# Gender-Affirming Surgery: Overview and Chest Procedures

## Introduction

**Gender-affirming surgery (GAS)** encompasses surgical procedures that align physical characteristics with a patient's gender identity. Terminology has evolved: previously termed "sex reassignment surgery"; current preferred language is **gender-affirming** or **gender confirmation** surgery. The **World Professional Association for Transgender Health (WPATH) Standards of Care** provide evidence-based guidelines for surgical readiness criteria. Chest surgery (top surgery) is the most commonly performed gender-affirming procedure and is often the first surgical step in transition.

Plastic surgeons play a central role in providing comprehensive, multidisciplinary, patient-centered care for transgender and gender-diverse individuals.

## Epidemiology and Patient Population

Estimated **0.3-0.6% of the population** identifies as transgender or gender diverse. Increasing demand for gender-affirming surgical services globally. **Masculinizing chest surgery** (mastectomy) is the most frequently performed GAS procedure. **Feminizing breast augmentation** is common but performed less frequently than masculinizing procedures due to hormonal breast development. Patient satisfaction rates for chest surgery exceed **90-95%** across multiple studies.

## Preoperative Assessment and Criteria

### WPATH Standards of Care Requirements

**Persistent, well-documented gender dysphoria** diagnosed by a qualified mental health professional. **Capacity to make a fully informed decision** and consent for treatment. Age of **majority** in the given country (or adherence to specific adolescent protocols). If significant medical or mental health concerns exist, they must be **reasonably well-controlled**.

**Hormonal therapy** is recommended (but not required) for a minimum of **12 months** prior to breast augmentation to allow maximal hormonal breast development; no hormonal requirement for mastectomy.

### Surgical Consultation

Comprehensive assessment of **chest anatomy, skin quality, nipple-areolar complex (NAC) position, and body habitus**. Discussion of surgical techniques, expected outcomes, potential complications, and revision rates. **Photographic documentation** with standardized views. Assessment of **binding history**: prolonged chest binding can affect skin elasticity and influence technique selection. Address patient goals: desired chest contour, nipple size and position, scar acceptability, and sensation preservation.

## Masculinizing Chest Surgery (Top Surgery)

### Preoperative Classification

| Grade | Breast Size | Ptosis/Skin | Recommended Technique |
|-------|-------------|-------------|----------------------|
| I | Small (A/small B cup) | Minimal ptosis, good elasticity | Periareolar/semicircular |
| II | Moderate | Mild ptosis, moderate elasticity | Concentric circular |
| III | Large | Significant ptosis/excess skin | Double incision + free nipple graft |
| IV | Massive | Severe ptosis | Double incision + free nipple graft ± skin excision |

Technique selection based on **breast size, skin elasticity, degree of ptosis**, and NAC position. **Grade I**: small breast, minimal ptosis, good skin elasticity; periareolar/semicircular approach. **Grade II**: moderate breast, mild ptosis, moderate elasticity; concentric circular or extended approaches. **Grade III**: large breast, significant ptosis or excess skin; double incision (mastectomy) with free nipple graft. **Grade IV**: massive breast, severe ptosis; double incision with free nipple graft and possible skin excision.

### Surgical Techniques

#### Periareolar (Keyhole/Circumareolar)

Indicated for **small breasts (A cup or small B cup)** with good skin elasticity and properly positioned NAC. Semicircular incision along the inferior areolar border; breast tissue resected through this approach. NAC remains on its **native pedicle** (preserves sensation). Advantages: minimal scarring, preserved NAC sensation, single-stage. Limitations: risk of inadequate skin redraping; may require revision; not suitable for larger breasts.

#### Concentric Circular (Double Ring/Benelli-type)

Two concentric circles: inner circle defines new areolar diameter (typically 2.5-3 cm), outer circle defines extent of skin excision. Purse-string closure reduces skin envelope; breast tissue removed through the incision. Suitable for **moderate-sized breasts** with mild ptosis. Risk of **widened scars**, pleating, and inadequate chest contouring; highest revision rate.

#### Double Incision with Free Nipple Graft

**Most commonly performed technique** overall; indicated for moderate to large breasts with excess skin. Two horizontal incisions: inferior incision along the inframammary fold, superior incision at the desired chest contour line. Complete **mastectomy** of breast tissue between incisions; direct visualization ensures thorough tissue removal. NAC harvested as a **full-thickness skin graft** and repositioned at the desired location (typically at the inferior border of the pectoralis muscle, ~4th-5th intercostal space).

Ideal NAC position: approximately **2-3 cm** medial to the mid-clavicular line, at the level of the inframammary fold. NAC graft size: typically **2-2.5 cm diameter** for a masculine aesthetic. Advantages: most versatile, reliable contour, complete tissue removal. Disadvantages: NAC **sensory loss** (expected), visible horizontal scars, risk of graft loss.

#### Inverted-T or Inferior Pedicle

Used for very large or ptotic breasts where skin excision patterns from reduction mammaplasty are advantageous. NAC maintained on an **inferior pedicle** preserving sensation; excess skin and tissue excised. Produces an **inverted-T scar** pattern; more scarring but preserves NAC viability and sensation.

<image>Surgical illustration comparing the four main masculinizing chest surgery techniques: (A) periareolar approach for small breasts showing the semicircular incision, (B) concentric circular approach showing the double-ring purse-string design, (C) double incision with free nipple graft showing incision lines, tissue removal, and NAC repositioning, (D) final postoperative masculine chest contour with scar patterns for each technique</image>

### Intraoperative Considerations

**Complete glandular tissue removal**: leave a thin layer of subcutaneous fat for smooth contour; avoid skin flap necrosis from excessive thinning. **Chest contouring**: feather tissue at the periphery to avoid step-offs; liposuction of lateral chest and axillary tail complements direct excision. **Drain placement**: closed suction drains (typically 2) to reduce seroma and hematoma; remove when output <30 mL/24 hours. **Nipple graft bolster**: secured with tie-over bolster dressing; first dressing change at **5-7 days**. **Compression**: vest-type compression garment worn for **4-6 weeks** postoperatively.

## Feminizing Breast Augmentation

### Hormonal Breast Development

**Estrogen therapy** produces breast growth (Tanner stages); maximum development typically reached at **2-3 years** of hormone therapy. Most transfeminine patients achieve **Tanner stage III** (small B cup) with hormones alone; many desire surgical augmentation for further enhancement. WPATH recommends a minimum of **12 months** of feminizing hormones before augmentation to assess hormonal growth plateau.

### Surgical Considerations

Anatomy differs from cisgender female augmentation: **wider chest, broader sternum, wider intermammary distance**, and less developed breast footprint. **Implant selection**: moderate to high-profile implants to compensate for the wider chest; silicone gel preferred for natural feel. **Pocket placement**: dual-plane or subpectoral placement most common; provides better upper pole coverage given thinner breast tissue. **Incision options**: inframammary (most common and versatile), periareolar (limited by smaller areolar diameter), or transaxillary.

NAC position may need to be addressed if laterally positioned; can be corrected with crescentic mastopexy at time of augmentation. **Implant sizing**: typically **300-500 cc**; consider patient goals, chest wall dimensions, and soft tissue coverage.

### Outcomes

High satisfaction rates (**85-95%**); common reason for dissatisfaction is insufficient size. Capsular contracture rates similar to cisgender augmentation; may be slightly higher with subglandular placement. Revision rates: **10-20%** over 10 years (similar to general augmentation population).

<image>Preoperative planning illustration for feminizing breast augmentation showing the anatomical differences in a transfeminine chest (wider sternum, laterally positioned nipples, less subcutaneous tissue) alongside implant pocket planning with dual-plane technique and ideal implant positioning for natural breast contour</image>

## Complications

### Masculinizing Chest Surgery

**Hematoma**: 1-5%; early postoperative; may require surgical evacuation. **Seroma**: most common complication (5-15%); managed with aspiration and compression. **Nipple graft loss** (partial or complete): 2-5% with free nipple graft technique; partial loss managed conservatively; total loss may require tattooing or revision. **Contour irregularities**: residual breast tissue, dog ears, asymmetry; revision rate of **10-25%**.

**Hypertrophic scarring**: particularly in patients of African descent; manage with silicone sheeting, steroid injections, or scar revision. **Sensory loss**: expected with free nipple graft; periareolar techniques may preserve some sensation.

### Feminizing Breast Augmentation

**Capsular contracture**: Baker grade III-IV in 5-15%; may require capsulectomy and implant exchange. **Implant malposition**: lateralization due to wide chest; pocket adjustment or use of acellular dermal matrix. **Synmastia**: confluence of breast pockets across midline; higher risk with wide dissection on a broad sternum. **Nipple/areolar asymmetry**: may require secondary revision. **Animation deformity**: with subpectoral placement; consider prepectoral or dual-plane approach.

<image>Postoperative clinical photograph series showing results of masculinizing chest surgery with the double incision technique at 6 months: front view demonstrating flat masculine chest contour with well-positioned nipple areolar grafts and mature horizontal incision scars</image>

## Key Clinical Pearls

Technique selection for masculinizing chest surgery should be individualized based on breast size, skin elasticity, NAC position, and patient scar tolerance. The double incision with free nipple graft is the most versatile and commonly performed masculinizing technique; counsel patients about expected NAC sensory loss. Allow at least 12 months of feminizing hormones before breast augmentation to maximize hormonal breast development. Meticulous chest contouring with peripheral tissue feathering and adjunctive liposuction produces the most natural masculine chest appearance. Patient satisfaction is consistently high across gender-affirming chest procedures; thorough preoperative counseling and realistic expectations are essential.

## References

1. Cregten-Escobar P, Bouman MB, Bremmer MA,"; Meijerink WJ, Mulder JW. Mastectomy in transgender persons: a report of personal experience and a review of the literature. *Ann Plast Surg*. 2012;68(2):135-141.
2. McEvenue G, Xu FZ, Gast KM, et al. Female-to-male gender affirming top surgery: a single surgeon's 15-year retrospective review and treatment algorithm. *Aesthet Surg J*. 2018;38(1):49-57.
3. Kanhai RC, Hage JJ, Mulder JW. Long-term outcome of augmentation mammaplasty in male-to-female transsexuals. *Ann Plast Surg*. 2000;45(5):456-461.
4. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. *Int J Transgend Health*. 2022;23(Suppl 1):S1-S259.