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Bonapace-Potvin et al. Plast Aesthet Res. 2025;12:34 https://dx.doi.org/10.20517/2347-9264.2025.65 Page 3 of 14

Case series
We assessed the proportion of procedures performed using the DIFNG technique compared to alternative
approaches, selected based on individual patient anatomy and transition goals. The criteria guiding surgical
technique selection are outlined in the decision-making algorithm presented in Figure 1. For patients who
underwent an alternative to the DIFNG technique, descriptive statistics were used to quantify the frequency
of each surgical variation. A detailed technical overview of these alternative technical approaches to gender-
affirming chest surgery is provided.

RESULTS
Literature review
A total of 214 records were identified through database searches of PubMed, Scopus, and Embase. After
removing 16 duplicates, 198 records were screened by title and abstract, resulting in the exclusion of 142
studies. The remaining 56 full-text articles were assessed for eligibility, of which 32 were excluded due to
wrong population, lack of outcomes, or small sample size (fewer than five patients). Ultimately, 24 studies
were included in the qualitative synthesis.

The DIFNG technique has been the most frequently described and widely adopted method, particularly for
[1-3]
patients with larger chest size, reduced skin elasticity, or ptosis . Numerous studies have demonstrated its
consistent aesthetic results and safety profile. Current trends demonstrate a shift away from a standardized
DIFNG approach and toward more personalized techniques that reflect patient-specific anatomy, scarring
[4,5]
preferences, and gender expression . This mirrors broader shifts in gender-affirming care, emphasizing
the need to match surgical outcomes with individual goals and identities rather than traditional binary
aesthetic norms.

While the DIFNG remains the most studied technique, there has been a gradual rise in the literature
focusing on non-DIFNG approaches, including peri-areolar, concentric circular and targeted nipple
reinnervation (TNR) . However, other techniques have been emerging for patients seeking alternatives to
[6-9]
traditionally masculine chest contour. These include buttonhole, radical reduction (central mound, central
wedge, wise pattern reduction with nipple grafts), mastopexy and nipple-sparing techniques (inferior
wedge) [10,11] . In our experience, these techniques are growing in demand but currently remain published only
in case reports or small case series.

Despite these emerging trends, the literature still lacks a robust framework for individualized surgical
planning. Few studies systematically address how factors such as gender identity (including nonbinary
identification), cultural background, body habitus, or patient-defined outcomes influence surgical decision-
[12]
making .

As top surgery continues to evolve, there is a clear need for future research to prioritize inclusion of non-
DIFNG techniques, document decision-making algorithms that support individualized care, and develop
validated tools for capturing diverse patient goals. A more comprehensive, patient-centered evidence base is
essential for aligning surgical offerings with the full spectrum of gender-diverse identities and expressions.

Case series
The senior author’s most recent 250 gender-affirming chest cases were performed between August 2022 and
April 2025. Of these, 180 were DIFNG and 70 were non-DIFNG (42 double incision without free nipple
graft, 1 keyhole, 3 buttonhole, 11 TNR, 1 nipple-sparing mastectomy, 3 breast reductions, 6 radical
reductions, and 1 mastopexy) [Table 1]. More recent cases showed a significant trend away from DIFNG
with greater variability in technique choice. For example, in the first 125 procedures (2022-2023), 103 were
classic DIFNG, whereas in the most recent 125 cases (2023-2025), only 77 were DIFNG [Figure 2].