Your Introductory Guide to Transfeminine Top Surgery

There are multiple forms of top surgery that may be eligible for insurance coverage as part of gender-affirming care.

Top surgery is a step in medical transition where transgender and nonbinary people can address gender dysphoria, feel more comfortable in their bodies, and better align their appearance with their identity.

This article answers common questions for trans women, transfeminine nonbinary folks, or anyone considering breast augmentation — often referred to as “top surgery.”

Transfeminine choices for breast augmentation

By this stage in your transition you might already be on hormone replacement therapy (HRT), or you may be planning to begin medical steps soon. If you are a trans woman or a nonbinary person exploring these options, remember your transition is personal. You choose what fits your needs.

Top surgery is a very safe operation, and research shows that breast augmentation in transfeminine patients is comparably safe to the procedure in cisgender patients. The procedure itself generally takes about 1–2 hours.

If you’re weighing top surgery, your choices mirror those available to cisgender women. These include breast augmentation using different implant types and the potential use of fat grafting (lipofilling).

Breast augmentation using implants

With implant-based augmentation, the surgeon makes an incision beneath the breast or around the areola. If you haven’t been on estrogen-based HRT before surgery, a temporary tissue expander may be placed to create space for the implant.

A few months later the expander is usually swapped out for a permanent saline-filled implant. The surgeon then shapes the nipple and areola to achieve a typically feminine appearance.

Common implant types include:

• Saline implants: Filled with sterile saline (salt water). If the implant ruptures, the saline is naturally absorbed by the body.
• Structured saline implants: Also filled with sterile saline but featuring an internal structure that helps the implant feel more lifelike.
• Silicone implants: Contain silicone gel. If a rupture occurs, the gel may remain within the shell or leak into surrounding tissue. Recipients of silicone implants often need regular follow-ups with their plastic surgeon to ensure implant integrity.
• Form-stable (“gummy bear”) implants: These keep their shape even if the outer shell is compromised. They use a firmer silicone gel and are more solid than traditional implants, requiring a longer incision.

Most implants will need replacement at some point. Read more about typical lifespans of different implant types.

Fat grafting (lipofilling) for breast augmentation

Fat grafting involves harvesting fat from another part of the body via liposuction and injecting that fat into the breasts. It can be used to enhance cleavage and create a more feminine contour.

However, fat grafting carries a 40–50% failure rate due to tissue necrosis. Many surgeons advise against using fat grafting alone, as it often yields disappointing outcomes when performed without implants.

Costs and insurance coverage for transfeminine breast augmentation

Out-of-pocket costs without insurance typically range from $4,000–$10,000, depending on individual circumstances. Insurers may cover part or all of the procedure. In certain states, Medicaid enrollees can receive full coverage.

Some insurers do not cover gender-affirming surgeries. This list of states shows where discrimination is prohibited and insurers are required to cover gender-affirming care.

Before scheduling, confirm with your insurer that the procedure code, surgeon, anesthesiologist, and facility are considered in-network. The billing code for breast augmentation with implants is 19325.

Medicaid coverage differs by state; some cover more procedures than others. Consult this Movement Advancement Project guide for your state’s policies.

Here is an updated, detailed list of private insurers and their requirements for transfeminine breast reconstruction/augmentation.

If you lack paid time off or face unexpected expenses, plan to save about $5,000 for possible extra costs like hospital stays, anesthesia, and recovery care.

Does Medicare cover breast augmentation for transgender people?

Medicare does not cover breast augmentation for transgender people because it classifies the surgery as “cosmetic,” not “medically necessary.”

While many in the community and clinicians view gender-affirming care as medically necessary and potentially lifesaving, Medicare’s policy does not provide coverage at the time of publication.

Preparing for recovery after breast augmentation

More detailed recovery information is available elsewhere, but recovery from breast augmentation commonly takes about 6–8 weeks, according to Dr. Jamie L. Swartz, a plastic surgeon in Beverly Hills. Full resolution of swelling may take up to 12 weeks.

Follow your surgeon’s instructions closely, reach out with any questions, and remember recovery timing varies by person.

Generally, avoid showering until your surgeon says it’s safe, refrain from strenuous activity until cleared, and wear the surgical bra provided. It’s also helpful to have a trusted friend or family member support you during recovery.

Finding the right surgeon for you

A good starting point is seeking recommendations from other trans people in your area. Local support networks or Facebook community groups can be useful if you don’t know where to begin.

They may refer you to experienced, gender-affirming surgeons who have performed many procedures for trans and gender-nonconforming patients. This directory of surgeons can also be a helpful resource.

Questions to ask during a top surgery consultation:

• Are you board-certified by the American Board of Plastic Surgery?
• How many years of training in plastic surgery do you have?
• Are you a member of the World Professional Association for Transgender Health (WPATH)?
• What specific training do you have in transfeminine augmentation techniques?
• Do you have hospital privileges to perform this operation? If so, at which hospitals?
• Is the office-based surgical facility accredited by a recognized national or state accrediting body, state-licensed, or Medicare-certified?
• Which surgical approach do you recommend for me? Am I a suitable candidate?
• What will be expected of me to achieve the best results?
• Where and how will the procedure be performed?
• How long is the expected recovery, and what level of assistance will I need?
• What are the possible risks and complications?
• How are complications managed?
• If I’m unhappy with the result, what are my options?
• Do you have before-and-after photos I can review, and what outcomes are realistic for me?

Frequently asked questions about transfeminine top surgery

Can you get top surgery without having gender dysphoria?

Yes, but obtaining insurance approval can be challenging. Many insurance plans require a psychological evaluation confirming gender dysphoria before authorizing surgery.

If you are paying out of pocket for a cosmetic procedure, not having dysphoria does not preclude you from surgery.

What is the best age to get top surgery?

Surgery is available at age 18 or at 16 with parental or guardian consent. Ultimately, the appropriate time is when you feel ready. Learn more from relevant clinical guidelines.

What risks are associated with breast augmentation?

Risks are similar for trans women, transfeminine people, and cis women. Possible complications related to breast implants include:

• scarring that alters breast shape
• uneven breasts
• breast pain
• reduced breast sensation
• loss of nipple feeling
• visible implant inconsistencies
• implant deflation or rupture
• implant migration from its original position
• need for additional surgeries to reach desired results
• breast implant illness

How long should you be on estrogen before surgery?

WPATH recommends transfeminine people receive estrogen therapy for at least 12 months before breast augmentation. The goal is to encourage natural breast growth and improve aesthetic outcomes.

Note this recommendation is not an absolute rule but a widely followed guideline by many surgeons and private insurers.

Is top surgery right for everyone?

No — top surgery isn’t necessary or desired by everyone, and that’s perfectly valid.

Some people find satisfaction with estrogen and progesterone alone, while others choose surgical enhancement if hormones don’t meet their needs. Timing is personal and financial factors can also influence the decision. Not everyone pursues surgery shortly after starting HRT.

Choosing not to have top surgery does not change your gender identity.

Bottom line

If you’re a trans woman, nonbinary person, or transfeminine individual seeking a more feminine chest appearance, breast augmentation could be a meaningful option.

If top surgery would reduce gender dysphoria or increase gender euphoria for you, consider consulting a physician or therapist to start the process when you’re ready.