Tips and Tricks in Gender-Affirming Mastectomy

Ara A. Salibian, M.D.; Eduardo Gonzalez, M.D.; Jordan D. Frey, M.D.; Rachel Bluebond-Langner, M.D.


Plast Reconstr Surg. 2021;147(6):1288-1296. 

In This Article

Abstract and Introduction


Summary: Gender-affirming mastectomy has become a highly sought-after procedure for the treatment of gender dysphoria and has been shown to improve quality of life in transgender and gender-nonbinary individuals. Aesthetic outcomes after double-incision mastectomy can be influenced by several factors; however, certain operative variables can be controlled to obtain aesthetic and 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 pectoralis 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 borders of the pectoralis muscle are critical to an aesthetic outcome. The authors have found that appropriate preoperative planning to control these three factors—(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.


Rates of gender-affirming mastectomy have increased significantly following the reversal of the Medicare exclusion in 2014, with a subsequent increase in commercial insurance coverage and Medicaid coverage in some states.[1] Gender-affirming mastectomy, otherwise known as masculinizing "top surgery," is one of the most commonly performed gender-affirming procedures for the treatment of gender incongruence, and is associated with improvement in quality of life. As more transmasculine and gender-nonbinary individuals seek these procedures, it is increasingly important to refine our approach to these cases to provide safe, reproducible, and aesthetic outcomes.

Surgical techniques for gender-affirming mastectomy have evolved from gynecomastia treatments,[2,3] which include the removal of glandular breast tissue and skin and reconstruction of the nipple-areola complex, while highlighting the pectoralis muscle and minimizing scars.[4] Performing a gender-affirming mastectomy is not typically a technically challenging procedure. However, there are several details along the entire continuum of surgical care that can differentiate excellent aesthetic outcomes from those that require revision.

Although each approach must be tailored to the individual patient's anatomy and specific aesthetic goals, we discuss here the most commonly requested outcomes in our practice, the appearance of the chest typical to cisgender men with culturally masculine features. This outcome may be requested by both male identified and nonbinary patients, who may or may not be using testosterone therapy. The senior author has observed several factors that consistently improve this surgical outcome, particularly in double-incision mastectomies. These considerations span the spectrum of preoperative planning, surgical technique, intraoperative decisions, and postoperative management, and are presented here for the double-incision free nipple graft technique.