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✨Keyhole Top Surgery✨

I had Top Surgery this spring (finally🎊) and I just wanted to share some of my experiences, since the Keyhole method is still somewhat lesser known. I'll try to make the post as detailed as possible because god knows I wanted to know eeeeeeverything beforehand - so it's gonna be a long one.

(Disclaimer: I'm not a doctor)

This post contains mentions of surgery, blood, wounds, scars, vomit, misgendering & issues with body image

I don't assume anyone is really going to read this but I'd be happy to answer any questions, should they come up :) There's also a lot of helpful information on Reddit!

(and ofc if you think something I wrote is false/misleading let me know!)

Here's a list of the contents in case you're only interested in a specific topic and want to skip the rest:

What is keyhole Top Surgery?

What makes you a keyhole candidate?

personal info for context

financial stuff

social circumstances

getting an appointment

preparing for surgery

surgery day

1. day post op

2 weeks post op

6 weeks post op

long term scar care

progress pics 3 days post op Vs. 6 weeks post op

First of all: What is keyhole Top Surgery? It's a type of mastectomy that creates very minimal scarring. As opposed to DI (the most common method) where the nipples are removed/ reattached and the breast tissue is removed through horizontal cuts below the pectoral muscle, the nipples stay on the body the entire time. There's a small cut just along the underside of the areola through which the mammary glands are pulled out and the fat is removed via liposuction. There's no skin removal or resizing of the areola. This means if there are no complications and the healing goes well people likely won't be able to tell you've had top surgery. Another upside is that more sensation can be retained with this method and feeling in the chest area can improve more rapidly than with other methods. I should mention that keyhole requires revisions more often than other top surgery types and that it can take much longer until the chest has properly settled in. Since there is no resizing/replacing the nipple the results might not look as stereotypically masculine. You can find more detailed information here.

What makes you a keyhole candidate? A lot of surgeons have different opinions on this so take my info with a grain of salt, but overall it's important to know that only a small percentage of people will have good results with this method. Generally it's only possible for people with smaller chests - A cups and in some cases small B cups. You need good skin elasticity since they don't remove skin - just the tissue underneath. Meaning the skin needs to be able to "shrink" back and grow onto the muscle without too much excess. there can't be much sagging either - the breast shouldn't hang over the fold underneath (also because the skin needs to settle in properly after surgery). And lastly you have to be okay with your nipple placement and size preop. With DI/periaerolar/fishmouth the nipples get resized (if you keep them) when they take them off your body - since they stay on you with keyhole changing the size is not possible. Same goes for the placement - with DI the nipples usually get reattached much higher and more outward - with keyhole the placement stays the same. While nipple size and placement MIGHT naturally change after keyhole surgery that's not guaranteed at all so what you have going on before is likely what you'll be stuck with afterwards. If you're worried about your chest or areola size being slightly too big but you still want minimal scarring you might want to look into peri areolar top surgery!

personal info for context (because these things might influence process and results)

mid 20s

university student

~ 160cm

~ 50kg

physically active

agender/genderqueer

on low dose T for almost a year

vegan

non smoker

I live in Germany (Sachsen)

Financial stuff If you want the surgery to be covered by insurance, the process is the same as for other top surgery methods - there's a lot of detailed information about that already so I'm not going to repeat all of it. I paid out of pocket (because I'm 'not trans enough' according to the German healthcare system🙃) but I had suspected that would happen so I was able to save up enough money by working for 3 years before I started uni. There are quite a few other costs than just the surgery to consider though! I'll try to list everything that I had to pay in order to get surgery - keep in mind that prices may differ depending on the provider and that some surgeons have more prep requirements (i.e. having a recent mammogram)

the surgery itself: 5.700€

taxes on the surgery: 2.300€

narcosis: ~850€

initial surgeons appointment: 40€

psychological assessment: 100€

insurance in case of complications/revisions: ~160€

bloodwork: ~20€

the postop binder, pain meds, first bandages and overnight stay were included in the price. Same with all preop and postop doctors visits except for the very first one.

These are not the only costs that come up depending on what your needs are - I also bought scar care stuff, bandages and I know some people like to buy additional binders or mastectomy pillows and so on. Not everything people put on their lists is going to be useful to you personally so don't feel like you *have to* buy it all - try to do a realistic assessment beforehand. Connecting with local trans groups can be helpful since people there might be selling/giving away their surgery items - cheaper, more sustainable and a way to connect with the community :)

social circumstances I was really lucky to be able to just skip uni for as long as I wanted - I took 2½ weeks which was perfect for me! I stayed with my mum for those 2 weeks since I was very restricted in my movements and needed a lot of help. It's definitely also possible to go through recovery by yourself if you don't have a "caretaker", you just need to plan ahead! I was incredibly thankful to have my mum help out though - it made things a lot easier! My nuclear family was pretty neutral about the whole thing but I didn't tell everyone. Uncomfortable questions might come up & having the same conversation over and over again can be tiring after a while so I think it's important to be clear about one's boundaries in these situations. Noone has the right to personal/intimate information - you're allowed to say you don't want to talk about it! One thing I did struggle with was a feeling of isolation. I don't have a huge friend group to begin with and while some of my friends are also genderqueer, none of them want to transition at the moment - which is totally fair ofc but it did feel like I had noone to talk to about it who was as invested as i was. Plus some of my closest friends live really far away so I only had one visitor shortly after surgery 🥲. If you're feeling the same way/ you think this might become an issue for you as well - don't let it tear you down! There's a huge trans community online and most (bigger) cities have groups where you can meet other trans people, so you're not alone!

Getting a surgery appointment The first step is to book a consultation ofc. To find a surgeon I considered my priorities which was basically to stay as close to home as possible. Most gender clinics are in the west and paying for the train tickets + accommodation + travelling for <5h post op + having to potentially go back for appointments after a few months just seemed like a nightmare. And more expensive. My local hospitals either don't have breast centres or don't have very good reviews when it comes to gender affirming care so I opted for a cosmetic surgeon. My only real criteria was that the person had done mastectomies before, had an average price range and was relatively close to home. I didn't check out multiple surgeons because the initial consultation always costs 40-50€ so meeting many people to find someone I 'click' with could have ended up being expensive. My surgeon has operated on other trans people before - I did let him show me the results and talk about revision rates and stuff - he seemed competent so I was happy. He did keep misgendering his other patients and me - a lot of the time he didn't even seem to notice. In conversations he was always adamant about being supportive of trans people but in a way where you could tell that he doesn't really know any outside of his work if that makes sense?. Make sure to also talk about pricing early on as well as hidden costs that might come up later. And don't forget to ask about what the plan is in case revisions are necessary or you have a complication! I had to get an extra insurance for that for example. For some reason that I still don't fully understand I also had to get a psychological assessment to prove that it wasn't a rash decision or anything. As I mentioned before my regular insurance wouldn't cover the surgery since I'm not a trans guy (🫩) so it technically counted as a cosmetic procedure and I've never heard of someone needing a psychological assessment for a nose job or a breast augmentation so I don't understand why that was necessary but whatever. When I had the documents to prove that I actually experienced dysphoria (I'm not sure I have the official diagnosis since it was only one session and you usually need more) and that I wanted the surgery for a long time now, I sent it to my surgeon who replied with possible surgery dates. I picked one and that was it. The entire process from the first email to the set date took about 4 months for me but obviously that might be different if you're already in therapy and have those documents or if you want to meet several surgeons to find the one you like the most. But it's safe to say that things can move very quickly when you're paying out of pocket!

Preparing for the Operation I had multiple consultations where we talked about the results I wanted and what can be possible - initially I was going to decide between DI and fishmouth. I got all the documents and consent forms to read through and started working out more since stronger pectoral muscles/ overall fitness improve the results. Made an appointment with my GP for the blood tests. Talked to the people that needed to know about getting the surgery. Bought all the scar care stuff already. Looked through my wardrobe to find the most accessible clothes (button ups, sandals,...). Talked to my surgeon about the schedule on surgery day and open questions. I also started taking zinc supplements to support the immune system so that healing would be easier. I always wear masks in public spaces anyways (and so should everyone else!) but I was especially conscious with it pre op. I cleaned my room, did as much laundry as possible and changed my bed sheets - basically everything I wouldn't be able to do for a while. I also took everything I would need in the kitchen down from shelves I wouldn't be able to reach. And I packed some books and crochet stuff so I wouldn't get bored during recovery. I also prepared a folder with all the important documents in one place, just to be sure. And got my additional insurance and transferred the surgery money. (the narcosis bill came after the surgery). I also did a bunch of reading of other peoples experiences (SO much ... like seriously you have no idea) and looked at progress pictures from other people to get realistic ideas as to what healing would be like. I think understanding how the surgery works/ what to expect really helps with moving through the process and feeling less lost - at least for me. If you have piercings don't forget to take them out/ put in retainers! I also took some pictures of my preop body just for myself to compare later. (I documented the entire healing journey as well for me to look back on!)

Surgery Day Woke up. Did my last workout for a while. took my last shower for a while. had to switch to pads which I really don't like because ofc I had my period :| Had my last sip of water at 07:00 - no breakfast ofc. My appointment was at 13:15h and I decided to walk there. Turned up at the clinic and waited for a while. Got taken to the preparation area, had another talk with my surgeon and found out that I had built enough muscle/ lost enough weight to be eligible for keyhole afterall! I was really happy about it and immediately agreed. I changed into my surgical gown & hair net and my surgeon drew on the incision site. Then I talked with the anaesthesiologist and went into the operating room. It was my first time with general anaesthesia so I was relatively nervous. After he pushed the first medication the room started spinning and then I was out like a light - genuinely don't remember closing my eyes. Woke up again at around 20:30h - the surgery took longer than expected and I guess the narcosis medication didn't agree with me. The night nurse tried to get me to stand up and eat something - I felt so nauseous I turned him down a few times. When I finally ate the banana he gave me we walked up to my room where I immediately threw up the banana onto his feet🫠. I had a room for myself which was great but honestly I was too tired to pay much attention to anything. So I just texted some people that I made it out alive and went to bed. I was already wearing the post op binder when I woke up. They accidentally nicked my skin so I had a spot that kept bleeding which looked kinda scary especially in combination with the drains. I had no issue using the toilet by myself from the very beginning.

1. day post-op Got up, brushed my teeth and had some fruit for breakfast (if you're vegan definitely bring your own food! - clinics are usually very poorly equipped). The nausea was still very much there and it was like I was moving in slow motion the entire time. My surgeon came by to check up on me - he removed the drains which was fine and I could take a first look at my chest! I had pretty noticeable discolouration from the hematoma but it wasn't big enough to be problematic. The left side looked sort of deflated and the nipple was a bit inverted. But I didn't really care about any of it because I was so busy taking in my flat chest! I didn't have a huge breakdown moment with happy tears it was more a quiet realisation that this was what my chest was always supposed to look like - it just felt right. My surgeon cleaned the incision site and covered all open wounds with bandages, then I got a care package for home and went back to my room. I got my appointment for the next check up and waited for my mum to get there. Her car broke down 2 days before my surgery (perfect timing🙄) so we had to take the train. But with her carrying my things it was actually fine and I was surprised how well I could dress myself - I expected to be even more restricted! Once we were at home I pretty much went straight to bed - the nausea was still there and i just felt absolutely exhausted. I had a little nest/ elevated mattress where I slept pretty comfortably. The pain was very manageable - I took some ibuprofen but more to prevent pain from coming up not because I had any. I've started cooling to help with the swelling.

the first 2 weeks My sutures have been pulled and I'm finally allowed to take full body showers again🙌 Before that I showered my lower body and used a washcloth for my upper body + my mum washed my hair. My surgeon told me I didn't need bandages after the first few post op days but I put some on anyway - just felt more protected. And I think that was a good call because some spots kept exuding wound fluids well beyond the first days! I'm also allowed to take binder breaks for 2h per day now. (I may or may not have taken breaks already to wash it but pssst.) I'm really happy about the binder off-time because it's starting to cut into my shoulder blades - I'm using Bepanthen to keep the skin intact but not wearing the binder helps the most obv! The hematomas have pretty much completely disappeared now but the swelling is still intense - especially in my upper chest area. The spot I was nicked at during surgery still hasn't healed properly. Until now I had steri strips on the incisions which I could take off at that point - my surgeon suggested applying Bepanthen to the scars as well to help them close fully/ because it strengthens the tissue. Getting all the dried blood off in the shower was a bit of work but it was nice to get a proper look at the scars. I haven't had as many issues with bloating or constipation as others seemingly did, but it took a while for the nausea to pass and my appetite to come back. I've heard people talking about hormone imbalances with acne/ post-op depression for this phase but ngl I was mostly mad horny during this time - no idea why. The pain has been very manageable - I only took ibuprofen 600mg for the first 3 days and since then nothing. Now I just get pain when I make an unfortunate movement or try to use too much strength. I can't open the door to our house by myself so i can't leave the flat on my own. Pulling plugs is also difficult. I've been using my cooling pack a lot and I think it's helping. Sleeping on my back is not as hard as I thought it would be - my mum put a folded blanket under the top part of my mattress so it was at a 45° angle (no need to buy one of those pillows). With another pillow under my knees i slept really well so far! I'm starting with massages - not on the scars just yet, they're still too sensitive - but all the surrounding area. I started feeling hard lumps recently and panicked ofc but apparently it's just scar tissue where the skin is growing onto the muscle and massaging helps keep it soft. I'm going for walks everyday but I'm starting to miss other kinds of exercise. My movements are becoming faster again but I still walk at about half the speed as I did before surgery. The social isolation was really hitting me during this time. The drain punctures were no trouble at all - I covered them with plasters but honestly they probably didn't need it - they seemed closed after the first couple days already.

6 weeks post-op I was allowed to stop wearing the post op binder! Now I only have to wear it for strenuous activities where there's a lot of movement in the chest area. the indents/injured skin on my shoulder blades where the binder cut in is still very visible. I can start sleeping on my side again and my movement restrictions are lifted - I can slowly start getting back to exercising and moving my arms freely in ways that feel right. One of my scars is still slightly hypertrophic and the nipple on my left side is still sort of folded/inverted? I was told that it's likely going to resolve itself in the next few weeks and if not an injection of hyaluronic acid underneath the nipple can be considered for the future. Theres still a bit of swelling in both sides and in my upper chest area near the armpits. There's a bit of adhesion in my left side so I'm going to have to massage more/harder there. It looks a bit "deflated" compared to my right. My surgeon says the time period between 6 weeks and 3 months show the most rapid improvements in healing. the spot I was accidentally cut in during surgery has finally healed. Also I know not everyone has a say in when their surgery date is but I'm so happy with my timing because I was able to stop wearing the binder just as it started hitting 25-30°C which is such a relief😅 I also started getting sorta electric zaps (?) occasionally - a sign that the nerves are reconnecting. I haven't regained sensation in the nipples yet and below them there's still a large numb area but I have regained some feeling in other chest areas! There's still a 'barrier' with twisting movements and when lifting my arms above my head so I'm doing gentle stretching in the mornings. I can also tell that they manipulated the muscle a lot (because the incisions are so small the can't see what they're doing quite as well as with DI) - i don't know how to describe it, it's not pain exactly but it just felt irritated from the beginning. It's getting better but the irritation is still there I think. wearing a shirt with nothing underneath & being flat is soooo satisfying - it really just feels natural, like it was always supposed to be this way. I'm really looking forward to building some muscle again - I was beginning to struggle with watching all of my training progress disappear lately! I'm kinda obsessed with looking at my chest right now - a mirror hates to see me coming lol. Just to be clear: the results still are nowhere near final - I'm not perfectly flat (yet) and there's still asymmetry going on but I'm already really happy with it anyway. Now I'm massaging directly on the scars as well as the surrounding area. I stopped using Bepanthen on the scars/nipples at about 4 weeks and started wearing silicone tape.

long term scar care the most important thing is UV-protection and patience! Wear your sunblocker! reapply sunscreen! The sun can damage scars especially during the first year, but wearing sunscreen is always a good idea (and not just on your scars either). I'm going to keep massaging my scars every day for as long as I can be bothered to keep them soft and flat. I'll be wearing silicone tape - also to help with texture and so they stay thin. Between tape changes I'll use Bi-Oil to massage the scars for better healing/ against discolouration. (pro tip: a vibrator works great for the massages!) Just in general: listen to your body and don't start stretching & straining the surgery site too early! With keyhole there's less risk of stretching the scars by moving to much than with DI but it's still something to look out for! Listen to your doctors advice/restrictions and be kind to yourself. Also keep in mind that keyhole can take up to a year to fully settle so don't be discouraged if the results don't look perfect from the beginning!

progress pics 3 days Vs. 6 weeks post op

As I said before - the 6 weeks photo is not the final result.

You can see the discolouration and swelling in the first photo. In the second one you can see the swelling has gone down but there are clearly some hardened spots in both sides and asymmetry in the left side where the nipple hasn't returned to its normal shape. I think it looks like there is more 'sagging' in the photo than there actually is irl - probably because my posture was horrible when I took it😬. Also these pictures were obviously taken at different angles/ in different lighting.

__________________________________________

at the moment I'm just 7 weeks post op so things are still very much in the early stages!

I might update this after my check up appointments - once I reach the 6 months mark and then again after 1 year (if I remember lol) but that's all I have for now - I hope it can be helpful to someone out there🫶🏳️‍⚧️

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