Board-Based Medicine

On February 3, 2026, the American Society of Plastic Surgeons (ASPS) issued a statement on gender-affirming surgery.1 At 9 pages, including references, it is a long read. Each page comes with a 1-paragraph legal disclaimer. The statement does not name any individual authors. The statement was issued by the ASPS and Plastic Surgery Foundation Board of Directors. It is phrased as if the organization is of a single mind (eg, “ASPS’s understanding has continued to evolve…”). It is a consensus statement that makes no acknowledgment of alternative views. The statement concedes that no formal guideline development process was undertaken. The text clarifies that it is a position statement, rather than a clinical practice guideline. The reader may be forgiven for not understanding the difference. Despite dispensing with factual support, the statement endorses a balance between compassion and scientific rigor. The report is presented not as a retroactive judgment but rather a forward-looking response. The statement concludes, in bold type, “ASPS recommends that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.”1 INDIVIDUALIZED CARE The release emphasizes that physicians should “exercise independent professional judgment guided by the best available evidence.”1 At the same time, it imposes a 19-year-old age limit across the board. This advice does not allow a plastic surgeon to determine that the benefit of an earlier surgical intervention outweighs any potential harm from waiting. The plastic surgeon’s professional judgment is subordinated to an arbitrary age requirement that lacks evidence. By imposing this unprecedented age requirement, the Board directors are carving out—for the first time in ASPS history—a subset of patients whose surgery must be delayed. The traditional practice in medicine is an individualized risk-benefit analysis, whether for adults or minors. Physicians evaluate capacity, indications, comorbidities, and psychosocial stability on a case-by-case basis rather than by applying a categorical exclusion. The position statement cautions, “physicians should offer interventions only when there is a reasonable expectation that anticipated benefits outweigh potential harms.”1 Of course, this standard is true for all medicine and surgery. It could also be applied to position statements. INDICATIONS FOR SURGERY The authors recognize that transgender patients are being treated differently. The Board directors make a distinction between gender-related surgical interventions for minors (eg, mastectomy and vaginoplasty) and other plastic surgical procedures “occasionally performed on adolescents (eg, breast reduction and gynecomastia surgery).”1 The statement (incorrectly) clarifies that procedures such as breast reduction or gynecomastia surgery address objective physical conditions rather than strictly psychological or psychosocial ones. The psychological importance of breast reduction and gynecomastia surgery on cisgender patients is well-known.2–7 Moreover, transgender patients do report physical symptoms from their condition.7,8 The impact of unwanted breasts in a cisgender male is heavily psychological,2,3,6 just as unwanted breast tissue is in a transgender patient.6–8 Transgender patients frequently bind their chests,6,7 underscoring the impact of this condition. Their distress is genuine. MEDICAL MALPRACTICE LAWSUITS The timing of this communication is not coincidental. It was issued on February 3, 2026, just 4 days after a New York jury trial concluded, awarding a patient $2 million in damages.9–11 The allocation of blame was 70% to the psychologist and 30% to the plastic surgeon who performed bilateral mastectomies on a 16-year-old. This case has gathered nationwide attention. At least 28 similar lawsuits have been filed. An analysis of insurance claims from 2017 to 2023 found that over 5200 teenage girls had their breasts removed as part of a gender transition procedure.10 EVIDENCE-BASED RECOMMENDATIONS The position statement does not provide evidence to support the conclusion that a 19-year-old is better able to consent to surgery than an 18-year-old. The unnamed authors recognize that a problem with the initial enthusiasm for gender-related treatments was a lack of high-level evidence.1 At the same time, they impose an age restriction without any high-level evidence. Evidence-based medicine places little value on collective opinions. In fact, evidence-based medicine was conceived to correct such unscientific behavior.12 Sackett, a founder of modern evidence-based medicine, commented: “The first sin committed by experts consists in adding their prestige and their position to their opinions, which give the latter far greater persuasive power than they deserve on scientific grounds alone.”13 MINIMUM AGE LIMITS In the US, the age of majority, and the minimum age for individuals to consent for surgery, is 18.14 Many states now impose an 18-year-old limit for transgender treatment, including surgery.15 Many insurance plans also require this age. However, in January 2025, an executive order directed the federal government to ban gender-affirming treatment for individuals under 19.16 In 2025, Stanford University17 and Kaiser Permanente18 followed suit, implementing a minimum age of 19 for gender-affirming treatment. Of course, the age requirement may change now that the world’s largest plastic surgery society has issued such a recommendation in bold type, even if it is accompanied by a disclaimer stating that this restriction is not a rule and not meant to serve as the standard of medical care.1 REVERSIBILITY AND NIPPLE PRESERVATION A vital issue associated with gender-affirming surgery is reversibility. Surprisingly, the document does not mention this essential consideration. Not all top surgery is the same. The patient who was awarded $2 million underwent mastectomies.9–11 Today, the most commonly performed top surgery is a bilateral breast amputation with nipple grafts.6 This surgery is also called double-incision surgery, which is a euphemism for bilateral mastectomies. Some operators even perform the mastectomies without nipple grafts (ie, the patient is left with no nipples).19 The ASPS position statement does not recognize a central problem with gender-affirming top surgery. The problem is not the patient's age. The problem is the operation itself. It is overly aggressive and cannot be reversed.6 It would have been bold indeed (and immeasurably beneficial for patients) for the ASPS to recommend that its members reconsider the operation they are performing. This author has recently challenged this mainstream approach,6 which results in inferior aesthetic outcomes and functional loss. Once the nipple is grafted, it is no longer truly a nipple.6,20 It is a malpositioned, insensate, functionless, flattened, and frequently hypopigmented facsimile juxtaposed to a conspicuous across-the-chest scar. Patients are unlikely to be comfortable without a shirt. The word “mutilated” (favored by plaintiff’s attorneys) is not an exaggeration. This procedure is an unfortunate departure from the usual goal of plastic surgeons: improving the human form. To the author’s knowledge, there are no publications reporting reversal.6 Irreversibility is a problem that is not corrected by an age restriction. Going forward, there should be no role for nipple grafting, whether in gynecomastia surgery, breast reduction in cisgender females, or top surgery.6,20 The nipple areola complex is a unique and irreplaceable body part. The importance of erogenous nipple sensation should not be overlooked.6 This recognition is highly relevant to reversibility. In my practice, I have not encountered a female-to-male transgender patient who returned after experiencing regret. However, if such a patient did decide later to regain a feminine form (“detransition”), this goal could be accomplished with breast implants. Interestingly, I have encountered a similar clinical presentation once, not in a transgender patient, but rather a cisgender male patient with gynecomastia.6 After undergoing gynecomastia treatment using semicircular incisions and local breast tissue excision at age 53 years, he returned 12 years later, requesting breast implants, explaining that he had “gender issues.” The implant surgery was uncomplicated and successful. For the majority of patients with small to moderate-sized breasts, the best surgical option is a semicircular incision accompanied by direct excision of breast tissue and liposuction (Fig. 1).6 This operation is no different from gynecomastia surgery. Reversibility is a key advantage of this more limited surgery.6 The nipple areola complexes and their innervation are preserved.FIGURE 1: A–F, This 18-year-old transgender male with a moderate breast volume is seen before and 3 months after liposuction-assisted transgender top surgery using semicircular lower areolar incisions. A volume of 150 mL was aspirated from each breast. The resection weights were 221 g from the right breast and 196 g from the left breast. The scars are inconspicuous, and the skin contraction is excellent. The nipple areola complexes are preserved intact. Reversibility is preserved. Reprinted from Swanson.6DISPARITY IN TREATMENT RECOMMENDATIONS Although the indications are similar for gynecomastia and gender-affirming top surgery, there is a prejudice for breast amputation in transgender patients.6 Remarkably, <4% of gynecomastia patients are offered mastectomies and nipple grafting, as opposed to over 80% of gender-affirming top surgery patients.6 It is reasonable to ask why. The alternative is 100% nipple preservation. If this approach is used, the consequences of a detransition are less severe. Implants can be inserted to regain a feminine chest.6 Many plastic surgeons have had the successful experience of inserting breast implants in cisgender women after previous breast reductions. BREAST REDUCTION FOR CISGENDER AND TRANSGENDER PATIENTS For patients with large, pendulous breasts, the approach for a transgender or nonbinary patient is very similar to a breast reduction in a cisgender female.6 Very large breasts in adolescent girls can create a huge psychosocial (not just physical) problem. On one memorable operating day, I performed breast reductions on twin 13-year-old girls with gigantomastia, producing a profound psychological benefit to the girls, who were becoming increasingly withdrawn from social interaction. Would it have been advisable to make them wait until they reached 19? Is it fair to insist on a (heightened) age limit for transgender patients but not cisgender patients? In my practice, transgender adolescents are usually female-to-male. Male-to-female patients tend to present later, in their 20s, and are simply treated with breast implants that can be removed at any time. With this new selective age restriction, an obvious concern is whether we are now treating the transgender patient who wishes to remove unwanted breast tissue in a less compassionate manner than a cisgender patient. I recall a transgender adolescent with scars covering both breasts from self-mutilation. Forcing transgender patients to live with their unwanted breasts and bind them every day until they turn 19 does not seem very compassionate. Plastic surgeons who treat transgender patients seeking top surgery know that the decision is rarely an impulsive one. Most transgender adolescents are enrolled in gender clinics.7 Most have parental support. After surgery, they tend to be highly satisfied.6 A 17-year-old transgender patient in my practice, patiently waiting for top surgery until he turns 18, called my office a few days after the ASPS announcement, worried that he would have to wait another year because of “this new law.” TERMINOLOGY When treating a transgender patient with pendulous breasts, the surgery is (accurately) called a breast reduction. Second-stage liposuction, when performed, is called “liposuction of breasts.” These labels precisely describe the procedures and avoid the gender question. The breasts are not being removed. They are being reduced. Transgender and gynecomastia patients do not require the complete removal of breast tissue. This is not cancer surgery. These patients are satisfied with a major reduction that preserves their nipples intact.6 Secondary liposuction is available for additional flattening if desired. Going forward, plastic surgeons should consider avoiding the word “mastectomy.” Even a “subcutaneous mastectomy” is not accurate. Some breast tissue is always preserved on the chest wall, deep to the nipple-areola complex, to avoid a sunken chest deformity and disproportionate appearance with the abdomen. TOP SURGERY IS THE PRIMARY OBJECTIVE IN ADOLESCENTS This discussion does not pertain to bottom surgery, which, of course, is more invasive and irrevocable. Genital surgery is not the first objective for transgender patients. Top surgery is their priority.21 Transgender patients frequently defer the decision regarding bottom surgery, making an age restriction a moot point. Plastic surgeons are not usually involved in medical treatment (ie, hormonal treatments). MORAL HAZARD Position statements are typically consensus statements. They are not based on evidence. Blanket recommendations are based on the judgment of a group of people, as opposed to a single physician treating a single patient to the best of his or her ability. Anonymity compromises accountability. Moral hazard arises when those making recommendations are shielded from the consequences of their recommendations. UNINTENDED CONSEQUENCES This unprecedented minimum age recommendation is likely to have unforeseen repercussions, in keeping with the law of unintended consequences. This new requirement is already being interpreted as a concession that doctors were wrong all along,9–11,22 and that past operations performed under the age of 19 were ill-advised. A national news release on February 7, 2026, was titled, “Medical associations admit gender surgery on minors not standard practice.” A patient who detransitioned concluded, “gender surgeries should not be considered standard medical practice. The ASPS said surgery is not recommended ‘until a patient is at least 19 years old.’ To me, these policy reversals amount to a confession—one that arrived years too late, after childhoods like mine were permanently altered.”22 Plaintiff’s attorneys will use this self-inflicted error to their advantage. Attorneys will start by asking the plastic surgeon defense expert, “Do you consider the American Society of Plastic Surgeons to be authoritative?” SUMMARY The new minimum age recommendation is governance-driven rather than evidence-driven. Table 1 summarizes the issues. Perhaps it is best to avoid the temptation to tell plastic surgeons what to do. Guidelines quickly become obsolete.23 Society recommendations in plastic surgery do not have a stellar track record.24–27 It is preferable to allow physicians to make evidence-based decisions in their patients’ best interests, without pressure to conform to an arbitrary age benchmark. Our societies would do well to follow the lead of evidence-based medicine.12 Board-based medicine is a poor substitute. TABLE 1 - Problems With Position Statement of the American Society of Plastic Surgeons Topic Issue Individualized care A categorical age limit substitutes governance for individualized medical judgment Risk versus benefit This analysis is missing Consistency Age thresholds are not applied to similar elective procedures in adolescents Arbitrary limit An age limit that exceeds the age of majority is unsupported by evidence Reversibility This critical issue is neglected Precedence A blanket ban on a procedure based on age is unprecedented in plastic surgery Disparity in recommendations A double standard may exist for transgender patients compared with cisgender patients Procedure problems The limitations of an overly aggressive procedure and the need for a change are not addressed Consequences Unintended consequences include an apparent concession of past wrongdoing and a new standard of practice