Female-to-Male Transition – The Keys to a Natural-Looking Chest


The transgender female-to-male mastectomy may not be a new procedure, but significant strides have been made to provide increasingly natural-looking results that match the anatomic details and characteristics of natural born males.

To understand this increasingly common procedure—also known as “top surgery”—we spoke with Dr. Richard Tholen, a board-certified plastic surgeon whose expertise in the field has resulted in him being voted by his peers as a Castle Connolly Top Doctor.

“Although female-to-male transgender mastectomies are often the only surgical procedures for this type of gender reassignment, there is a significant amount to consider in order to deliver results that are pleasing to the patient,” Dr. Tholen asserts. 

First and foremost, he emphasizes that all breast surgery patients—not just transmen—carefully consider the surgeon they choose to perform this intricate procedure. “This is not a simple operation,” he explains. “It is complex and requires a tremendous amount of skill to be performed safely and correctly.”

With that in mind, Dr. Tholen advises patients to seek out a board-certified plastic surgeon. Board certification is a solid indicator that the doctor has the proven education, experience, and expertise to deliver superior results. Dr. Tholen was certified in General Surgery, as well as maintaining full training and board certification in Plastic and Reconstructive Surgery.

Another key step—albeit an obvious one—is to examine the breadth and excellence of the doctor’s work. Dr. Tholen encourages patients to look at the doctor’s gallery of previous work, as well as seek out feedback from previous patients. 

Dr. Tholen also provided keen insight on the actual surgery. 

For most patients—outside of those will the smallest breasts—the most common operation involves bilateral total mastectomies with skin excisions and nipple/areola grafting. To achieve the best results, Dr. Tholen says that the mastectomy incision placement is critical. “The incision should be positioned along the lower edge of the pectoralis major folds,” he explains. “This emphasizes the normal male musculature while simultaneously making the scars less apparent.”


“Although female-to-male transgender mastectomies are often the only surgical procedures for this type of gender reassignment, there is a significant amount to consider in order to deliver results that are pleasing to the patient,” Dr. Tholen asserts.


He further asserts that precise measurement and skin closure in layers avoids the vertical scars of female breast reduction operations. “Plastic surgeons who use ‘standard’ female mastectomy techniques will leave scars that are both unnecessary and unsatisfactory,” Dr. Tholen explains. 

The nipples and areolas are another important consideration because proper positioning (and size) is critical to obtaining a masculine result. “When the female breast is compared to the male chest, it’s simple to see that male nipple placement is lower and lateral, near the edge of the pectoralis muscles,” he explains. “In women, it is more central and medial”. 

In addition to the surgical procedures, it may also be important for transmen to think about the importance of hair growth. “Hair growth on the chest of transmen serves a dual purpose—it helps create a more natural appearance and it can further conceal the surgical scars,” Dr. Tholen explains. 

Regarding recovery, Dr. Tholen says his experience shows the following must be done to achieve the best results:

  • Graft dressings and drains must remain in place for about 10 days after the operation.

  • The mastectomy scars and nipple/areola grafts must be kept dry and protected from excessive activity or shear forces for a total of three-four weeks in order to reduce bleeding, bruising, seroma formation, and failure of part or all of the nipple grafts to heal properly to their recipient areas. 

  • Absolute avoidance of tobacco (nicotine) products including vaping, nicotine gum, patch, spray, and even exposure to second-hand smoke is critical to skin graft healing. 

  • Scars are permanent but will fade over 6-12 months.

  • Exposure to ultraviolet rays must also be avoided during this period when scars are still pink and susceptible to hyperpigmentation.

“I firmly believe that the creation of a proper masculine appearance for transmen involves much more than ‘standard’ mastectomies,” Dr. Tholen concludes. “The best results are achieved by a skilled surgeon who not only understands the intricacies of the required procedures but has deep experience with transgender patients to bring natural-looking outcomes to life.”



Richard H. Tholen, MD

Plastic Surgery
Face, Breast & Body Surgery
Minneapolis, MN