Beyond the double incision mastectomy: a narrative literature review and case series exploring alternative techniques in gender-affirming top surgery

Abstract

The double incision mastectomy with free nipple graft (DIFNG) remains the most widely performed technique in gender-affirming chest surgery. However, as patient goals and models of gender-affirming care have evolved, a more individualized, patient-centered approach has emerged. This study reviews historical and current trends in the literature and retrospectively examines 250 consecutive gender-affirming chest surgeries performed by the senior author to assess the breadth of surgical techniques utilized beyond the traditional DIFNG. A total of 70 cases (28%) employed alternative approaches, including double incision without nipple grafts, keyhole, buttonhole, nipple-sparing mastectomy, targeted nipple reinnervation, breast reduction, radical reduction, and mastopexy. These variations reflect a growing diversity in aesthetic, functional, and psychosocial goals, including preservation of nipple sensation, minimized scarring, the option to forgo nipple reconstruction, and maintaining the potential for chest-feeding. This paper outlines the indications and technical considerations for each method and presents a decision-making algorithm to guide individualized surgical planning. As the field of gender-affirming surgery continues to evolve, expanding the operative toolkit is essential to support patients across the gender spectrum and deliver affirming, patient-specific outcomes.

Keywords

Gender-affirming surgery / top surgery / double incision mastectomy / nipple-sparing techniques / targeted nipple reinnervation / non-binary surgical options / patient-centered care

References

[1] Monstrey S,Ceulemans P.Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm.Plast Reconstr Surg2008;121:849-59

[2] Ammari T,Gast K.Female-to-male gender-affirming chest reconstruction surgery.Aesthet Surg J2019;39:150-63

[3] Wolter A,Scholz T,Liebau J.Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy.J Plast Reconstr Aesthet Surg2015;68:184-91

[4] Raner GA,Tse T,Potter E.Binary and nonbinary transgender patient experiences accessing gender-affirming top surgery.Plast Reconstr Surg Glob Open2024;12:e6198 PMCID:PMC11452094

[5] Hu AC,Chan CH.Gender affirming surgery in nonbinary patients: a single institutional experience.Arch Plast Surg2023;50:63-9 PMCID:PMC9902078

[6] Wilson SC,Anzai L.Masculinizing top surgery: a systematic review of techniques and outcomes.Ann Plast Surg2018;80:679-83

[7] Kuruoglu D,Melson VA,Fahradyan V.Masculinizing chest wall gender-affirming surgery: clinical outcomes of 73 subcutaneous mastectomies using the double-incision and semicircular incision techniques.J Plast Reconstr Aesthet Surg2023;85:515-22

[8] Rifkin WJ,Kloer C.Gender-affirming mastectomy: comparison of periareolar and double incision patterns.Plast Reconstr Surg Glob Open2022;10:e4356 PMCID:PMC9132529

[9] Truong AY,Chen Y,Valerio IL.Targeted nipple reinnervation in gender-affirming mastectomy using autologous nerve graft.Plast Reconstr Surg Glob Open2023;11:e5203 PMCID:PMC10752481

[10] McTernan M,Tong W.A comparison of gender-affirming chest surgery in nonbinary versus transmasculine patients.Ann Plast Surg2020;84:S323-8

[11] Schafer RE,Marlar R.Nonbinary and transgender male patient preferences for gender-affirming top surgery.Ann Plast Surg2024;93:e36-44

[12] Bertrand AA, DeLong MR, McCleary SP, et al; Plastic Surgery Research Group. Gender-affirming mastectomy: psychosocial and surgical outcomes in transgender adults. J Am Coll Surg. 2024;238:890-9.

[13] Ferrin PC,Isbester K.Factors affecting the choice to forgo nipple grafts in gender-affirming chest surgery.Ann Plast Surg2024;93:189-93

[14] Rahmani B,Adebagbo OD.Along the spectrum from reduction to mastectomy: comparing the opinions of an online transmasculine and gender-diverse community on an algorithmic approach to gender-affirming top surgery.Aesthetic Plast Surg2025;49:4332-42

[15] Garvey SR,Nanda AD.Along the continuum from reduction to mastectomy: an algorithmic approach to the gender diverse top surgery patient.J Plast Reconstr Aesthet Surg2023;83:246-9

[16] Cuccolo NG,Boskey ER.Masculinizing chest reconstruction in transgender and nonbinary individuals: an analysis of epidemiology, surgical technique, and postoperative outcomes.Aesthetic Plast Surg2019;43:1575-85

[17] Bluebond-Langner R,Sabino J,Singh D.Top Surgery in Transgender Men: How Far Can You Push the Envelope?.Plast Reconstr Surg2017;139:873e-82

[18] Tang A,Jackson JE.Gender-affirming mastectomy trends and surgical outcomes in adolescents.Ann Plast Surg2022;88:S325-31 PMCID:PMC9555285

[19] McEvenue G,Cai R.Female-to-male gender affirming top surgery: a single surgeon’s 15-year retrospective review and treatment algorithm.Aesthet Surg J2017;38:49-57

[20] Top H.Transsexual mastectomy: selection of appropriate technique according to breast characteristics.Balkan Med J2017;34:147-55 PMCID:PMC5394296

[21] Bramati ML,Garcia Rodriguez B,Mayer HF.Ultrasound-assisted liposuction for top surgery in transgender men: clinical experience and evaluation of satisfaction and quality of life with TRANS-Q and BREAST-Q.Aesthetic Plast Surg2025;49:1290-8

[22] Beaufils T,Freton L.A new surgical technique for female-to-male top surgery: the posterioinferior pedicle (PIPe) approach.Aesthetic Plast Surg2023;47:2283-94

[23] Swanson E.Comparative outcome study of gynecomastia surgery and gender-affirming mastectomy with 100% nipple preservation.Ann Plast Surg2025;95:e1-17 PMCID:PMC12321345

[24] Rochlin DH,Wapnir I.Immediate targeted nipple-areolar complex reinnervation: improving outcomes in gender-affirming mastectomy.Plast Reconstr Surg Glob Open2020;8:e2719 PMCID:PMC7253256

[25] Remy K,Gonzales E.Targeted reinnervation during gender-affirming mastectomy and restoration of sensation.JAMA Netw Open2024;7:e2446782 PMCID:PMC11584927

[26] Peters BR,Dhami JK,Shepard E.Targeted nipple reinnervation in gender-affirming mastectomy: a “how to do it” technical primer.Plast Reconstr Surg Glob Open2025;13:e6657 PMCID:PMC11932578

[27] Krakauer KN,Meza-Rochin A,White E.Addressing the gray zone in affirmative mastectomy: an analysis of fischer 2 patients.Ann Plast Surg2023;91:376-80

[28] Robinson IS,Zhao LC.Nipple-preserving inferior-ellipse mastectomy: a new technique for gender-affirming top surgery.Plast Reconstr Surg2024;154:237e-40

[29] Tse T,Armstrong K.Techniques for preserving the nipple areolar complex in chest masculinization for all chest sizes.Cureus2025;17:e80757 PMCID:PMC12004420

[30] Salim A,Constant JS,Yokoo K.Does previous breast reduction affect the outcome of gender-affirming subcutaneous mastectomy?.Ann Plast Surg2018;80:S279-84