Intramuscular Fat Grafting for Pectoralis Volumization in Transmasculine Patients. Combining Chest Masculinization and Chest Contouring in One Surgery

Abstract

Introduction

Chest masculinization surgery represents a key component of gender-affirming care for transgender men and has been associated with significant improvements in psychological well-being and reduction of gender dysphoria. Although established techniques such as double-incision mastectomy with nipple–areola complex grafting and periareolar approaches effectively remove breast tissue, postoperative chest contour may remain flat and lack pectoral definition in some patients. Autologous fat grafting has been widely used in cisgender male aesthetic surgery to enhance pectoral projection and muscular definition. However, its application during masculinizing mastectomy in transgender patients remains poorly described. This study evaluates the outcomes and safety of intramuscular pectoralis major fat grafting performed concurrently with chest masculinization surgery.

Methods

A retrospective analysis of prospectively collected data was conducted on transgender patients who underwent chest masculinization surgery with simultaneous pectoralis major fat grafting between January 2022 and January 2025 at a single institution. Patients underwent either double-incision mastectomy with free nipple–areola complex grafting or ultrasonic-assisted subcutaneous mastectomy depending on breast characteristics. Autologous fat was harvested from the flanks, axillary pillar, or back and injected into the pectoralis major muscle in intramuscular and sub-muscular planes. Primary outcomes included patient satisfaction assessed at 12 months using the validated TRANS-Q questionnaire. Secondary outcomes included postoperative complications and revision procedures classified according to the Clavien–Dindo system.

Results

Sixty transgender patients (120 mastectomies) were included. The mean age was 32.5 years, and the mean body mass index was 22.5 kg/m². Forty patients underwent double-incision mastectomy and twenty ultrasonic-assisted subcutaneous mastectomy. The mean fat graft volume was approximately 150–200 cc per side. High satisfaction scores were reported across all TRANS-Q domains, with the highest values observed in gender congruence (mean > 93). Overall complications included fat necrosis (16.7%), seroma (13.3%), and partial nipple–areola complex necrosis (3.3%). Secondary aesthetic revisions were required in 16.7% of patients.

Conclusions

Intramuscular pectoralis major fat grafting combined with chest masculinization surgery appears to be a safe and effective strategy to enhance thoracic contour and improve masculine chest definition in transgender men. This integrated approach may optimize aesthetic outcomes and contribute to high levels of patient satisfaction and gender congruence.

Level of Evidence IV

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