Date of Award

January 2021

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

John A. Persing

Second Advisor

Michael Alperovich


With the increasing demand for gender-affirming surgeries, it has become paramount for plastic and reconstructive surgeons to evaluate their techniques through assessment of clinical outcomes and patient satisfaction. Chest wall masculinization is the most commonly performed gender-affirming surgical intervention for transgender male and non-binary patients. The procedure has been cited to alleviate gender dysphoria, defined as the stress that results from the incongruence between one’s sex assigned at birth and one’s gender identity. Peri-areolar and double-incision mastectomy with free nipple grafts, are the most common techniques employed in chest masculinization surgery, but are limited by their relative inconsistency and inefficiency in reconstructing a natural anterior contour that comprehensively resembles that of a cis-masculine chest. The proposed “hockey stick” approach expands on the widely performed double-incision mastectomy to the axilla, with an additional step of revising the lateral chest wall folds of tissue excess. The central purpose of this study is to compare the “hockey stick” incision to existing reconstructive options, with respect to clinical outcomes and patient satisfaction. In addition, this review will discuss multiple challenges and considerations, with respect to validated survey instruments, access to care, healthcare disparities, legislative acts, insurance coverage, medical education, the Coronavirus pandemic, and evolving terminology, that may complicate the delivery of gender-affirming care. With such investigations and analyses, we hope to provide a valuable introduction and resource for healthcare providers, trainees, and medical students to refer to in the context of gender-affirming care.

Patients who received chest masculinization surgery at Yale-New Haven Hospital were included in our analysis. A retrospective chart review, comprising demographic variables, procedural details, and post-operative events, was conducted. Selected modules from a validated survey instrument, the BODY-Q, were measured. Patients were classified by body mass index and incision, which included peri-areolar, inframammary fold, and “hockey stick” incision by date.

27 of 73 (37.0%) participants completed the full survey and were included in the analysis. The “hockey stick” incision had comparable patient satisfaction and post-operative outcomes, compared to peri-areolar and double-incision mastectomy with free nipple graft techniques. Greater BMI patients had a higher incidence of wound dehiscence, compared to other weight classifications.

The “hockey stick” incision is a readily performed, effective surgical technique for building a cis-masculine appearing chest in transgender men with efficient and predictable outcomes. While performed in patients with higher BMI, the “hockey stick” confers equivalent patients. Future outcomes should include a greater sample of patients.

Gender-affirming surgery presents with promising opportunities to innovate new techniques and study clinical outcomes and patient satisfaction. Amidst such advancements, it is imperative to recognize the barriers in delivering gender-affirming care, to collaborate with other stakeholders, and together, strengthen efforts in medical education, policy, entrepreneurship, research, and advocacy for transgender and non-binary patients. There is great potential for plastic surgeons and their colleagues to lead the movement - to best serve the social and healthcare needs of such communities.


This is an Open Access Thesis.

Open Access

This Article is Open Access