Top surgery (chest reconstruction surgery) is the removal of breast tissue to give a more masculine looking chest. There are a few procedures used to accomplish this.
Double incision/Bilateral mastectomy is used for guys with bigger chests, C cup or higher but is also recommended for some guys around a B cup. In this method, large incisions are made horizontally across each breast, usually below the nipple. The skin is then peeled back so that the mammary glands and fatty tissue can be removed with a scalpel. The muscles of the chest are not touched. Certain areas of harder-to-reach fatty tissue may also be removed via liposuction (such as areas near the armpits). Once the breast tissue has been removed, the excess chest skin is trimmed and the incisions closed, leaving two seams/scars just below the line of the pectoral muscles.
The placement of the nipples varies from doctor to doctor. Usually the nipples are completely removed, trimmed to a smaller size and then grafted back on in a more aesthetically-male location. However, as with any graft there is a chance of poor circulation and tissue death.
Another technique is the "pedicle" technique, wherein the nipples are left partially attached to the body via a stalk of tissue. They are then repositioned in a more aesthetically-male location, while their connection to the body via the pedicle stalk remains intact. They may or may not be trimmed to a smaller size. The pedicle option is sometimes chosen in an attempt to maintain sensation in the nipples.
Keyhole/Peri-areolar incision techniques are effective for individuals with small amounts of breast tissue (cup size A or smaller is ideal; sometimes recommended by certain surgeons for cup size B). They are both done via incisions around the areola, though the techniques differ slightly.
In the keyhole method, a small incision is made along the border of the areola (usually along the bottom), and the breast tissue is removed via a liposuction needle through the incision. The nipple is left attached to the body via a pedicle (a stalk of tissue) in order to maintain sensation. Once the breast tissue has been removed, the incision is closed. The nipple is usually not resized or repositioned.
In the peri-areolar method, an incision is made along the entire circumference of the areola. The nipple is usually left attached to the body via a pedicle in order to maintain sensation. Breast tissue is then "scooped out" by scalpel, or with a combination of scalpel and liposuction. The areola may be trimmed somewhat to reduce its size. Excess skin on the chest may also be trimmed away along the circumference of the incision. The skin is then pulled taut toward the center of the opening and the nipple is reattached to cover the opening-- much like pulling a drawstring bag closed. Thus, this procedure is also sometimes referred to as the drawstring or "purse string" technique. The nipple/areola may be repositioned slightly, depending on original chest size and the available skin.
