The resistance that you fight physically in the gym and the resistance that you fight in life can only build a strong character.
A double mastectomy, colloquially known as “top surgery”, can be one of the most life-changing experiences for a gender-diverse individual who was assigned female at birth.
Since the beginning of my coaching career, I’ve had the honour of helping multiple clients prepare for this procedure and safely return to training once recovered.
In this article, I’m going to share training and nutrition practices to create a sustainable and effective top surgery prep plan that I’ve been learning, perfecting, and developing for years.
So, if your top surgery is coming up, read on.
Where to start
First of all, you need a plan based on the time at your disposal.
For most clients who want to make a significant lifestyle change, I recommend a top surgery prep lasting a minimum of three to six months for almost all physique-related goals.
For instance, if you’re a beginner with a sizeable amount of body fat you wish to lose, the longer the timeline, the more progress you’ll be able to make in a sustainable way.
As another example, if you want to go through a muscle-building phase or bulk, then lean down in time for surgery, a longer timeline will enable you to dedicate to both of these phases the time that they require for best results, without rushing through a “dirty bulk” or a “crash diet”.
Of course, there’s an obvious problem: many people won’t know their exact top surgery date with months of notice, not to mention the fact that the operation could be brought forward or delayed last minute.
Don’t let this discourage you from making a plan.
No plan is ever perfect from the beginning, and it doesn’t need to be in order to help you progress.
In my coaching practice, I use plans as flexible guidelines, which can be adjusted depending on any unexpected life events that may require a change of pace.
For this reason, you don’t need a specific date. A rough idea is enough.
For example, if you’re in the UK and getting surgery through the NHS, you can request a rough estimate of the current wait time for surgery. Once you get a ballpark figure, you can run a quick calculation.
Let’s say that the estimated wait time from referral to surgery is 20 months. From March 2023, that would mean that your surgery is likely to take place in November 2024. That’s more than enough information to craft your top surgery prep plan.
Assuming you want to take advantage of the full six months, your top surgery prep would start around May 2024.
The phases of a successful top surgery prep plan
Once you have a date, it’s time to divide your plan into segments, or phases.
The number of phases and what each one will aim to accomplish, depend on your goal hierarchy.
As I covered in depth in my guide to successful goal setting, the goal hierarchy I recommend, based on Höchli and colleagues’ research, includes three different types of goal:
While a superordinate goal is the foundation of your plan, you can’t stop there. You also need intermediate and subordinate goals as more specific, shorter-term milestones that pave the way to the achievement of your superordinate goal.
All three types of goal will help you flesh out the entire timeline for your prep.
This is a practical example of a potential prep timeline, leveraging fat loss as the main tool to accomplish the client’s superordinate goal:
“I want to be in the best shape I can for my top surgery in November 2024.”
Intermediate goals, starting from May 2024:
Subordinate goals for the Kickstart Phase in Month 1:
This is almost the same plan I created for my client Corey, who worked with me from January to June 2022 and had surgery in early July.
In the six months leading up to surgery, we ran a two-week Kickstart Phase, followed by four and a half months in a fat loss phase – which included periods at maintenance, such as a few diet breaks for his holidays – and a four-week maintenance phase before the operation.
This plan enabled him to get into the best shape of his life up to that point, improve his relationship with food, and fall in love with lifting weights.
The best body composition for top surgery
A stronger body will more easily cope with surgery and recovery.
You can strengthen and sculpt your body with a well-structured resistance training program that covers at least your major muscle groups – chest, back, core, and legs – and includes lifting weights, bodyweight exercises, or a combination of the two.
In addition, if you want a “typically masculine-looking” chest, your top priority (pun intended) is to grow your pecs.
As a secondary concern, you may choose to go through a fat loss phase, especially if you’re overweight or live with obesity, in order to further boost your physical health.
If you aren’t overweight and don’t have obesity, then losing fat may not be necessary to improve either your health or your results.
You can still choose to get a little leaner for surgery – unless you’re already so lean or underweight that it may be unhealthy – but you may want to dedicate more time to a muscle-building phase, since muscle growth is a far slower process.
How to maximise pec growth with training
1. Prioritise technique and intensity of effort in this order.
First and foremost, ensure your technique is appropriate to target the pecs, without overcompensating with other muscles for the sake of lifting heavier weights.
Once you’re confident with this, then you can focus on training with the right intensity of effort. According to the available scientific evidence, this likely means stopping a set when you’re only three reps away from muscular failure or less (RPE 7 to 10). You can read more about the concept of intensity of effort for hypertrophy here.
2. Perform the right amount of high-quality volume.
There seems to be a dose-response relationship between volume and hypertrophy, whereby more high-quality volume appears to result in more hypertrophy, as long as you can recover from it. I have an in-depth article about this here.
However, the quality of your volume is arguably as important as the quantity.
You could be doing 30 sets of push-ups every week and still not grow your pecs much if the majority of that volume is of a subpar quality.
“High-quality” volume is volume performed with the appropriate technique and the right intensity of effort.
To achieve this high degree of quality, start with a minimalistic amount of volume, such as four to six sets per week, which seem to be enough to trigger hypertrophy, according to this research. Work on being consistent, improving your technique, and training with the right intensity of effort.
If you’re confident that you’re maximising both technique proficiency and intensity of effort, but you don’t think you’re providing your muscles with the stimulus to grow efficiently, then you can consider adding more volume.
3. Start with the pecs.
The beginning of any training session is usually the most productive part because you’re fresh.
For this reason, train your pecs first in every workout in which you’re planning to target this muscle group, so you can stimulate it as much as possible.
Should you do cardio?
According to Ioannis Ntanos, one of the UK leading gender-affirming surgeons, whom I’ve had the pleasure to interview on my podcast, cardio isn’t only important for general health.
Developing a solid cardiovascular base can also ensure you have an appropriate breathing rate to sustain several hours under anaesthesia.
Furthermore, if your goal is to build your physique, cardio can be an additional tool to help you achieve a caloric deficit during a fat loss phase. I wrote more about the benefits of cardio in the context of the physique development process in this article.
The physical activity guidelines for adults in the UK include the following recommendations for cardiovascular exercise:
If these guidelines are too advanced, choose a goal that meets you where you’re at, but that still feels like a stimulating challenge. For example, for a completely sedentary individual, working up to walking at least 30 minutes five days per week, is likely going to be a suitable starting point.
As you get fitter, you can increase your daily step target, include a more intense cardio modality – jogging, rowing, cycling, etc. – or a combination of both, until you achieve an amount of cardiovascular work that suits your needs, goals, and lifestyle.
The finish line
In my example prep plan in one of the previous sections, I included a maintenance phase in the last month before surgery. I’d recommend this whether you’re in a fat loss phase or in a muscle-building phase leading up to the procedure.
There are two main reasons for this:
1. Both a caloric deficit and a surplus cause physiological and psychological stress.
They do this by disrupting the body’s preferred state of balance, known as homeostasis.
Before a major surgery, it would be wise to restore both your nutritional and bodyweight balance in order to lower stress and place your body and mind in the most appropriate position to undergo the operation as well as a smooth recovery.
2. Maintaining your hard-earned results tends to be harder than dieting for fat loss or muscle gain.
For example, research shows that, while diets work, the problem for most people is that they can’t maintain their weight or, worse, that they regain all the lost weight back and then some.
One of the reasons is that they only commit to changing their habits during the fat loss phase, but don’t often take time away from dieting to practise those same habits. As a result, they don’t really know how to adapt said habits to a phase in which they’re eating more calories because they’re trying to maintain their weight rather than losing it.
A maintenance phase – whether it’s before surgery or at any other point in your physique development process – affords you the opportunity to do exactly that and thus increase your chances of long-term maintenance of your results.
Furthermore, you may decide not to track calories in this phase and instead hone your ability to eat a balanced diet and respect your hunger and fullness cues without relying on a calorie-tracking app.
I usually implement an untracked phase with most clients because, after surgery, your calorie requirements for maintenance won’t be the same as before the operation.
You’ll have lost your chest weight, you’ll be more sedentary as you recover, and you’ll also likely burn more calories than you would if you were sedentary without undergoing such a procedure, because the body requires extra calories during the healing process.
As a result, it’s unlikely that your maintenance calories will be the same as they were prior to top surgery. Moreover, they’ll likely keep changing as your body heals and you become more and more active with each passing day.
For these reasons, during this unpredictable period, it may be more reasonable to set your calorie-tracking app aside and do your best to listen to your body, eating as much or as little as you feel you can.
You can pair this strategy with all the other healthful eating habits you’ll have hopefully developed during your top surgery prep, such as:
If you wish to, you can then resume tracking calories at a later stage, when you’re physically ready to build up to your previous physical activity levels.
1. Working on your fitness for any length of time before surgery is going to be beneficial, but starting three to six months in advance at a minimum is likely going to yield the best results.
2. Structure your top surgery prep plan using superordinate, intermediate, and subordinate goals.
3. Include a combination of resistance training and cardio, prioritising resistance training in order to sculpt a well-balanced physique.
Thanks for reading. May you make the best gains.
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An online fitness coach who likes bodybuilding, superheroes, and bread.
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