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1 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. I Massachusetts, publicly funded insurance plans are required to cover gender affirming care. However, the degree to which various procedures are covered varies from plan to plan. Two surgical teams performing large numbers of chest reconstruction surgeries for transmasculine patients have experienced problems with insurance plans denying coverage for free nipple grafts as part of double incision mastectomy procedures. The stated reason for those denials is that such nipple grafts are “cosmetic” rather than being an integral part of the procedure. The denial of nipple grafts for cosmetic reasons is highly problematic. Nipple reconstruction has been linked to improved psychosocial and psychosexual outcomes after breast cancer treatment.1 In that context, nipple grafts are not considered to be a cosmetic procedure. Indeed, coverage of nipple reconstruction and/or grafting is mandated by federal law if the procedure is completed as part of a postmastectomy breast reconstruction. The Women’s Health and Cancer Rights Act of 1998 mandates coverage of “all stages of reconstruction of the breast on which the mastectomy has been performed; [and] surgery and reconstruction of the other breast to produce a symmetrical appearance.” There are fewer data on the importance of nipple reconstruction and/or free nipple grafting for transgender patients. Studies that have looked at chest dysphoria in transgender men have identified discomfort with swimming and going to the beach as a common component of dysphoria.2 Satisfaction with nipple appearance has also been correlated with overall satisfaction with chest reconstruction.2 The ability to go shirtless in places where other young men do is also brought up frequently as a goal and/ or benefit of surgery by our patients. If the goal of chest reconstruction surgery is to create a male appearing chest, as is generally assumed, it would be inappropriate to perform chest reconstruction without nipple grafting. Nipples are generally present on male chests, and affect male appearance both when wearing clothes and when shirtless. This is why research on the anthropometry of the male chest, and techniques for transgender chest reconstruction surgery, focus extensively on nipple size and placement. The World Professional Association of Transgender Health Standards of Care (SOC), seventh version, recognize that chest reconstruction for gender dysphoria, in the form of a subcutaneous mastectomy, is medically necessary.3 However, they do not explicitly address the role of nipple reconstruction and/or free nipple grafting in this procedure. Depending on breast size, nipple grafting may be necessary during chest reconstruction, if the nipple areola complex is to be retained on the reconstructed chest. Although free nipple grafts may not be necessary when a circumareolar, nipple-sparing, approach is used in surgery, this procedure is only appropriate for individuals with smaller breasts. Research suggests that nipplesparing mastectomies have greater complication rates and decreased outcome satisfaction than procedures involving free nipple grafts.4,5 Nipple sparing has also higher rates of reoperation and revision than free nipple graft procedures.4,5 This implies that free nipple graft procedures may actually be less expensive in the long run, even if initial procedural costs are higher. The Women’s Health and Cancer Rights Act of 1998, despite its name, does not limit coverage of breast reconstruction to women after cancer. The text of the legislation is gender neutral. Section 1557 of the Affordable Care Act also contains provisions which prohibit discrimination in health care on the basis of sex including “sex stereotyping and gender identity.” As such, transgender men undergoing chest reconstruction should not be denied equivalent care to women undergoing similar procedures. This is not restricted to breast reconstruction after mastectomy for breast cancer. The free nipple graft technique is also used in women undergoing a reduction mammaplasty, depending on the amount of tissue being removed, and is considered to be a component of the basic procedure for coding purposes. We are concerned that the fact that the current SOC do not explicitly address the role of nipple reconstruction and/or nipple grafting in effectively treating dysphoria may be contributing to insurance company denials for this portion of the chest reconstruction procedure. We encourage the World Professional Association of Transgender Health to consider addressing this in version 8 of the SOC.

Congruence Is Not Cosmetic: Denials of Nipple Grafts for Chest Reconstruction Surgery