Refining Surgical Decision-Making in Top Surgery: Insights from a Learning Curve in Transgender and Non-Binary Chest Contouring

Introduction: Top surgery, historically associated with transgender individuals, is increasingly recognized as chest contouring due to the growing visibility of non-binary individuals. The procedure involves the removal of breast tissue to achieve a more masculine or gender-neutral chest appearance. While it may appear straightforward, optimal results depend on attention to key preoperative and intraoperative details. Methods: A retrospective review was conducted of 90 patients who underwent chest wall contouring using the double incision free nipple graft (DIFNG) technique. Demographic and clinical data, operative details, and complication rates were analyzed. The rationale for major and minor revisions was assessed, and a simplified decision-making algorithm was proposed based on patient characteristics and intraoperative findings. Results: Complications included dog ear formation, hypertrophic scarring, and hematoma, with contributing factors such as insufficient liposuction and poor scar placement. The implementation of adjunctive techniques—such as quilting sutures and targeted liposuction—reduced the need for drains and improved contour outcomes. Patient-specific refinements were incorporated into a decision-making framework to aid technique selection and anticipate common pitfalls. Conclusion: Top surgery is a critical gender-affirming procedure that requires thoughtful technical execution. Sharing lessons learned during the early learning curve can help novice surgeons optimize outcomes. A structured algorithm based on skin quality, anatomical characteristics, and patient goals can support better decision-making and reduce revision rates.