Buttonhole Top Surgery
Buttonhole is a double incision that keeps the nipple alive. The chest is opened and flattened through the same two horizontal incisions, but instead of taking the nipple off and grafting it back, the surgeon leaves it attached to a stalk of tissue, called a pedicle, that carries its blood and nerve supply. The skin flap is drawn down over it, a small round opening is cut in the flap where the nipple should sit, and the nipple is brought up through it like a button through a buttonhole.
What you gain is sensation. With nipple grafts the nerves are cut and most people lose erotic feeling for good. With buttonhole the nerves are never divided, and many people keep some or all of it.
What you give up is control and flatness. The stalk can only stretch so far, so the nipple cannot be moved as freely as a graft. The stalk is also tissue left behind under the nipple, and on a chest that started too big for this technique, that tissue reads as a mound. That trade between sensation and a perfectly flat, perfectly placed nipple is the whole decision.
At a glance
- Also known as
- Double incision with pedicle, pedicled nipple top surgery, double incision with inferior pedicle, DI with nipple preservation
- Surgery time
- 2.5–4 hours
- Anaesthesia
- General
- Hospital stay
- Outpatient, occasionally 1 night
- Back to work
- 2–3 weeks
- Full recovery
- 6–8 weeks; nipple shape settles over 6–12 months
- Scar
- Two horizontal scars along the lower chest, plus a ring round each areola
- Sensation
- Often kept, because the nerves feeding the nipple are never cut
- Typical cost
- $8,000–$14,000 (United States, self-pay)
Figures reviewed .
On this page
Who it’s for
The person this suits has a small to moderate chest, roughly an A to a C cup, with skin that still has some spring in it. Their nipples sit in a position that does not need to travel far to reach a masculine place on the chest. And keeping nipple sensation matters enough to them to accept a little less precision.
Larger chests are where buttonhole struggles. The further the nipple has to travel, the longer the stalk, and the longer the stalk, the more tissue sits under the nipple and the more its blood supply is stretched. On a large chest most surgeons will offer inverted-T instead, which keeps the nipple on its supply in a different way at the cost of an extra vertical scar.
If you want the flattest possible result with nipples placed exactly, or you are not attached to nipple sensation, standard grafts are simpler and more predictable. If you are borderline, ask the surgeon how far your nipples have to move and how much tissue the stalk will leave. A surgeon who can answer that in centimetres has thought it through.
Testosterone is not required. Nicotine matters more here than in a standard double incision, because the nipple's survival depends on a blood supply running through a narrow stalk. See smoking and nicotine.
Before you book
Decide how much nipple sensation matters to you, compared with the flattest possible chest. If the answer is "a lot", say so in the first five minutes of the consultation, because it changes which technique a surgeon will reach for.
How it’s done
The markings are done sitting up, like any double incision, but with one extra decision drawn on the skin. The surgeon outlines a stalk of tissue running from the nipple down towards the fold under the chest, which is the commonest design. Some surgeons run it from above or from the middle instead, depending on where the nipple has to go.
Under general anaesthetic they make the two horizontal incisions and remove the breast tissue around the stalk, leaving the nipple sitting on its column of living tissue. The areola is usually trimmed smaller at this stage, since a masculine areola is noticeably smaller than most pre-surgery ones. The upper skin flap is drawn down and closed along the fold.
Then comes the buttonhole itself. With the chest closed, the surgeon marks where the nipple should sit, cuts a small circle of skin out of the flap, and brings the nipple up through it, stitching it in place. Drains go in as usual, unless your surgeon also closes with tension sutures, which is the drainless variant and combines with this one well.
There are no bolster dressings, because nothing has been grafted. That is one of the small pleasures of this variant in the first week.
At the consultation
Ask the surgeon to show you, with a finger on your own chest, where the nipple will end up and how far it has to travel. Seeing the distance makes the trade between sensation and placement real.
Buttonhole recovery
The shape of recovery is the same as any double incision. Home the same day for most, a compression vest, drains for about a week, sleeping propped up and nothing above shoulder height. What differs is what you watch. Instead of waiting for grafts to take, you are watching the nipples' colour, which should stay pink or their usual shade rather than turning dusky or dark.
Swelling round the nipple lasts longer than people expect, and the stalk underneath makes the area feel fuller than the rest of the chest for months. Judge the shape at six months, not six weeks. Your surgeon's protocol wins on vest time and lifting.
| Day 0 | Home the same day for most. Drains in, vest on. Nipples checked for colour before you leave. |
|---|---|
| Days 1–3 | Peak swelling. Empty and log drains. Report any nipple turning dark or purple straight away. |
| Week 1 | Drains out. No bolsters to come off. Nipples swollen and sometimes numb, which is common early. |
| Weeks 2–3 | Desk work realistic. Showering normally. Vest still on. |
| Weeks 4–6 | Vest comes off. Light exercise returns. Fullness under the nipples still obvious. |
| Months 3–6 | Swelling under the nipples easing. Feeling often returning, sometimes as tingling first. |
| Months 6–12 | Final shape visible. Any puffiness left now is what a revision would address. |
In the first few days
Get used to glancing at your nipples' colour each time the vest is opened. Pink and warm is good, and anything turning dark or purple means a phone call to your surgeon that day, not the next morning.
Read more: Top Surgery Recovery
Buttonhole scars
The same two horizontal scars as any double incision, along the lower border of each pec, plus a ring round each areola where it was brought through the flap. The ring sits on the colour change at the areola's edge and usually becomes hard to see. The horizontal scars follow the same course as every double incision, red and raised for months, then fading over 12–18 months.
Sensation after buttonhole
This is the reason to choose buttonhole. Because the stalk carries the nerves into the nipple, a good share of people keep nipple sensation, and some keep erotic sensation too. It is not guaranteed. The nipple is often numb for weeks or months after surgery while bruised nerves recover, and in some people feeling comes back only partly.
The chest skin around it behaves exactly as it does after any double incision. Numb in patches for months, then mostly back over a year, often with a tingling phase on the way.
I would go in expecting a good chance of keeping feeling rather than a promise. Surgeons who do this often will tell you how often their patients keep it, and that is the figure to ask for.
Risks and complications
The early risks are those of any double incision. Bleeding under the skin, called hematoma, fluid collecting under the flap, infection and wound breakdown at the ends of the scars.
The risk specific to buttonhole is the nipple's blood supply. If the stalk is kinked, stretched or squeezed by swelling, part or all of the nipple can lose its blood flow and die back. It is uncommon in good hands and more likely in smokers, larger chests and longer stalks. When it happens the nipple usually heals with a scar and lighter pigment, and it can be rebuilt later with nipple reconstruction.
The commonest complaint is cosmetic. Puffiness or a mound under the nipple from the stalk tissue, nipples that sit slightly lower than ideal, or a nipple that projects more than the person wanted. These are the usual reasons for a revision after buttonhole.
Buttonhole results
A flat chest with two horizontal scars, and nipples that are your own, attached and often still feeling. On the right chest it looks the same as a graft result from across a room, and it feels better to the person living in it.
What tends to disappoint is the area right under the nipple. A slight fullness, or a nipple that sits a little lower than a graft would have placed it. Most people find that a fair price. Some have a small trim later, which takes out tissue under the nipple without touching its supply.
Read more: Top Surgery Results: What to Expect
Alternatives to buttonhole
Buttonhole sits between grafts and the techniques that do not need horizontal scars at all. If your chest is small and tight enough, peri-areolar or keyhole also keep the nipple on its supply, with far less scar. If it is too large for buttonhole, inverted-T keeps sensation at the cost of a vertical scar. If flatness and placement matter more to you than feeling, grafts are the safer choice.
Nipple Grafts
The nipple and areola are removed, trimmed smaller, and stitched back onto the flat chest where they look best. Grafts give full control over size and position, at the cost of sensation, since there is no nerve supply and most people lose erotic feeling.
Best for: anyone having double incision who wants nipples placed exactly right and can let go of nipple sensation
Inverted-T Top Surgery
Like double incision, but the nipple stays on a stalk of tissue and is moved up rather than grafted, so sensation is usually kept. The price is the most scar of any technique: around the areola, a vertical line down, and the line along the fold.
Best for: a C cup or larger who want to keep nipple sensation and will accept a vertical scar
Peri-Areolar Top Surgery
A circular incision around the areola, a ring of skin removed with the tissue, and the edge gathered in with a purse-string stitch. The scar hides at the areola edge and sensation is usually kept. Only for small chests with tight skin, and revision risk climbs quickly on a borderline chest.
Best for: an A or small B cup with tight skin, who want to keep sensation and will accept revision risk
Combining buttonhole with other surgery
Buttonhole combines naturally with drainless closure, and with liposuction at the sides to blend the contour. It can go alongside a hysterectomy under the same anaesthetic, as any double incision can, when both surgeons work at the same hospital.
Buttonhole cost
Buttonhole is usually priced the same as a standard double incision, or a little above it, because the operation takes longer and fewer surgeons do it often. Ask for the all-in figure with surgeon, anaesthetist and facility together.
The question that matters most is what the quote says about revision. A trim of fullness under the nipple is a real possibility with this variant, and knowing whether it is included changes what the surgery actually costs you.
| Country | Self-pay | Public / insurance |
|---|---|---|
| United States Fewer surgeons offer it; ask whether the quote is all-in | $8,000–$14,000 | Covered by many plans on the same terms as double incision |
| Thailand Usually includes 1–2 hospital nights; plan 2–3 weeks in Bangkok | $4,000–$7,500 | Self-pay only for international patients |
Read more: Top Surgery Cost
Choosing a buttonhole surgeon
Every top surgeon does double incision. Fewer do buttonhole regularly, and the difference shows in the results. Ask how many buttonhole cases they do a year and how often a nipple loses its blood supply in their hands. I would want a number, not reassurance.
Then look at healed photos at a year on chests your size, and look at two things. How flat the chest is under the nipple, and where the nipple sits relative to the pec. A buttonhole gallery full of small chests shows a surgeon who knows where the technique works best. One that shows large chests should make you ask how those turned out at a year.
Finally, ask which stalk design they would use on you, and why. Every surgeon I have put that question to answers it differently, and the answer tells you whether they tailor the operation or do one version for everyone.
Before you book
Ask to see buttonhole results at a year on a chest your size, from the side as well as the front. The side view shows any fullness under the nipple far better than the straight-on photos most galleries use.
Frequently asked questions
Will I definitely keep nipple sensation with buttonhole?
No, but the chances are much better than with grafts, because the nerves are never cut. Feeling is often reduced at first and returns over months. See sensation.
Why would a surgeon say no to buttonhole?
Usually chest size. On a larger chest the stalk gets long, the nipple's blood supply is stretched, and the tissue left under it shows. See who it's for.
Can I have buttonhole without drains?
Often, yes. Drainless closure is about how the flap is closed and combines with buttonhole well. See combining.
What if a buttonhole nipple fails?
It usually heals with a scar and paler skin, and can be rebuilt later with a small procedure and tattooing. See risks.