Nerve Preservation

When it comes to reshaping the chest for transmasculine patients, the most common surgical method is double-incision (DI) top surgery with free nipple grafting (FNG). This technique allows Dr. Keith and Dr. Marano the flexibility to remove a large amount of excess breast tissue and reshape/resize the dimensions of the nipples and areolas to create the most masculine-looking chest appearance possible. Unfortunately, one of the tradeoffs for undergoing this surgery is the loss of sensation in the nipple-areola complex.

At Gender Affirming Medical and Microsurgical Associates (GAMMA) in New York City and New Jersey, Dr. Keith and Dr. Marano collaborate to address nerve preservation, drawing on their years of expertise and elite training in microsurgery techniques.

Reasons for nerve preservation include the following:

• The desire to maintain erogenous zones and sexual pleasure/satisfaction after surgery
• The desire to remain connected to one’s body via chest sensation

Sensation-preserving techniques with FTM top surgery focus on reconnecting nerves in the chest to the nipple and areola. These are some of the treatment options:

• Nerve Preservation: Before removing excess breast tissue, Dr. Keith and Dr. Marano can identify and release the nerves responsible for sensation in the chest. These nerves can then be reconnected to the nipple through Targeted Nipple Reinnervation (TNR). This technique has a positive track record of restoring sensory and erogenous feelings in the nipple-areolar complex (NAC).
• Nerve Grafting: In cases where the nerves do not reach the nipple after breast tissue is removed, Dr. Marano and Dr. Keith can perform nerve grafts to bridge gaps in nerve connections. Nerve grafting has shown good results in helping patients regain sensation in the chest after top surgery. Our team may use an allograft tissue scaffolding to guide the nerves as they regenerate over time.

Transmen who wish to undergo top surgery without losing sensation in the nipples and areolas – as is common with the double incision (DI) method with free nipple grafting (FNG) – will make excellent candidates for the procedure, provided that they are healthy, non-smoking individuals at a healthy weight with positive yet realistic expectations for their outcomes. Dr. Marano and Dr. Keith offer a detailed consultation process to ensure nerve preservation in New York City and New Jersey will be a safe, effective, and successful procedure for you.

Preparing for FTM top surgery with nerve preservation is no different from preparation for traditional double incision top surgery. Taking the following steps will help ensure your treatment process is seamless and stress-free:

• Provide Mental Health Letter – Many insurance providers and surgical guidelines require a letter from a qualified mental health professional confirming a diagnosis of gender dysphoria and the patient’s readiness for surgery. This letter should follow WPATH (World Professional Association for Transgender Health) standards and address the patient’s understanding of the procedure and its implications. Our team will assist in ensuring the proper language is used and the provider is appropriately credentialed
• Quit Smoking – Nicotine constricts blood vessels and significantly increases the risk of complications, including poor wound healing and tissue loss. Patients must stop using all nicotine products—including cigarettes, vapes, nicotine patches, and gum—at least 4-6 weeks before and after surgery.
• Manage Medications – You may be asked to discontinue certain medications that increase surgical risks.
• Well-Controlled Medical or Mental Health Issues / Medical Clearance – To ensure safe surgery and recovery, patients with underlying medical conditions such as diabetes, high blood pressure, or psychiatric conditions should have them well-managed. Medical clearance from a primary care provider or specialist is required.
• BMI Cutoff – There is no strict BMI cutoff for double incision top surgery at GAMMA. Every patient is evaluated individually, considering overall health and surgical goals rather than BMI alone.
• Insurance Coverage – GAMMA works with various insurance providers to help patients access gender-affirming surgery. Our team assists with insurance verification, prior authorization, and necessary documentation. Patients should check with their insurance carrier regarding coverage criteria, including mental health letters and medical clearance requirements.
• Complete Your Consultation – You will undergo a detailed consultation with Dr. Keith or Dr. Marano to ensure your expectations are realistic and your health supports the treatment process. Our team will discuss the risks and benefits, recovery and results, of top surgery.
• Schedule Help – For the first 24 – 48 hours after surgery, a responsible adult will drive you home and assist you with basic chores. You should also prepare your home environment to support your recovery process.

Nerve preservation is an intricate and delicate undertaking that can only be performed by highly skilled providers with extensive expertise in gender-affirming care. Dr. Marano and Dr. Keith are both award-winning, fellowship-trained plastic surgeons who have undergone elite training in advanced techniques for top surgery. Their artistry and meticulous attention to detail ensure the success of your results.

The goal of nerve preservation is to make sure the nerves in the chest are preserved and reattached properly to maintain nipple/areolar sensitivity. During FTM top surgery, Dr. Marano and Dr. Keith will dissect the nipple from the chest, at first severing the nerve attachment, as is common with the double-incision/free nipple graft approach. They will then identify and dissect the sensory nerves and reconnect them to the nipple graft under a microscope using sutures as fine as human hairs. These specialized, ultra-fine monofilament sutures are crucial to the success of the procedure.

On the day of surgery, patients should arrive at the surgical center on time and follow pre-operative fasting instructions. Here’s what to expect:

• Check-In and Pre-Op Preparation – You will check in at the surgery center and complete any final paperwork. A nurse will take your vital signs and place an IV for fluids and medications. You will meet with your surgeon for final markings on your chest, which will guide the incisions and nipple graft placement. An anesthesiologist will discuss general anesthesia and answer any questions before administering sedation.
• During the Surgery – The procedure typically lasts 2–3 hours under general anesthesia. The surgeon will make two horizontal incisions along the chest, remove excess breast tissue, contour the chest, and resize/reposition the nipples as grafts (if desired). Surgical drains will be placed to help prevent fluid buildup.
• Post-Op Recovery – After surgery, you will wake up in the recovery area, where nurses will monitor your vitals. You will be wearing a compression garment to help reduce swelling and support healing. Once you are stable and alert, you will be discharged the same day with detailed post-operative instructions.
• Leaving the Hospital or Surgery Center – A responsible adult must accompany you home or to your recovery accommodation. You cannot take public transportation or drive yourself. You may feel groggy from anesthesia, and mild discomfort is expected. Pain medication will be provided as needed. It is essential to rest, stay hydrated, and follow all aftercare instructions.

Recovery times can vary depending on your individual healing abilities and the details of your surgery. In general, you can expect the following sequence of events:

• Pain Management – Most patients experience moderate pain in the first few days, which gradually decreases. Pain is managed with prescribed medications and over-the-counter options as needed.
• Drains – Drains are placed to prevent fluid buildup and are typically removed within 7–10 days post-surgery.
• Dressings & Showering– A compression garment or dressings will be applied immediately after surgery. This garment will stay in place until your follow up appointment. During this time, dressings must stay dry and showering is not allowed.
• Activity Restrictions – Patients must avoid heavy lifting, strenuous exercise, and raising their arms above shoulder level for the first few weeks. Light activities can be resumed once notified by your surgeon
• Time Off Work – Most patients need 2–3 weeks off work, depending on their job and recovery speed. Jobs requiring heavy physical activity may require a longer recovery period.
• Post-Op Appointments – Follow-up visits are crucial to monitor healing. Patients typically have appointments at 1 week, 1 month, and 6 months, and 12 months post-op. Virtual check-ins are available for out-of-town patients

Insurance carriers will typically cover gender affirmation surgery, including FTM top surgery, when it is performed to treat gender dysphoria, a condition in which the patient’s outer traits do not reflect their authentic gender identity. You’ll need a letter from a mental health provider detailing your decision to undergo top surgery and another letter explaining whether or not you are on hormone therapy. Our team can go over the insurance requirements in greater detail during your private NYC consultation.

• Resources – For patients traveling to NYC for surgery, GAMMA provides recommendations for LGBTQ+ friendly accommodations, post-op caregivers, and recovery services. Our team can also assist with logistics such as medical transport and aftercare arrangements.
• Requirements – Out-of-town patients must plan to stay in NYC for at least two weeks after surgery to ensure proper healing and attend necessary post-operative appointments. We encourage having a trusted friend, family member, or professional caregiver for the first few days post-surgery.

Our team at Gender Affirming Medical and Microsurgical Associates (GAMMA) in New York City and New Jersey is known for providing the highest-level care in an affirming environment. We utilize today’s most progressive and cutting-edge techniques to provide the highest level of service possible. Our goal is to help transgender, nonbinary, and gender nonconforming individuals achieve their unique appearance goals and thrive with confidence, security, and peace of mind.

Dr. Drew Marano

Dr. Drew Marano is an accomplished, board- certified, and fellowship-trained plastic and reconstructive surgeon who has devoted his career to the art of gender affirmation surgery. He graduated from Rutgers New Jersey Medical School at the top of his class, receiving AOA honors before embarking on a competitive six-year Integrated Plastic and Reconstructive Surgery Residency at Columbia University/Cornell University in New York City. Following his residency, Dr. Marano was selected as the first-ever Harvard University Complex Gender and Microsurgery Fellow, during which time he underwent advanced training in groundbreaking and innovative surgical techniques. He is a prolific author, researcher, and lecturer who has contributed to over 40 publications and presentations at regional and national meetings. Dr. Marano offers ongoing support for transgender patients as they navigate their unique and rewarding journey of transitioning.

Dr. Jonathan Keith

Dr. Jonathan Keith is a renowned, fellowship-trained, board-certified plastic surgeon known for his progressive approach to microvascular surgery. He is an active member of the World Professional Association for Transgender Health and the founder of the Rutgers Center for Transgender Health. In 2018, Dr. Keith created the first multidisciplinary clinical program for transgender patients in New Jersey and was the first surgeon in the state to perform a female-to-male phalloplasty for gender affirmation. Regarding his extensive educational background, Dr. Keith completed a demanding seven-year residency at the University of Pittsburgh, one of the nation’s most elite and well-regarded plastic surgery training programs. As a testament to his skill and artistry, in 2012, he received the Stephen S. Kroll Fellowship in microsurgery at the University Hospital of Gent, Belgium. Today, Dr. Ketih performs a range of complex and delicate procedures to assist transgender and nonbinary individuals in achieving their ideal appearance, including DIEP flaps for breast reconstruction, vaginoplasty, and phalloplasty.