Mutual understanding in the field of gender affirmation surgery: A systematic review of techniques and preferences for top surgery in nonbinary patients

Gender-affirming surgery (GAS) has taken great strides, allowing patients to live in bodies affirming their gender identities. This study reviews the unique nonbinary surgical and aesthetic techniques and preferences for top surgery to aid surgeons and patients in discussions surrounding this procedure. A literature review was conducted to include “nonbinary,” “gender identity,” “top surgery” and related terms. Peer-reviewed manuscripts addressing any gender-affirming top surgery technique in patients identifying as nonbinary and other synonymous terms were included. Of 818 non-duplicate studies identified, 10 met inclusion criteria. Most reported chest masculinization techniques in nonbinary patients. They most commonly underwent the double incision technique (88.8%), similar to transgender patients. However, nonbinary patients preferred a nonflat, androgynous-appearing chest, versus a flatter, masculine-appearing chest in transgender patients. Breast reduction provided increased flexibility for nonbinary patients to present as feminine or chest bind to present as masculine. Nonbinary patients differed in preferences for the nipple areolar complex (NAC), either preferring larger, rounder NAC located closer to the chest meridian with preserved sensitivity, or forgoing NAC reconstruction altogether. No studies reporting chest feminization techniques in nonbinary patients assigned male at birth (AMAB) were found. Nonbinary patients seeking chest masculinization prefer fuller chests with larger, sensitive NAC located closer to the chest meridian compared to transgender patients. No published studies discuss chest feminization, despite an estimated one-third of nonbinary patients being AMAB. Further studies are needed to provide patient-reported preferences and determine external factors possibly influencing decisions to undergo top surgery.