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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 5 of 14

Figure 2. Distribution of cases demonstrating a trend away from the classic double incision mastectomy with free nipple grafts.

from healing [14-16] . Among these factors, it is important to recognize that some individuals seek out no-
nipple top surgery specifically viewing it as a non-binary surgical option. Technically speaking, the
mastectomy and skin contouring portion of a double incision mastectomy without nipple grafts is the same
as a standard DIFNG without the need to perform nipple reconstruction.

Keyhole surgery
With access to early pubertal suppression, more young adult transmasculine patients may present with
[17]
limited chest development, often Fischer 1 or 2A . These patients have minimal glandular breast volume
and minimal skin excess. If skin elasticity is good and the nipple-areolar complex (NAC) is in an
appropriate location overlying the pectoralis major muscle, then keyhole top surgery can provide an
unparalleled chest aesthetic [18-20] . The key to this technique is patient selection. In the United States, where
70% of the adult population is overweight or obese, keyhole top surgery can be a relatively infrequent
technique. Performing keyhole top surgery in patients with too much glandular tissue or excess skin with
poor elasticity will result in skin rippling, contour irregularities and redundant lower pole skin. This is only
corrected with revision surgery which often results in an outcome inferior to that of a primary double
incision free nipple graft procedure. Although some patients may present with limited chest development
and minimal skin excess, counseling on nipple position is also important. Some trans masculine patients
will have a low-lying NAC. If keyhole surgery is performed in this setting, the NAC can lie below the
pectoralis muscle and appear as if it is lying on the upper abdomen. This is an important part of patient
counseling to ensure this is understood in these clinical scenarios. If patients wish to have the NAC moved
superiorly, a DIFNG or buttonhole procedure may be preferable.