Surgical Complications: what happens when things don’t go according to plan
Complications are one of the topics I get asked about, directly or indirectly, more than almost anything else, and I think it's a subject that doesn't get nearly enough airtime. Recently we covered the topic on the Top Surgery Podcast and, given I was deep in thought on the subject, I thought I would extend it to a blog post too, laying out the realities clearly and honestly.
What is a complication?
In a surgical context, a complication is generally defined as an unwanted event that takes place before, during, or after a procedure. No one wants a complication: not the surgeon, not the patient, not the team around them. But - like it or not - complications are part of surgery. There's a well-known quote among surgeons: the only surgeon who never reports a complication is the one who never operates. We plan for them not to happen, but they will sometimes occur, and it's worth discussing openly with your surgeon so you have the full picture.
Why can't a single consultation cover everything?
Complications are broad and do not only relate to the individual surgeon’s practice. There are risks related to general anaesthesia, general surgical risks that apply to any procedure, and risks specific to the procedure being carried out. It is important to note that figures available online, in terms of risks of complications for a specific procedure, are often wide ranging, because different providers report different numbers, so the real question becomes where your specific surgeon sits within that range. I always encourage patients to do their research before the consultation so that - when they are in front of the surgeon - they can focus on what matters most to them.
Are some complications more common than others?
This depends on how you define "common." According to the WHO:
1-10% is considered common
anything at or above 10% is very common
0.1-1% is uncommon
below that is rare or very rare.
I tend to discuss the most frequent, the most serious risks, as well as the ones with the greatest potential impact, but no list can ever be fully exhaustive.
The numbers behind common complications
To put some real figures behind this, when it comes to top surgery specifically, these are some common complications:
Hematoma (a blood clot collection, usually from a bleeder) - by far the most common reason for a return to theatre. The published range is between 0 and 30%, though the overall risk is probably closer to 2-10%. My own personal numbers are under 1%.
Seroma (a collection of serous fluid rather than blood) sits at around 5%. Surgical infection can occur in up to around 3% of cases.
Delayed wound healing, sometimes called wound dehiscence, can occur in up to 8-10% of cases.
Nipple graft loss, partial or complete, is one of the more distressing potential outcomes. Partial loss risk sits between 2 and 10%, complete loss under 1% up to around 3%. If you're the one this happens to, it won't matter that it didn't happen to the previous 999 patients, but these are the numbers.
Persistent numbness or chronic discomfort in the chest, something that can take a while to settle, has been reported in some series at rates as high as 80%. That's not a typo. It can genuinely take one to three years to fully resolve, though for most patients the satisfaction of having a flat chest far outweighs it.
General surgical risks, like pulmonary embolism, are extremely low, likely under 0.2%.
Revision surgery is its own topic. Published numbers for requiring a revision after top surgery range from around 8% to 35%, depending on country, provider, technique, and patient population. That gap exists partly because surgeons report differently: some count a revision only when a patient requests one, others whenever they personally think the result could be improved, even if the patient is thrilled with it. Ideally a revision is performed by the original surgeon, but that isn't always possible, and revision surgery generally carries higher risk than a first operation, since you're working on tissue and blood supply already altered once.
Why the numbers vary so much
None of this means something went wrong. A complication doesn't automatically mean a technique failure or a mistake. Every body heals differently. Age, BMI, smoking, health conditions like autoimmune disease or diabetes, previous surgery, even the recovery environment, all factor into outcomes. Surgery, in that sense, is closer to an art than an exact science: the intention is always the best possible outcome, but the result can't always be fully predicted or controlled.
Common fears: nipple loss and scar symmetry
Two of the concerns I hear most often are nipple loss and scar symmetry, and I understand why: they're vivid, visible fears that tend to circulate as urban-legend-style stories online. A loss of nipple sensation or graft doesn;t have to be the end of the world if overall flatness isn't compromised. There are also options available including 3D nipple tattooing, which is incredibly effective.
Scar straightness is a common preoccupation, especially before surgery, but in my experience it's something patients worry about far more before their operation than after. Scar appearance can be affected by things well outside a surgeon's control, from dominant-hand use during healing to rib cage shape, and with consistent, patient scar care, most of this improves significantly over time.
If a complication occurs away from your surgeon
This comes up often for patients who travel for surgery. If a complication happens after you've returned home and your surgeon isn't readily available, don't hesitate to contact local emergency or urgent care services. This doesn't replace contacting your surgeon too - sometimes reassurance is all that's needed, and they may be able to direct you to a colleague closer to home.
On patient satisfaction
Despite all of the considerations outlined above, top surgery consistently has one of the highest satisfaction rates of any gender-affirming procedure, a finding repeatedly confirmed in research, including at the most recent WPATH conference. The overwhelming majority of patients find their outcome meets or exceeds expectations. By comparison, a procedure like hip replacement has a dissatisfaction rate of up to 25%.
What I want patients to take away
Complications happen. They don't necessarily reflect a bad technique or a mistake in the process. Surgery is a major trauma to the body, and everyone responds differently, physically and emotionally. My advice is simple: be transparent with your surgeon, ask questions, understand that risk numbers are ranges shaped by many factors, and know that if something happens - even something rare - the relationship between you and your surgeon should still be one you can rely on to work it out together.
If a surgeon ever tells you a complication "has never happened to me, you'll be absolutely fine," I'd treat that as a red flag rather than reassurance. What matters is being properly informed, working with a surgeon who is transparent about their own individual numbers, and understanding that a good outcome and the possibility of a complication are not mutually exclusive.
Complications in top surgery are real, documented, and an unavoidable part of any surgical procedure, but in the vast majority of cases they are also rare and manageable. Transparency about risk, honest published numbers, and realistic expectations matter far more than chasing the idea of a "perfect" result.
A flat chest, and the freedom that comes with it, remains the outcome that matters most.
If you'd like to hear more on this topic, I recently discussed complications in more depth on the Top Surgery Podcast, available at ioannisntanos.com and on Spotify.