Double Incision Mastectomy

Conveniently located to serve Washington DC, Arlington, Bethesda

What is a double incision surgery?

Double incision top surgery is a procedure to remove breast tissue (mastectomy) and skin in transmale or gender non-conforming /non-binary individuals.  We also resize, reshape and reposition your nipple/areolar.

We perform hundreds of these surgeries per year and can modify the surgery to your specific requests.  The most common procedures are double incision or periareolar/keyhole, however we can also perform fishmouth incisions, no nipple techniques, breast reduction techniques or customized surgeries if requested. 

Who is a good candidate?

Patients that have been socially transitioned for 1 year and desire removal of their breast tissue are good candidates.  You should be healthy and at a stable weight.  Most patients who have top surgery have the double incision technique due to extra skin.

Will insurance cover the surgery?

In most cases, yes. Most insurance companies require that you have been socially transitioned for 1 year and that you have a letter of support from your mental health therapist recommending the surgery.  Some insurances (e.g. blue cross federal) require a second letter from a psychiatrist/psychologist and 1 year of testosterone.  

Most insurances require that you are 18 years of age, although there are some plans that will cover the surgery in below 18 year olds.  The surgery can still be done with parental consent, but if insurance doesn’t cover the surgery, it may be self-pay.  

Insurance companies consider liposuction of the underarm area/upper back fat roll to be cosmetic and self-pay.  If you need/desire this, we can give you a quote, however it is never required and is up to you if you’d like to have this performed.

What are my out of pocket costs?

If you are a self pay patient, we can give you an exact quote for surgery, operating room facility charge and anesthesia. If you are using insurance, only your insurance company knows the exact amounts. For a typical double incision procedure, the codes you can give your insurance company for them to  calculate your out of pocket expenses are 19303 X 2 (mastectomy for each side) and 19350 (nipple/areolar reconstruction for each side).  For blue cross federal, only the 19303 X 2 are used and Aetna uses 19318 X 2.  The facilities and anesthesiologist we use are in network, so your insurance company should be able to give  you an exact amount (we don’t even know this information until after surgery when the insurance calculates it).

Prior to surgery

Most patients don’t require any specific labs prior to surgery.  The anesthesiologist performs a phone interview a few days prior to surgery.  Testosterone does not need to be stopped.  You would need to stop using all nicotine 1 month prior to surgery to minimize risks. 

How is the surgery performed?

1. Double incision – in this technique a lower breast incision is used to remove the extra skin and breast tissue, the scar is relatively straight across the chest and then in most cases follows the lateral border of the pectoralis muscle to “frame” the muscle.  In some patients the incision may be straight across.  If you have large breasts or breasts that are very close in the middle, the incisions may need to be connected.  The nipples and areolas are taken off and replaced after decreasing the size and modifying the position on the chest to a more “masculine” position. Nipple size and position changes can be specifically requested depending on patient preference including no nipples/areolas.  
2. Fishmouth – This is a technique to leave the double incision scar in a non-anatomic/androgynous position across the middle of the breast.  This is generally done without nipple replacement.
3. No nipple techniques – same as double incision, but no nipple is replaced

Recovery

All patients have a drain placed for approximately a week, this is removed in the office.  In double incision techniques, the nipple dressing is removed at that time and we will give you supplies for nipple care.  The nipples often peel for a few weeks.  Most patients go back to work in 1-2 weeks (2-3 weeks for more active jobs).  You would wear the compression vest for 2 weeks to minimize the risk of fluid buildup (we will provide this).  With no nipple techniques, you can shower fully in 72 hours.  For double incision with nipple creation, there is no showering for 2 weeks. At that time you can start showering from the back.  At the 3 week mark, full frontal showers are allowed and after 4 weeks, bath and pool is allowed.  Walking can be performed right after surgery, however gym activities can start being resumed at 2 weeks (light), at 3 weeks, jogging/running, light weights are allowed and at 4 weeks there are no restrictions.  We generally start scar care with either silicone tape, silicone gel or another scar treatment once the surgical steri strips are removed.  Pain control is generally managed with Percocet, however we have many patients that don’t want narcotics or don’t need them. In those cases, we will use high dose ibuprofen. 

Risks

1. Seroma – fluid buildup after the drains are removed. This is a minor issue, but the most common potential issue.  This is generally managed by using a needle to drain the fluid in the office. You will be numb, so you shouldn’t feel this.  In rare cases where the fluid continues to return, a drain may need to be placed
2. Hematoma – a small percentage of patients have bleeding after surgery, this may need to be drained in the office or rarely in the operating room
3. Infection – extremely uncommon, but could require antibiotics or drainage
4. Numbness – expected after surgery, can sometimes take a year or more for sensation to return, generally nipple erogenous sensation is not able to be saved with nipple grafts
5. Need for revision – some patients require small touch ups. This can almost always be done in the office under local anesthesia and if you used insurance for your procedure, they will generally cover any revisions.  These are uncommon due to the number of surgeries we perform
6. Underarm fat – some patients have underarm fat/back – this is not a complication and we give patients a quote at the time of their initial consult for liposuction of this area.  Liposuction can be performed at a later date, but generally results are better if it can be done at the time of surgery.  This is different from dog ears.
7. Dog ears – fairly uncommon, but due to a small amount of extra skin at the ends of the incision, can be revised in the office if needed under local anesthesia
8. Nipple loss – extremely uncommon, would require tattooing or revision
9. Loose skin – more common in periareolar techniques since no skin is removed, may require revision or conversion to double incision technique. 

Before & After