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Page 4 of 14 Bonapace-Potvin et al. Plast Aesthet Res. 2025;12:34 https://dx.doi.org/10.20517/2347-9264.2025.65

Table 1. Distribution of cases
Surgery Number of cases
Double incision with free nipple grafts 180
Double incision without nipple grafts 42
Keyhole 1
Buttonhole 3
Targeted nipple reinnervation 11
Nipple sparing double incision 1
Breast reduction 3
Radical reduction 6
Mastopexy 1
Total 250

Figure 1. Technique selection in AFAB patients seeking gender-affirming top surgery. AFAB: Assigned female at birth.

Alternative techniques
Double incision mastectomy without nipple grafts
Nipple preservation is a goal for the majority of transmasculine patients seeking affirming chest surgery, but
it is not true for all. There is an increasing number of individuals choosing surgical options that deviate
from what has been “traditional” or fully binary. As education and awareness of these options have
increased, our practice has seen an increasing number of individuals choosing to forgo nipple
reconstruction and pursue a nipple-free chest. In a study by Ferrin et al., reasons expressed for this choice
ranged from simple and pragmatic choices such as choosing a procedure with a simpler recovery to
profound and deeply meaningful choices regarding individual gender expression . Additional factors that
[13]
influenced patients’ decision to forgo nipple grafts have included an aesthetic that best aligns with gender
identity, dysphoria from the presence of nipples and areolae, plans for future chest tattoos, concerns about
the aesthetics and outcomes of free nipple grafts, and concerns of nipple loss or increased complications