Female-to-male transgender chest reconstruction: a large consecutive, single-surgeon experience

Patient-reported satisfaction and health-related quality of life after chest masculinization in transgender men using the BODY-Q Chest module and the 15D instrument

Chest masculinization is the most common surgical intervention in transgender men. Studies indicate good patient-reported postoperative satisfaction, but only recently has a patient-reported outcome instrument, the BODY-Q Chest module, been developed and validated for this patient group. This study aimed to evaluate postoperative patient-reported satisfaction and health-related quality of life (HRQoL) using the BODY-Q Chest module and the 15D after surgical chest masculinization in transgender men. The data comprised all patients receiving chest masculinization from 2005 to 2018. The patients were invited by letter to complete the BODY-Q Chest module and the 15D questionnaire in May 2020. Of the 220 patients invited, 123 completed the survey, resulting in a response rate of 56%. The median chest and nipple scores were 76 and 68 out of 100, respectively. The number of secondary corrections was negatively associated with the chest score (p value < 0.001). The 15D index score was lower compared with the age-standardized male population (p value < 0.001), but similar to the age-standardized female population. Psychiatric comorbidity was associated with lower 15D index scores (p value < 0.001). There were no statistically significant differences between the BODY-Q Chest module scores or the 15D index score among the different surgical techniques. The postoperative satisfaction with chest masculinization was good and in line with previous literature. HRQoL resembles that of the reference population. The periareolar technique is not associated with better satisfaction despite causing less scar burden. The negative association between the chest score and number of secondary corrections is unsettling and requires further examination in a prospective setting.

Nipple-Preserving Inferior-Ellipse Mastectomy: A New Technique for Gender-Affirming Top Surgery

SUMMARY

The 2 most common techniques for gender-affirming mastectomy are the double-incision free nipple graft and periareolar techniques. However, some patients are not well suited for either technique. When the nipples are high and on the pectoralis muscle, but there is marked breast tissue and skin redundancy, a double-incision free nipple graft would land the incision above the pectoral shadow, but a periareolar approach would not adequately remove the excess skin. In these patients, a nipple-preserving inferior-ellipse incision allows for appropriate chest contouring, leaving the nipple position unchanged and placing the incision in the pectoralis muscle shadow. A retrospective review identified all consecutive patients undergoing nipple-preserving inferior-ellipse mastectomy by the senior author (R.B.-L.). Indications were patients with moderate glandular tissue, skin excess, and a high nipple-areola complex (NAC) above the inferior border of the pectoralis major. Sixteen patients underwent inferior-ellipse mastectomy and were included. Mean follow-up was 203 days. Two patients (14%) required revision of the NAC. There was no partial or complete NAC loss. One patient (7%) developed postoperative seroma, which resolved with aspiration. For patients with moderate glandular tissue, excess skin in the inferior pole, and NAC position above the inferior border of the pectoralis major, the nipple-preserving inferior-ellipse mastectomy technique achieves excellent chest contour.

Direct neurotization of free nipple grafts with cadaveric nerve grafts following mastectomy for gender affirming surgery

BACKGROUND

Free nipple grafting makes sensory recovery challenging. Permanent decreased sensation to touch and temperature in skin-grafted skin is common. Direct neurotization of the nipple-areolar complex (NAC) graft has been described. However, quantitative data regarding degree of nipple reinnervation possible is unknown. This study aims to quantify and qualify sensation recovery following nerve coaptation to reinnervate the NAC.

METHODS

Patients undergoing mastectomy for gender dysphoria from 2020 to 2022 were offered nerve allograft to restore nipple sensation. A lateral intercostal nerve was selected and coapted to allograft which was embedded beneath the nipple graft. Semmes Weinstein testing was used to assess nipple sensation. Assessments were made at visits <1 year and >1 year from surgery. Filaments used represented normal sensation, minor diminished sensation, diminished sensation, loss of protective sensation, and deep pressure sensation only.

RESULTS

A total of 115 patients elected for direct neurotization. Semmes Weinstein testing was limited to 46 patients representing 46 encounters and 92 nipples in the <1 year group and 24 encounters and 48 nipples in the >1 year group. Of the 92 nipples in the <1 year group, 17 (18.5%) noted return of normal sensation and 37 (40.2%) noted minor diminished or diminished sensation, indicating nerve reinnervation. There were 38 (41%) nipples with loss of protective sensation or deep sensation only. There were 48 nipples included in the >1 year group. Of the 48 nipples, 4 (8.3%) noted normal sensation and 30 (62.5%) noted minor diminished or diminished sensation, indicating nerve reinnervation. For the remaining 14 nipples, 14 (29%) noted loss of protective sensation or deep sensation only.

CONCLUSION

Sensory outcomes in NAC grafts used for reconstruction in patients undergoing double incision mastectomy remain poor. Sensation restoration beyond that expected from full thickness skin grafts can be achieved in the majority of patients with nerve allograft via direct neurotization.

Gender-Affirming Mastectomy: Psychosocial and Surgical Outcomes in Transgender Adults

BACKGROUND

Limited literature exists examining the effects of gender-affirming mastectomy on transmasculine and nonbinary patients that is prospective and uses validated survey instruments.

STUDY DESIGN

The psychosocial functioning of transmasculine and nonbinary patients was compared between patients who underwent gender-affirming mastectomy and those who had not yet undergone surgery. Participants were enrolled in a single-site, combined study of surgical and psychosocial outcomes, including a cross-sectional cohort of preoperative and postoperative patients, as well as separate prospective cohort. Participants completed the BREAST-Q psychosocial and sexual well-being modules, the BODY-Q satisfaction with chest and nipples modules, the Body Image Quality of Life Inventory, the Transgender Congruence Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 scale before and after surgery. We also examined how patient demographic factors correlated with postoperative surgical and psychosocial outcomes.

RESULTS

A total of 111 transmasculine and nonbinary patients 18 to 63 years of age (mean ± SD 26.5 ± 8) underwent mastectomy and were included in the study. All were included in the cross-sectional cohort, and 20 were enrolled in the prospective cohort. More than one-third (34.2%) of patients were nonbinary. After surgery, psychosocial and sexual well-being, satisfaction, body image-related quality of life, and gender congruence were increased (p < 0.001) in both cohorts, and depression (p < 0.009 cross-sectional), and anxiety (p < 0.001 cross-sectional) were decreased. The most common adverse event was hypertrophic scarring, which occurred in 41 (36.9%) participants.

CONCLUSIONS

In this study of transmasculine and nonbinary adults, gender-affirming mastectomy was followed by substantial improvements in psychosocial functioning.

Breast Cancer Screening Recommendations for Transgender Patients: A Review

Shifting societal attitudes trending toward increased acceptance of transgender people has contributed to a growth in the population of individuals who openly identify as transgender as well as an increase in utilization of gender-affirming surgeries. Therefore, health care providers should work toward increasing their knowledge with respect to the health care needs of the transgender population, particularly given that these individuals often face discrimination in the health care system. Moreover, transgender breast cancer screening rates lag behind breast cancer screening rates for cisgender individuals. We attempt to clarify important terminology about the transgender population and introduce the concept of equity-centered language. We review current transgender breast cancer screening guidelines by using PubMed, Google Scholar, and Google with search terms that included transgender breast cancer guidelines, transgender breast cancer screening guidelines, and transgender cancer screening guidelines. Searches were not filtered based on year of publication, language of publication, or geographic location. We compare the various guidelines as they pertain to both transgender men and transgender women and offer special considerations for upholding inclusivity in the health care field. An easy-to-reference summary of the current transgender breast cancer screening guidelines and the major points of this article were compiled into an original infographic that health care providers can reference to ensure that appropriate care is being offered.

Masculinization of the Chest in Transmen with Large Breasts

Background and Objectives  Surgery to masculinize the chest is a frequently sought-after procedure by transmen who wish to conform their physical appearance to their gender identity. In our study, the outcomes of surgical masculinization comprising subcutaneous mastectomy through a modified elliptical incision, liposuction, reduced inert nipple-areola grafting, and quilting stitches were analyzed. Materials and Methods  Thirty-two transmen with large breasts and hypertrophied nipples and areolae underwent the above-mentioned masculinizing procedure in this prospective cohort study. Our statistically validated institutional aesthetic outcome assessment score (IAOAS) was used to analyze the outcomes at the end of the follow-up period. Results  The average period of follow-up was 24.5 months. The average final IAOAS was 23.1. The rate of complications was found to be associated with using breast binders. In all, 22 of 32 patients (68.75%) had an excellent outcome score, while 10 patients (31.25%) had a good outcome score ( p  = 0.025). Conclusion  Top surgery is crucial for transmasculine patients to achieve their desired gender identity as males. It is imperative that this procedure is performed to their complete satisfaction. Our single-staged comprehensive approach of subcutaneous mastectomy and liposuction with reduced inert nipple and areola grafts, which aids in a swift transition to a male role, is a prerequisite for bottom surgery at our institute.

Advocating for Enhanced Patient Engagement in Breast Cancer Care: Impact of Residual Increased Lateral Adiposity and Consideration of the Pursuit of "Living Flat"

Breast cancer is a significant health concern, accounting for a substantial proportion of cancer cases. Despite improvements in cancer survivorship, many women still require mastectomy as part of their therapeutic treatment. Mastectomy alone or delayed breast reconstruction (DBR) are two options available to women not suitable for immediate breast reconstruction at initial mastectomy. However, the presence of increased lateral adiposity (ILA) following mastectomy, commonly referred to as ``dog-ears,'' can lead to discomfort and aesthetic concerns. This paper explores the benefits and harms of ILA postmastectomy and its impact on patient satisfaction when choosing between mastectomy alone or DBR. A literature search was completed within OVID Medline, 1946-current, with the following terms, filtered for relevance: "mastectomy," "autologous reconstruction," "scar," "body image/dysmorphia," "patient-reported outcomes," "reconstructive surgical procedures/excess skin," "surgical flaps/dog ear." The disparity between clinical support and educational resources available for patients considering DBR options compared to those choosing mastectomy alone or pursuit of "living flat" is discussed. A common theme from qualitative research was the reported feeling of lack of inclusion in reconstruction planning by the patient. There were instances reported of residual skin remaining postmastectomy, against patient wishes. The findings emphasized the importance of shared decision-making and comprehensive preoperative education to ensure that patients are well-informed and satisfied with their chosen treatment approach. Further research is needed to address the specific needs and preferences of patients opting for mastectomy and to improve surgical techniques and education regarding living-flat options.

Masculinizing chest-wall surgeries in transgender patients, a retrospective single-center study

INTRODUCTION

Masculinizing chest-wall contouring surgery is an important surgical intervention for most transmasculine patients; a vast improvement in quality of life for this group of patients has been documented as a result of receiving surgery. The aim of this study was to evaluate the results of such surgeries performed at our university hospital between 2008 and 2020, as well as the current quality of life of the patients.

METHODS

All 16 patients operated between 2008 and 2020 were sent a questionnaire consisting of both BREAST-Q and BODY-Q modules, considered fitting for our study purposes, as well as the BECK Depression Index and a short two-question form with space for feedback. Patients were divided into groups called double incision (DI) and periareolar (PA) depending on the surgical technique used.

RESULTS

We found an overall complication percentage of 31.3%, with the DI group scoring 33.3% and PA 28.6%, while secondary aesthetic corrections were necessary for 50% of all patients. The questionnaires yielded 6 responses (37.5%). Participants rated on a scale of 1 to 10 their willingness to undergo the operation again if given the choice; the DI group averaged 10/10, and the PA group 9/10, despite the statistically significant complication and correction rates.

CONCLUSIONS

Masculinizing chest-wall contouring surgery has significant complication risks. In our study, frequency of complications did not appear to depend on the surgical technique used. Additionally, the complication rates found in our low volume centre seem to be comparable with those reported from bigger units.

Subcutaneous mastectomy in female-to-male transsexuals is associated with higher risk of postoperative bleeding complications

Introduction

Chest contouring or subcutaneous mastectomy (SCM) in female-to-male (FtM) transgender individuals is the primary surgery in the gender reassignment process. Many authors report high rates of postoperative bleeding in these patients and discuss a possible influence of preoperative hormone therapy. However, there is a lack of data on the analysis between different surgical techniques and postoperative bleeding risk.

Materials and Methods

In this retrospective study, we included 22 FtM transgender individuals who underwent bilateral SCM using 4 different techniques (44 breasts) between June 2014 and September 2023. Postoperative complications regarding surgical techniques and patient demographics were collected and analyzed.

Results

SCM with free nipple grafting was the most commonly used technique (n = 12, 54.5%). The mean operative time was 163.4 ± 49.2 minutes. There were no significant differences in operative time between the surgical techniques (p ≥ 0.20 in all cases). The rate of acute postoperative bleeding was 20.5% (n = 9). Acute postoperative bleeding occurred most frequently in patients who received a semi-circular incision for SCM. There was no significant difference in the rate of acute postoperative bleeding between the different surgical techniques. BMI, breast weight, and duration of surgery were not associated with the rate of acute complications (p > 0.17 in all cases).

Conclusions

Less invasive SCM techniques in FtM transgender individuals are associated with higher postoperative bleeding risk.

Quantifying Nipple-Areolar Complex Shape and Location After Transmasculine Top Surgery: A Study of Postoperative Photographs Posted on Social Media and Surgeons' Professional Websites

Purpose

The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions.

Methods

In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed.

Results

We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012).

Conclusion

Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.

Impact of surgical technique on outcome measures in chest masculinization: A systemic review and meta-analysis

BACKGROUND

Among plastic surgeons, there are several conventional techniques for performing chest surgery. Research on surgical approaches has focused cis-gender patients with medical conditions, such as breast cancer or gynecomastia, but has never studied transgender populations. The aim of this study is to perform the first systematic review of gender-affirming surgery (GAS) in transgender populations and determine postoperative outcomes differences in relation to surgical technique.

METHODS

Two reviewers independently searched Medline, Embase, CINAHL, Web of Science, and Cochrane databases for studies published prior to 2021. Studies selected for inclusion were retrospective or prospective studies of adult transgender men undergoing GAS that utilized appropriate operative techniques and reported complications and/or patient-reported outcomes.

RESULTS

A total of 26 randomized controlled trials, including 40 distinct populations and 3055 patients, were identified. Surgical techniques compared double incision free nipple graft (DIFNG) (2053 patients [67.20%]), pedicled nipple techniques (PNT) (297 [9.72%]), and periareolar techniques (PAT) (705 [23.08%]). Pairwise analysis found the lowest complication rates associated with procedures utilizing DIFNG, followed by PNT, then PAT. Patients with PAT had significantly higher satisfaction scores than DIFNG.

CONCLUSIONS

This is the first systematic review to evaluate outcomes of chest surgery techniques among the transgender population. Results indicate significantly more complications for PAT compared to DIFNG or PNT. Analysis of patient-reported outcomes was limited due to heterogeneity in reporting.

[Thoracic reassignment surgeries]

Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.

High Self-Reported Satisfaction After Top Surgery in Gender-Affirming Surgery: A Single-Center Study

Purpose

Top surgery, or masculinization of the chest, is often the first and sometimes only procedure in gender-affirming surgery for transgender- and gender-diverse persons assigned female at birth. In recent years, there has been improved access to care for transgender individuals and increased demand for top surgery. Our aim was to investigate the degree of satisfaction with the postoperative outcome after top surgery in transgender men.

Methods

Ninety transgender men who underwent top surgery between September 1, 2013 and August 31, 2018 were included. Patients were surveyed from 5 to 62 months after surgery. Participants' files were evaluated for complications, and 84 (response rate 93.3%) participants answered a questionnaire evaluating patient satisfaction postoperatively.

Results

Patients were either satisfied or partially satisfied with the overall experience of undergoing surgery and the postoperative result in 90.5% of responses. Patients were very satisfied with their clothed appearance in 89.3% of responses, whereas only 44.1% were very satisfied with their nonclothed appearance and 46.4% partially satisfied. Patients were also very satisfied with postoperative scars in 47.6% of responses and nipple reconstruction in 48.8%. Only two patients expressed their regret.

Conclusion

Satisfaction outcomes after top surgery are generally positive, especially in respect of clothed appearance, self-confidence, and self-acceptance.

Chest Wall Contouring in Transgender Men: A 20-Year Experience from a National Center

Several western countries have experienced a drastic increase of referrals to specialist gender services of transgender and gender-diverse people. Chest wall contouring is an important element in treatment of gender dysphoria. National data concerning this group have yet to be investigated. The aim of this study was to examine and evaluate the techniques and surgical outcome of chest wall contouring from the last 20 years from a single center in Norway.

Methods

This study is a retrospective review of all female-to-male patients who underwent chest wall contouring surgery at Oslo University Hospital between 2000 and 2020. Statistical analysis with comparison of techniques and evaluation of development over time was examined.

Results

In total, 333 patients underwent bilateral chest wall contouring, 209 (62.8%) with inframammary incision with free nipple graft (IM), and 124 (37.2%) with periareolar technique (PA). In 20 years, the average age decreased from 31 (19-68) to 24.9 years (17-61). Average body mass index was significantly lower in the PA-group than in the IM-group. Complication rate was 20.7%, with postoperative bleeding being the most frequent (9.6%). Revision surgery was required in 24.9% of the cases; periareolar technique required significantly more procedures.

Conclusions

The number of patients referred and operated on has increased drastically over a 20-year period. When comparing the techniques, the outcome concerning complications and revisions is at an acceptable level. Postoperative bleeding and revision surgery occur more often with the periareolar technique. There remains a knowledge gap concerning quality of life and satisfaction after surgery within this patient group.

Blood Pressure Challenge Reduces Hematomas in Gender-Affirming Mastectomy: A Retrospective Chart Review of 92 Consecutive Patients

BACKGROUND

Gender-affirming mastectomy is a common surgery for the treatment of gender incongruence and gender dysphoria and improves quality of life. Hematoma rates for gender-affirming double incision mastectomies are between 2.8% and 8.1%. This study aims to investigate the utility of a blood pressure challenge, whereby the patient's blood pressure is medically increased intraoperatively to reveal bleeding vessels that can be addressed with additional hemostasis before skin closure, to reduce postoperative hematoma.

METHODS

A retrospective chart review of patients who underwent gender-affirming double incision mastectomies over a 6-year period by a single surgeon was conducted. Surgeries were separated into a blood pressure challenge experimental group and a non-blood pressure challenge control group. Demographics, surgical characteristics, and postoperative complications were compared between the 2 cohorts using Pearson χ2, Fisher exact, t tests, univariate logistic regression, and multivariable logistical regression. Significance was established at P < 0.05.

RESULTS

A total of 92 patients (184 breasts) were included with 32 patients (64 breasts) in the control group and 60 (120 breasts) in the blood pressure challenge group. In the control group, there were 5 hematomas (7.81%) compared with 1 (0.83%) in the blood pressure challenge group (P = 0.02). On univariate logistical regression analysis, blood pressure challenge was the only variable significantly associated with hematoma (odds ratio, 0.1; 95% confidence interval, 0.01-0.63; P = 0.04). On multivariable logistical regression, after controlling for age, body mass index, smoking status, and mass of excised breast tissue, patients who underwent blood pressure challenge demonstrated lower hematoma rates (odds ratio, 0.08; 95% CI, 0.004-0.59; P = 0.04).

CONCLUSIONS

Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

Age-related Outcomes of Chest Masculinization Surgery: A Single-surgeon Retrospective Cohort Study

Many transmasculine individuals face chest dysphoria, an emotional distress associated with breast development. The definitive management for reduction of existing breast tissue and alleviation of chest dysphoria comes in the form of chest masculinization surgery. Over the years, a substantial increase in the number of youth seeking gender-affirming chest masculinization surgery was observed globally. The study was hypothesized to answer the question as to whether the age limit of chest masculinization surgery should be lowered to include adolescents.

Methods

A retrospective cohort study was conducted, based on the experience of a single surgeon over a period of 20 years.

Results

Two-hundred eight patients were included in this cohort. Patients were divided into two equal groups based on their age. No statistically significant differences between the groups were observed in terms of resected breast tissue (P = 0.62 and 0.30, for the right and left breast, accordingly), auxiliary liposuction (P = 0.30), liposuction volume (P = 0.20), procedure (P = 0.15), postoperative drains (P = 0.79), and surgery duration (P = 0.72). Statistically significant differences were found in the 18 years or younger group, with lower rates of complication (P < 0.001), lower rates of revision surgery (P = 0.025), and higher satisfaction rankings (P < 0.001). Apart from age, no other factors were found to potentially explain the different rates of complications between the age groups.

Conclusion

Patients aged 18 or younger opting for chest masculinization surgery experience fewer complications and revision procedures while having higher satisfaction rates with the surgical outcome.

Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone before Top Surgery Really Necessary?

BACKGROUND

Gender-affirming mastectomy, or "top surgery," has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone before top surgery. This is the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone.

METHODS

This retrospective review included patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, before May of 2019, all patients were required to discontinue testosterone before surgery; all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographic characteristics and postoperative outcomes compared among groups.

RESULTS

A total of 490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients; 104 patients never received testosterone therapy. Demographic characteristics were similar among groups and there was no difference in rates of hematoma (2.9% versus 2.8% versus 2.9%, respectively; P = 0.99), seroma (1.1% versus 0% versus 1%, respectively; P = 0.31), venous thromboembolism (0% versus 0.5% versus 0%, respectively; P = 0.99), or overall complications (6.9% versus 4.3% versus 5.8%, respectively; P = 0.54).

CONCLUSIONS

Our results demonstrate no difference in postoperative complication rates among groups. Whereas further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Health State Utility Values in Patients Undergoing Chest Masculinization Surgery

BACKGROUND

Chest masculinization surgery is the most common gender-affirming procedure performed in transgender and gender-diverse individuals. While evidence on the health-related quality of life (HRQL) impact of chest masculinization is starting to emerge, data on health state utility values (HSUVs) associated with the surgery is largely missing. The objectives of this study were to estimate the HSUVs using EQ-5D for patients seeking chest masculinization surgery and assess the determinants of EQ-5D score at 6 months postoperatively.

METHODS

Patients seeking chest masculinization at a single community plastic surgery clinic by 2 surgeons completed 3 patient-reported outcome measures - EQ-5D-3L, Patient Health Questionnaire (PHQ)-9, and BODY-Q Chest module - preoperatively and postoperatively at 6 weeks and 6-months. Friedman test was used to assess the differences in PROM scores at the 3 timepoints. Simple and backward stepwise regression analyses of 6-month postoperative EQ-5D scores were performed.

RESULTS

A total of 113 patients (mean [SD] age, 25.7 [6.9] years) were included. The mean [SD] EQ-5D scores at preoperative, postoperative 6 weeks and 6 months were 0.81 [0.15], 0.84 [0.15] and 0.87 [0.12], respectively. Postoperatively, problems were most frequently reported in the dimensions "pain/discomfort" and "anxiety/depression". Preoperative PHQ-9 score was a predictor of 6-month postoperative EQ-5D scores following simple (p < 0.01) and backward stepwise linear regression analysis (p < 0.01).

CONCLUSION

Chest masculinization was associated with an improvement in overall HRL at 6 months postoperatively; however, this did not achieve statistical significance. Preoperative depression severity was a significant determinant of postoperative HRL. Consequently, additional support must be offered to patients who have a higher level of preoperative depression.

Mastectomy is a safe procedure in transgender men with a history of breast reduction

Little is known about the safety and surgical outcomes of mastectomy after breast reduction in the trans male population. Several concerns have been voiced that performing mastectomy with prior breast reduction surgery, increases the risk for complications and revision surgery. All transgender men with a history of breast reduction, who underwent a mastectomy at our center between 01-1990 and 01-2021 were identified from our hospital registry. A retrospective chart study was conducted recording surgical characteristics, surgical complications, revision surgery, and clinical follow-up. A total of 1362 subcutaneous mastectomies were performed between 01-1990 and 01-2021. A total of 36 (2.6%) individuals were included (35 bilateral and 1 unilateral breast reduction). The mean age at mastectomy was 37 ± 10 years, and the median time between breast reduction and mastectomy was 6.3 years (range 1.0-31.1). Most individuals underwent a Wise-pattern breast reduction (91%) and a double incision mastectomy with free nipple grafts (86%). Following mastectomy, one acute reoperation was performed because of hemorrhage (3%). Partial pedicled nipple necrosis was seen in 7% and (partial) non-take of nipple grafts in 4%. Scar revisions were performed in 9%, dogear corrections in 20%, and both nipple corrections, and contour corrections in 6%. When comparing the outcomes in literature for surgical complications, scar revision, contour correction or nipple areolar complex revision, no clear disadvantage seems to be present when performing mastectomy after breast reduction. Mastectomy is a safe procedure in transgender men with a history of breast reduction.

The Role of Sex Hormones in Pain-Related Conditions

Millions of people are affected by pain-related conditions worldwide. Literature has consistently shown that each individual experiences and perceives pain in a unique manner due to biological, environmental, and cultural factors in which they have been raised. It has been established that biological males and females perceive pain differently and that it may be partially explained by their distinct hormonal profiles since birth, which are only further magnified during puberty. For biological males, high levels of testosterone have shown to increase their pain threshold; and for biological females, estrogen fluctuations have shown to increase pain intensity and perception. However, sex hormones have not been studied in the context of pain treatment or their impact on biochemical pathways involved in pain perception. For this purpose, the transgender community serves as a unique population to investigate the impact of hormone replacement therapy on molecular pathways involved in the perception of pain. The purpose of this review is to explore the biochemistry of hormone replacement in transgender patients who also have other pain-related conditions such as headaches, fibromyalgia, temporomandibular myalgia, and visceral pain.

A Single-Center 10-Year Experience of 180 Transmasculine Patients Undergoing Gender-Affirming Mastectomy While Continuing Masculinizing Hormone Replacement Therapy

BACKGROUND

Gender-affirming mastectomy is a fundamental step in the transition process of transmasculine patients following the initiation of hormone replacement therapy. Its perioperative management, however, remains underreported and controversial. In this study, a large series of mastectomies in transmen maintaining hormonal therapy is presented.

METHODS

Over a 10-year study period, a consecutive series of 180 transmasculine patients undergoing chest masculinizing surgery was evaluated. Demographical and surgical data were collected and analyzed for potential factors influencing outcome.

RESULTS

The overall rate of complications was 15.5%. Patients who underwent periareolar incision mastectomy were significantly more likely to develop any type of complication than patients with a sub-mammary incision (28.6% vs. 13.2%, p = 0.045). Hematoma was the most common reason for surgical revision. It occurred significantly more often among the periareolar group (21.4% vs. 7.9%, p = 0.041). Duration and type of hormonal therapy did not differ between patients with or without complications. In a multivariate regression analysis, smoking and type of incision were identified as significant predictors of the all-cause complication rate, whereas the influence of BMI and resection weight diminished after adjusting for confounding factors.

CONCLUSION

There is scarcity of information concerning the influence of perioperative hormonal therapy in patients undergoing chest wall masculinization. The observed complication rates-with special regard to hematoma-were comparable to current reports; yet further research is needed to profoundly evaluate this topic and provide evidence-based recommendations for the perioperative management of HRT of transmasculine patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Hematoma following gender-affirming mastectomy: A systematic review of the evidence

BACKGROUND

Hematomas are reported to be the most common immediate complication in patients undergoing gender-affirming mastectomy, with rates substantially higher than those associated with other types of breast surgery. This study sought to examine the breadth of current literature and provide evidence-based explanations regarding the development of hematomas in chest masculinizing surgery and technical considerations for reducing their incidence.

METHODS

A systematic review was conducted to identify all articles related to gender-affirming mastectomy published through September 2021. Literature search yielded 2,661 articles for screening, of which 20 met inclusion criteria. Themes from the selected articles were compiled to generate consensus statements qualified by associated level of evidence (LOE).

RESULTS

The rate of hematoma following gender-affirming mastectomy is reported in the literature ranging from 0% to 31.2%. The use of more limited, nipple-sparing incisions is associated with a higher hematoma rate than mastectomy with free nipple grafting (Level III). There is no conclusive evidence indicating any relationship between the use of masculinizing hormones and the incidence of hematoma (Level IV). Factors such as body mass index (Level III) and breast size (Level III) were not found to influence hematoma risk, though nicotine use (Level IV) was significantly associated with the incidence of hematoma.

CONCLUSIONS

Hematoma is a known complication following gender-affirming mastectomy. The use of limited incision approaches has the strongest association with an increased risk of hematoma. There is no evidence indicating an association between hormone use (i.e., testosterone) and hematoma incidence. Future studies are needed to better define factors, interventions, and protocols to reduce the rate of hematoma.

LEVEL OF EVIDENCE

III.

Transgender Mastectomy: Incidence of High-Risk Pathologic Findings and the Need for Postoperative Cancer Surveillance

BACKGROUND

Chest masculinization surgeries are one of the most common gender-affirming procedures performed. There is a need for better understanding of the risk of breast cancer and postsurgical screening in female to male (FtM) individuals. This study aimed to evaluate the incidence of high-risk pathologic findings in FtM transgender patients undergoing gender-affirming chest reconstructive surgery.

METHODS

Medical records were reviewed from all FtM patients undergoing gender-affirming chest reconstructive surgery from January 2010 to February 2021 by 3 plastic surgeons at the University of Pittsburgh Medical Center. Relative risk of malignant progression was used to stratify pathologic data. Subsequent management of atypical, in situ, and invasive pathology were recorded.

RESULTS

A total of 318 patients were included in this study; the average age at surgery was 24.6 ± 8.1 years. Eighty-six patients (27%) had a family history of breast and/or ovarian cancer. Overall, 21 patients (6.6%) had some increased risk of breast cancer: 17 (5.3%) had proliferative lesions, mean age 38.2 ± 12.4 years; 2 had atypical ductal hyperplasia, ages 33.4 and 38.3 years; and 2 had invasive ductal carcinoma, ages 35.4 and 40.6 years.

CONCLUSIONS

In this study, we found that 6.6% of FtM transgender patients undergoing top surgery had an elevated risk of breast cancer, with 1.2% of patients having a greater than 2 times risk of breast cancer. These results highlight the importance of appropriate preoperative screening as well as pathological analysis of surgical specimens to help guide clinical care. The authors advocate for a thorough breast cancer risk assessment before surgery for all patients, as well as using pathologic findings to guide postoperative cancer screening and follow-up.

Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents

Background

There are over 150,000 transgender adolescents in the United States, yet research on outcomes following gender-affirming mastectomy in this age group is limited. We evaluated gender-affirming mastectomy incidence, as well as postoperative complications, including regret, in adolescents within our integrated health care system.

Methods

Gender-affirming mastectomies performed from January 1, 2013 - July 31, 2020 in adolescents 12-17 years of age at the time of referral were identified. The incidence of gender-affirming mastectomy was calculated by dividing the number of patients undergoing these procedures by the number of adolescents assigned female at birth ages 12-17 within our system at the beginning of each year and amount of follow-up time within that year. Demographic information, clinical characteristics (comorbidities, mental health history, testosterone use), surgical technique, and complications, including mention of regret, of patients who underwent surgery were summarized. Patients with and without complications were compared to evaluate for differences in demographic or clinical characteristics using chi-squared tests.

Results

The incidence of gender-affirming mastectomy increased 13-fold (3.7 to 47.7 per 100,000 person-years) during the study period. Of the 209 patients who underwent surgery, the median age at referral was 16 years (range 12-17) and the most common technique was double-incision (85%). For patients with greater than 1-year follow-up (n=137, 65.6%), at least one complication was found in 7.3% (n=10), which included hematoma (3.6%), infection (2.9%), hypertrophic scars requiring steroid injection (2.9%), seroma (0.7%), and suture granuloma (0.7%); 10.9 % underwent revision (n=15). There were no statistically significant differences in patient demographics and clinical characteristics between those with and without complications (p>0.05). Two patients (0.95%) had documented postoperative regret but neither underwent reversal surgery at follow-up of 3 and 7 years postoperatively.

Conclusion

Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two expressed regret, neither of which underwent a reversal operation. Our study provides useful and positive guidance for adolescent patients, their families, and providers regarding favorable outcomes with gender-affirming mastectomy.

The Effect of Preoperative Gender Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation

BACKGROUND

Many providers require cessation of gender affirming hormone therapy (GAHT) for transgender patients prior to undergoing masculinizing chest surgery due to concern for increased adverse events in the presence of exogenous hormones. Evidence has suggested that continuation of GAHT for certain patients may be safe for gender affirming procedures.

OBJECTIVES

To compare adverse event rates in GAHT cessation versus GAHT continuation in patients undergoing masculinizing chest surgery.

METHODS

This multicenter, retrospective study included patients at the Cleveland Clinic and MetroHealth System who underwent masculinizing chest surgery between 2016 and 2020.

RESULTS

There were 236 patients who met inclusion criteria. Of these, 172 (72.9%) discontinued testosterone GAHT prior to surgery (T-GAHT cessation), and 64 (27.1%) patients continued testosterone GAHT prior to surgery (T-GAHT continuous). Mean (SD) age at surgery was 25 (8) years, and mean (SD) BMI was 29.5 (6.6). Average duration of testosterone therapy was 18 months (range 0-300). There was no significant difference in tobacco use (p=0.73), diabetes (p=0.54), thrombophilia (p=0.97), or history of thromboembolism (p=0.39). Most patients underwent double incision free nipple graft technique (77.9%). There was no significant difference in surgical time (p=0.12), intraoperative complications (p=0.54), or postoperative complications (p=0.34). The most common complication was postoperative bleeding/hematoma (7.2%). Other complications included seroma (2.1%), infection (1.3%), and nipple graft failure (0.4%). There were no thromboembolic complications.

CONCLUSIONS

There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively versus patients who undergo GAHT cessation for masculinizing chest surgery.

The Impact of Incisional Negative Pressure Wound on Scar Quality and Patient Reported Outcomes: a Within-Patient Controlled, Randomized Trial

Literature provides a moderate level of evidence for the beneficial effects of incisional negative pressure wound therapy (iNPWT) on scar quality. The purpose of this study was to establish if iNPWT results in improved scar outcomes in comparison to the standard of care. Therefore, a within‐patient randomised controlled, open‐label trial was conducted in transgender men undergoing gender‐affirming mastectomies. A unilateral side was randomised to receive iNPWT (PICO™, Smith&Nephew) without suction drains and contrastingly the standard dressing (Steri‐Strips™) with suction drain. Scar quality and questionnaires were bilaterally measured by means of objective assessments and patient‐reported outcome measures (PROM) at 1, 3 and 12 months. Objective scar outcomes were scar pliability (Cutometer®), colouration (DSM‐II) and scar width (3‐D imaging). PROM outcomes were related to scars (POSAS and SCAR‐Q) and body satisfaction (BODY‐Q). From 85 included patients, 80 were included for analyses. No significant difference between treatments was seen in the quantitative outcomes of scar pliability, colour, and width. For qualitative scar outcomes, several significant findings for iNPWT were found for several subscales of the POSAS, SCAR‐Q, and BODY‐Q. These effects could not be substantiated with linear mixed‐model regression, signifying no statically more favourable outcome for either treatment option. In conclusion, this study demonstrated that some PROM outcomes were more favourable for the iNPWT compared to standard treatment. In contrast, the quantitative outcomes showed no beneficial effects of iNPWT on scar outcomes. This suggests that iNPWT is of little benefit as a scar‐improving therapy.

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

BACKGROUND

After gender-affirming mastectomies with free nipple grafts, satisfaction with nipples tends to fall short behind chest outcomes. This might be related to changes in nipple areolar complex (NAC) dimensions over time. Therefore, the aim of this study is to establish the long-term changes in NAC morphology and compare these to cisgender male NAC outcomes.

MATERIALS

An observational, cross-sectional study was performed. Data from two prospective cohorts were collected: (1) transgender men after a mastectomy with free nipple grafts and (2) cisgender men (reference sample). Demographics and 3-D images were collected for both groups. NAC measurements were performed on the 3-D images at 4 time points (7-, 30-, 90- and 365-days postoperative) in transgender men and once in cisgender men. Furthermore, the BODY-Q (nipple module) was administered postoperatively at 30-, 90- and 365-days in transgender men.

RESULTS

In total, 67 transgender and 150 cisgender men were included. NAC width and height in trans men changed from 21.5 mm (±2.7) to 23.8 mm (±3.9, p<0.001) and 16.2 mm (±2.5) to 14.7 mm (±3.0, p=0.01) within a year, respectively. On average, the NACs increasingly rotated 21 degrees in the latero-caudal direction (p<0.001). The mean NAC width and height in cisgender men were 28.1 mm (±5) and 20.7 mm (±4), being significantly larger than in transgender men. Satisfaction for size, shape and flatness decreased significantly after postoperative day 30 (p=<0.05) in transgender men.

CONCLUSIONS

Morphology of and satisfaction with the NACs in transgender men significantly changed over time. Understanding and incorporating these differences into pre-operative counseling and surgical planning might help increase patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Patient satisfaction following gender reassignment mastectomy in female-to-male transsexual patients: a questionnaire-based analysis using a modified version of the BREAST-Q]

BACKGROUND

Mastectomy is an essential part of gender reassignment surgery for female-to-male transgender patients. Available studies indicate high patient satisfaction within this patient group; however, a standardised evaluation procedure is yet to be established.

METHOD

Based on the BREAST-Q questionnaire, we developed a modified version targeting issues concerning FM patients; hence, all questions focussing on the physiology of biologically female patients were removed or tailored to address more specific transgender issues. Post-mastectomy transgender male patients from 1991 until 2017 were contacted and evaluated based on the questionnaire. This questionnaire comprises a total of 57 questions regarding general satisfaction with the ches area, as well as specific questions regarding satisfaction with the nipple-areola complex (NAC) and topics regarding expectations, regrets, self-confidence and sex life after mastectomy.

RESULTS

Overall, we found a high level of patient satisfaction after mastectomy. The level of regret was low and all patients would repeat mastectomy if needed.

CONCLUSION

For most transgender males, mastectomy plays an essential role in gender reassignment surgery, overall leading to an improved quality of life for this patient population.

Perioperative Considerations for Person-Centered Gender-Affirming Surgery

With more than 1 million people identifying as transgender in the United States alone, the likelihood of encountering a transgender patient and their family of choice in the perioperative setting is very high. A lack of data exists to equitably inform transgender-specific issues, as well as the associated morbidity during the transgender reassignment perioperative period. Anaesthesiologists should actively acquire the knowledge and skills needed to inclusively and respectfully manage these patients and be aware of their unique physiological and psychosocial needs. The pre-operative approach includes a detailed history, focusing on the patients cross-sex hormone treatment (CSHT) regimen and associated medical conditions. An in-depth understanding of commonly used hormones such as estrogen and testosterone and their effect in the perioperative periods is essential. The physical examination should be relevant to the anatomy that is currently present while taking into consideration feminising and masculinising procedures (e.g., genioplasty, thyroid cartilage augmentation), how these interventions alter the anatomy, and potential airway complications. Laboratory results should be interpreted with care – and with expert assistance if needed - as hormone therapy might affect reference values. In addition, risk assessment tools should be used with caution since they often include sex in their scoring system but do not account for the use of CSHT. Intraoperative considerations include urethral catheter placement, drug dosing, and drug interactions that are commonly encountered in the transgender patient. Special attention should be taken in transgender females who have undergone vocal feminization, as case reports have described unexpected difficult airway management. A multimodal approach, which includes regional blocks and attention to pre-existing chronic pain conditions, should be employed as part of the post-operative pain management plan. The post-operative nausea and vomiting risk has not yet been established in this population, requiring appropriate anti-emetic prophylaxis. Despite societal advances that improve transgender health, the medical community still lacks empirical evidence to effectively mitigate the distinctive challenges confronted by this at-risk population.

Double-sided Nipple-areola Complex Marker for Masculinizing Chest Surgery

In addition to chest contour and incision placement, nipple-areola complex size, orientation, and position is a primary concern of patients undergoing masculinizing chest surgery with free nipple grafting for gender dysphoria or gynecomastia. The author has developed a double-sided nipple-areola complex harvest and inset marker that facilitates graft healing in an optimized masculine orientation.

Low Risk of Persistent Pain, Sensory Disturbances, and Complications Following Mastectomy After Gender-Affirming Surgery

Purpose: In recent years, there has been a significant increase in referrals for gender-affirming surgery to departments of plastic surgery in Denmark. There is currently no literature on postsurgical pain in trans men after mastectomy. We aimed at investigating the prevalence and severity of postsurgical persistent pain, sensory disturbances, and complications in trans men after mastectomy. Methods: The 90 trans men who underwent bilateral mastectomy between September 1, 2013 and August 31, 2018 were included. Patients' files were evaluated for complications, and 84 (response rate 93.3%) patients answered a questionnaire (validated for women undergoing oncologic mastectomy) regarding persistent pain and sensory disturbances. Results: Twenty-three patients (27.4%) reported either unilateral or bilateral persistent pain after mastectomy. Of these, 14 (60.9%) patients categorized the pain as mild. However, 77 (95.2%) of the patients did not use analgesics and nonopioid pain medication was sufficient for the remainder. Sensory disturbances were found in 44 (47.5%) of the patients, and 4 (4.8%) patients reported clear signs of neuropathic pain. Seven (7.8%) patients developed hematomas, and areola necrosis was seen in four (4.4%) patients. Due to infection, seven (7.8%) patients received antibiotics. Conclusion: Mastectomy as a part of gender-affirming surgery is a safe procedure with a few, nonsevere, complications. Although a quarter of the patients experienced persistent pain, the majority of that pain is mild, intermittent and can be treated with nonopioid pain medication.

[Masculinizing mastectomy with nipple-areola graft autotransplantation for female-to-male transsexualism]

OBJECTIVE

To develop the method of masculinizing mammoplasty with nipple grafting female-to-male transsexuals with BMI >30 kg/m², large breast volume and severe ptosis.

MATERIAL AND METHODS

There were 114 mastectomies in 57 patients with nipple grafting technique. The methods of areola grafting and scar design were modified to improve aesthetic results. Inclusion criteria were BMI >30 kg/m², breast size B+ and severe ptosis (Regnault grade ≥2). Anonymous survey for evaluation of aesthetic outcome and quality of life was performed a year after surgery.

RESULTS

Postoperative complications included hematoma (5.2%), seroma (7.9%), tangential graft necrosis (9.6%), wound dehiscence (0.8%), ligature-induced inflammation (1.7%), scar hypertrophy (12.2%). Three patients (5.2%) developed nipple hypersensivity in long-term postoperative period. Three patients (5.2%) required redo urgent surgery for hematoma. Additional surgical correction of scar hypertrophy was performed in 4 patients (7%). In a year after surgery, patients rated aesthetic postoperative result as 4.45 out of 5 scores.

CONCLUSION

Masculinizing mammoplasty with areola autotransplantation is preferable for FtM transsexuals with large breast volume and severe ptosis. This surgery ensures a good aesthetic result with minimal secondary corrections and complication rate.

Improved Surgical Outcome with Double Incision and Free Nipple Graft in Gender Confirmation Mastectomy

Background:

Mastectomy and chest-wall contouring is the most common gender confirmation surgery. With increasing prevalence of transgender individuals, there is a demand for better surgical outcomes and aesthetic results. Our aim was to evaluate surgical techniques used and assess modifications in gender confirmation mastectomies at Karolinska University hospital in Stockholm, Sweden.

Methods:

A retrospective cohort study was performed on 464 patients undergoing gender confirmation mastectomies in our department between 2009 and 2018. Patient demographics, psychiatric comorbidity, surgical method, and outcome were analyzed. Follow-up was at least one year.

Results:

The most frequently used surgical technique for gender confirmation mastectomies was double incision with free nipple graft (243 patients, 52.4%), followed by periareolar incision (113 patients, 24.4%) and semicircular incision (67 patients, 14.4%). The double incision technique and periareolar technique were associated with 18.9% and 28.3% complications, 3.3% and 12.4% acute reoperations, 28.4% and 65.5% secondary revisions, respectively. The double incision technique increased from being used in 17.8% of all mastectomies during 2009–2013 to 62.9% during 2014–2018, while periareolar incision decreased from 43.0% to 18.5%.

Conclusions:

The current study describes a successful transition of surgical technique from periareolar incision to double incision with free nipple graft in gender confirmation mastectomy, leading to significant improvements in the overall outcome with fewer complications, less acute reoperations and less secondary corrections. Hence, we consider the double incision with free nipple graft technique to be the favored technique in the vast majority of cases in female-to-male chest wall contouring.

Feasibility, Safety, and Satisfaction of Combined Hysterectomy with Bilateral Salpingo-Oophorectomy and Chest Surgery in Transgender and Gender Non-Conforming Individuals

The demand for masculinizing breast surgery and hysterectomy with bilateral salpingo-oophorectomy (HBSO) from transmen has increased. With a multidisciplinary approach, these surgeries can be performed in a single session. The objective of this study was to retrospectively evaluate the feasibility, safety, and satisfaction of HBSO and chest surgery in transmen. A cohort of 142 subjects who underwent HBSO alone or combined with chest surgery at Sant’Orsola Hospital was analyzed. Intra and post operation events were evaluated. Subjective post-intervention satisfaction, acceptability, and impact of intervention were assessed via a semi-structured interview. Nineteen transmen underwent HBSO alone and 123 underwent combined surgery. HBSO was performed laparoscopically in 96.5% of transmen (137/142). As expected, length of hospital stay and blood loss were significantly higher in the combined surgery group. A total of 13 intra or post-operative complications occurred in the combined surgery group (10.5%) with thoracic hematoma being the most frequent complication (7.6%). Only one rare complication occurred in the HBSO group (omental herniation through a laparoscopic breach). The overall subjective satisfaction score was 9.9 out of 10 for both groups. Positive changes in all areas of life were reported, with no significant differences. We found that the combined surgery appears to be well tolerated, safe, and feasible in transmen and satisfaction with the combined procedure was high in all subjects.

Gender-Affirming Mastectomy in Transmasculine Patients: Does Obesity Increase Complications or Revisions?

BACKGROUND

Obesity can often be a barrier to gender-affirming top surgery in transmasculine patients because of concern for increased surgical site complications.

STUDY DESIGN

All adult patients (N = 948) within an integrated health care system who underwent gender-affirming mastectomy from 2013 to 2018 were retrospectively reviewed to evaluate the relationship between obesity and surgical site complications or revisions.

RESULTS

One third of patients (n = 295) had obese body mass index (BMI), and those patients were further stratified into obesity class I (BMI of 30-34.9 kg/m2, 9.4%), class II (BMI of 35-39.9 kg/m2, 8.9%), and class III (BMI of ≥40 kg/m2, 2.9%). A majority of patients across BMI categories underwent double incision surgery. There were no significant differences in complications or revisions between patients with obesity versus those with normal BMI, when BMI was treated as a categorical or continuous variable and when evaluating only patients who underwent double incision surgery.

CONCLUSIONS

Obesity alone should not be considered a contraindication for gender-affirming mastectomy. Attention should be given to several modifiable risk factors identified in this study, including lesser incision surgical techniques, tobacco use, and testosterone use. Further research is needed to understand risks associated with the highest BMI (≥40 kg/m2) patients and to assess patient satisfaction with surgical outcome.

Tips and Tricks in Gender-Affirming Mastectomy

SUMMARY

Gender-affirming mastectomy has become a highly sought-after procedure for the treatment of gender dysphoria and has been shown to improve quality of life in transgender and gender-nonbinary individuals. Aesthetic outcomes after double-incision mastectomy can be influenced by several factors; however, certain operative variables can be controlled to obtain aesthetic and reproducible results. Chest wall contour is arguably the most critical component of these procedures and requires highlighting the definition of the pectoralis muscle. Planning incisions within the inferior and lateral borders of the pectoralis major rather than the inframammary fold, and ensuring removal of all breast tissue in the lateral and medial chest and the axillary tail, will help obtain an aesthetically pleasing chest wall shape while concealing scars. Finally, attention to nipple resizing and repositioning inferiorly and laterally relative to the borders of the pectoralis muscle are critical to an aesthetic outcome. The authors have found that appropriate preoperative planning to control these three factors-(1) contour, (2) nipple position, and (3) scars-and critical analysis and adjustment of on-table results will help achieve the goals of creating an aesthetic and gender-congruent chest.

Quantifying the Psychosocial Benefits of Masculinizing Mastectomy in Trans Male Patients with Patient-Reported Outcomes: The University of California, San Francisco, Gender Quality of Life Survey

BACKGROUND

Gender-affirming surgery is a medically necessary treatment to alleviate gender dysphoria for transgender patients. Although previous studies suggest improved psychosocial outcomes after gender-affirming surgery, there are no transgender-specific instruments available to assess its effects on patient quality of life.

METHODS

Using qualitative methods, the authors developed the first quality-of-life survey, the University of California, San Francisco, Gender Quality of Life (UCSF Gender QoL) survey, for trans male patients undergoing gender-affirming mastectomy. The UCSF Gender QoL survey was then administered prospectively to 51 trans male patients undergoing inframammary mastectomy with free nipple grafting at the University of California, San Francisco. The brief version of the World Health Organization Quality of Life survey was also given as a measure of external validity. The Cronbach alpha was value calculated to measure internal validity.

RESULTS

Thirty-six patients completed surveys 6 weeks after surgery, and 22 patients completed surveys 1 year after surgery, for response rates of 71 percent and 43 percent, respectively. The UCSF Gender QoL survey detected a significant improvement in quality of life 6 weeks and 1 year after chest surgery. The effect sizes were large, and the Cronbach alpha exhibited excellent internal validity.

CONCLUSIONS

This study establishes the UCSF Gender QoL survey as one of the first patient-reported outcomes tools for evaluating quality of life in trans male patients after gender-affirming chest reconstruction. Although the study is limited by a small cohort at a single center, establishing the validity of the UCSF Gender QoL survey provides an invaluable tool for future research into various aspects of gender-affirming chest surgery.

Hockey stick incision: a modified technique for chest wall masculinization

Background

Chest wall masculinization is often performed for transgender men in order to address gender dysphoria. Peri-areolar and double-incision mastectomy with free nipple grafts, are the most common techniques employed in chest masculinization surgery, but are limited by their relative inconsistency and inefficiency in reconstructing a natural anterior contour that comprehensively resembles that of a cis-masculine chest. The purpose of this study is two-fold. The first is to describe the "hockey stick" approach, which expands on the widely performed double-incision mastectomy to the axilla, with an additional step of revising lateral chest wall folds of tissue excess. This technique is scalable to the degree of pre-operative excess tissue on the anterior and lateral chest wall. The second is to compare the "hockey stick" incision to existing reconstructive options, with respect to clinical outcomes and patient satisfaction.

Methods

Patients who received chest masculinization surgery at Yale-New Haven Hospital were included. A retrospective chart review, comprising demographic variables, procedural details, and post-operative events, was conducted. Selected modules from a validated survey instrument, the BODY-Q, were measured. Patients were classified by body mass index and incision, which included peri-areolar, inframammary fold, and "hockey stick" incision by date.

Results

Twenty-seven of 73 (37.0%) participants completed the full survey and were included in the analysis. The "hockey stick" incision had comparable patient satisfaction and post-operative outcomes, compared to peri-areolar and double-incision mastectomy with free nipple graft techniques. Greater BMI patients had a higher incidence of wound dehiscence, compared to other weight classifications.

Conclusions

The "hockey stick" incision is a readily performed, effective surgical technique for building a cis-masculine appearing chest in transgender men with efficient and predictable outcomes. While performed in patients with higher BMI, the "hockey stick" confers equivalent patient satisfaction and clinical outcomes to peri-areolar and double-incision mastectomy.

Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes

Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.

Transgender and Gender-nonbinary Patient Satisfaction after Transmasculine Chest Surgery

Supplemental Digital Content is available in the text.

Background:

Transmasculine chest surgery is the most common surgery performed in transmasculine patients, with high overall acceptance and low postoperative complication rates. Trends have shown clear improvement in quality of life and satisfaction. However, to the best of our knowledge, overall patient satisfaction after transmasculine chest surgery and associated factors are largely unknown. The aim of this study is to estimate the overall patient satisfaction in transgender men and nonbinary population after transmasculine chest surgery and to assess associated factors.

Methods:

A systematic review was conducted by searching literature in several databases. Meta-analyses of prevalence with a random-effect model for overall and subgroup prevalence were performed. Meta-regression, publication bias, and sensitivity analyses were conducted.

Results:

A total of 1052 transmasculine patients underwent any type of transmasculine chest surgery. The pooled overall postoperative satisfaction was 92% [95% confidence interval (CI) 88–96%]. In the subgroup metanalysis, patient satisfaction after periareolar mastectomy was 93% (CI 88%–97%) and after mastectomy with or without free nipple grafting was 90% (CI 84%–95%). Patient satisfaction for studies with mean follow-up >1 year was 91% (CI 83%–97%) and for mean follow-up of 1 year or less was 93% (CI 89%–96%).

Conclusions:

This study shows a high level of satisfaction in transmasculine chest surgery for both techniques, which remain stable over time. Also, our results show that this procedure impacts patient satisfaction beyond chest appearance and surgical outcomes. This corroborates its broad acceptance and the improvements in the standard of care, and decision-making approach.

Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth

OBJECTIVES

Transmasculine individuals, those assigned female sex at birth but who identify as masculine, have high rates of suicidal behavior and often suffer from chest dysphoria (discomfort and distress from unwanted breast development). Growing numbers of transmasculine youth are pursuing definitive treatment with masculinizing chest surgery (MCS), and adult studies reveal marked benefits of MCS, although little is known about the impact of chest dysphoria on transmasculine youth or the optimal timing of MCS. In this study, we aimed to explore youth experiences of chest dysphoria and the impact of MCS.

METHODS

Transmasculine youth aged 13 to 21 were recruited from a pediatric hospital-based gender clinic. Participants completed a semistructured qualitative interview exploring the experience of chest dysphoria and thoughts about or experiences with MCS. Interview transcripts were coded by 3 investigators employing modified grounded theory, with the median interrater reliability at κ = 0.92.

RESULTS

Subjects (N = 30) were a mean age of 17.5 years, and 47% had undergone MCS. Youth reported that chest dysphoria triggered strong negative emotions and suicidal ideation, caused a myriad of functional limitations, and was inadequately relieved by testosterone therapy alone. All post-MCS youth reported near or total resolution of chest dysphoria, lack of regret, and improved quality of life and functioning.

CONCLUSIONS

We observed consensus that chest dysphoria is a major source of distress and can be functionally disabling to transmasculine youth. MCS performed during adolescence, including before age 18, can alleviate suffering and improve functioning. Additional research is needed to develop patient-reported outcome measures to assess the impact of chest dysphoria and MCS.

The ideal location of the male nipple-areolar complex: A pinpointing algorithm

Background

In the treatment of gender dysphoria, appropriate nipple-areola complex (NAC) positioning is essential for achieving a natural appearing male chest after subcutaneous mastectomy. An accurate predictive model for the ideal personalized position of the NAC is still lacking. The aim of this study is to determine the anthropometry of the male chest to create individualized guidelines for appropriate NAC positioning in the preoperative setting.

Materials and methods

Cisgender male participants were recruited. Multiple chest measurements were manually recorded. Best subset regression using linear models was used to select predictors for the horizontal coordinate (nipple-nipple distance; NN) and vertical coordinate (sternal notch-nipple distance; SNN) of the NAC. Internal validation was assessed using bootstrapping. Furthermore, a cohort of transgender men who had received a mastectomy with replantation of nipples according to current practice was identified. Comparison testing between the algorithm and standard practice was performed to test the limitations of standard practice.

Results

One hundred and fifty cis male participants were included (median age: 26, IQR: 22-34 years). Four predictors were found to predict NN (age, weight, chest circumference (CC), anterior-axillar fold to anterior-axillar fold (AUX-AUX)) and reads as follows: NN = 4.11 + 0.035*age + 0.041*weight + 0.093*CC + 0.140*AUX-AUX Two predictors were found to predict SNN (NN and weight), and reads as follows: SNN = 7.248 + 0.303*NN + 0.072*weight. Both models performed well (Bootstrapped R2: 0.63 (NN), 0.50 (SNN)) and outperformed previous models predicting NAC position. Ninety-six transgender men were eligible for evaluation of current practice and showed an average placement error of -0.9 cm for NN and +2.2 cm for SNN.

Conclusion

The non-standardized approach of NAC repositioning results in a significant error of nipple placement. We suggest that the two predictive models for NN and SNN can be used to optimize NAC positioning on the masculinized chest wall.

Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1884926.

Power-assisted Liposuction and a Single Incision Pull-through Technique for Top Surgery: A Case Report

Various treatment approaches exist for female-to-male subcutaneous mastectomy, also known as “top surgery.” The most commonly performed techniques for patients with decreased volume of breast tissue, no ptosis, and good skin elasticity continue to involve areolar or periareolar incision. Here, we report a case of a 17-year-old patient who underwent top surgery performed through power-assisted liposuction and a non-areolar single-incision “pull-through” technique. Operative management included initial liposuction for contouring of adipose tissue. Surgical subcision of excess breast tissue adherent to the subdermal plane was then performed and removed with a grasp-and-pull motion using the pull-through technique. We obtained a favorable result with low scar burden, preserved nipple sensation, and no nipple contracture. No complications were reported. This procedure is limited for patients with small breast size (A cup, <100 grams of glandular tissue per side), minimal to no ptosis, appropriate nipple size and position, soft fibroglandular tissue, and good skin elasticity.

New Algorithm for Chest-wall Surgery and Quality of Life Assessment in Female-to-male Reassignment Patients

Background:

Chest-wall contouring surgery (chest-wall reconstructive surgery) is often the first surgical procedure in female-to-male (FtM) gender reassignment surgery (GRS). The main goal of this procedure is to create an aesthetically pleasing male-like chest contour. No universally accepted algorithm exists for detection of the appropriate surgical technique. Also, there is no tool for objective evaluation of the quality of life and satisfaction of these patients after the operation.

Methods:

This study involves a single-center clinical trial assessing the patients who underwent subcutaneous mastectomy in FtM GRS between 2003 and 2019. The selection of patients was based on the new “simplified” algorithm consisting of 2 different surgical techniques: the semicircular and the double-incision with free nipple grafting. The selection was based on 3 criteria: breasts size, breast ptosis, and skin elasticity. The outcomes and complication rates were collected and analyzed. The patients’ satisfaction and Quality of Life was assessed with a 5-point Likert scale questionnaire, specifically conceived for FtM patients. The aesthetic evaluation was performed using a 5-point Likert scale dealing with the 5 items featuring as the main goals of GRS.

Results:

184 mastectomies were performed in 92 FtM GRS patients. The overall reoperation rate was 11.9%. The patient survey revealed both a high satisfaction rate and a good aesthetic result (4.4/5).

Conclusions:

The proposed algorithm facilitates the selection of the most suitable technique for top surgery. The patient satisfaction rate evaluated by the proposed Health-Related Quality of Life questionnaire confirmed the outcomes of the use of the algorithm. Further studies to validate the proposed evaluating tools are needed.

Female-to-Male Transgender Chest Contouring: A Systematic Review of Outcomes and Knowledge Gaps

PURPOSE

The number of gender affirmation surgeries performed in the United States is increasing. Frequently, chest contouring is the first surgery for female-to-male transgender patients; it fosters assimilation into the new gender role with a desired sense of masculinity. Creating an aesthetic male chest requires adjustment of breast tissue volume, proper nipple-areolar complex placement, and abolishment of the inframammary fold. Although much has been published on various techniques and outcomes, there is no consensus on how to approach transmale top surgery. We have reviewed the most up-to-date literature and in so doing have uncovered significant knowledge gaps.

METHODS

An electronic literature review was performed. PubMed search keywords included combinations of "female-to-male," "transgender surgery," "chest contour," and "nipple-areolar complex." Articles were included if the patients were transgender female to male.

RESULTS

Our literature search yielded 67 unique articles, 22 of which met our inclusion criteria. A total of 2447 unique patients were analyzed. The articles discussed aspects of chest surgery in female-to-male transsexuals including mastectomy and nipple aesthetics. Relevant data trends were extracted and subsequently investigated.

DISCUSSION

Female-to-male transgender patients often undergo chest contouring as their initial gender affirmation surgery. As the surgical treatment of gender dysphoria continues to grow, it is imperative for plastic surgeons to understand the surgical options and associated outcomes for transmasculine top surgery. Future research is needed to improve patient selection, surgical decision making, and patient-reported outcomes for different chest contouring techniques. In addition, there is a significant knowledge gap for the ideal nipple-areolar complex shape, size, and location.