By Dirk Smith, MSc, CSCS, SDL (He/Him) For a lot of trans men, top surgery is recognized as one of the major guiding points in gender affirming care. During top surgery, the surgeon will remove the breasts, remove excess skin, and if necessary, reposition the nipples. For most trans men, this is a generally positive, life changing experience and goes a long way toward enhancing gender identity by adjusting appearance to fit more in line with a masculine gender identity.

Since top surgery is a surgery of the chest, it is easy to assume that most exercise and training programs should reflect strengthening your chest muscles. According to Dr. Scott Mosser, a leading surgeon who specializes in health and surgery for transgender and non-binary people…

Chest-focused weight lifting can enhance the contour of your chest and improve your final results over time. “

According to it is recommended that people who are preparing for top surgery exercise and increase the muscle mass and density in their chest. This is important to help you recover quickly from the surgery, but the increased muscle mass will give the surgeon more “contour” to work with, allowing better aesthetic results. 

Strengthening exercises to build strength and mass in your chest are important to improve the overall strength, mass, and appearance of the chest muscles while also helping with the post-surgery recovery process. However, it is important to incorporate chest work in part of a larger strength and conditioning program to maintain overall body posture and strength, while minimizing your risk of developing injuries and ensuring that you are training safely and with balance to the other muscle groups in the body.

The main anatomy of the chest consists primarily of the Pectoralis Major, which is the most common of all the chest muscles. The Pectoralis Major connects both at the Sternum (middle of the chest) and the Clavicle (collar bone) and consists of a large swatch of muscle tissue which can be recruited on the upper or lower ends depending on the exercise. The purpose of the Pectoralis Major is to assist in the movement of the upper arm in moving it toward the body and rotating the arm internally (downward and toward the midline). It is a very strong and powerful muscle capable of building great strength and size.

The Pectoralis Major is assisted by several smaller muscles, including the Pectoralis Minor which runs between the Pectoralis Major and the Serratus Anterior along the mid to side section of your torso along the rib cage. The Subclavius helps to stabilize the shoulder joint when the Pectoralis Major is contracting. The Anterior Deltoids also assist the Pectoralis Major during chest press and pushing type exercises.

Remember, the Pectoralis Major is not the only muscle you should train when preparing for top surgery or to help build a more masculine upper body. There are muscles throughout the shoulders, back, arms, and core that require training as well to help balance the load, maintain your posture and work together with the chest muscles through a variety of movements and functions.

It is important to remember that top surgery is a major surgery, and thus there is a preparation and recovery phase of the surgery, including time to rest and recover. Prior to your schedule surgery, there are many ways to prepare yourself for the surgery that help improve recovery as well as help you achieve a more masculine appearance. Here are some tips…

  • Start Light!
    • Always start with light weights and higher repitions 2-4 sets of 15-20 repitions. Learn the technique of each exercise and build the endurance first. When you have these down, then you can start adding more weight and doing less reps to build more strength and mass.
  • Chest work is important, but in moderation
    • Top Surgery is a surgery for the chest, so it’s easy to want to jump into an intensive strength training program focused on the chest/ pectoralis major. Too much isn’t always a good thing, and it’s easy to burn yourself out from training. Going too intense too fast increases the risk of injuries which only makes things more difficult.  
    • Depending on your level of conditioning and training experience, you should train the upper body 2-3x per week at most. Think of these days as “Upper Body Days” and incorporate exercises such as the Bench Press, Push Up, Internal Rotations, and Chest Flys for the chest. But also, incorporate exercises such as Lat Pull Downs, Rows, Reverse Flys, External Rotations, Bicep Curls and Tricep Extensions that incorporate the muscles of the back, shoulders and arms as well. This will help ensure an even balance of strength and tension for your muscles and also enhance your upper body appearance.
  • Don’t forget Leg Day!
    • Top Surgery is just that, surgery for the top. So, it’s easy to focus on training your upper body, but it’s equally as important to train your lower body as well. Lower body days should fit in between your upper body days, to help you stay active while giving your upper body a chance to recover. In addition, building strength and fitness in your lower body will help enhance your posture and complement the upper body training. Exercises such as Squats, Lunges and Deadlifts are excellent to train with that target a lot of different muscle groups. Depending on your level of conditioning and training experience, you should train lower body 2-3x per week at most.
  • Start off light, and build technique through repetition
    • The most often seen injuries that come out of the gym are from people who lift too much, too quickly and with poor technique. It’s understandable to be excited about starting a new training program, but the last thing anybody wants is to get injured. Your training should focus on lifting lighter weights with more repetitions while focusing on proper technique. For a lot of lifting exercises, start off with dumbbells first. Dumbbells are good for building “Unilateral” strength, which is the strength focused one specific side, as well as engaging more of the smaller muscles that stabilize your joints (such as the Subclavius). A good starting point is to select a weight that you can complete 15-20 repetitions for 2-4 sets that is challenging but allows you to maintain your form.
    • As your strength builds, if you can complete all the reps/ sets comfortable with good form then you can add more weight. As your training experience and technique builds, you can focus on lifting more weight with fewer reps.
  • Be careful of shoulder impingement
    • Shoulder impingement is a condition in which Acromion Process (a part of the bone in the shoulder) and the tendons of the Rotator Cuff muscles rub against each other and cause irritation which leads to pain during overhead movements. This is common in athletes who use a lot of overhead movements and weightlifters who train a lot of chest and upper body. The most common cause is due to a lack of strength in the Rotator Cuff muscle group, so it’s important to include exercises such as external rotations into your training program to train the Rotator Cuff. However, if the pain worsens, it is advised that you seek medical advice.
  • Chest for Days
    • There are many ways to train your chest and there are plenty of variations of the chest press to help you keep things interesting. Pushups are the perfect go to and can be modified to incorporate all levels of fitness. For bench press exercises, it’s good to start with dumbbells first before moving up to the bar, as we shared above, the dumbbells build unilateral strength and engage stabilizer muscles. They also help you focus more on technique rather than maximum strength. With dumbbells you can do a variety of chest exercises, including incline/decline/flat bench press as well as chest flys, pushups, internal rotations, and wide grip pullups.
  • Remember the Five Point Stance
    • If you are doing any exercise that involves you lying on your back (at least for at the gym while strength training!) make sure you use the Five Point Stance. Lay on the bench with your feet flat on the ground (1, 2), Butt, Shoulders and Head flat on the bench (3, 4, 5) and keep them all there during the entire lift.
  • Recovery Days Count Too
    • The most important component of a good training program is to give your body and mind a chance to recovery from the rigors of training. When you strength train, you are ripping your muscle tissue apart so that it will regenerate itself to be stronger, bigger and more resilient. Recovery days are crucial for this process to occur.  A good rule of thumb is for every two days of training, you should take one recovery day. A schedule based on our recommendations above a week might look like this.
      • Day #1 Upper Body, Day #2 Lower Body, #Day 3 Recovery, Repeat.
  • Listen to your body, if you need another recovery day or are having a hard time lifting your normal weight, it’s okay! Focus on what you can do in the moment, if you need to back off on the weight, or take a few extra seconds rest between sets, do it.

The earlier you start training prior to your scheduled surgery, the better of a head start you will have in anticipation for the big day. Following your surgery, doctors advise a minimum of 3 weeks of recovery before you’ll be cleared to start exercising again and depending on your doctor’s orders, it will vary. Following surgery, it’s important to ease back into training again. You definitely will not be at the same level that you were before, so be patient and allow yourself time to build it back up; following advice from your doctor.