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SPECIAL TOPIC

Tips and Tricks in Gender-Affirming Mastectomy


Ara A. Salibian, M.D.
Summary: Gender-affirming mastectomy has become a highly sought-after pro-
Eduardo Gonzalez, M.D. cedure for the treatment of gender dysphoria and has been shown to improve
Jordan D. Frey, M.D. quality of life in transgender and gender-nonbinary individuals. Aesthetic out-
Rachel Bluebond-Langner, comes after double-incision mastectomy can be influenced by several factors;
M.D. however, certain operative variables can be controlled to obtain aesthetic and
New York, N.Y. reproducible results. Chest wall contour is arguably the most critical component
of these procedures and requires highlighting the definition of the pectoralis
muscle. Planning incisions within the inferior and lateral borders of the pectora-
lis major rather than the inframammary fold, and ensuring removal of all breast
tissue in the lateral and medial chest and the axillary tail, will help obtain an
aesthetically pleasing chest wall shape while concealing scars. Finally, attention
to nipple resizing and repositioning inferiorly and laterally relative to the bor-
ders of the pectoralis muscle are critical to an aesthetic outcome. The authors
have found that appropriate preoperative planning to control these three fac-
tors—(1) contour, (2) nipple position, and (3) scars—and critical analysis and
adjustment of on-table results will help achieve the goals of creating an aesthetic
and gender-congruent chest. (Plast. Reconstr. Surg. 147: 1288, 2021.)

R
ates of gender-affirming mastectomy have Although each approach must be tailored to
increased significantly following the rever- the individual patient’s anatomy and specific aes-
sal of the Medicare exclusion in 2014, with thetic goals, we discuss here the most commonly
a subsequent increase in commercial insurance requested outcomes in our practice, the appear-
coverage and Medicaid coverage in some states.1 ance of the chest typical to cisgender men with
Gender-affirming mastectomy, otherwise known culturally masculine features. This outcome may
as masculinizing “top surgery,” is one of the most be requested by both male identified and nonbi-
commonly performed gender-affirming proce- nary patients, who may or may not be using testos-
dures for the treatment of gender incongruence, terone therapy. The senior author has observed
and is associated with improvement in quality of several factors that consistently improve this sur-
life. As more transmasculine and gender-non- gical outcome, particularly in double-incision
binary individuals seek these procedures, it is mastectomies. These considerations span the
increasingly important to refine our approach to spectrum of preoperative planning, surgical tech-
these cases to provide safe, reproducible, and aes- nique, intraoperative decisions, and postoperative
thetic outcomes. management, and are presented here for the dou-
Surgical techniques for gender-affirming mas- ble-incision free nipple graft technique.
tectomy have evolved from gynecomastia treat-
ments,2,3 which include the removal of glandular
breast tissue and skin and reconstruction of the PREOPERATIVE PLANNING
nipple-areola complex, while highlighting the pec- Surgical Decision-Making
toralis muscle and minimizing scars.4 Performing a We use either the circumareolar or double-
gender-affirming mastectomy is not typically a tech- incision free nipple graft technique for gender-
nically challenging procedure. However, there are affirming mastectomy based on the Fischer
several details along the entire continuum of sur- grading scale,5 accounting for the amount of skin
gical care that can differentiate excellent aesthetic laxity, glandular tissue, and degree of nipple-are-
outcomes from those that require revision. ola complex ptosis. This grading system, in con-
junction with patients’ individual goals for surgical
From the Hansjörg Wyss Department of Plastic Surgery, New
York University Langone Health.
Received for publication November 13, 2019; accepted
December 14, 2020. Disclosure: The authors have no financial interest
Copyright © 2021 by the American Society of Plastic Surgeons to declare in relation to the content of this article.
DOI: 10.1097/PRS.0000000000007997

1288 www.PRSJournal.com
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Volume 147, Number 6 • Gender-Affirming Mastectomy

outcomes and contour, is used to decide on the


best surgical technique together. A double-inci-
sion mastectomy is most appropriate for Fischer
grade 3 and 4 patients. In a double-incision mas-
tectomy, there is an incision on each side of the
chest in the pectoralis muscle shadow, and the
nipple-areola complex is grafted into a new posi-
tion. In grade 2b patients, achieving an aesthetic
outcome can be more challenging because of a
moderate amount of glandular tissue, increased
skin laxity, and a nipple-areola complex located
at or below the inframammary fold. Although
Fischer grade 2b patients can undergo periareo-
lar mastectomies if they wish to avoid the scar of
a double-incision mastectomy, one must counsel
them on a higher revision rate with this technique
because of residual inferolateral skin or areolar Fig. 1. Preoperative markings for double-incision mastectomy.
widening. The patient is marked in the standing position with arms raised
As with all patients undergoing gender- to help accentuate the inferior and lateral borders of the pecto-
affirmation surgery, a comprehensive, multidis- ralis muscle. The superior incision is marked straight across the
ciplinary approach should be taken following inferior border of the pectoralis major and is angled superiorly
the standards of care of the World Professional toward the axilla to follow the inferolateral border of the pecto-
Association for Transgender Health.6 Patients ralis muscle.
undergoing gender-affirming mastectomy require
one letter from a qualified mental health pro- travels just above the nipple-areola complex. If the
vider. Preoperative counseling and education on nipple-areola complex is in an acceptable position
scars, contour, outcomes, revisions, and complica- above the pectoralis muscle shadow but there is
tions are critical components of these procedures. pseudoptosis with significant tissue below the nip-
Previous or planned use of gender-affirming hor- ple-areola complex and lax skin, the nipples can
mone replacement therapy is not a requirement, be left untouched and the incision designed in the
although if testosterone use is planned or recently pectoralis muscle shadow below the nipple-areola
begun, physiologic changes expected from hor- complex (Fig. 2). Laterally, this incision should not
mone use alone such as hypertrophy of the pecto- be carried transversely across the chest but should
ralis muscle and adipose redistribution will begin instead be angled superiorly toward the axilla to
within 12 months.7 follow the inferolateral border of the pectoralis
A process of shared decision-making is key major muscle (Fig. 3). In patients with significant
to arrive at the appropriate surgical plan based
on a combination of anatomical considerations
and patient goals and wishes. Patients are also
counseled that residual breast tissue is always left
behind, and the possibility of developing breast
cancer exists despite undergoing mastectomy.

Patient Marking
Patients are marked preoperatively in the
standing position. After marking the midline,
lateral pectoralis muscle border, and the bilat-
eral inframammary folds, the superior incision is
marked straight across the inferior border of the
pectoralis muscle (Fig. 1) while the nondominant
hand tensions the skin surrounding the breast tis-
sue downward. Having the patient raise their arms
at 90 degrees can help accentuate the inferior and Fig. 2. In patients with a high-riding nipple and a long nip-
lateral borders of the pectoralis. In patients with ple-to–inframammary fold distance, an elliptical excision of skin
higher nipple-areola complexes, this line often can be marked just below the nipple-areola complex.

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Plastic and Reconstructive Surgery • June 2021

Fig. 3. Proper placement of the incision laterally is critical for aesthetic scar placement. (Above) The inci-
sions are curved superiorly to follow the lateral pectoral border and are therefore aesthetically concealed
in the lateral pectoral shadow. (Below) The incision here was carried across laterally in the inframammary
fold, which decreases accentuation of the pectoralis and also results in a more readily visible scar outside
the chest aesthetic unit.

excess lateral tissue, the incision continues as lat- the superior mastectomy flap is performed first
erally as possible while still in the supine position and the superior incision is carried down to the
to be able to excise additional skin. Medially, the breast capsule. Dissection then proceeds cepha-
incision stops approximately 2 cm from the mid- lad in the plane between the subcutaneous fat
line. However, in patients with larger breasts, this and breast capsule to create the superior flap. As
may not be possible, in which case we advocate always, traction and countertraction are key to
connecting the incisions medially in a gull-wing identifying and maintaining the proper plane of
or inverted-V pattern to avoid a medial dog-ear dissection. The dissection is carried superiorly and
(Fig. 4). The inferior incision will be marked intra- laterally until the pectoralis fascia is reached, tak-
operatively after completion of the superior dissec- ing care to remove all breast tissue in the axillary
tion by transposing the superior flap inferiorly to tail to prevent unwanted fullness. Care is taken to
ensure closure without tension. dissect up into the axillary fold and laterally to the
edge of the latissimus muscle, therefore directly
excising breast and fatty tissue. Liposuction can
INTRAOPERATIVE DETAILS be used for contouring8 but is infrequently used
Mastectomy in our practice, as we find it increases hematoma
At the start of the operation, before perform- rates and similar contouring can be achieved with
ing the mastectomy, the nipples are marked as 2.2 direct excision. The breast is then elevated off of
× 2.2-cm circles, excised sharply as grafts, and kept the pectoralis fascia, proceeding caudally beyond
on the back table. The nipples will later be thinned the pectoralis insertion. Unlike in an oncologic
before inset to improve graft take. Dissection of mastectomy, the pectoralis fascia is preserved; this

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Volume 147, Number 6 • Gender-Affirming Mastectomy

Fig. 4. If there is excess tissue medially, the incisions often have to be carried to meet in the midline. In this
case, the incisions are angled slightly superiorly in a gull-wing fashion to accentuate the pectoralis muscles.

decreases postoperative pain and postoperative distortion of the chest while abducted and the
bleeding and seromas. We advocate for removal patient is then brought up into the seated posi-
of all breast tissue in these cases. In patients with tion on the operating table. The placement and
higher body mass indices, it is important to pre- symmetry of the incisions are confirmed using a
serve the entirety of the subcutaneous fat to main- smartphone camera grid. Adjustments are often
tain adequate fullness of the chest wall. made to the incision to ensure that the pectora-
Before marking the inferior incision, the breast lis shadow is followed both medially and laterally
parenchyma, still attached to the inferior skin flap,
is pulled superiorly on tension to estimate and
ensure the ability to close. The inferior incision is
then marked at the lower border of the pectoralis
major muscle, not the inframammary fold. In most
patients, the inframammary fold is lower than the
pectoral shadow, with the exception being patients
with prior massive weight loss. Keeping the incision
along the border of the pectoralis muscle conceals
the scar in the pectoralis shadow (Fig. 5). The dis-
section of the inferior flap proceeds along the same
plane until the inframammary fold is reached. The
inframammary fold is then obliterated by continu-
ing the dissection inferiorly beyond the fold, and
excising the fascia that defines the inframammary
fold. Disrupting the fold and excising its fascial
attachments also addresses asymmetries in fold posi-
tion. Once the specimen is removed, the pocket is
inspected to ensure that flaps are of even thickness,
with removal of all gross breast parenchyma. Often,
more tissue is then removed medially and laterally
to avoid dog-ears.
Fig. 5. The inferior incision should be placed in the inferior pec-
Nipple Reconstruction toral shadow and not the inframammary fold, which is often
The incisions are approximated with staples lower than the pectoral shadow. This is marked intraoperatively
before determining new nipple position. The while pulling the breast parenchyma and skin flap superiorly on
arms are moved to the patient’s side to prevent tension to estimate the closure.

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Plastic and Reconstructive Surgery • June 2021

Fig. 6. The nipple-areola complex is resized to 2.2 × 2.2 cm for a male size and shape. The nipple is placed
approximately 2 cm above the incision and 2.5 cm medial to the lateral pectoral shadow.

and that the height of the incisions are symmet- a wedge excision if the nipple has a wide stalk
ric. A suture foil template is used to mark the (Fig. 8) and a composite graft technique if the nip-
desired nipple-areola complex position, the cen- ple is both long and wide (Fig. 9). For the compos-
ter of which is typically 2 cm above the incision ite nipple graft, a 2.2 × 2.2-cm circle of areola and
and 2.5 cm medial to the lateral pectoral border an 8 × 8-mm segment of nipple is harvested. The
(Fig. 6).9 The position of the middle of the nipple areolar graft is thinned and sutured to the deepi-
is usually confirmed with a vertical line dropped thelialized areolar site. An 8-mm punch biopsy is
down from the medial aspect of the deltopectoral then used to cut out the center of the areolar graft
triangle with the patient’s arms at the sides in the and the nipple graft is sutured in place.
seated position. These multiple reference points
are used to increase the reliability and reproduc- Closure
ibility of appropriate positioning. Measurements Drains are placed bilaterally and are appro-
are taken to ensure symmetry and the smart- priately positioned to collect fluid in the most
phone photograph grid is used to confirm accu- dependent dissection plane. The incisions are
rate position relative to the pectoralis border and subsequently closed with a dermal stapler and an
equal height bilaterally. Once ideal position is absorbable running barbed suture in the intrader-
determined, a 2.2 × 2.2-cm circle is marked and mal plane. Petroleum gauze, cotton, and mineral
the patient is then laid flat. The arms are brought oil bolsters are used for the nipples and secured
back out to the sides. If the marked circle of the with an adhesive dressing. Soft foam padding is
nipple-areola complex becomes distorted, it is re- placed along the chest wall over which a compres-
marked as a circle while flat and then deepithelial- sion binder is used to evenly distribute pressure.
ized (Fig. 7).
The nipples are thinned on the back table to
improve graft take while still maintaining some POSTOPERATIVE CARE
residual thickness centrally to preserve projec- Patients typically stay in the hospital overnight
tion. A running, half-buried, fast, absorbable gut to be monitored for hematoma formation. Nurses
suture is used to inset the rest of the nipple graft, are instructed to strip drains frequently during
placing the stitch within the subcuticular plane this period to evacuate any residual fluid and
on the chest wall skin to avoid track marks. Four blood that can lead to seromas and asymmetries.
central tacking sutures are also used to secure the Prevention of fluid accumulation in the chest is
nipple graft to the underlying bed. These quilt- key to maintaining the ideal contour in the post-
ing sutures are placed to define the nipple and operative period, and we therefore have taken
bolster the graft to improve appearance and avoid several precautions to minimize the chances of
hematoma. fluid collections. Patients are discharged to home
Nipple reduction may be necessary for larger the subsequent morning after being instructed on
nipples. There are two techniques that we use: stripping and drain care.

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Volume 147, Number 6 • Gender-Affirming Mastectomy

Fig. 7. After marking the position of the new nipple-areola complex while the patient is in the seated
position (left), distortion of the circular shape can occur after the patient is laid back down (right), requir-
ing remarking of this area to prevent distortion of the final nipple-areola complex shape (inset).

Nipple-areola complex bolsters are removed double-incision mastectomies. Pressure from


at 5 days, after which patients shower and apply hematomas can contribute to poor nipple-are-
antibiotic ointment to the grafts daily. Drains are ola complex graft take and is another reason to
removed when output is less than 30 ml over 24 aggressively manage any collections. Total nipple-
hours, generally 7 to 10 days, after which binder areola complex necrosis is managed with nipple
compression is continued for approximately 1 reconstruction after 6 months. Depigmentation in
additional week. Patients are instructed to refrain darker skin patients is not uncommon. We advise
from any strenuous activity or exercise for 6 weeks patients to wait 9 months to 1 year and then offer
after surgery. Postoperative scar management tattooing to correct this.
includes scar massage and silicone sheets. Widened and/or hypertrophic scars are not
necessarily complications but can be significant
sources of patient dissatisfaction. These can be
MANAGING COMPLICATIONS
revised in the office or operating room, depend-
Hematomas are one of the most common ing on the extent of the revision. Preoperative
complications of gender-affirming mastectomy.5,10 patient education on scar appearance is critical.
Any expanding collection warrants return to the Massage and silicone sheeting are useful postop-
operating room for evacuation. Smaller collec- erative adjuncts.
tions can often be evacuated through the drains.
However, a low threshold for open evacuation
should be maintained, as residual clot can result in DISCUSSION
significant contour deformities caused by seromas The goals for gender-affirming mastectomy
and fibrosis, which often require future revision. outlined by Hage and Bloem in 19954 still hold
Seromas can lead to fibrosis and contour true today. These endpoints include removal of
deformities. We therefore always place drains and all breast tissue while providing an aesthetic chest
do not remove them until outputs are low. In addi- contour, creating an appropriately sized and posi-
tion, we aspirate even small seromas in the office. tioned nipple-areola complex, obliterating the
Care should be taken to leave lymph nodes undis- inframammary fold, and minimizing noticeability
turbed during the lateral mastectomy dissection, of scars. For a double-incision mastectomy tech-
further reducing the risk of fluid accumulation. nique, the unique challenges for achieving an aes-
Nipple-areola complex necrosis is rare11 thetic, gender-congruent chest are attaining a flat
and occurs secondary to poor graft take in but proportional chest contour that highlights the

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Plastic and Reconstructive Surgery • June 2021

Fig. 8. Reduction of large nipples can be performed using a wedge excision.

Fig. 9. In patients with long and wide nipples, a composite graft technique can be used. A 2.2 × 2.2-cm circle of areolar
graft is harvested and sutured to the desired deepithelialized areolar site after tailor-tacking the incisions. A segment of
nipple graft is harvested, and an 8-mm punch biopsy is used to core out the center of the areolar graft (left). The nipple
graft is then sutured to the edges of the punch biopsy opening in the areolar graft (right).

pectoralis major muscle, reconstructing the nip- Residual breast tissue left superiorly in the axillary
ple-areola complex, and remaining cognizant of fold and laterally results in fullness that is uncom-
ideal scar placement. fortable for patients and blunts lateral definition.
Obtaining the ideal chest wall contour is Any excess tissue medially should similarly be
dependent on multiple variables. Certain factors, excised to have an even on-table contour with no
such as the patient’s natural thoracic asymmetries, dog-ear formation, even if this requires carrying
mild pectus deformities, and other bony abnor- the incisions to meet in the midline. It is impor-
malities are beyond the surgeon’s control and tant to maintain all of the fat in the subcutaneous
should be noted and discussed with the patient layer above the breast capsule to prevent contour
preoperatively. Highlighting the contour of the deformities, highlight the underlying pectora-
pectoralis major is one of the most critical aspects lis major muscle, and maintain a slightly convex
of preoperative planning. Marking the inferior shape to the chest. The subcutaneous tissue is nat-
incision at the inferior aspect of the pectoralis urally thicker superiorly and toward the periphery
instead of the inframammary fold and carrying of the chest.12 This allows for preservation of the
the incisions along the lateral border of the pec- appropriate contour and fullness, particularly in
toralis instead of straight across the chest will aes- patients with higher body mass indices.13
thetically define the boundaries of the muscle. There are some important considerations in
Removal of all breast tissue is also important patients with higher body mass indices (Fig. 10).
to allow the muscle contours to be visualized. The incision still curves superiorly but extends to

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Volume 147, Number 6 • Gender-Affirming Mastectomy

Fig. 10. Certain adjustment to markings and technique are made in patients with higher body mass indices. The incision is carried
more laterally on to the chest wall to excise excess skin, though it still curves superiorly on the chest wall. Care must also be taken
to avoid setting the transverse incisions too high and the nipple too medial, as the outline of the pectoralis major can be more
difficult to palpate in patients with higher body mass indices.

the lateralmost extent of chest wall to facilitate exci- Widening is sometimes unavoidable, but can be
sion of the excess skin and tissue and all excess tis- corrected with scar revision.
sue is cleared. The pectoralis muscle can be difficult
to palpate; thus, the incision is set slightly lower and
CONCLUSIONS
can be adjusted intraoperatively as necessary. In
addition, the nipple position can be inadvertently Gender-affirming mastectomy is a powerful
too medial because the lateral border of the pecto- procedure that has been shown to improve quality
ralis muscle can be difficult to define. of life and well-being for transgender and gender-
Nipple size and position can also have a dramatic nonbinary individuals. As this operation becomes
effect on the appearance of the chest wall. Resizing more widely performed, techniques should con-
the areola in almost all (and nipple in many) cases tinue to be refined to optimize outcomes. We
is needed. Although nipple position has been tra- have found that chest wall contour, nipple posi-
ditionally based on rib interspaces, we have found tion, and scar placement are three highly critical
aspects of these procedures that can significantly
that placement relative to the contour of the pecto-
influence aesthetic outcomes after double-inci-
ralis muscle, and the line dropped from the delto-
sion mastectomy.
pectoral groove, results in a consistent aesthetically
Preoperative planning and operative tech-
appealing position. Importantly, this allows nipple
niques should be tailored to highlight the con-
position to be individualized to the specific pectora-
tours of the pectoralis major muscle, resize and
lis and chest contour of each patient.
place the nipples in the appropriate position,
Scars are inevitable, and patients must under-
and conceal scars within the pectoral shadows.
stand and accept the scar burden of a double-
Executing surgical steps precisely, and taking the
incision mastectomy, which is not insignificant. time to examine the aesthetic consequences of
However, certain steps can be taken to minimize each step intraoperatively, will help obtain the
visibility, and create “acceptable” scars. This again goals of this operation consistently. Finally, con-
relies on appropriate preoperative planning to stantly reflecting on the shortcomings of one’s
place the incision in the shadow of the pectoralis surgical results, which helped develop these mod-
major muscle, most notably at the lateral pecto- ifications and continues to change our practice,
ralis border and inferior insertion of the muscle. will aid in improving outcomes and driving the
Scars then can actually accentuate the shape of the field of gender-affirming surgery forward.
pectoralis major muscle, rather than distract from
it, providing a culturally masculine appearance Rachel Bluebond-Langner, M.D.
in patients who desire it. In addition, widening Hansjörg Wyss Department of Plastic Surgery
New York University Langone Health
of scars can be minimized be preventing undue 222 East 41st Street, 6th Floor
tension on mastectomy flaps, which requires pre- New York, N.Y. 10017
cise marking of superior and inferior incisions. rachel.bluebond-langner@nyulangone.org

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Plastic and Reconstructive Surgery • June 2021

REFERENCES An Endocrine Society clinical practice guideline. J Clin


1. American Society of Plastic Surgeons. 2018 plastic surgery Endocrinol Metab. 2017;102:3869–3903.
8. Berry MG, Curtis R, Davies D. Female-to-male transgender
statistics report. Available at: https://www.plasticsurgery.
chest reconstruction: A large consecutive, single-surgeon
org/documents/News/Statistics/2018/plastic-surgery-statis-
experience. J Plast Reconstr Aesthet Surg. 2012;65:711–719.
tics-full-report-2018.pdf. Accessed October 18, 2019.
9. Agarwal CA, Wall VT, Mehta ST, Donato DP, Walzer NK.
2. Davidson BA. Concentric circle operation for massive gyne-
Creation of an aesthetic male nipple areolar complex in
comastia to excise the redundant skin. Plast Reconstr Surg.
female-to-male transgender chest reconstruction. Aesthetic
1979;63:350–354.
Plast Surg. 2017;41:1305–1310.
3. Monstrey S, Selvaggi G, Ceulemans P, et al. Chest-wall con- 10. McEvenue G, Xu FZ, Cai R, McLean H. Female-to-male
touring surgery in female-to-male transsexuals: A new algo- gender affirming top surgery: A single surgeon’s 15-year
rithm. Plast Reconstr Surg. 2008;121:849–859. retrospective review and treatment algorithm. Aesthet Surg J.
4. Hage JJ, Bloem JJ. Chest wall contouring for female-to- 2017;38:49–57.
male transsexuals: Amsterdam experience. Ann Plast Surg. 11. van de Grift TC, Elfering L, Bouman MB, Buncamper ME,
1995;34:59–66. Mullender MG. Surgical indications and outcomes of mastec-
5. Bluebond-Langner R, Berli JU, Sabino J, Chopra K, Singh D, tomy in transmen: A prospective study of technical and self-
Fischer B. Top surgery in transgender men: How far can you reported measures. Plast Reconstr Surg. 2017;140:415–424.
push the envelope? Plast Reconstr Surg. 2017;139:873e–882e. 12. Frey JD, Salibian AA, Choi M, Karp NS. Mastectomy flap
6. The World Professional Association for Transgender thickness and complications in nipple-sparing mastectomy:
Health. Standards of Care for the Health of Transsexual, Objective evaluation using magnetic resonance imaging.
Transgender, and Gender Nonconforming People. 7th Plast Reconstr Surg Glob Open 2017;5:e1439.
Version. Available at: https://www.wpath.org/publications/ 13. Frey JD, Salibian AA, Choi M, Karp NS. Optimizing out-
soc. Accessed October 18, 2019. comes in nipple-sparing mastectomy: Mastectomy flap
7. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine thickness is not one size fits all. Plast Reconstr Surg Glob Open
treatment of gender-dysphoric/gender-incongruent persons: 2019;7:e2103.

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COSMETIC

Top Surgery in Transgender Men: How Far


Can You Push the Envelope?
Rachel Bluebond-Langner, Background: The authors present their grading scale and the outcomes of the
M.D. largest cohort of top surgery published to date. Application of this grading
Jens U. Berli, M.D. system can help determine which patients will benefit from a subcutaneous
Jennifer Sabino, M.D. mastectomy with free nipple graft versus a circumareolar technique, with the
Karan Chopra, M.D. primary endpoint being need for aesthetic revisions.
Devinder Singh, M.D. Methods: The authors reviewed their database of transgender males who un-
Beverly Fischer, M.D. derwent bilateral mastectomy between 2006 and 2015. Data collected included
Baltimore, Annapolis, and Timonium, age, body mass index, American Society of Anesthesiologists class, smoking,
Md.; and Portland, Ore. diabetes, testosterone use, months of social transition, technique used, post-
operative complications, and need for revision. Two techniques were used,
circumareolar incision and free nipple graft technique.
Results: Between 2006 and 2015, 1686 consecutive mastectomies were per-
formed on 843 patients. Of those, 548 patients were excluded because of inad-
equate follow-up. Of the 295 included, 109 were treated using a circumareolar
incision and 186 were treated using a free nipple graft technique. There was
no statistically significant difference in complications between the two groups;
however, there was a statistically significant difference in the rate of aesthetic
revisions in the grade 2B circumareolar incision group (34 percent versus
8.8 percent).
Conclusions: The authors’ outcomes are comparable to the literature, and dem-
onstrate that these procedures can safely be performed in an outpatient setting.
The authors’ grading scale classifies patients and helps the surgeon select a surgi-
cal technique. The authors show a statistical difference in rates of aesthetic revi-
sions in Fischer grade 2B patients when a circumareolar incision is selected over
a free nipple graft technique. (Plast. Reconstr. Surg. 139: 873e, 2017.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

T
op surgery, excision of the female glandular the United States, subcutaneous mastectomy for
breast tissue and shaping of a male chest, is transmasculine individuals has increased. Despite
often the first surgical procedure performed the increase in the number of procedures per-
on female-to-male (transmasculine) transgender formed, there is a paucity of outcome literature
individuals. This marks the beginning of the on the topic.
surgical transition into a masculine phenotype, In 1979, Davidson published his concen-
thereby facilitating a physical cohesiveness with tric circumareolar technique for gynecomastia,
gender identity. The psychological and aesthetic which later was modified by Hage and Bloem
impact of this operation can be profound and and applied to transmasculine top surgery.3,4 This
lasting.1,2 With the expansion of health insurance technique allowed a concomitant nipple-areola
coverage to include gender affirming surgery in complex reduction and at the same time remov-
ing excess skin. Based on his early experience,
From the Division of Plastic Surgery, University of Mary- Hage and Bloem proposed four fundamental con-
land School of Medicine; Anne Arundel Medical Center; siderations for chest wall contouring in the trans-
Advanced Center for Plastic Surgery; and Oregon Health & masculine individual: (1) aesthetic correction of
Science University. contour and elimination of the inframammary
Received for publication January 13, 2016; accepted O­ ctober fold, (2) resection of excess skin and resulting scars,
11, 2016.
Drs. Bluebond-Langner and Berli contributed equally to the
study and should be considered co–first authors. Disclosure: The authors have no financial interest
Copyright © 2017 by the American Society of Plastic Surgeons to declare in relation to the content of this article
DOI: 10.1097/PRS.0000000000003225

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Plastic and Reconstructive Surgery • April 2017

(3) proper reduction and positioning of mamilla for an individual breast type, thereby improving
and areola, and (4) minimization of chest wall the outcome and possibly decreasing the need
scars.4,5 After these initial publications, several for aesthetic revisions. Furthermore, irrespective
authors presented modifications, some of which of the technique applied, the grading system will
were less extensive, using only a semicircular or help classify patients, guide the discussion of sur-
transareolar approach, and some that were more gical technique with the patient, and allow out-
involved, using an extended circumareolar inci- comes to be compared between surgeons.
sion.4–10 At a certain breast size, no circumareolar
technique will sufficiently reduce the skin enve- PATIENTS AND METHODS
lope; thus, most authors advocate for a double- We reviewed our database and identified all
incision mastectomy with a free nipple graft.4–8,10 transmasculine individuals undergoing bilateral
In 2008, Monstrey et al. published a series of 92 mastectomy performed by the senior surgeon
patients who underwent top surgery and proposed (B.F.) between 2006 and 2015. Demographic data
an algorithm in which patients were divided into collected included age, body mass index, smoking
five different surgical approaches depending on status, preexisting diabetes, use of testosterone,
their cup size, ptosis grade, and skin elasticity. This and months of social transition (Table 1). Only
article summarized the five most commonly used patients with follow-up of greater than 42 days were
techniques, described an algorithm, and demon- included. Looking at revisions, we included only the
strated its application based on breast type.7 In our patients with a follow-up of greater than 180 days.
experience, five different surgical approaches can All patients were classified using the Fischer grading
be overwhelming when discussing options with the system (Table 2). Outcome data collected included
patient. Furthermore, some techniques, such as the technique used, postoperative complications, and
extended circumareolar incision, leave the patient need for aesthetic revision. Complications were
with a less-than-ideal scar. In our experience, defined as hematoma, seroma, surgical-site infec-
there are two techniques that deliver consistent tion, and nipple necrosis (Table 3). Revisions were
results, the double incision with free nipple graft categorized as liposuction, direct excision of skin/
and the circumareolar technique. We developed fat, scar revision, nipple-areola complex revision,
the Fischer grading scale to classify patients and and conversion from circumareolar incision to dou-
guide the surgeon’s application of the best tech- ble incision (Table 4). All patients older than 40
nique based on the patient’s chest anatomy. This years underwent screening mammography within 1
grading scale is similar to the Simon gynecomastia year before the surgical procedure with free nipple
grading scale but accounts for higher glandular graft. Testosterone was discontinued 2 weeks before
volume, ptosis, and skin elasticity from chronic surgery. The seventh version of the Standards of
binding. We believe this approach expands on the Care set forth by the World Professional Association
algorithm published by Monstrey et al.7 for Transgender Health was followed. This includes
In this article, we present our grading scale a letter from a mental health provider confirming
and the outcome of the largest cohort of top sur- readiness for surgery. Approval from the University
gery published to date. We demonstrate that appli- of Maryland Medical Center Institutional Review
cation of this grading system can help determine Board was obtained before data collection.
which patients will benefit from a double incision
and free nipple graft, with the primary endpoint Statistical Analysis
being need for aesthetic revisions. This can help Using IBM SPSS Version 22.0 (IBM Corp.,
surgeons better select the appropriate technique Armonk, N.Y.), descriptive statistics were computed

Table 1. Demographics
Total (%) CI (%) FNG (%) p
Mean age ± SD, yr 29.2 ± 8.9 27.7 ± 7.9 30.1 ± 9.4 0.026*
Mean BMI ± SD, kg/m2† 26.8 ± 6.4 23.0 ± 3.3 29.0 ± 6.8 <0.0001
Diabetes 3 (1.0) 0 (0.0) 3 (1.6) 0.183
Smoking status 31 (10.5) 9 (8.3) 22 (11.8) 0.432
Testosterone use 229 (77.6) 85 (78.0) 144 (77.4) 1.000
Mean social transition time ± SD, mo 51.0 ± 94.0 42.0 ± 53.2 56.4 ± 108.5 0.197
CI, circumareolar incision; FNG, free nipple graft; BMI, body mass index.
*Statistically significant.
†Individual BMI was not available for 25 patients.

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Table 2. Fischer Grades A Fischer grade 1 patient has minimal glan-


dular tissue, no skin laxity, and with the nipple-
Grade Total (%*) CI (%) FNG (%)
areola complex above the inframammary fold. A
1 14 (4.7) 14 (12.8) 0 (0.0) Fischer grade 2A patient has moderate glandular
2A 39 (13.2) 34 (31.2) 5 (2.7)
2B 84 (28.5) 50 (45.9) 34 (18.3) tissue, little to no skin laxity, with the nipple-areola
3 133 (45.1) 6 (5.5) 127 (68.3) complex above the inframammary fold. A Fischer
4 25 (8.5) 5 (4.6) 20 (10.8) grade 2B patient has moderate glandular tissue,
Total 295 109 186
increased skin laxity, with the nipple-areola com-
CI, circumareolar incision; FNG, free nipple graft.
*% of total procedures. plex at or below inframammary fold. A Fischer
grade 3 patients has significant glandular tissue,
irrespective of skin laxity, with the nipple-areola
Table 3. Outcomes complex below the inframammary fold. A Fischer
Total (%) CI (%) FNG (%) p
grade 4 patients has a deflated breast with signifi-
cant skin laxity and the nipple-areola complex
Complications 53 (18.0) 23 (21.1) 30 (16.1) 0.346
Major complications below the inframammary fold.
 SSI 5 (1.7) 1 (0.9) 4 (2.2) 0.428 It is important to understand that a Fischer
 Seroma 15 (5.1) 6 (5.5) 9 (4.8) 0.790 grade 2A patient may well have more breast vol-
 Hematoma 20 (6.8) 10 (9.2) 10 (5.4) 0.235
Minor complications
ume than a grade 2B patient. It is the amount of
 Nipple necrosis 9 (3.1) 5 (4.6) 4 (2.2) 0.240 skin laxity and nipple-areola complex position
CI, circumareolar incision; FNG, free nipple graft; SSI, surgical-site that defines the distinction.
infection.
Operative Technique
The senior author (B.F.) uses two different
Table 4. Revision Types techniques for transmasculine mastectomy: the
Total (%) CI (%) FNG (%) p circumareolar technique and the free nipple graft
technique.
Total no. of patients 67 33 34
Total no. of revisions 171 71 100 Circumareolar Technique
Type of revision
 Direct excision 27 (15.8) 17 (23.9) 10 (10.0) 0.019 For the circumareolar technique, the size of
 Liposuction 24 (14.0) 11 (15.5) 13 (13.0) 0.661 the nipple is marked in an oval shape measuring
 Scar revision 10 (6.8) 2 (2.8) 8 (8.0) 0.155 2 × 3 cm with the goal of mirroring the male phe-
 Conversion 1 (1.0) 1 (1.4) 0 (0.0) 0.234
 NAC revision 24 (14.0) 13 (18.3) 11 (11.0) 0.188 notype (Fig. 10). The area from the 9-o’clock to
CI, circumareolar incision; FNG, free nipple graft; NAC, nipple-are- 3-o’clock position is deepithelialized to avoid dis-
ola complex. rupting the dermal blood flow to the nipple. A
full-thickness incision is made from the 3-o’clock
for both total sample size and for each type of position to 9-o’clock position, through which the
procedure group (circumareolar incision ver- mastectomy is performed. The inferior flap is kept
sus free nipple graft). Continuous variables were thin, and care is taken to disrupt the inframam-
expressed as mean ± SD, and categorical variables mary fold using electrocautery. The superior flap
were expressed as frequencies and percentages. is kept thicker, taking care to leave at least 2 cm
To identify significant mean differences of subcutaneous tissue behind the nipple-areola
across the two types of procedures (circumareo- complex, thereby preserving the blood supply and
lar incision versus free nipple graft), t tests were preventing a saucer deformity. Liposuction can be
used for the continuous variables; chi-square used to feather and contour laterally. A 15-French
analyses were used for the categorical variables. drain is placed in the subcutaneous pocket and
Further subgroup analysis of the Fischer grade the incision is closed in layers. Then, 3-0 polydiox-
2B patients was performed using chi-square anal- anone pursestring suture is applied.
ysis. Statistical significance was defined as a value Free Nipple Graft Technique
of p < 0.05. For the free nipple graft technique, in the pre-
operative area, the incision is marked (Fig. 11).
Grading System Using a pinch test, it is ensured that the site of the
The Fischer grading system is a modification nipple excision can be encompassed in the trans-
of the Simon gynecomastia grading scale, which verse closure. The lateral border of the pectoralis
accounts for skin laxity, glandular volume, and major is identified and the incision begins 2 cm
degree of ptosis (Figs. 1 through 9).11 below this lateral margin. The incision is carried

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Plastic and Reconstructive Surgery • April 2017

Fig. 1. Fischer grade 1 patient treated with circumareolar incision shown (left) preoperatively and (right) postoperatively.

Fig. 2. Fischer grade 2A patient treated with circumareolar incision shown (left) preoperatively and (right) postoperatively.

along the inferior border of the pectoralis major fast absorbing plain gut. Liposuction is used to
muscle and not necessarily following the infra­ contour the lateral chest wall and medially to thin
mammary fold. Medially, the incision should stop any potential dog-ears.
two fingerbreadths from the midline. The new
nipple position is marked at the junction of the
lateral two-thirds of the clavicle and one to two RESULTS
fingerbreadths above the incision. Between January of 2006 and December of
The nipple is removed full thickness, the 2015, 1686 consecutive subcutaneous mastectomies
superior incision is made, and the superior flap is were performed on 843 patients. Five hundred
elevated. Through this incision, the subcutaneous forty-eight patients were excluded from the study
mastectomy is performed with the breast paren- because of inadequate follow-up. Of the 295 that
chyma left attached to the inferior flap. The supe- were included, 109 (37 percent) were treated using
rior flap is then put under tension, and the ability a circumareolar incision and 186 (63 percent) were
to close the incision is confirmed. The inferior treated using a free nipple graft technique. Using
cut then completes the mastectomy. The incision the Fischer grading system, the majority of patients
is closed in layers over a 15-French closed suction were either grade 2B (28.5 percent) or grade 3
drain. The patient is then brought up into seated (45.1 percent) (Table 2). Follow-up ranged from 42
position to confirm nipple position. The mastec- to 2947 days, with a mean of 297 days.
tomy flap is then deepithelialized and the nipple Patients that underwent free nipple graft sur-
graft is thinned and sutured into place using 5-0 gery were statistically significantly more likely to

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Volume 139, Number 4 • Aesthetic Revisions in Top Surgery

Fig. 3. Fischer grade 2B patient treated with free nipple graft shown (left) preoperatively and (right) postoperatively.

Fig. 4. Fischer grade 3 patient treated with free nipple graft shown (left) preoperatively and (right) postoperatively.

Fig. 5. Fischer grade 4 treated with free nipple graft shown (left) preoperatively and (right) postoperatively.

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Plastic and Reconstructive Surgery • April 2017

revision, either a minor procedure or a surgical


revision in the operating room (Table 4). Eight
of the 67 patients (11.9 percent) had two separate
revisions. Forty-three percent of patients under-
going revisions had two to four different types of
revision procedures. A total of 171 revisions were
performed in these 67 patients (Table 4). The
incidence of revision between the two groups was
not statistically significant; however, there was a
trend toward more revisions in the circumareolar
incision group (46.5 percent versus 34 percent).
When a circumareolar incision is chosen in a
grade 2B breast, the likelihood for a revision is
statistically significantly higher than when a free
nipple graft is chosen (75 percent versus 33.3 per-
cent) (Table 5 and Fig. 11). Also, not surprisingly,
there was a trend toward higher revision rates for
grade 4 when a circumareolar incision was cho-
sen (13.3 percent versus 7.4 percent). Only one
patient in the entire cohort was converted from
the circumareolar incision technique to the free
nipple graft technique.

DISCUSSION
For many transgender individuals, surgery can
be the definitive treatment in transition to their
affirmed gender.1,2 In 2014, Medicare lifted the
30-year ban on gender affirming surgery. Com-
mercial insurance companies have also come to
Fig. 6. Fischer grade illustrations.
recognize the value of surgical treatment. Thus,
more patients are able to undergo top surgery.
be older (mean, 27.7 years versus 30.1 years) and Top surgery is the most frequently performed sur-
have a higher body mass index (mean, 23.0 kg/m2 gical intervention in the transmasculine popula-
versus 29.0 kg/m2) than patients undergoing the tion. It is important for surgeons to understand
circumareolar incision technique. There was no the difference between chest masculinization
statistical difference in the months of social transi- and a female mastectomy. Beyond minimizing
tion, smoking, use of testosterone, or incidence of and camouflaging the scars, the goals of surgery
diabetes (Table 1). are more akin to those of gynecomastia surgery:
The overall complication rate was 18 percent, to flatten the chest, and to reduce and shape the
consisting of hematomas (6.8 percent), seromas nipple to mimic the male phenotype. However, in
(5.1 percent), infections (1.7 percent), and partial contrast to gynecomastia surgery where liposuc-
nipple necrosis (3.1 percent). The complication tion alone may be used for a small breast, liposuc-
rate was 21.1 percent for the circumareolar incision tion is rarely effective as the sole surgical method
group and 16.1 percent for the double-incision in top surgery because of the higher percent-
group, with hematoma being the most common age of glandular tissue and ptosis present. The
complication in both groups. Overall, there was no degree of ptosis is particularly marked in patients
statistically significant difference in complications with decreased skin elasticity from years of breast
between the two groups; however, as expected, binding.4,5,7 It should also be mentioned that in
there was a trend toward more complications in a transgender mastectomy, a significant amount
the circumareolar incision group (Table 3). of actual glandular tissue is excised. This has con-
Of the 843 patients, 171 had a follow-up sequences, as the abundant blood supply to the
of greater than 180 days and were included in genetic female breast tissue may lead to higher
the analysis of aesthetic revisions. Of those 171 rates of hematoma compared with gynecomastia
patients, 67 (39.1 percent) had some type of surgery.

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Volume 139, Number 4 • Aesthetic Revisions in Top Surgery

Fig. 7. Fischer grade illustrations, continued.

Fig. 8. Fischer grade illustrations, continued.

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Plastic and Reconstructive Surgery • April 2017

Fig. 10. Markings for the circumareolar technique.

Selection of the surgical technique is dic-


tated by the patient’s desire and phenotype. In
our cohort, almost all Fischer grade 1 and 2A
patients were treated using the circumareolar
technique, and most grade 3 and 4 patients were
treated using the free nipple graft technique.
Selection of surgical technique in Fischer grade
2B patients is more challenging; 45.9 percent
of grade 2B patients (n = 50) were treated with
the circumareolar incision technique. We dem-
onstrated that grade 2B patients who underwent
the circumareolar technique had a higher revi-
sion rate (48.6 percent) compared with grade
2B patients that underwent the free nipple graft
technique (20 percent) (Table 5). Use of the
circumareolar technique in grade 2B and grade
4 patients is often patient driven. Based on our
results and the increased acceptance of the free
nipple graft, we are strongly advocating using
Fig. 9. Fischer grade 2B patient treated with circumareolar inci- the free nipple graft for grade 2B and 4 patients.
sion needing revisions shown (above) preoperatively, (center) If the patients insist on a circumareolar tech-
postoperatively, and (below) after revision using direct excision. nique, they are counseled about the likely need
for additional skin removal and revision of the
nipple-areola complex.
The revision rate in the literature is reported
Achieving optimal and durable results requires to be between 9 and 46 percent.5,8,10,12,13 Our over-
attention to breast shape, volume, and skin redun- all aesthetic revision rate is 39.1 percent (circum-
dancy. As stated previously, a patient’s individual areolar incision, 46.5 percent; free nipple graft, 34
breast size is a major determining factor when percent), which is close to the 32 percent reported
selecting the appropriate surgical technique. The by Monstrey et al.7 and 40.4 percent reported by
circumareolar technique is typically indicated for Cregten-Escobar et al.8 Our revision rate is higher
patients with smaller breasts, whereas the double- than in some studies because we include small
incision technique is indicated for patients with revisions that can be performed under local anes-
larger breasts. Compared with the algorithm thesia in the office.
established by Monstrey et al., we used only two There is a trend toward the use of the free
techniques, the circumareolar technique and the nipple graft technique in older patients and in
free nipple graft technique. patients with a higher body mass index. Although

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Volume 139, Number 4 • Aesthetic Revisions in Top Surgery

Fig. 11. Markings for the free nipple graft technique.

Table 5. Revisions by Fischer Grade technique. For marketing purposes and in select
patients with very little glandular tissue, this tech-
Total No. of
Grade Patients (%) CI (%) FNG (%) p nique is certainly appealing, but hemostasis is
technically challenging. Because of the high rate
All 67 (39.1) 33 (46.5) 34 (34.0) 0.113
1 6 (54.5) 6 (54.5) — — of hematomas, the inability to reduce the nipple-
2A 6 (30.0) 6 (31.6) 0 (0) 0.502 areola complex, and the minimal morbidity of a
2B 20 (40.0) 17 (48.6) 3 (20.0) 0.049 circumareolar incision, we do not offer this tech-
3 29 (37.6) 1 (50.0) 28 (37.3) 0.715
4 6 (46.2) 3 (75.0) 3 (33.3) 0.164 nique to our patients.
CI, circumareolar incision; FNG, free nipple graft. All of our procedures were performed as out-
patient surgery, whereas in Europe, most patients
are admitted for an inpatient stay. Cregten-Esco-
statistically not significant, there was a slightly bar et al. advocate keeping the patient for 4 days in
higher incidence of hematomas in the circumare- the hospital until the dressings are removed.8 With
olar incision group compared with the free nipple similar morbidity and reoperation rates, we dem-
graft group. This is consistent with the results of onstrate that these procedures can be performed
Cregten-Escobar et al. and Monstrey et al. and safely and effectively in an outpatient setting.
makes sense, as proper hemostasis is more diffi- A shortcoming of the current study is that it
cult through the smaller incision.7,8 does not quantify patient satisfaction and measur-
The overall complication rate (18 percent) in able quality-of-life outcomes. Overall acceptance
our large retrospective study is comparable to the of the free nipple graft technique seems to have
rates published in other series of transmasculine increased based on social media and anecdotal
top surgery. It is difficult to compare complica- surgeon experience. Monstrey et al., with a limited
tion rates between studies, as each study included response rate, suggested a similar trend in their
different variables and used different surgical article. Based on our results, we have changed our
techniques. Monstrey et al. included the same practice and encourage grade 2B and 4 patients to
variables that we did and had an overall compli- have a free nipple graft.
cation rate of 12.5 percent.7 The overall hema-
toma rate reported in the literature ranges from
5.4 to 11.8 percent. Cregten-Escobar et al. have CONCLUSIONS
the second largest cohort of patients (n = 202) Our outcomes are comparable to those in the
and report an overall hematoma rate of 9 per- literature and we have shown that these proce-
cent, which is higher than in our study (6.8 per- dures can be performed safely in an outpatient
cent).8 The hematoma rate is higher in patients setting. Our grading scale classifies patients and
undergoing transareolar mastectomy without skin helps the surgeon select a surgical technique. We
resection (21 percent). Monstrey et al. had a simi- show a clear trend toward a higher rate of aes-
lar hematoma rate (20 percent) when using this thetic revisions in Fischer grade 2B patients when

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Plastic and Reconstructive Surgery • April 2017

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