There are several types of top surgery that may be covered under your insurance for gender-affirming care.

Top surgery is a medical transition step in which transgender and nonbinary people can address their gender dysphoria, feel more at home in their own bodies, and align more with their identities.

This article addresses your questions about seeking options as a trans woman, transfeminine nonbinary person, or anyone interested in getting a breast augmentation, or “top surgery.”

At this point in your transition, you may have already been on hormone replacement therapy (HRT) for a while now, or are making plans to start medical transition steps soon. If you’re a trans woman, or a nonbinary person looking for these options, your transition is yours alone. You decide what’s best for you.

Top surgery is a completely safe procedure, and research indicates that breast augmentation in the transfeminine population is just as safe a procedure compared with cisgender patients. The surgery itself only takes about 1–2 hours.

If you’re considering top surgery, you have the same options as cisgender women. Options include breast augmentation with a variety of implants and the possible addition of fat grafting (or lipofilling).

Breast augmentation with implants

With a breast augmentation with implants, an incision is made under the breast or around the areola. A temporary breast tissue expander may be inserted to make room for the implant if you do not take estrogen-based HRT prior to the surgery.

A few months later, the tissue expander is replaced, usually with permanent saline-filled implants. The nipple and areola are then reconstructed to a typical feminine shape.

There are a few different types of implants:

  • Saline breast implants: These implants are filled with sterile saline (salt water). If the implant were to break inside your breast, your body would absorb the saline naturally.
  • Structured saline breast implants: These implants are filled with sterile saline (salt water) and have an inner structure that helps the implant feel more natural.
  • Silicone breast implants: These implants are made of silicone gel. If the implant were to break, the gel could stay within its shell or leak into your breast. If you get silicone implants, you may have to see your plastic surgeon regularly to make sure your implants are working properly.
  • Form-stable breast implants: These implants are often called “gummy bear” breast implants because they keep their shape even if the implant shell breaks. They are made of a thicker silicone gel and are firmer than traditional implants. Form-stable breast implants require a longer surgical incision in your skin.

It’s typical for implants to need replacing over time. Learn more about how long different implants last.

Breast augmentation with fat grafting

In fat grafting breast augmentation, the surgeon uses liposuction to take fat from another area of your body and then inject that fat into your breasts. This type of augmentation is sometimes used to help create a “more feminine” looking cleavage.

However, fat grafting also has a 40–50% failure rate ― resulting in tissue necrosis. Most surgeons do not recommend fat grafting, and when used on its own, it typically produces unsatisfactory results.

The average expected out-of-pocket costs (no insurance) can be anywhere from $4,000–$10,000, depending on the individual. Your insurance company may cover some or all of your surgery costs. In some states, Medicaid participants may be eligible for full coverage.

Some companies may not cover any gender-affirming procedures. This is a list of states that prohibit discrimination and require insurance companies to cover gender-affirming-related surgeries.

Make sure to confirm with your insurance company that the procedure type, surgeon, anesthesiologist, and hospital are all considered in-network before scheduling your surgery. The billing code for breast enlargement with implants is 19325.

For people with Medicaid, coverage will vary by state, with some covering or prohibiting more than others. You can check your state’s Medicaid policies using this guide from the Movement Advancement Project.

Here is a comprehensive updated list on private insurances, and what they require for transfeminine breast reconstruction/augmentation.

Be prepared to save up to $5,000 for any surprise costs, hospital stays, anesthesia and recovery care if you do not have paid time off of work.

Does Medicare cover breast augmentation for transgender people?

Medicare does not cover breast augmentation for transgender people because it is viewed as “cosmetic” and not “medically necessary.”

We recognize that any gender-affirming care is medically necessary (especially considering that it’s known to be lifesaving), but at the time of publication, it is not covered.

There’s more information about breast augmentation surgery recovery outlined here, but recovering from breast augmentation will usually take roughly 6–8 weeks, according to Dr. Jamie L. Swartz, a plastic surgeon in Beverly Hills. It may take up to an estimated 12 weeks for the swelling to go down fully.

It’s important to always follow your surgeon’s advice and instructions, don’t hesitate to call them if you have questions, and know that your recovery time depends on your specific situation.

In general, it’s important to not shower until your surgeon recommends it, avoid all strenuous activity until you’re allowed to, and wear the surgical bra you’ve been given. It’s also advised to have a supportive friend or family member with you during your recovery.

One of the best places to start is to ask other trans people in your area for advice. Look for local support groups or social groups on Facebook if you’re not aware of any others.

They may be able to recommend comprehensive, gender-affirming surgeons who have performed hundreds of surgeries for trans and gender nonconforming people. You can also check out this list of surgeons.

Here are some questions to ask prospective surgeons in your top surgery consultation:

  • Are you certified by the American Board of Plastic Surgery?
  • How many years of plastic surgery training have you had?
  • Are you a member of the World Professional Association for Transgender Health (WPATH)?
  • What specific training do you have in transfeminine top surgery techniques?
  • Do you have hospital privileges to perform this procedure? If so, at which hospitals?
  • Is the office-based surgical facility accredited by a nationally recognized or state-recognized accrediting agency? Or is it state-licensed or Medicare-certified?
  • What surgical technique is recommended for me? Am I a good candidate for this procedure?
  • What will be expected of me to get the best results?
  • Where and how will you perform my procedure?
  • How long of a recovery period can I expect, and what kind of help will I need during my recovery?
  • What are the risks and complications associated with my procedure?
  • How are complications handled?
  • What are my options if I am dissatisfied with the outcome?
  • Do you have before-and-after photos I can look at for this procedure, and what results are reasonable for me?

Can you get top surgery without having gender dysphoria?

Yes, but it might be very difficult to navigate insurance. Many providers require you to meet with a psychologist to confirm that you experience gender dysphoria before the procedure is approved.

However, if you are paying out-of-pocket costs as a cosmetic procedure, a lack of dysphoria cannot disqualify you.

What is the best age to get top surgery?

You’re able to access surgery after you turn 18 years old, or 16 years old with your legal guardian’s consent. Ultimately, the best time is when you feel ready. Learn more here.

What are the potential risks of breast augmentation?

The potential risks of breast augmentation are the same for trans women, transfeminine people, and cis women. Complications specific to breast augmentation include:

  • scarring that changes the breast shape
  • asymmetrical breasts
  • breast pain
  • breast numbness
  • loss of nipple sensation
  • inconsistencies in the appearance of the implant
  • implant deflation or rupture
  • implant displacement, which is when the implant moves from the location where it was positioned during surgery
  • needing additional surgery to obtain your desired result
  • breast implant illness

How long do you need to be on estrogen before getting top surgery?

According to the WPATH, it is recommended that transfeminine people undergo estrogen hormone therapy a minimum of 12 months prior to breast augmentation surgery. The purpose is to maximize breast growth to obtain better surgical (aesthetic) results.

It’s important to note that this is not an explicit criterium but a strongly recommended suggestion that most doctors and private insurance companies follow.

Is top surgery for everyone?

No, top surgery is not for everyone, and that’s OK.

Some people are happiest with taking estrogen and progesterone, and some want to medically enhance their chests through surgery if hormones were not sufficient for their needs.

It depends on what you need for your transition, and you alone can decide how you feel about your body. It’s also a big financial decision. Not everyone can make that choice a year or two after accessing HRT.

Choosing not to undergo top surgery will not affect your gender in any way.

If you’re a trans woman, nonbinary person, transfeminine person, or someone looking to enhance your chest, and present a more feminine perception ― top surgery might be the right choice for you.

If you know this will alleviate some gender dysphoria, or help induce gender euphoria, consult a doctor or therapist to begin your top surgery journey as soon as you’re ready.