Aesthetic Plastic Surgery

, Volume 43, Issue 6, pp 1575–1585 | Cite as

Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes

  • Nicholas G. Cuccolo
  • Christine O. Kang
  • Elizabeth R. BoskeyEmail author
  • Ahmed M. S. Ibrahim
  • Louise L. Blankensteijn
  • Amir Taghinia
  • Bernard T. Lee
  • Samuel J. Lin
  • Oren Ganor
Original Article Body Contouring



Chest reconstruction (‘top surgery’) is an important component of transition in the transmasculine population that can substantially improve gender incongruence. The aim of this study was to evaluate the demographic characteristics, surgical technique, and postoperative outcomes following transmasculine chest surgery.


Using ICD codes, we identified all cases of gender-affirming transmasculine chest surgery from the ACS NSQIP database (2010–2017). CPT codes were used to categorize patients by reconstructive modality: reduction versus mastectomy (± free nipple grafting [FNG]). Univariate analysis was conducted to assess for differences in demographics, comorbidities, and postoperative complications. Multivariable regression analysis was used to control for confounders.


A total of 755 cases were identified, of whom 591 (78.3%) were mastectomies and 164 (21.7%) were reductions. No significant differences were noted in terms of age or BMI. Mastectomies had shorter operative times, but similar length of stay compared to reductions. Rates of postoperative complications were low, with 4.7% (n = 28) of mastectomies and 3.7% (n = 6) of reductions experiencing at least one all-cause complications. Postoperative complication rates were not statistically different between mastectomy with (3.4%) and without (5.6%) FNG. After controlling for confounders, there was no difference in terms of risk of all-cause complications between reduction and mastectomy, with or without FNG.


Mastectomy and reduction mammaplasty are both safe procedures for chest reconstruction in the transmasculine population. These results may be used to encourage shared decision making between patient and surgeon such that the reconstructive modality of choice best aligns with the desired aesthetic outcome.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors


Gender affirmation surgery Top surgery Mastectomy Reduction mammaplasty Transmasculine 



There was no internal or external financial support for this study.

Compliance with Ethical Standards

Conflict of interest

None of the authors have a financial interest in any of the products, devices, drugs, or procedures mentioned in this manuscript.

Ethical Approval

The patient information in this study is deidentified and available to all institutions complying with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Data Use Agreement.

Informed Consent

For this type of study, informed consent is not required.


  1. 1.
    Coleman E, Bockting W, Botzer M et al (2012) Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism 13(4):165–232CrossRefGoogle Scholar
  2. 2.
    Winter S, Diamond M, Green J et al (2016) Transgender people: health at the margins of society. The Lancet 388(10042):390–400CrossRefGoogle Scholar
  3. 3.
    Monstrey S, Selvaggi G, Ceulemans P et al (2008) Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm. Plast Reconstr Surg 121(3):849–859PubMedCrossRefGoogle Scholar
  4. 4.
    James SE, Herman J (2017) The report of the 2015 US transgender survey: executive summary: National Center for Transgender EqualityGoogle Scholar
  5. 5.
    Olson-Kennedy J, Warus J, Okonta V et al (2018) Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr 172(5):431–436PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Agarwal CA, Scheefer MF, Wright LN et al (2018) Quality of life improvement after chest wall masculinization in female-to-male transgender patients: a prospective study using the BREAST-Q and body uneasiness test. J Plast Reconstr Aesthet Surg 71(5):651–657PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    van de Grift TC, Elfering L, Greijdanus M et al (2018) Subcutaneous mastectomy improves satisfaction with body and psychosocial function in trans men: findings of a cross-sectional study using the BODY-Q chest module. Plast Reconstr Surg 142(5):1125–1132PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Departmental Appeals Board Appellate Division (2014) Transsexual surgery. Washington, D.C. Docket No. A-13–87, Decision No. 2576Google Scholar
  9. 9.
    American Society of Plastic Surgeons (2017) Gender confirmation surgeries rise 20% in first ever report. ASPS press releasesGoogle Scholar
  10. 10.
    Lane M, Ives GC, Sluiter EC et al (2018) Trends in gender-affirming surgery in insured patients in the United States. Plast Reconstr Surg Glob Open 6(4):e1738PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Ammari T, Sluiter EC, Gast K et al (2019) Female-to-male gender-affirming chest reconstruction surgery. Aesthet Surg J 39(2):150–163PubMedGoogle Scholar
  12. 12.
    Wilson SC, Morrison SD, Anzai L et al (2018) Masculinizing top surgery: a systematic review of techniques and outcomes. Ann Plast Surg 80(6):679–683PubMedCrossRefGoogle Scholar
  13. 13.
    Claes KEY, D'Arpa S, Monstrey SJ (2018) Chest surgery for transgender and gender nonconforming individuals. Clin Plast Surg 45(3):369–380PubMedCrossRefGoogle Scholar
  14. 14.
    Knox ADC, Ho AL, Leung L et al (2017) A review of 101 consecutive subcutaneous mastectomies and male chest contouring using the concentric circular and free nipple graft techniques in female-to-male transgender patients. Plast Reconstr Surg 139(6):1260e–1272ePubMedCrossRefGoogle Scholar
  15. 15.
    Top H, Balta S (2017) Transsexual mastectomy: selection of appropriate technique according to breast characteristics. Balkan Med J 34(2):147–155PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Donato DP, Walzer NK, Rivera A et al (2017) Female-to-male chest reconstruction: a review of technique and outcomes. Ann Plast Surg 79(3):259–263PubMedCrossRefGoogle Scholar
  17. 17.
    McEvenue G, Xu FZ, Cai R et al (2017) Female-to-male gender affirming top surgery: a single surgeon's 15-year retrospective review and treatment algorithm. Aesthet Surg J 38(1):49–57PubMedCrossRefGoogle Scholar
  18. 18.
    Cardenas-Camarena L, Dorado C, Guerrero MT et al (2017) Surgical masculinization of the breast: clinical classification and surgical procedures. Aesthet Plast Surg 41(3):507–516CrossRefGoogle Scholar
  19. 19.
    Takayanagi S, Nakagawa C (2006) Chest wall contouring for female-to-male transsexuals. Aesthet Plast Surg 30(2):206–212. (discussion 213-4)CrossRefGoogle Scholar
  20. 20.
    Kaariainen M, Salonen K, Helminen M et al (2017) Chest-wall contouring surgery in female-to-male transgender patients: a one-center retrospective analysis of applied surgical techniques and results. Scand J Surg 106(1):74–79PubMedCrossRefGoogle Scholar
  21. 21.
    Berry MG, Curtis R, Davies D (2012) Female-to-male transgender chest reconstruction: a large consecutive, single-surgeon experience. J Plast Reconstr Aesthet Surg 65(6):711–719PubMedCrossRefGoogle Scholar
  22. 22.
    Lo Russo G, Tanini S, Innocenti M (2017) Masculine chest-wall contouring in FtM transgender: a personal approach. Aesthet Plast Surg 41(2):369–374CrossRefGoogle Scholar
  23. 23.
    Namba Y, Watanabe T, Kimata Y. Mastectomy in female-to-male transsexuals. Okayama University, 1999.Google Scholar
  24. 24.
    Hage JJ, van Kesteren PJ (1995) Chest-wall contouring in female-to-male transsexuals: basic considerations and review of the literature. Plast Reconstr Surg 96(2):386–391PubMedCrossRefGoogle Scholar
  25. 25.
    Lindsay WR (1979) Creation of a male chest in female transsexuals. Ann Plast Surg 3(1):39–46PubMedCrossRefGoogle Scholar
  26. 26.
    Antoszewski B, Bratos R, Sitek A et al (2012) Long-term results of breast reduction in female-to-male transsexuals. Pol Przegl Chir 84(3):144–151PubMedCrossRefGoogle Scholar
  27. 27.
    Kenney JG, Edgerton MT (1989) Reduction mammoplasty in gender dysphoria. Abstract presented at the 11th symposium of the Harry Benjamin International Gender Dysphoria AssociationGoogle Scholar
  28. 28.
    Nelson L, Whallett EJ, McGregor JC (2009) Transgender patient satisfaction following reduction mammaplasty. J Plast Reconstr Aesthet Surg 62(3):331–334PubMedCrossRefGoogle Scholar
  29. 29.
    Birkmeyer JD, Shahian DM, Dimick JB et al (2008) Blueprint for a new American College of Surgeons: National Surgical Quality Improvement Program. J Am Coll Surg 207(5):777–782PubMedCrossRefGoogle Scholar
  30. 30.
    NSQIP A. User guide for the 2012 ACS NSQIP participant use data file. 2016.Google Scholar
  31. 31.
    Hall BL, Hamilton BH, Richards K et al (2009) Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg 250(3):363–376PubMedGoogle Scholar
  32. 32.
    Ingraham AM, Richards KE, Hall BL et al (2010) Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg 44(1):251–267PubMedCrossRefGoogle Scholar
  33. 33.
    Purnell JQ (2000) Definitions, classification, and epidemiology of obesity. In: Feingold KR, Anawalt B, Boyce A et al. (eds) Endotext. Inc, South Dartmouth.Google Scholar
  34. 34.
    McDowell MJ, Hughto JMW, Reisner SL (2019) Risk and protective factors for mental health morbidity in a community sample of female-to-male trans-masculine adults. BMC Psychiatry 19(1):16PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Heylens G, Verroken C, De Cock S et al (2014) Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. J Sex Med 11(1):119–126PubMedCrossRefGoogle Scholar
  36. 36.
    Cerwenka S, Nieder TO, Briken P et al (2014) Intimate partnerships and sexual health in gender-dysphoric individuals before the start of medical treatment. Int J Sexual Health 26(1):52–65CrossRefGoogle Scholar
  37. 37.
    American Society of Plastic Surgeons (2017) Plastic surgery statistics report. Accessed 5 Jan 2019
  38. 38.
    American Society of Plastic Surgeons (2016) Plastic surgery statistics report. Accessed 5 Jan 2019
  39. 39.
    Flores AR, Brown TN, Herman J (2016) Race and ethnicity of adults who identify as transgender in the United States. Williams Institute, UCLA School of Law, Los Angeles, CAGoogle Scholar
  40. 40.
    Justin T, Jack H, Mara K (2011) Injustice at every turn: a report of the national transgender discrimination surveyGoogle Scholar
  41. 41.
    Wolter A, Diedrichson J, Scholz T et al (2015) Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy. J Plast Reconstr Aesthet Surg 68(2):184–191PubMedCrossRefGoogle Scholar
  42. 42.
    Ganor O, Boskey ER (2019) Submitting appropriately for breast surgery in transmasculine patients. Plast Reconstr Surg 143(1):254ePubMedCrossRefGoogle Scholar
  43. 43.
    Esmonde N, Heston A, Ramly E et al (2018) What is "Non-Binary" and what do I need to know?. A primer for surgeons providing chest surgery for transgender patients. Aesthet Surg J 39:NP106–NP112CrossRefGoogle Scholar
  44. 44.
    Salim A, Metz E, Constant JS et al (2018) Does previous breast reduction affect the outcome of gender-affirming subcutaneous mastectomy? Ann Plast Surg 80(5S Suppl 5):S279–S284PubMedGoogle Scholar
  45. 45.
    Puckett JA, Cleary P, Rossman K et al (2018) Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sex Res Soc Policy 15(1):48–59CrossRefGoogle Scholar
  46. 46.
    Antony AK, Yegiyants SS, Danielson KK et al (2013) A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle wise-pattern reduction (100 breasts): an outcomes study over 3 years. Plast Reconstr Surg 132(5):1068–1076PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Simpson AM, Donato DP, Kwok AC et al (2019) Predictors of complications following breast reduction surgery: a National Surgical Quality Improvement Program study of 16,812 cases. J Plast Reconstr Aesthet Surg 72(1):43–51PubMedCrossRefGoogle Scholar
  48. 48.
    Bjerrome Ahlin H, Kolby L, Elander A et al (2014) Improved results after implementation of the Ghent algorithm for subcutaneous mastectomy in female-to-male transsexuals. J Plast Surg Hand Surg 48(6):362–367PubMedCrossRefGoogle Scholar
  49. 49.
    Bluebond-Langner R, Berli JU, Sabino J et al (2017) Top surgery in transgender men: How far can you push the envelope? Plast Reconstr Surg 139(4):873e–882ePubMedCrossRefGoogle Scholar
  50. 50.
    McGregor JC, Whallett EJ (2006) Some personal suggestions on surgery in large or ptotic breasts for female to male transsexuals. J Plast Reconstr Aesthet Surg 59(8):893–896PubMedCrossRefGoogle Scholar
  51. 51.
    van de Grift TC, Elfering L, Bouman MB et al (2017) Surgical indications and outcomes of mastectomy in transmen: a prospective study of technical and self-reported measures. Plast Reconstr Surg 140(3):415e–424ePubMedCrossRefGoogle Scholar
  52. 52.
    Frederick MJ, Berhanu AE, Bartlett R (2017) Chest surgery in female to male transgender individuals. Ann Plast Surg 78(3):249–253PubMedCrossRefGoogle Scholar
  53. 53.
    Hage JJ, Bloem JJ (1995) Chest wall contouring for female-to-male transsexuals: Amsterdam experience. Ann Plast Surg 34(1):59–66PubMedCrossRefGoogle Scholar
  54. 54.
    Namba Y, Watanabe T, Kimata Y (2009) Mastectomy in female-to-male transsexuals. Acta Med Okayama 63(5):243–247PubMedGoogle Scholar
  55. 55.
    Boskey E, Jolly D, Semnack M, Tobias A, Ganor O (2019) Congruence isn’t cosmetic, denials of nipple grafts for chest reconstruction surgery. PRS Global Open. Accepted Manuscript.Google Scholar
  56. 56.
    Cregten-Escobar P, Bouman MB, Buncamper ME et al (2012) Subcutaneous mastectomy in female-to-male transsexuals: a retrospective cohort-analysis of 202 patients. J Sex Med 9(12):3148–3153PubMedCrossRefGoogle Scholar
  57. 57.
    van de Grift TC, Mullender MG, Bouman MB (2018) Shared decision making in gender-affirming surgery. Implications for research and standards of care. J Sex Med 15(6):813–815PubMedCrossRefGoogle Scholar
  58. 58.
    Boss EF, Mehta N, Nagarajan N et al (2016) Shared decision making and choice for elective surgical care: a systematic review. Otolaryngol Head Neck Surg 154(3):405–420PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Authors and Affiliations

  • Nicholas G. Cuccolo
    • 1
    • 2
  • Christine O. Kang
    • 1
    • 2
  • Elizabeth R. Boskey
    • 1
    • 3
    Email author
  • Ahmed M. S. Ibrahim
    • 2
  • Louise L. Blankensteijn
    • 2
  • Amir Taghinia
    • 1
    • 3
  • Bernard T. Lee
    • 2
  • Samuel J. Lin
    • 2
  • Oren Ganor
    • 1
    • 3
  1. 1.Department of Plastic and Oral Surgery, Boston Children’s HospitalHarvard Medical SchoolBostonUSA
  2. 2.Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  3. 3.Center for Gender Surgery, Boston Children’s HospitalHarvard Medical SchoolBostonUSA

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