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Page 2 of 14 Bonapace-Potvin et al. Plast Aesthet Res. 2025;12:34 https://dx.doi.org/10.20517/2347-9264.2025.65

INTRODUCTION
Gender-affirming mastectomy is the most frequently performed procedure in gender-affirming surgical
care, with the double incision with free nipple graft (DIFNG) technique remaining the most common
approach worldwide. However, as models of gender-affirming healthcare have continued to evolve towards
more personalized, patient-centered approaches to care, there has been a growing need for a broader range
of surgical techniques to better align with diverse transition goals and individual experiences and sources of
gender dysphoria. Contemporary gender-affirming chest surgery - or “top surgery” - looks markedly
different from what it did even five to ten years ago, as patients increasingly present with more detailed
knowledge of a range of surgical options and a wider variety of aesthetic and functional goals. These may
include preservation or improvement of nipple sensation, the desire to forego nipple reconstruction
altogether, minimization of visible scarring and avoidance of large incisions, breast reduction, or the pursuit
of significant chest reduction and contouring without undergoing a full mastectomy.

In this paper, we review the literature as well as the senior author’s most recent 250 gender-affirming top
surgery cases to examine the range of techniques employed beyond the DIFNG approach. The aim is to
provide an overview of these alternative techniques, discuss their indications, and offer a patient-centered
decision-making algorithm to support both providers and patients in selecting the most appropriate surgical
approach to meet individualized transition goals. This study highlights the evolving spectrum of gender-
affirming chest surgeries, with a focus on techniques beyond the DIFNG, reflecting the increasing
personalization of surgical care.

METHODS
A review was conducted of the senior author’s most recent 250 gender-affirming chest surgeries on patients
assigned female at birth to evaluate the distribution of surgical techniques used. This study did not involve
access to patient records or identifiable personal data; therefore, the principles outlined in the Declaration of
Helsinki were followed. All clinical images included in this review are fully de-identified, and informed
consent for the use and publication of photographs was obtained from all patients. We also conducted a
narrative literature review informed by PRISMA (Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) guidelines.

Literature review
To assess how contemporary top surgery literature reflects evolving techniques, we performed a PRISMA-
informed review of publications from January 2014 to April 2024. We searched PubMed, Scopus, and
Embase using terms including “gender-affirming top surgery”, “chest masculinization”, “nipple-sparing
mastectomy”, “buttonhole top surgery”, “non-binary chest surgery”, and “targeted nipple reinnervation”.
Inclusion criteria were original articles describing surgical techniques or outcomes in gender-affirming
mastectomy, in English or French. We excluded case reports with fewer than five patients, editorials, and
studies not focused on surgical techniques. The PRISMA flowchart is detailed in Supplementary Figure 1.
Articles were screened independently by two reviewers. Reference lists of included studies were also hand-
searched for additional citations. As no pooled statistical outcomes are presented, this review is best
characterized as a narrative review that integrates available evidence to highlight trends, identify gaps, and
provide context for clinical decision-making. This approach allows for a qualitative synthesis of the
literature while acknowledging the current limitations of the evidence base and the need for future
standardized, multi-institutional research.