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Bonapace-Potvin et al. Plast Aesthet Res. 2025;12:34 Plastic and
DOI: 10.20517/2347-9264.2025.65
Aesthetic Research

Review Open Access

Beyond the double incision mastectomy: a narrative
literature review and case series exploring

alternative techniques in gender-affirming top
surgery

Michelle Bonapace-Potvin 1 , Kelsey A. Isbester 2 , Rui Heng Chen 2 , Blair R. Peters 2,3,4
1
Division of Plastic and Reconstructive Surgery, University of Minnesota, Minneapolis, MN 55455, USA.
2
Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR 97239, USA.
3
Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA.
4
Department of Surgery, Oregon Health and Science University, Portland, OR 97239, USA.
Correspondence to: Assoc. Prof. Blair R. Peters, Division of Plastic and Reconstructive Surgery, Oregon Health and Science
University, Portland, OR 97239, USA. E-mail: petersbl@ohsu.edu
How to cite this article: Bonapace-Potvin M, Isbester KA, Chen RH, Peters BR. Beyond the double incision mastectomy: a
narrative literature review and case series exploring alternative techniques in gender-affirming top surgery. Plast Aesthet Res.
2025;12:34. https://dx.doi.org/10.20517/2347-9264.2025.65
Received: 30 Jun 2025 First Decision: 4 Sep 2025 Revised: 20 Sep 2025 Accepted: 17 Nov 2025 Published: 16 Dec 2025

Academic Editor: Raymund E. Horch Copy Editor: Ting-Ting Hu Production Editor: Ting-Ting Hu

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

© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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