title: Top Surgery in Transgender Men: How Far Can You Push the Envelope?
abstract: BACKGROUND
  The authors present their grading scale and the outcomes of the largest cohort of top surgery published to date. Application of this grading system can help determine which patients will benefit from a subcutaneous mastectomy with free nipple graft versus a circumareolar technique, with the primary endpoint being need for aesthetic revisions.
  
  
  METHODS
  The authors reviewed their database of transgender males who underwent bilateral mastectomy between 2006 and 2015. Data collected included age, body mass index, American Society of Anesthesiologists class, smoking, diabetes, testosterone use, months of social transition, technique used, postoperative complications, and need for revision. Two techniques were used, circumareolar incision and free nipple graft technique.
  
  
  RESULTS
  Between 2006 and 2015, 1686 consecutive mastectomies were performed on 843 patients. Of those, 548 patients were excluded because of inadequate follow-up. Of the 295 included, 109 were treated using a circumareolar incision and 186 were treated using a free nipple graft technique. There was no statistically significant difference in complications between the two groups; however, there was a statistically significant difference in the rate of aesthetic revisions in the grade 2B circumareolar incision group (34 percent versus 8.8 percent).
  
  
  CONCLUSIONS
  The authors' outcomes are comparable to the literature, and demonstrate that these procedures can safely be performed in an outpatient setting. The authors' grading scale classifies patients and helps the surgeon select a surgical technique. The authors show a statistical difference in rates of aesthetic revisions in Fischer grade 2B patients when a circumareolar incision is selected over a free nipple graft technique.
  
  
  METHODS
  Therapeutic, III.
authors.affiliation: Baltimore, Annapolis, and Timonium, Md.; and Portland, Ore.|From the Division of Plastic Surgery, University of Maryland School of Medicine; Anne Arundel Medical Center; Advanced Center for Plastic Surgery; and Oregon Health & Science University.
authors.forename: Rachel
authors.initials: R
authors.lastname: Bluebond-Langner
authors.affiliation: Baltimore, Annapolis, and Timonium, Md.; and Portland, Ore.|From the Division of Plastic Surgery, University of Maryland School of Medicine; Anne Arundel Medical Center; Advanced Center for Plastic Surgery; and Oregon Health & Science University.
authors.forename: Jens U
authors.initials: JU
authors.lastname: Berli
authors.affiliation: Baltimore, Annapolis, and Timonium, Md.; and Portland, Ore.|From the Division of Plastic Surgery, University of Maryland School of Medicine; Anne Arundel Medical Center; Advanced Center for Plastic Surgery; and Oregon Health & Science University.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sabino
authors.affiliation: Baltimore, Annapolis, and Timonium, Md.; and Portland, Ore.|From the Division of Plastic Surgery, University of Maryland School of Medicine; Anne Arundel Medical Center; Advanced Center for Plastic Surgery; and Oregon Health & Science University.
authors.forename: Karan
authors.initials: K
authors.lastname: Chopra
authors.affiliation: Baltimore, Annapolis, and Timonium, Md.; and Portland, Ore.|From the Division of Plastic Surgery, University of Maryland School of Medicine; Anne Arundel Medical Center; Advanced Center for Plastic Surgery; and Oregon Health & Science University.
authors.forename: Devinder
authors.initials: D
authors.lastname: Singh
authors.affiliation: Baltimore, Annapolis, and Timonium, Md.; and Portland, Ore.|From the Division of Plastic Surgery, University of Maryland School of Medicine; Anne Arundel Medical Center; Advanced Center for Plastic Surgery; and Oregon Health & Science University.
authors.forename: Beverly
authors.initials: B
authors.lastname: Fischer
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D008297:Male; D008408:Mastectomy / Q000379:methods*; D009558:Nipples / Q000637:transplantation*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D057830:Gender-Affirming Surgery / Q000379:methods*