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In buttonhole top surgery and the inverted-T technique the nipple is not removed but stays attached to a tissue pedicle that preserves its blood supply and nerves. These options suit medium or larger chests when sensation is a priority, at the cost of more scarring and some trade-offs.
What is buttonhole top surgery?
Buttonhole top surgery is a mastectomy in which the nipple is not removed but stays attached to a tissue pedicle that keeps its blood supply and some nerves. It is designed for medium or larger chests when nipple sensation is a priority, in exchange for more scarring and a contour that may be slightly less flat.
In the buttonhole technique the surgeon makes incisions similar to double incision, but the nipple-areola complex is not turned into a free graft. Instead it stays attached to a pedicle – a strip of tissue that keeps blood vessels and some nerves intact. The nipple is then brought through a small round opening in the skin (the "buttonhole") at its new position.
The inverted-T (or T-anchor) technique combines a horizontal incision along the lower chest fold with a vertical incision rising towards the areola, forming an upside-down T. Here too the nipple stays on a pedicle, and the vertical scar allows excess skin to be removed both horizontally and vertically.
Some surgeons propose other variants in specific cases, such as the fishmouth technique (fish-mouth-shaped incisions, sometimes without nipples) or the batwing technique (a wing-shaped incision running through the areola). Not every option suits every chest – discuss them with your surgeon.
Pedicle top surgery: who is it suitable for?
| Criterion | Typical situation |
|---|---|
| Chest size | Medium to large, where keyhole and periareolar are not enough |
| Personal priority | Keeping nipple sensation and a natural nipple appearance where possible |
| Sagging | Moderate; with very marked sagging the pedicle may become too long |
| Scars | Accepting additional scars (e.g. vertical in the inverted T) |
| Flatness | Accepting a contour that may be slightly less flat |
Feasibility depends strongly on anatomy: with a very large chest or very low nipples, the pedicle may be bulky or have a poor blood supply, and the surgeon may advise against it. Our guide on choosing a technique compares the options, and our overview of all top surgery procedures sums up the key differences.
How buttonhole top surgery works
The operation takes place under general anaesthesia and usually lasts around 2–3 hours, sometimes longer because shaping the pedicle is more complex. An overnight stay is common, often with drains for a few days and a compression vest for several weeks. Practical advice for the weeks beforehand is in our guide on preparing for top surgery; every other step is explained in our complete top surgery guide.
Before deciding, ask the surgeon how often they perform pedicle techniques, how they assess the blood supply to the nipple during surgery, and what the fallback plan is if the nipple does not appear well perfused – in some cases the surgeon may convert to a free nipple graft during the operation.
Scars, top surgery nipple sensation and trade-offs
Compared with double incision with grafts, buttonhole top surgery and the inverted T generally mean more scarring: in addition to the horizontal line there is a scar around the areola and, with the inverted T, a vertical scar. More in our guide on top surgery scars.
The main advantage is a better chance of keeping nipple sensation and natural projection, as described in studies on nipple-areola complex preservation. Sensation is not guaranteed, though. The pedicle also leaves some tissue under the nipple, so the result may be less flat with a slight mound, and there is less freedom in choosing the nipple position.
Recovery, risks, pros and cons
Recovery is similar to other techniques: roughly 1–2 weeks before desk work and about 6–8 weeks before strenuous exercise. Details are in our recovery guide.
Risks include hematoma, seroma, infection, impaired blood flow or partial necrosis of the nipple on the pedicle, sensation changes, residual fullness, asymmetry, raised scars and the need for revision. Smoking significantly increases the risk of blood supply problems.
| Pros | Cons |
|---|---|
| Possible with medium or larger chests | More scars than double incision |
| Better chance of keeping sensation | Contour may be less flat |
| More natural-looking nipple | Less control over nipple position and size |
| No free grafts to care for | Risk of pedicle blood supply problems |
Buttonhole top surgery cost and consultation
Because of the added complexity, quotes may be slightly higher than for standard double incision; indicative figures are in our guide on top surgery cost. Also consider the alternatives: periareolar and keyhole for smaller chests.
Not every centre offers pedicle techniques, so compare our top surgery destinations in Europe and worldwide, for example top surgery in Turkey or top surgery in Italy.
Is keeping sensation important to you? Request a free top surgery consultation: an experienced plastic surgeon will assess whether a pedicle technique is realistic for your chest.
Sources and further reading
- Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 – WPATH – International Journal of Transgender Health (2022)
- Techniques for Preserving the Nipple Areolar Complex in Chest Masculinization for All Chest Sizes – Cureus (2025), PubMed Central
- Postoperative care and common issues after masculinizing chest surgery – UCSF Transgender Care
- Masculinizing surgery – Mayo Clinic
- Top Surgery – TransHub – ACON (NSW, Australia)
Last checked: 10/2026
Frequently asked questions
No. The chances of keeping it are better than with free grafts, but sensation may still be reduced or absent, temporarily or permanently.
In both the nipple stays on a pedicle. The inverted T adds a vertical scar, which allows more excess skin to be removed vertically.
Not always: the pedicle leaves some tissue under the nipple, so the contour may be slightly less flat. Your surgeon can show you typical results during the consultation.
They are variants with different incision shapes that some surgeons propose in specific situations. Whether they suit you depends on anatomy and personal goals.
Sometimes, because the operation is more complex. Indicative figures are in our guide on top surgery cost; a written quote is always needed.
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