Top Surgery


Gender dysphoria describes a group of individuals who are dissatisfied with their anatomic gender and want to acquire the secondary sexual characteristics of the opposite gender 

  1. Prevalence 
  2. 1 in 11 900 males 
  3. 1 in 30 400 females 


Criteria for diagnosis 

  1. Desire to dress and live as opposite gender (and make his/her body a closer resemblance to the opposite gender) 
  2. Gender identity present for > 6 months 
  3. Not a symptom of another genetic or psychiatric disorder 


Treatment requires a multidisciplinary team

  1. Mental health professionals for psychotherapy
  2. Patients need to have life-experiences in their desired gender role 
  3. Hormone therapy (monitored by medical physicians) 
    • Feminization: via suppression of androgens and induction of female characteristics (i. GnRH antagonists ii. Estrogens )
    • Masculinization: testosterone induces clitoral hypertrophy 
    • Special consideration needs to be taken for adolescents, and puberty suppression may be indicated
  4. Surgeon


Transition surgery in Ontario must be pre-approved and is covered under the provincial plan (OHIP) 

Referrals are accepted once approval is received by the primary care provider for the transgender person. We primarily provide top surgery only. Referral out of Northern Ontario is required for facial feminization/masculinization or bottom surgery. 

Female to Male

 Chest wall contouring/mastectomy 

1. Typically, the first surgical procedure in these patients

2. Need to decrease breast/skin, obliterate IMF, reduction of nipple/areola

3. Incision choices depend on amount of ptosis

  • Subcutaneous keyhole or periareolar mastectomy for small breasts with minimal skin excess 
  • Double incision mastectomy with free nipple grafts for medium and large/ptotic breasts
  • A small revision for skin excess may be required, contour issues are a major side effect of these procedures
  • Compression garment/wrap recommended for first 4-6 weeks, avoiding heavy lifting/elevated blood pressure as there is a high risk of bleeding/hematoma after this surgery.

Male to Female

 Breast augmentation 

1. Some breast growth from hormones

2. Different that natal female: chest is wider, nipple to IMF distance is less, areolae are smaller, pectoralis major more developed

3. Implant can be placed pre- or sub-pectoral 

4. Any incision is ok: peri-areolar, IMF (most common)

5. Areolar tattoo (to enlarge). 

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