Long-Term Changes in Free Nipple Graft Morphology and Patient-Reported Outcomes in Gender-Affirming Mastectomies

Comparative Outcome Study of Gynecomastia Surgery and Gender-Affirming Mastectomy With 100% Nipple Preservation

BACKGROUND

Gynecomastia and gender-affirming top surgery share similarities in objectives. Traditionally, a subcutaneous mastectomy using a semicircular incision has been recommended for most gynecomastia patients. In recent years, mastectomies and nipple grafting have become the most popular treatment for gender-affirming top surgery. Nipple grafting is very debilitating to this unique body part, which also provides erogenous sensation. This study was undertaken to compare methods, complications, and outcomes using an approach that preserves nipples in 100% of patients.

METHODS

A retrospective study was conducted, comparing all gynecomastia patients and gender-affirming top surgery patients treated by the author over the period 2016-2024. Most (92%) gynecomastia patients were treated with liposuction in combination with a semicircular incision and subcutaneous mastectomy. Twelve top surgery patients (71%) were also treated with this method. Two gynecomastia patients and 5 top surgery patients with pendulous breasts underwent vertical mammaplasties incorporating a medial pedicle. A telephone survey was also administered.

RESULTS

Fifty-three patients were evaluated, including 36 gynecomastia patients and 17 top surgery patients. The complication rate was 21%. Three patients (6%) developed hematomas. Five patients (9%) underwent revisions. No patient experienced complications of the nipple/areola complex. All surveyed patients reported that nipple preservation was important. Two patients (11%) reported reduced nipple sensation after surgery. No patient reported scar dissatisfaction. Fifteen patients (83%) were comfortable exposing their chest after surgery, compared with 1 patient (6%) before surgery.

DISCUSSION

Today, a major disparity exists in treatment recommendations, with almost all gynecomastia patients being offered nipple-preserving methods and the majority of top surgery patients undergoing mastectomies with nipple grafting, or even without grafting. In view of the importance of nipple sensation, and the success of an alternative approach, surgical priorities should be realigned to preserve nipple/areola complexes.

CONCLUSIONS

Nipple preservation is offered to all patients. Subcutaneous mastectomies are often sufficient, and limit scarring. Vertical mammaplasties with a medial pedicle are effective in patients with pendulous breasts. Liposuction is offered as a second-stage procedure, although many patients are satisfied with some residual breast fullness. The need for secondary surgery of the nipple/areola complex and scar revisions is minimized.

Patient-Reported Outcomes on Subjective Nipple Sensation After Double-Incision and Periareolar Mastectomy for Chest Masculinization: Subjective Nipple Sensation After Chest Masculinization

ABSTRACT

We evaluated patient-reported outcomes to assess for patient and procedural factors associated with postchest masculinization subjective nipple sensation. Patients who underwent double-incision or periareolar mastectomies for chest masculinization by a single senior surgeon (2015-2019) were surveyed at 2 time points regarding postoperative nipple sensation and satisfaction, including patient-reported outcomes using BODY-Q modules (Q-Portfolio.org). Demographic, operative, and postoperative variables were obtained from medical records. Patients were stratified according to survey responses. Univariate and multivariate analyses were performed.Response rate was 42% for survey 1 and 22% for survey 2. Of the 151 survey 1 responders, 138 (91.4%) received double-incision mastectomies and 13 (8.6%) received periareolar mastectomies. Among Survey 1 responders, 84.6% periareolar patients and 69.6% double-incision patients reported "completely" or "a little" nipple sensation preservation, and the difference trended toward significance (P = 0.0719). There was a stepwise increase in proportion of patients reporting sensation with greater recovery time until response to survey 1. Obesity (P = 0.0080) and greater tissue removed (P = 0.0247) were significantly associated with decreased nipple sensation. Nipple satisfaction scores were significantly higher for patients reporting improved nipple sensation (P = 0.0235). Responders to survey 2 who reported greater satisfaction with nipple sensation were significantly more likely to report preserved sensitivity to light touch (P = 0.0277), pressure (P = 0.0046), and temperature (P = 0.0031). Preserved erogenous sensation was also significantly associated with greater satisfaction (P = 0.0018).In conclusion, we found that nipple sensation may be associated with postoperative nipple satisfaction. Operative techniques to optimize nipple sensation preservation may improve this population's postoperative satisfaction.

Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review

Importance

Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.

Objective

To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.

Evidence Review

In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).

Findings

In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.

Conclusions and Relevance

In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.

Masculinizing and defeminizing gender-affirming surgery

Transmasculine transgender and gender-diverse individuals may request gender-affirming surgery, standalone or in addition to other interventions. The choices and preferred outcomes of surgery can be highly individual. Besides surgeons' technical skills and patient physique, professionals in this field should be able to cooperate with other disciplines and with patients. The most requested surgery is masculinizing chest surgery, aiming to create a masculine chest with minimal scarring. For genital surgery, metoidioplasty refers to the procedure where the hypertrophic clitoris is released and possibly a scrotum is created from local labia flaps, whereas phalloplasty refers to a procedure in which a neophallus is created from a flap. Possible other surgeries include hysterectomy/oophorectomy, colpectomy, and the implants of scrotal or erection prostheses. In order to guide patients and clinicians, standardized outcome measures as well as evidence-based decision aids have been developed. Such aids, in combination with collaborative medical and psychosocial care, may further leverage the long-term outcomes of these surgeries.