OasisLMS

1. Patient Care

By the end of this course, learners will be able to:

1. Perform a comprehensive preoperative evaluation for patients seeking gender-affirming mastectomy, including chest dysphoria history, medical and mental health history, nicotine/substance use, social support, breast cancer risk, prior surgery, hormone use, and patient goals.

2. Conduct a focused chest examination assessing breast volume, nipple-areola complex size and position, ptosis, skin elasticity, excess skin, inframammary fold characteristics, and chest wall contour.

3. Select an appropriate operative technique based on patient anatomy, Fisher grade, goals, sensation priorities, scar preferences, and surgeon experience, including keyhole, periareolar/circumareolar, buttonhole, inverted-T, double-incision, and free nipple graft approaches.

4. Anticipate, recognize, and manage common complications after gender-affirming mastectomy, including hematoma, seroma, infection, hypertrophic or widened scars, contour deformity, nipple-areola complex necrosis, pigment changes, and need for revision surgery.

2. Medical Knowledge

By the end of this course, learners will be able to:

1. Describe the goals of gender-affirming mastectomy, including removal of breast tissue, creation of an aesthetic chest contour, nipple-areola complex resizing and repositioning, obliteration of the inframammary fold, and scar minimization.

2. Explain the Fisher grading system and use it to relate glandular volume, skin laxity, nipple-areola complex position, and ptosis to surgical technique selection.

3. Compare the indications, advantages, and disadvantages of keyhole, periareolar/circumareolar, buttonhole, inverted-T, and double-incision mastectomy techniques, including tradeoffs in contour, scar burden, revision risk, and nipple sensation.

4. Summarize evidence discussed in the course regarding outcomes of gender-affirming mastectomy, including quality-of-life benefits, complication rates, revision rates, nipple sensation outcomes, and reported rates of regret or reversal.

3. Systems-Based Practice

By the end of this course, learners will be able to:

1. Apply WPATH-informed and insurance-related criteria to the care pathway for gender-affirming mastectomy, including capacity for consent, documentation requirements, referral letters, hormone considerations, and recognition of state-level variability in access and coverage.

2. Coordinate perioperative care with primary care clinicians, mental health professionals, radiology, pathology, anesthesia, nursing, and other surgical teams when combined procedures or additional screening are needed.

3. Incorporate breast cancer screening and risk assessment into surgical planning, including preoperative imaging for age- or risk-appropriate patients and postoperative counseling for residual breast tissue, chest wall, subareolar tissue, and axillary examination.

4. Identify systems-level barriers affecting access to top surgery, including insurance variation, restrictive legislation, discrimination, poor access to breast cancer screening, and logistical barriers to postoperative follow-up.

4. Practice-Based Learning and Improvement

By the end of this course, learners will be able to:

1. Use postoperative outcomes, patient satisfaction, complication rates, and revision patterns to refine patient selection, technique choice, and preoperative counseling for future cases.

2. Critically evaluate the evidence supporting perioperative practices, including the role of testosterone therapy, combined procedures, liposuction, breast cancer screening strategies, and approaches to nipple sensation preservation.

3. Reflect on how assumptions about masculinity, flatness, nipple size, scar acceptability, and “ideal” chest contour may affect counseling and operative planning for transgender and non-binary patients.

4. Identify gaps in the current evidence base, including long-term breast cancer screening after gender-affirming mastectomy, outcomes in non-binary patients, sensation-preserving techniques, and predictors of revision or dissatisfaction.

5. Professionalism

By the end of this course, learners will be able to:

1. Demonstrate respectful, affirming, and patient-centered care for transgender and non-binary patients seeking top surgery, including appropriate language and recognition of diverse gender goals.

2. Obtain informed consent by discussing expected benefits, alternatives, limitations, scars, sensation changes, nipple graft risks, contour irregularities, complications, revision options, and the possibility of residual breast tissue.

3. Respect patient autonomy in surgical decision-making, including patients who do not desire testosterone therapy, patients who seek a non-flat or androgynous chest, and patients who prefer nipple preservation, nipple reconstruction, or no nipple-areola complex reconstruction.

4. Demonstrate accountability in preoperative preparation, including completion of screening requirements, pathology planning when indicated, smoking or risk-factor optimization, equipment readiness, and clear documentation of the operative plan.

6. Interpersonal and Communication Skills

By the end of this course, learners will be able to:

1. Conduct an affirming consultation that elicits the patient’s priorities regarding chest flatness, contour, nipple size and position, nipple sensation, scar placement, revision tolerance, and aesthetic goals.

2. Use shared decision-making to align surgical technique selection with anatomy, Fisher grade, patient goals, breast cancer risk, insurance requirements, and the risks and benefits of each approach.

3. Communicate clearly with patients about postoperative expectations, including drains, scars, sensation changes, pigmentation changes, contour evolution, potential need for revision, and ongoing screening considerations.

4. Communicate effectively with interprofessional team members about perioperative risk factors, imaging or pathology needs, combined surgical procedures, postoperative monitoring, and management of complications.
   
   
   Copyright © 2026 American Society of Plastic Surgeons. All rights reserved. Materials made available through ASPS’ Resident Education Curriculum (including but not limited to patient images) may not be downloaded, copied, shared, distributed, or utilized outside the ASPS online learning platform for any purpose without ASPS’ express prior written consent. V16.
   

Cristiane Ueno, MD 2026
Associate Professor of Clinical Surgery
Indiana University School of Medicine