OBJECTIVE: To analyze the impact of Body Mass Index (BMI) on clinical and patient-reported outcomes following gender-affirming mastectomy (GM). BACKGROUND: BMI is a barrier for obese patients seeking GM despite increasing evidence that it is safe in this population. Currently, little is known about the impact of BMI on chest-specific body image and satisfaction after GM. METHODS: This single-center, cross-sectional study included individuals 18 years and older who underwent GM between 1990 and 2020 and were at least 2 years postoperative. Patient-reported chest-specific body image was measured using the BODY-Q and Gender Congruence and Life Satisfaction chest subscales. Satisfaction was measured using the Holmes-Rovner Satisfaction with Decision scale. Clinical and demographic variables were identified from the chart review. Bivariate analysis was performed to determine whether BMI was associated with chest-specific body image, satisfaction, and complications within 30 days or revisions in GM. RESULTS: Two hundred twenty-seven individuals meeting eligibility criteria were contacted to participate and 137 responded (60.4% response rate). The mean age was 29.1 (SD=9.0), and mean BMI was 30.9 (SD=8.0), with 26.4% (N=60) of the cohort having a BMI>
35. Chest-specific body image and satisfaction with the decision did not vary by BMI or breast resection weight. Complications and revisions were not associated with BMI. CONCLUSIONS: Individuals undergoing GM reported high rates of satisfaction after GM regardless of BMI. Complication and revision rates did not vary significantly by BMI or breast resection weight. Surgeons should re-evaluate the role BMI plays in patient selection and counseling for GM.