I worked in a fairly large clinic (office assistant type stuff) and always wondered why the top-surgery patients looked so much “better” than the mastectomy patients. Finally I asked one of the doctors, and he explained that top surgery is quite different than a mastectomy, with different protocols and goals and results.
Someone with training and experience performing mastectomies can’t just step in and do a top surgery.
They shouldn’t, but I have heard way too many horror stories about trans men who have been misled and ripped off by unethical surgeons who just perform a mastectomy as they would with a cancer patient and have no care at all for doing the aesthetic work for chest masculinization.
That's dreadful, and also I gather that nowadays there is of emphasis on getting an aesthetic result for female cancer patients who do not want their breast(s) to be rebuilt & that it is increasingly common to prefer to be flat.
Of course, flat-chested femininity looks very different to flat-chested (or ripped-pecced) masculinity, but I find it a bit baffling that an experienced surgeon couldn't figure out how to create a good result for any sort of chest.
So it feels like it maybe comes down to attitudinal issues amongst some surgeons.