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The Fishmouth Incision: 5 Crucial Things You Need To Know About This Non-Binary Top Surgery Technique

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Fishmouth Top Surgery, often referred to as the "Batwing Incision," is one of the most unique and least common procedures in the landscape of chest reconstruction. As of December 24, 2025, this technique is gaining particular attention within the non-binary and gender-expansive community due to its distinctive scar pattern and its potential to preserve a critical element: erotic nipple sensation.

Unlike the widely known Double Incision (DI) method, the Fishmouth technique offers a compromise for patients who do not qualify for minimal-scar procedures like Keyhole or Periareolar, but wish to avoid a traditional scar placement. Understanding this procedure's specific criteria, benefits, and long-term results is crucial for anyone exploring gender-affirming chest surgery options.

The Fishmouth Procedure: A Comprehensive Profile

The Fishmouth Incision Method is a specialized procedure for chest masculinization, also referred to as FTM/N top surgery, designed to remove chest tissue and achieve a flatter contour.

  • Procedure Name: Fishmouth Incision, Batwing Incision, Areolar Excision Top Surgery
  • Surgical Goal: Chest reconstruction/masculinization with tissue removal, while attempting to retain the neurovascular bundle (pedicle) connected to the nipple.
  • Incision Pattern: Two incisions are placed around the areola and extend horizontally outward from each side, creating a shape reminiscent of a fish's mouth or a bat's wing. The resulting scar is a horizontal line across the center of the chest, often situated higher than the inframammary fold scar of a Double Incision.
  • Nipple Treatment: The nipple and areola remain attached to a stalk of tissue (the pedicle), preserving the blood and nerve supply. This is the key difference from Double Incision with Free Nipple Grafts.
  • Target Patient Group: Often utilized for non-binary patients or those with moderate chest size and good skin elasticity who prioritize nipple sensation retention.

5 Essential Facts About Fishmouth Top Surgery in 2025

The Fishmouth technique occupies a unique niche in gender-affirming care. Here are the most important, up-to-date considerations for potential candidates.

1. It Offers the Highest Chance of Retaining Erotic Nipple Sensation

The single most compelling reason patients choose the Fishmouth procedure over the Double Incision method is the potential for preserved nipple sensation.

  • The Mechanism: The technique is essentially a mastectomy that leaves the nipple and areola attached to the underlying tissue and blood supply, known as the neurovascular pedicle.
  • The Outcome: While not guaranteed, the likelihood of retaining some, or even full, erotic sensation is significantly higher than with procedures that require a Free Nipple Graft (FNG), such as DI, where the nipple is completely detached and reattached.
  • Candidacy Consideration: This makes Fishmouth a popular choice for individuals whose transition goals include maintaining this form of physical sensation and connection.

2. The Scar Pattern is Intentionally Non-Anatomical

The resulting scar is one of the most defining characteristics of the Fishmouth technique, and it is a deliberate choice for many patients.

  • Unique Placement: The scar runs horizontally across the chest, often at or near the level of the nipple, instead of following the natural crease (inframammary fold) typical of Double Incision.
  • A Non-Binary Preference: Many non-binary individuals specifically prefer this non-anatomical scar layout, viewing it as a unique marker of their journey rather than a traditional "masculine" chest scar.
  • Scar Management: As with any top surgery, proper scar care—including silicone sheets, massage, and sun protection—is essential for the best long-term aesthetic result.

3. Candidacy is Highly Specific and Often Restrictive

The Fishmouth procedure is not suitable for everyone. It is considered a less common technique because it requires a precise combination of factors.

  • Tissue Size: Candidates typically have small to moderate chest size. If the chest is too large, the surgeon may not be able to achieve a flat result while keeping the nipple attached to its pedicle.
  • Skin Elasticity: Good skin elasticity is vital. The surgeon needs to remove excess tissue and re-drape the remaining skin without significant puckering or "dog ears."
  • The Compromise: It is often a middle ground between Keyhole/Periareolar (for very small chests) and Double Incision (for larger chests). It is sometimes categorized with the Extended Wedge or Buttonhole techniques.

4. The Risk of a "Non-Flat" Result Exists

While the goal of all chest reconstruction is a flat, masculine or neutral contour, the Fishmouth technique carries a specific risk profile related to the degree of flatness.

  • Limited Tissue Removal: Because the surgeon must preserve the neurovascular pedicle, there is a limit to how much tissue can be removed directly beneath the nipple-areola complex (NAC).
  • Contouring Concerns: In some cases, this can result in a slightly less flat appearance compared to the Double Incision method, which allows for maximum tissue excision and precise chest contouring.
  • Potential Complications: General surgical risks like hematoma (blood pooling), seroma (fluid buildup), infection, and temporary loss of sensation apply, though the unique risk involves scar stretching in the non-anatomical location.

5. Recovery Protocol Involves Drains and Compression

The recovery for Fishmouth surgery is generally consistent with other forms of top surgery, requiring diligence and patience.

  • Immediate Post-Op: Patients will typically wake up with surgical drains (to prevent seroma and hematoma) and a compression binder or surgical vest. The drains are often placed through the existing incision lines.
  • Timeline: Drains are usually removed within the first week, and the compression binder is worn for several weeks to manage swelling and aid in chest contouring.
  • Return to Activity: Most patients can return to light, non-strenuous work within 1 to 2 weeks. Full physical activity, including heavy lifting and intense exercise, is typically restricted for 6 weeks.
  • Long-Term Healing: While initial healing is quick, it can take 6 months to a year for the final chest contour to settle and for scars to mature.

Choosing the Right Top Surgery Technique

The decision to pursue Fishmouth Top Surgery should be made in close consultation with a board-certified plastic surgeon specializing in gender-affirming care, such as those at the Gender Confirmation Center.

The technique is a powerful option for individuals—especially non-binary patients—who value retaining erotic nipple sensation and prefer a distinct, non-anatomical scar over the traditional inframammary scar. Surgeons like Dr. Scott Mosser and Dr. Ley have experience with this specialized procedure, which is a testament to its modern relevance in providing personalized, patient-centered results that align with the latest WPATH Standards of Care.

Ultimately, the "best" technique is the one that aligns with your specific body characteristics, aesthetic goals, and priorities regarding sensation and scar placement.

The Fishmouth Incision: 5 Crucial Things You Need to Know About This Non-Binary Top Surgery Technique
fish mouth top surgery
fish mouth top surgery

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