How you prepare

Top surgery for transgender women is typically deferred until adulthood. Before top surgery, you'll meet with your plastic or reconstructive breast surgeon. Consult a surgeon who is board certified and experienced in this procedure. Your surgeon will describe your options and potential results. The surgeon will provide information on the anesthesia, the location of the operation and the kind of follow-up procedures that might be necessary. Follow your doctor's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking.

In addition, before you can have top surgery, you'll be required to meet certain criteria. To start, your doctor will evaluate your health to rule out or address any medical conditions that might affect or suggest against treatment. The evaluation might include:

• A review of your personal and family medical history
• A physical exam, including an assessment of your internal reproductive organs
• Lab tests measuring your lipids, blood sugar, blood count, liver enzymes and electrolytes
• A review of your immunizations
• Age- and sex-appropriate screenings
• Identification and management of tobacco use, drug use, alcohol use, HIV and other sexually transmitted infections
• Discussion about contraception and future fertility

Although giving your informed consent after a discussion about the risks and benefits of the procedure is an acceptable standard of care, most surgeons and insurance companies will require a mental health evaluation by a provider with expertise in transgender health. The evaluation might assess:

• Your gender identity and dysphoria
• The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
• Mood or other mental health concerns
• Sexual health concerns
• Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
• Protective factors such as social support from family, friends and peers
• Your goals, risks and expectations of treatment and your future care plans

Before having top surgery, most surgeons and insurance companies require obtaining one letter of support from a mental health provider competent in transgender health. He or she will determine that you meet the World Professional Association for Transgender Health (WPATH) standards of care criteria. The criteria state that you must:

• Have persistent, well-documented gender dysphoria
• Have the capacity to make a fully informed decision and to consent to treatment
• Be of legal age to make health care decisions in your country (age of majority or age 18 in the U.S.)
• Be managing any significant medical or mental health concerns
• Undergo hormone therapy as appropriate to your gender goals for a minimum of 12 months prior to feminizing breast surgery, unless you have a medical contraindication, or you're otherwise unable or unwilling to take hormones

The purpose of hormone therapy prior to breast augmentation is to maximize breast growth in order to help you obtain better results.

Since top surgery for transgender women will cause irreversible physical changes, you must give informed consent after thoroughly discussing:

• Risks
• Benefits
• Cost
• Alternatives
• Social and legal implications
• Potential complications
• Procedure irreversibility

Health insurance might not cover surgical procedures considered cosmetic for the general population, even though these procedures might be essential to alleviating your gender dysphoria.

You might also consider talking to others who've had top surgery before taking this step. They can help you shape your expectations of what can be achieved and what personal and social problems you might experience during treatment.