonly accepted definitions and distinguishing factors between assigned sex and gender identity:

• Assigned Sex: When an infant is born the physician will look at the genitals and determine the infant ‘male’, ‘female’ or intersex

• Gender Identity: Gender is not the same as assigned sex. Gender identity is an introspective experience and way of naming the gender one identifies with. This could be male, female, non-binary, genderqueer, genderless etc

• Cisgender: Means you identify with the sex you were assigned at birth

• Transgender: Means that you don’t identify with the sex you were assigned at birth

• Gender Binary: This is essentially a societal system that splits people into one of two set of gender roles, gender identities and physical attributes as either ‘male’ or ‘female’
• Non-Binary: Non-binary gender identity is any gender identity that does not fall exclusively within the binary of male or female

It is important to note that non-binary gender identities are not ‘new identities’ or new concepts and have been recognised throughout the world for a very long time. Those who identify as non-binary may use pronouns outside of the binary such as they/them. However, there are many other gender-neutral pronouns and pronoun combinations (such as he/they, she/they) that people use so it’s always best to ask what someone’s pronouns are when initiating a conversation for the first time. Cosmedicare adopt this approach from our first contact with you.

Transitioning/aligning as a non-binary person can be medical (taking hormones, getting surgery) or non-medical (using different pronouns, binding, changing hair or clothing style). You may or may not already be engaged in medical transitioning. Since gender is a spectrum someone who identifies as non-binary, genderqueer, agender etc. may express their gender neutrally, masculine, feminine, a combination of all or some of these.

Technically all aspects of anatomy are non-binary if someone identifies as such. What we’re exploring is finding congruence between one’s non-binary identity and a physical presentation to the world through a gender affirming surgery, essentially helping you match how you feel on the inside with how you look on the outside. There’s no one answer to this question, which is why a full consult is required as this can provide opportunity to discuss available surgical options. Most commonly a second consult is offered prior to any surgery. This way you can make an informed decision on what surgical options may fit your needs.

You can think of gender-neutral top surgery results like we think of non-binary. There are a huge number of valid expressions of gender which fall within the broad category of non-binary. Similarly, there are a number of top surgery features where the result could be modified to a patient’s liking so they hold the results toward whatever it is that they personally consider to be non-binary.

It can get a bit confusing to think about all the different things in a top surgery result which can be modified and what it means to have a particular result look more male or more gender-neutral. Due to this the best way of discussing gender neutral results is to start with what might be considered the ‘ideal binary male’ top surgery result.

From there we can discuss its binary features and then how those features could be modified to an individual’s preference to express a more non-binary appearance.

Incisions and Chest Contours as well as Nipple and Areola Options content is a great starting place in learning more about non-binary top surgery.

Binary Male Appearing Chest Incisions

For patients interested in having a binary male appearing chest there are some modifications to the shapes of incisions that could achieve this listed below:

• Very gently curved incision that runs as close to as possible along the lower border of the pectoralis major muscle
• Straight incision lines instead of curved lines so their new chest doesn’t remind them of their chest before top surgery
• Diagonal incision which runs upward along the outer border of the pectoralis major muscle up and toward the armpit. This is not a very usual request, but it is included here because it is not really a non-binary request and still fits within the realm of a masculine result

Less Binary (or non-binary) Appearing Chest Incisions

Below are a few incisions requests we’ve received from patients who are interested in having more non-binary appearing incisions.

• Longer, higher, or lower than the position described above
• Incision not located anywhere close to the lower pectoralis major muscle line because of the perception that that is a distinctly male appearance for a mark that is on the chest

It’s important to note that the fish mouth procedure results in an incision across the very center of the chest horizontally. This could be a very popular non-binary procedure choice as most people don’t view the post-surgical results as a chest that was developed through an estrogenic or androgenic pubertal development period.

Binary Male Appearing

A typical masculine chest has a fairly uniform requirement for contour. There should be a uniform thickness of tissue throughout the entire chest area, matching the surrounding regions which are beyond the area of surgery. Meaning:

• After a successful top surgery procedure, one should be able to pinch the tissue of the chest anywhere and have it be more or less the same thickness. This is a degree of thickness that not only will be in balance at the conclusion of surgery, but will likely serve the patient well in the future
• If the patient loses weight and gains muscle bulk, then just like anyone they would have a much more muscular defined chest
• If the patient gained weight, then they would gain weight on their chest like they would gain weight elsewhere in their thorax and trunk
• A typical male result works to control the excess tissue that is present in the outer chest beneath the armpit and also in the upper outer front part of the chest. This is just next to the armpit on the front of the chest where there can be a small amount of puffy breast tissue that needs to be removed

Non-Binary Appearing

This may be one of the areas where there is the highest degree of variation among different procedure types. For example, with the  Inverted T and Buttonhole procedure:

• Even when performed successfully, it may result in a considerable degree of left over chest tissue. A patient deciding on these procedures would need to be prepared to have a heavy male chest (something like a male chest appearance where that individual has gynecomastia). In some cases, the patient might have a result that looks like there are relatively small breasts on the chest
• This may be the most appropriate for individuals who consider themselves to be somewhat gender fluid and may choose to present on varying spaces of the gender spectrum. However, some individuals who have considerable dysphoria of the chest due to breast tissue would not be satisfied with this sort of a result
• It’s important to note that the Double Incision procedure can also be performed in a way to maintain more than average tissue on the chest, and is more controllable than the inverted T/buttonhole procedures

In cases where a patient has a particular wish regarding the exact amount of chest tissue to be left over, I highly advise them to bring in photos of bodies that have the amount of chest tissue that they would be hoping to have at the conclusion of surgery. This helps to avoid any misunderstandings regarding what the procedures can offer and what the limitations of each procedure type are for a given body type are.

The areolas are the wide (usually circular) pigmented area that also contains the nipple. The nipple (in plastic surgery terms) is the only part that projects outward from the chest and is usually somewhat cylinder shaped.

During a top surgery procedure, the areolas are usually resized to the diameter of 22mm (about the size of a nickel) and is most commonly made to be circular. 22 mm is the average size of someone who was assigned male at birth (AMAB).

• Projection: For Double Incision top surgery, the degree of projection of the nipples is dramatically reduced. This is a necessary step as part of the nipple grafting procedure. However, in other procedures such as Keyhole or Periareolar top surgery, the nipple is not typically reduced though the areolas are typically reduced (in the periareolar procedure)

• Size: Most who wish to have a more AMAB appearing chest usually opt for considerably smaller areola (22 mm in diameter) and a considerably less projected nipple

• Location: A typical location of a AMAB areola would be approximately 3 cm inside and also superior to the pectoralis major muscle border. Though there are a number of calculations that try to define the optimal location, ultimately it is the surgeon’s sense of aesthetics which primarily determines the best location for the nipple at the time of the procedure. Certainly, a degree of obsession on the part of the surgeon about placement and symmetry is important to getting a good symmetrical result.

Most often, if a non-binary individual wants to have a less binary appearing areola, they may choose a size that is slightly larger in diameter (usually 25 to 26 mm). This slightly larger areola options is about the size of an American quarter or a European One Euro coin.

• Projection: Non-binary individuals may also wish to maintain more projection of the nipples. Nipple projection can be controlled to some degree with the free nipple grafting procedure, but the grafting procedure does require that at least a considerable amount of deprojection be performed as part of the preparation of the nipple graft

• Size: For those wanting to have larger diameter areolas it’s important to note that beyond about 30 mm in diameter the areola can begin to become more feminine in appearance

• Location: Non-binary folks may wish to have a location of the nipple areola more complex, so that is either slightly more narrow than usual or higher than usual that of someone wanting to obtain a male appearing result. The surgeons usually find that when patients choose a wider areola, a slightly higher placement seems to be overall aesthetically most pleasing

• No Nipples: It’s very important to mention that some non-binary individuals may not want to have any nipples at all as a part of their procedure. This would require the procedure to be a double incision procedure but one in which we would avoid using the free nipple grafts altogether. Some individuals wish to never have any nipples on their chest, and other individuals will tattoo nipples and areolas on their chest later in life. It is interesting to note that there are some outstandingly well designed temporary stick-on areolas made of silicone which can be attached to the chest as when desired

Though complications are uncommon, all surgeries carry a degree of risk and uncertainty. It is possible that you will experience a complication during recovery which will necessitate more time off from work and other daily routines. Complications associated with top surgery include adverse reaction to anesthesia, blood clots, infection, excess fluid build-up in your chest, pain, bleeding and undesirable cosmetic outcome.

While exploring non-binary and gender-neutral content it’s important to keep in mind the following:

• Gender neutrality is usually (and unfortunately) limited by social constructs that are binary (male or female). What feels and looks like a non-binary surgical result to you may still be seen as ‘male’ or ‘female’ to others
• Surgical results that are more representative of a gender-neutral appearance will ideally allow for more flexibility and adaptation within our binary society which may help alleviate symptoms associated with gender dysphoria
• Although some chose surgery as a method of finding congruence in their gender identity, others do not which is a completely valid decision

Looking to discuss the binary features of our procedures and how those features could be modified to your preference to express a more non-binary appearance? Reach out to us to start your journey.