A Superior Alternative to Double-Incision Surgery
Gender-affirming mastectomy—often referred to as top surgery—is a life-changing procedure for transgender men and nonbinary individuals who wish to remove unwanted breast tissue and achieve a masculine chest contour. Traditionally, the most common technique has been the double-incision mastectomy with free nipple grafts.
While this method is effective in flattening the chest, it comes with several important disadvantages, especially relating to nipple appearance, sensation, and scarring. Today, a newer approach—Gender-Affirming Mastectomy with 100% Nipple Preservation—can offer a far better aesthetic and sensory outcome.
The Limitations of Double-Incision Free Nipple Graft Surgery
Long, Visible Scars
The double-incision technique requires two major incisions across the top and bottom of the breast, leaving long horizontal scars across the chest. These scars are impossible to conceal and may be prone to hypertrophy (raised scarring) or “dog ears” (puckering at the ends of the scar) that often require revision.
Loss of Nipple Function and Sensation
During a free nipple graft, the nipple and areola are removed, thinned, and reattached as a skin graft.
Because the nipple loses its blood supply:
- Normal sensation is lost
- Erotic sensation is lost
- Erectile function disappears
- Pigmentation may fade, requiring tattooing
- The nipple becomes a 2-dimensional, non-functional facsimile
Artificial Appearance
A grafted nipple often lacks depth and natural projection. Patients frequently describe it as looking “stuck on,” with minimal or no softness or response to touch.
A Superior Option: 100% Nipple Preservation
A recent open-access article describes an alternative approach:
Swanson E. Comparative outcome study of gynecomastia surgery and gender-affirming mastectomy with 100% nipple preservation. Ann Plast Surg. 2025;95:e1-e17.
This method benefits:
- Transgender men seeking top surgery
- Cisgender men with gynecomastia
How the Procedure Works
Most patients can undergo breast tissue removal through a small incision along the lower border of the areola. Using this inconspicuous opening:
- Breast tissue is removed
- Skin naturally contracts over time
- The nipple remains fully intact
- No long incisions are required
When Skin Removal Is Needed
For patients with larger or pendulous breasts, skin removal may be necessary. In these cases, the nipple stays attached via its deep pedicle, maintaining:
- Blood supply
- Sensation
- Natural appearance
- Erectility
Free nipple grafting is avoided entirely.
Advantages of 100% Nipple Preservation
⭐ Natural, Intact Nipple Appearance
The nipple retains projection, shape, color, and texture—not the flat, graft-like appearance of older methods.
⭐ Preserved or Improved Sensation
Many patients report preserved or enhanced nipple sensation postoperatively—including erotic sensation.
⭐ Minimal, Well-Hidden Scars
Incisions are strategically placed around the areola or vertically, resulting in scars that are typically less conspicuous.
⭐ Reduced Complications
No long incisions, fewer dog ears, and easier healing.
⭐ Confidence and Psychological Well-Being
Patients who previously avoided going shirtless often feel comfortable doing so after surgery. The emotional impact is profound—one patient summarized it simply when asked if he was satisfied:
“You have no idea.”
⭐ Reversibility if Desired
Although rare, patients who later regret the surgery can pursue chest reconstruction with implants—an option not possible after nipple removal.
Real Patient Stories:
This 26-year-old transgender man underwent liposuction-assisted vertical mammaplasty with nipple preservation.
His experience included:
- Minimal nipple sensation before surgery
- Improved nipple sensation after surgery
- Development of new erogenous sensation, which he had never experienced before
- Scars he considered well-hidden
- Comfortable going shirtless publicly
- Additional chest flattening after a secondary liposuction procedure 4.5 years after the original surgery
This case highlights the long-term stability and sensory advantages of nipple-preserving techniques.
Age 20, subcutaneous mastectomies with liposuction. 4 months postop
Are You a Candidate?
This procedure is available to adults 18 years and older who desire:
- A masculine chest contour
- Minimal scarring
- Natural-looking nipples
- Preservation of nipple sensation
- A safer, more aesthetic alternative to double-incision surgery
Most patients qualify for the areola-border incision technique, while others may benefit from a vertical or limited skin-reduction approach.
Schedule a Consultation
If you’re considering top surgery and want the most advanced approach available, our team is here to guide you.
The Swanson Center
📍 11413 Ash St, Leawood, KS 66211
📞 Tel: +913.663.1030
🕘 Monday – Friday | 9 AM – 5 PM
Call us today to schedule your consultation.