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Many techniques exist for subcutaneous mastectomy in female-to-male transgender patients. The authors review outcomes for two techniques and present an algorithm to aid surgeons in technique selection.One hundred one consecutive female-to-male transgender patients undergoing subcutaneous mastectomy using the concentric circular or free nipple graft technique were retrospectively reviewed. An algorithm for procedure selection was created using classification and regression tree analysis. Aesthetic results (nipple-areola complex, scar, and chest contour) were also independently reviewed.Two hundred two subcutaneous mastectomies were performed (concentric circular, 92 breasts; free nipple graft, 110 breasts). The overall complication rate was 21.3 percent, with 6.4 percent requiring operative intervention (free nipple graft, 1 percent; concentric circular, 13 percent; p < 0.001). The overall revision rate was 23.8 percent (free nipple graft, 12.7 percent; concentric circular, 37.0 percent; p < 0.001). In the concentric circular group, there were 3.3 times the odds of total complications (p = 0.03) and 4.0 times the odds of revision surgery (p < 0.001). Mean aesthetic scores for the concentric circular technique were superior to free nipple graft for scar (3.39 versus 2.62; p < 0.001) and contour (3.82 versus 3.34; p < 0.001).In patients who meet selection criteria, the concentric circular technique is preferred because of fewer scars, improved aesthetic contour, and potential for retained nipple sensation. These patients must be counseled regarding the higher rate of complications and revisions. It was determined that smokers and those with a nipple-to–inframammary fold distance greater than 7 cm or nipple-to–inframammary fold distance less than 7 cm and a body mass index greater than 27 kg/m2 should undergo the free nipple graft technique because of the increased risk of complications with the concentric circular technique.Therapeutic, III.