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Kanjoor JR, Khan TM. Chest Feminization in Transwomen with Subfascial Breast Augmentation-Our Technique and Results. Aesthetic Plast Surg 2024; 48:2447-2458. [PMID: 37945759 DOI: 10.1007/s00266-023-03726-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The increasing population of this minority community is approaching plastic surgeons more frequently to achieve their dream of becoming a phenotypic female, the breast being the single sure identity. After undergoing the bottom surgery (SRS) which is essential for them to gain entry into the transgender community, very few take up hormone therapy; the rest approach plastic surgeons for chest feminization which includes breast augmentation. METHODS A total of 177 transgenders underwent subfascial breast augmentation between 2014 and 2023. They were followed up for 10 years. Their demographics were documented. Operative details and postoperative complications were analyzed. Patient-related outcome measures were performed for size, appearance and cleavage. RESULTS A well-performed surgery in our cohort had a good aesthetic outcome even after many years. Only three patients were dissatisfied with the size; revision surgeries of 12 patients done elsewhere had many complications like wound dehiscence and exposure, scar hypertrophy, low placed axillary scars, capsular contracture, asymmetry, and nonspecific pain. All of them had submuscular placement. CONCLUSIONS The subfascial placement of implants in transwomen had good aesthetic outcomes with fewer complications and good acceptance. 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 .
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McLaughlin MF, Rosser M, Song S, Mehta N, Terry MJ, Kim EA. Evaluating Access and Outcomes in Gender-affirming Breast Augmentation: A Comparative Study of a County Hospital and an Academic Center. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5972. [PMID: 39015360 PMCID: PMC11249717 DOI: 10.1097/gox.0000000000005972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/14/2024] [Indexed: 07/18/2024]
Abstract
Background Research on the diverse patient population undergoing gender-affirming breast augmentation remains scarce. We compared patients undergoing this procedure at San Francisco General Hospital (ZSFG), a county hospital, and the University of California, San Francisco (UCSF), an academic medical center. Methods This was a retrospective cohort study of patients who underwent primary gender-affirming breast augmentation at ZSFG (August 2019 to June 2023) and UCSF (March 2015 to June 2023). Differences in sociodemographic characteristics, surgical access, and outcomes between sites were assessed. Results Of 195 patients, 122 patients had surgery at UCSF and 73 patients at ZSFG. ZSFG patients were more likely to be unstably housed (P < 0.001), Spanish-speaking (P = 0.001), and to have obesity (P = 0.011) and HIV (P = 0.004). Patients at ZSFG took hormones for longer before surgical consultation (P < 0.001) but had shorter referral-to-surgery intervals (P = 0.024). Patients at ZSFG more frequently underwent a subglandular approach (P = 0.003) with longer operative times (P < 0.001). Major surgical complications were uncommon (2.1%) with no differences between sites. Aesthetically, implant malposition/rotation occurred more often in patients at UCSF (P = 0.031), but revision rates were similar at both sites. Patients at UCSF had longer follow-up periods (P = 0.008). Conclusions County hospital patients seeking gender-affirming breast augmentation have distinct sociodemographic profiles and more comorbidities than academic medical center patients. County patients might experience greater barriers that delay surgical eligibility, such as stable housing. Nevertheless, this procedure can be safely and effectively performed in both patient populations.
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Affiliation(s)
- Matthew F. McLaughlin
- From the School of Medicine, University of California, San Francisco, San Francisco, Calif
| | - Mica Rosser
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
| | - Siyou Song
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
| | - Nina Mehta
- School of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, N.C
| | - Michael J. Terry
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
| | - Esther A. Kim
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
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3
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Liu C, Shahid M, Yu Q, Orra S, Ranganath B, Chao JW. Complications following Breast Augmentation in Transfeminine Individuals: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2024; 153:1240-1251. [PMID: 37189242 DOI: 10.1097/prs.0000000000010691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Breast augmentation is the most commonly performed procedure for gender affirmation in transfeminine individuals. Although adverse events among breast augmentation in cisgender women are well described, their relative incidence in transfeminine patients is less elucidated. This study aims to compare complication rates after breast augmentation between cisgender women and transfeminine patients and to evaluate the safety and efficacy of breast augmentation in transfeminine individuals. METHODS PubMed, the Cochrane Library, and other resources were queried for studies published up to January of 2022. A total of 1864 transfeminine patients from 14 studies were included in this project. Primary outcomes including complications (capsular contracture, hematoma or seroma, infection, implant asymmetry/malposition, hemorrhage, skin or systemic complications), patient satisfaction, and reoperation rates were pooled. A direct comparison of these rates was performed against historical rates in cisgender women. RESULTS Within the transfeminine group, the pooled rate of capsular contracture was 3.62% (95% CI, 0.0038 to 0.0908); the hematoma/seroma rate was 0.63% (95% CI, 0.0014 to 0.0134); the infection incidence was 0.08% (95% CI, 0.0000 to 0.0054); and implant asymmetry rate was 3.89% (95% CI, 0.0149 to 0.0714). There was no statistical difference between rates of capsular contracture ( P = 0.41) and infection ( P = 0.71) between the transfeminine versus cisgender groups, whereas there were higher rates of hematoma/seroma ( P = 0.0095) and implant asymmetry/malposition ( P < 0.00001) in the transfeminine group. CONCLUSION Breast augmentation is an important procedure for gender affirmation and, in transfeminine individuals, carries relatively higher rates of postoperative hematoma and implant malposition relative to cisgender women.
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Affiliation(s)
- Chenyu Liu
- From the George Washington University School of Medicine and Health Sciences
| | | | - Qian Yu
- University of Chicago Medical Center
| | - Susan Orra
- Department of Plastic Surgery, Georgetown University
| | - Bharat Ranganath
- From the George Washington University School of Medicine and Health Sciences
| | - Jerry W Chao
- From the George Washington University School of Medicine and Health Sciences
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Sanchez Figueroa N, Kuruoglu D, Fahradyan V, Tran N, Sharaf B, Martínez-Jorge J. Feminizing Gender Affirming Breast Surgery: Procedural Outcomes at a Single Academic Institution. Aesthet Surg J Open Forum 2024; 6:ojae032. [PMID: 38813116 PMCID: PMC11134292 DOI: 10.1093/asjof/ojae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Background Implant-based breast augmentation is a gold standard procedure for transfeminine patients to create a more feminine-appearing chest. In many cases, ancillary procedures are performed simultaneously to achieve an optimal aesthetic result. Objectives To determine the clinical outcomes of patients undergoing feminizing gender-affirming breast surgery in a single academic institution. Methods A retrospective electronic chart review of feminizing gender-affirming breast surgery patients at Mayo Clinic, Rochester, from 2017 to 2022 was conducted. Patients' demographics and surgical outcomes were gathered. A survival analysis was performed to obtain the time-to-event complication rate. Results Over 5 years, 46 patients (92 breasts) were included. The mean age was 39 years (standard deviation [SD] ±15), and most had an above-normal body mass index (BMI) (58.7%). Thirty (65%) had previous gender-affirming surgeries. The mean implant volume was 289 mL (SD ±95; 140-520). Most implants were placed in a subglandular plane (81%) with an inframammary fold incision (91.3%). All implants used were smooth, round cohesive silicone gel implants. Ancillary procedures were performed in 32 patients (69.57%). Eight patients presented complications (4 major vs 4 minor) in a median postoperative follow-up of 372 vs 392 days; at 1-month follow-up, the probability of a complication having occurred is 2.17% (95% CI: 0%-6.3%) vs 5% (95% CI: 0%-11.5%), and at 1 year, the probability is 10.21% (95% CI: 0%-20.9%) vs 12.5% (95% CI: 0%-23.4%), which remains the same up to 4 years. Conclusions Breast augmentation with implants is a safe procedure to achieve feminization of the breast with a low rate of complications. Level of Evidence 4
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Affiliation(s)
| | | | | | | | | | - Jorys Martínez-Jorge
- Corresponding Author: Dr Jorys Martinez-Jorge, 200 1st Street SW, Rochester, MN 55905, USA. E-mail:
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Berger LE, Lava CX, Spoer DL, Huffman SS, Martin T, Bekeny JC, Fan KL, Lisle DM, Del Corral GA. The Effect of Obesity on Vaginoplasty Outcomes. Ann Plast Surg 2024; 92:447-456. [PMID: 38319959 DOI: 10.1097/sap.0000000000003808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. METHODS A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. RESULTS A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). CONCLUSIONS Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.
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Affiliation(s)
| | | | | | | | - Taylor Martin
- Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Kenneth L Fan
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - David M Lisle
- Division of Colorectal Surgery, Department of General Surgery, MedStar Franklin Square Medical Center, Baltimore, MD
| | - Gabriel A Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, DC
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Knoedler S, Knoedler L, Geldner B, Ghanad I, Kim BS, Alfertshofer M, Machens HG, Broer PN, Pomahac B, Kauke-Navarro M, Paik AM. Isolated and combined breast augmentation in transgender patients: Multi-institutional insights into early outcomes and risk factors. J Plast Reconstr Aesthet Surg 2024; 90:149-160. [PMID: 38367411 DOI: 10.1016/j.bjps.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/23/2024] [Accepted: 01/29/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The increasing demand for gender-affirming surgery (GAS) in transgender and gender-diverse healthcare highlights the importance of breast augmentation surgery (BAS) for transfeminine patients. Despite its significance, there is a lack of research on postoperative outcomes of BAS. METHODS We analyzed the multi-institutional American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) (2008-2021) database to identify female transgender individuals (TGIs) who underwent BAS surgery, both isolated and combined with concurrent GAS procedures. We evaluated 30-day outcomes, including the incidence of mortality, reoperation, readmission as well as surgical and medical complication occurrence. RESULTS Of 1699 female TGIs, 92% underwent isolated BAS and 7.7% underwent combined BAS. The mean age and body mass index (BMI) were 36 ± 12 years and 27 ± 6.6 kg/m2, respectively. Isolated BAS showed a 2.8% complication rate, while combined BAS had a higher rate with 9.1%. Specifically, all complications occurred in patients undergoing BAS with concurrent genitourinary surgery (n = 85; 14%), whereas no adverse events were recorded after combined BAS and facial feminization (n = 19) or chondrolaryngoplasty (n = 19). In patients seeking combined BAS, advanced age (p = 0.05) and nicotine abuse (p = 0.004) were identified as risk factors predisposing to adverse events, whereas American Society of Anesthesiology class 1 was found to be protective (p = 0.02). CONCLUSIONS Isolated BAS in TGIs demonstrates a positive safety profile. Combined surgeries, particularly with genitourinary procedures, pose higher risks. Identifying risk factors such as smoking and advanced age is crucial for patient selection and surgical planning. These findings can aid in refining patient eligibility and inform surgical decision-making for BAS.
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Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA; Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Benedikt Geldner
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Iman Ghanad
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany.
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Angie M Paik
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
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Simion L, Petrescu I, Chitoran E, Rotaru V, Cirimbei C, Ionescu SO, Stefan DC, Luca D, Stanculeanu DL, Gheorghe AS, Doran H, Dogaru IM. Breast Reconstruction following Mastectomy for Breast Cancer or Prophylactic Mastectomy: Therapeutic Options and Results. Life (Basel) 2024; 14:138. [PMID: 38255753 PMCID: PMC10821438 DOI: 10.3390/life14010138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.
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Affiliation(s)
- Laurentiu Simion
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | | | - Elena Chitoran
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Vlad Rotaru
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Ciprian Cirimbei
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Sinziana-Octavia Ionescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Daniela-Cristina Stefan
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.-C.S.); (D.L.S.); (A.S.G.)
| | - Dan Luca
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Dana Lucia Stanculeanu
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.-C.S.); (D.L.S.); (A.S.G.)
- Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Adelina Silvana Gheorghe
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.-C.S.); (D.L.S.); (A.S.G.)
- Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Horia Doran
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- Surgical Clinic I, Clinical Hospital Dr. I. Cantacuzino, 030167 Bucharest, Romania
| | - Ioana Mihaela Dogaru
- Department of Plastic Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Plastic Surgery, Emergency University Hospital, 050098 Bucharest, Romania
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Torres Perez-Iglesias CA, Heyman A, Koh DJ, Medina N, Roh DS, Slama J. Technical and Clinical Differences Between Transgender and Cisgender Females Undergoing Breast Augmentation. Ann Plast Surg 2023; 91:534-539. [PMID: 37823620 DOI: 10.1097/sap.0000000000003706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Gender-affirming surgery is a quickly expanding field. However, it is facing a shortage of specialized surgeons for a population exceeding 1.4 million individuals. Many studies comparing outcomes between cisgender and transgender patients fail to describe the technical differences of the operation. Breast augmentation in the transgender female patient involves important anatomical, technical, and clinical features that differ from the cisgender female. In this study, we aimed to describe and compare these characteristics between these 2 groups to better inform the new generation of gender-affirming surgeons. METHODS A retrospective cohort study of patients who underwent primary breast augmentation between 2009 and 2019 at a specialized tertiary center for transgender care was performed. Mastopexy, secondary augmentation, and reconstructive procedures were excluded. Demographic, operative, and clinical data were collected from medical records. All patients had a minimum of 1 year of follow-up after the initial surgery. Bivariate analysis was performed. RESULTS A total of 250 cisgender females and 153 transgender females were included. The transgender group showed higher rates of smoking ( P < 0.0001), immunosuppression ( P < 0.0001), obesity ( P < 0.0001), mental health disorders ( P < 0.0001), and hypertension ( P = 0.002). Median base width ( P < 0.0001), sternal notch to nipple distance ( P < 0.0001), and implant size (500 mL [interquartile range, 425-600 mL] vs 350 mL [interquartile range, 325-385 mL]; P < 0.0001) were larger in transgender patients. Transgender patients also demonstrated a stronger correlation between implant size and body surface area ( r = 0.71, P < 0.0001). Readmission, reoperation, and complication rates were similar between the groups; however, transgender females had a higher incidence of surgical site infections (3.9% vs 0.4%, P < 0.013). Capsular contracture was the most common complication and indication for reoperation in both groups. CONCLUSIONS There are important anatomical, clinical, and technical differences between reconstructive gender-affirming breast augmentation in transgender female patients and cosmetic breast augmentation in the cisgender female. The gender-affirming surgeon must know these differences to provide the best quality of care and help patients achieve better congruence between their gender identity and body image.
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Affiliation(s)
| | | | | | - Nilton Medina
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Daniel S Roh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Jaromir Slama
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
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Chartier R, Herlin C, Sinna R. [Thoracic reassignment surgeries]. ANN CHIR PLAST ESTH 2023; 68:436-445. [PMID: 37596145 DOI: 10.1016/j.anplas.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/23/2023] [Indexed: 08/20/2023]
Abstract
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.
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Affiliation(s)
- R Chartier
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Nord, CHU Amiens Picardie, 80054 Amiens cedex 1, France
| | - C Herlin
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Lapeyronie, CHRU de Montpellier, 34295 Montpellier, France
| | - R Sinna
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Nord, CHU Amiens Picardie, 80054 Amiens cedex 1, France.
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10
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Chun Fat S, Ray E. Gender-affirming microvascular breast reconstruction. Gland Surg 2023; 12:982-988. [PMID: 37727344 PMCID: PMC10506111 DOI: 10.21037/gs-23-133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 09/21/2023]
Abstract
Gender-affirming surgery (GAS), including breast feminization, is requested and performed with increasing frequency. Transgender women may seek chest feminization surgery to address gender dysphoria, and such procedures have been shown to increase psychosocial and sexual well-being. Despite the potential effects of hormone therapy and androgen blockade on breast development, the results of glandular growth in adult transgender women are typically disappointing and are often inadequate to achieve the patient's goals. When evaluating options for breast construction, an implant-based approach meets the needs of most patients. However, patient choice, implant complications, acquired and congenital alterations of chest anatomy and the unique challenges of feminizing a natal male chest occasionally require consideration of other options. We review the few cases of gender-affirming breast reconstruction using autologous tissue published in the literature and summarize the senior author's approach and technique. We also review two cases of autologous chest feminization by the senior author. Ultimately, while implant-based reconstruction should continue to be the default procedure and offered to the majority of patients, several factors need to be considered when determining the optimal approach to breast feminization for a given patient. In patients with congenital or acquired deformities or a variety of factors where a reasonable outcome cannot be achieved with implants, autologous reconstruction should remain an option.
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Affiliation(s)
- Shelby Chun Fat
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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11
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Sehgal I. Review of adult gender transition medications: mechanisms, efficacy measures, and pharmacogenomic considerations. Front Endocrinol (Lausanne) 2023; 14:1184024. [PMID: 37476490 PMCID: PMC10355117 DOI: 10.3389/fendo.2023.1184024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/16/2023] [Indexed: 07/22/2023] Open
Abstract
Gender dysphoria is the imparity between a person's experienced gender and their birth-assigned gender. Gender transition is the process of adapting a person's sexual characteristics to match their experienced gender. The number of adults receiving sex hormone therapy for gender dysphoria is increasingly and these pharmacotherapies are increasing being prescribed in a general practice setting. The role of hormone therapy is to reverse or reduce physical sexual characteristics of the birth-assigned gender and enhance and build characteristics aligning to the expressed gender and these therapies apply to both transgender and gender nonconforming patients. Recognizing the options and interpreting the effects of gender transition therapies are fundamental to the discussion and treatment of gender dysphoria. This review summarizes pharmacodynamics, comparative dosing, adverse effects, monitoring, and potential pharmacogenetic influence of current pharmacotherapy. These include the use of 17-beta-estradiol, spironolactone, testosterone, GnRH agonists as well as adjunctive phosphodiesterase-5 inhibitors. The article also addresses gaps within the published literature including optimal routes of administration for individual patients, risks of malignancy and dosing reductions as transgender patients age.
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Affiliation(s)
- Inder Sehgal
- Department of Biomedical Sciences, Rocky Vista University, Ivins, UT, United States
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12
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Hu AC, Liu MT, Chan CH, Gupta S, Dang BN, Ng GY, Litwin MS, Rudkin GH, Weimer AK, Lee JC. Gender Affirming Surgery in Nonbinary Patients: A Single Institutional Experience. Arch Plast Surg 2023; 50:63-69. [PMID: 36755659 PMCID: PMC9902078 DOI: 10.1055/s-0042-1758383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/30/2022] [Indexed: 02/09/2023] Open
Abstract
Background An increasing number of nonbinary patients are receiving gender-affirming procedures due to improved access to care. However, the preferred treatments for nonbinary patients are underdescribed. The purpose of this study was to investigate the goals and treatments of nonbinary patients. Methods A retrospective study of patients who self-identified as nonbinary from our institutional Gender Health Program was conducted. Patient demographics, clinical characteristics, surgical goals, and operative variables were analyzed. Results Of the 375 patients with gender dysphoria, 67 (18%) were nonbinary. Over half of the nonbinary patients were assigned male at birth ( n = 57, 85%) and nearly half preferred the gender pronoun they/them/theirs ( n = 33, 49%). A total of 44 patients (66%) received hormone therapy for an average of 2.5 ± 3.6 years, primarily estrogen ( n = 39). Most patients ( n = 46, 69%) received or are interested in gender-affirming surgery, of which, almost half were previously on hormone therapy ( n = 32, 48%). The most common surgeries completed or desired were facial feminization surgery ( n = 15, 22%), vaginoplasty ( n = 15, 22%), mastectomy ( n = 11, 16%), and orchiectomy ( n = 9, 13%). Nonbinary patients who were assigned male at birth (NB-AMAB) were more often treated with hormones compared to nonbinary patients assigned female at birth (NB-AFAB) (72% vs. 30%, p = 0.010). Conversely, patients who were AFAB were more likely to complete or desire surgical intervention than those who were AMAB (100% vs. 63.0%, p < 0.021). Conclusion Majority of nonbinary patients were assigned male at birth. NB-AFAB patients all underwent surgical treatment, whereas NB-AMAB patients were predominantly treated with hormone therapy.
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Affiliation(s)
- Allison C. Hu
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Mengyuan T. Liu
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Candace H. Chan
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Saloni Gupta
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Brian N. Dang
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Gladys Y. Ng
- Department of Urology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Mark S. Litwin
- Department of Urology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - George H. Rudkin
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Amy K. Weimer
- UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Justine C. Lee
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,Address for correspondence Justine C. Lee, MD, PhD, FACS Division of Plastic and Reconstructive Surgery, University of CaliforniaLos Angeles, 200 Medical Plaza, Suite 460, Los Angeles, CA 90095-6960
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13
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Zhu A, Callori S, Boonipat T, Hebel N, Jorge-Martinez J. Examining the Impact of Breast Augmentation vs Hormone Therapy on Chest Femininity of Transgender Women. Aesthet Surg J 2023; 43:NP114-NP121. [PMID: 36342750 DOI: 10.1093/asj/sjac288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND For transgender women, there is often the innate assumption that surgical breast augmentation will increase perceived chest femininity beyond hormone therapy alone. OBJECTIVES This study aimed to evaluate whether lay individuals found surgically augmented breasts more feminine than breast development from hormone replacement therapy alone in transgender patients. METHODS We obtained preoperative (maximal breast growth on hormone therapy) and postoperative chest (after primary augmentation) images of 22 transgender patients, and age- and BMI-matched cisgender male (n = 17) and female (n = 21) control patients. Survey respondents (n = 271) rated each image on a scale of 1 (very feminine) to 5 (very masculine). Results were compared by survey respondent gender identity and sexual orientation. RESULTS There was a significant difference in mean femininity score between all image types. Mean score for transgender patients fell by 0.478 points after surgery (P < .0001). Subgroup analysis looking at transgender participants revealed the same significance trend postoperatively. Transgender respondents also found no difference in femininity between female controls and postoperative transgender patients (P = .132). We also compared mean femininity scores across 4 self-identified respondent subgroups: cisgender and heterosexual, cisgender and lesbian, gay, or bisexual (LGB), transgender and heterosexual, and transgender and LGB. The cisgender and heterosexual subgroup rated the postoperative transgender patients more feminine than any of the other respondent subgroups (LGB P < .001, transgender and LGB P < .001, transgender only P = .018). CONCLUSIONS This study shows that breast augmentation significantly increased the perception of femininity. Furthermore, gender identity and sexual orientation are important in how lay persons perceive transgender patients. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Agnes Zhu
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | | | | | - Nathan Hebel
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
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14
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Kamali A, Sackey H, Gran I, Sigurjónsson H, Farnebo F, Lundgren K, Granath F, Sommar P. Implant Attributes or Patient Characteristics? Factors Affecting Outcome after Breast Augmentation in Transgender Women. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4645. [PMID: 37731908 PMCID: PMC10508468 DOI: 10.1097/gox.0000000000004645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/02/2022] [Indexed: 09/22/2023]
Abstract
Implant-based breast augmentation is a valuable tool for treatment of gender dysphoria in transgender women. The aim was to assess whether implant attributes, plane selection, and patient characteristics had an impact on the surgical outcome, and to compare these parameters between transgender and cisgender breast augmentations. Methods A cohort of transgender women who underwent breast augmentation at our department during 2009-2018 were retrospectively studied. The cohort was also compared with a cohort of 12,884 mainly cisgender women registered in the Swedish breast implant registry (BRIMP) during 2014-2019. Results A total of 143 transgender individuals were included, with a median follow-up of 5.7 years. Complications occurred in 20 patients (14.0%), four patients (2.8%) underwent acute reoperation, and 20 patients (14.0%) had secondary corrections. No differences were seen in complication rates when comparing prepectoral with subpectoral placement (15.1% versus 12.9%; P = 0.81); size, less than 400 mL versus greater than or equal to 400 mL (14.7% versus 13.3%; P = 0.81), or the shape of the implants, round versus anatomic (10.7% versus 22.2%; P = 0.10). In comparison with the cohort from BRIMP, the transgender cohort had more round implants (72.0% versus 60.7%; P < 0.01), larger implants (44.1% had volumes of 400-599 mL, compared with 25.4%; P < 0.0001), and more prepectoral placement (51.0% versus 7.3%; P < 0.0001). The risk of reoperation less than 30 days was 1.2% in BRIMP and 2.8% in the transgender cohort (P = 0.08). Conclusions In transgender women, implants are often larger, round, and placed prepectoral' compared with cisgender women. Despite these differences, complication rates were equivalent. Implant attributes, surgical techniques, and patient characteristics were not independently associated with the rate of complications.
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Affiliation(s)
- Alexander Kamali
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Akademiskt Centrum Plastikkirurgi, Department of Plastic Surgery, Stockholm, Sweden
| | - Helena Sackey
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Isak Gran
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Hannes Sigurjónsson
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Filip Farnebo
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Kalle Lundgren
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Granath
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Pehr Sommar
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
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15
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Schoffer AK, Bittner AK, Hess J, Kimmig R, Hoffmann O. Complications and satisfaction in transwomen receiving breast augmentation: short- and long-term outcomes. Arch Gynecol Obstet 2022; 305:1517-1524. [PMID: 35597817 PMCID: PMC9166844 DOI: 10.1007/s00404-022-06603-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND To achieve long-term improvement in health care of transgender women, it is necessary to analyze all aspects of gender-confirming surgery, especially the relation of risks and benefits occurring in these procedures. While there are many studies presenting data on the urologic part of the surgery, there are just few data about complications and satisfaction with breast augmentation. METHODS This is a retrospective study using parts of the BREAST-Q Augmentation Questionnaire and additional questions for symptoms of capsular contracture and re-operations and analyzing archived patient records of all transwomen which were operated at University Hospital Essen from 2007 to 2020. RESULTS 99 of these 159 patients (62%) completed the questionnaire after a median time of 4 years after surgery. Breast augmentation led to re-operations due to complications in 5%. The rate of capsular contracture (Baker Grad III-IV) in this population was 3%. Most patients (75%) rated high scores of satisfaction with outcome (more than 70 points) and denied to have restrictions due to their implants in their everyday life. All patients reported an improvement in their quality of life owing to breast augmentation. CONCLUSION Breast augmentation by inserting silicon implants is a safe surgical procedure which takes an important part in reducing gender dysphoria.
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Affiliation(s)
- A K Schoffer
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
| | - A K Bittner
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - J Hess
- Department of Urology, University Hospital Essen, Essen, Germany
| | - R Kimmig
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - O Hoffmann
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
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16
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Clennon EK, Martin LH, Fadich SK, Zeigen L, Blasdel G, Sineath C, Dy GW. Community Engagement and Patient-Centered Implementation of Patient-Reported Outcome Measures (PROMs) in Gender Affirming Surgery: a Systematic Review. CURRENT SEXUAL HEALTH REPORTS 2022. [DOI: 10.1007/s11930-021-00323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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17
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Pretterklieber B, Metka S, Klöppel M, Pretterklieber ML. Extramuscular and Intramuscular Course of the Nerve Innervating the Abdominal Part of the Pectoralis Major Muscle: An Anatomical Study with Regard to Transaxillary Endoscopic Subpectoral Breast Augmentation. Plast Reconstr Surg 2022; 149:410e-416e. [PMID: 35196672 DOI: 10.1097/prs.0000000000008814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND During transaxillary endoscopic subpectoral breast augmentation, the innervation of the abdominal part of the pectoralis major muscle can be injured. The question has been raised whether this could even be of value, as for a better result, the caudal fibers of the pectoralis major muscle have to be detached from their origin. The authors' aim was to identify the exact position and the intramuscular course and target of these nerve branches. METHODS Fifty pectoralis major muscles and their supplying nerve branches from 27 formalin-fixed anatomical specimens were studied using macroscopic dissection and anthropometry. Furthermore, eight muscles underwent the modified Sihler procedure to determine the intramuscular course and target of the supplying nerve branches. RESULTS The branches for the abdominal part of the pectoralis major muscle pierced the pectoralis minor muscle or coursed around its lower border 3.2 to 8.4 cm from the tip of the coracoid process. Within the muscle, at least one small nerve branch, innervating the abdominal part, ascended into the lowermost portion of the sternocostal head, and anastomosed with the lowest small branch of its supplying nerve branches. CONCLUSIONS Because of the variable position of the nerve branches, they may often cross the operative field during transaxillary endoscopic breast augmentation. However, their interruption can be of value, because weakening of the lower part of the pectoralis major muscle is desired to keep the implant in place, and to avoid animation deformity.
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Affiliation(s)
- Bettina Pretterklieber
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
| | - Susanne Metka
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
| | - Markus Klöppel
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
| | - Michael L Pretterklieber
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
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18
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Patel H, Samaha Y, Ives G, Lee TY, Cui X, Ray E. Chest Feminization in Male-to-Female Transgender Patients: A Review of Options. Transgend Health 2022; 6:244-255. [PMID: 34993297 DOI: 10.1089/trgh.2020.0057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.
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Affiliation(s)
- Harsh Patel
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Yasmina Samaha
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Graham Ives
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Tian-Yu Lee
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Xiaojiang Cui
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Edward Ray
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
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19
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Wilhelmus Timmermans F, Elisabeth Mokken S, Scheffers B, Bouman MB, Mullender M, van de Grift T. An anthropometric evaluation of the augmented breast: differences between cis-and transgender women and possible clinical implications. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01856-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Background
The morphometric results after breast augmentations are generally understood to be clinically different between trans(gender) and cis(gender) women. The objective of this study was to establish these morphometric differences between the augmented breasts of trans and cis women and their implications for preoperative planning and expectation management of trans women.
Methods
A single-center, observational cross-sectional study was conducted. Three-dimensional images (VECTRA) of the chest were taken and used to measure preset morphometric parameters. Subsequently, several proportional morphometric outcome variables were calculated. We compared body, breast, and nipple dimensions and their interdependence between trans and cis women. The main outcome sets were (1) the relative dimensions of the chest, (2) the position of the breasts relative to the chest, (3) and the position of the nipple relative to the breast and nipple size.
Results
A total of 22 transgender and 22 cisgender women were included. The results showed that the breasts of the trans women were positioned more cranial. Furthermore, the nipple-areola complexes (NAC) were significantly smaller and positioned relatively more latero-cranial on the breasts.
Conclusions
Morphological characteristics of augmented breasts differ significantly between trans and cis women. The results of this study identified distinct differences between the augmented breasts of trans and cis women. Because of the apparent differences in results, surgical considerations, expectation management, and shared decision-making should play an even more pronounced role in breast augmentations in trans women.
Level of evidence: Level III, risk/prognostic study.
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20
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Martin SA, Patel V, Morrison SD, Kahn D, Satterwhite T, Nazerali R. Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze? Aesthetic Plast Surg 2021; 45:1860-1868. [PMID: 34114074 DOI: 10.1007/s00266-021-02378-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity. METHODS Transgender and cisgender participants were enrolled and shown images of surgery naïve chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image. RESULTS Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naïve: 802 vs. 395 ms; p = 0.02, masculinized: 940 vs. 692 ms, p = 0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391 ms; p = 0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847 ms; p = 0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59 ms; p = 0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p < 0.05). CONCLUSIONS This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery. LEVEL OF EVIDENCE III 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Shanique A Martin
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Viren Patel
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shane D Morrison
- Section of Plastic Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA.
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - David Kahn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA
| | | | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA
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21
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Sijben I, Timmermans FW, Lapid O, Bouman MB, van der Sluis WB. Long-term Follow-up and Trends in Breast Augmentation in 527 Transgender Women and Nonbinary Individuals: A 30-year experience in Amsterdam. J Plast Reconstr Aesthet Surg 2021; 74:3158-3167. [PMID: 34020905 DOI: 10.1016/j.bjps.2021.03.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/22/2021] [Accepted: 03/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transgender women and transfeminine spectrum nonbinary individuals may opt for breast augmentation. The aim of the study is to analyze the complications, surgical trends, and long-term follow-up of breast augmentations in this population over the past 30 years. METHODS All transgender women and nonbinary individuals who underwent breast augmentation at our center between 01-1990 and 01-2020 were retrospectively identified. A retrospective chart study was conducted, recording individual demographics, implant characteristics, surgical timing, postoperative complications or other reasons requiring reoperation, and implant survival. A literature search was performed in MEDLINE on clinical outcomes and revision surgery of this procedure. RESULTS A total of 527 individuals were identified. Median clinical follow-up time was 11.2 years (interquartile range 3.3-17.5). Median implant size increased significantly over the last years (1990-1990 median 275cc, 2000-2009 252cc, 2010-2019 375cc, p<0.01). Most individuals underwent breast augmentation and genital gender-affirming surgery in one-stage. Reoperations due to short-term complications were infrequent (hematoma (0.4%) or infection (0.4%)). Reoperations due to long-term complications comprised: implant rupture (5.7%), capsular contracture (4.9%), aesthetic problems (3.8%), low-grade infection (0.4%), or seroma (0.6%). In total, 2.5% of individuals requested larger implants. After performing the literature search and manuscript screening, 9 out of 115 identified studies were included for review. Follow-up time ranged from 30 days to 5.5 years. Reported complications requiring reoperation were capsular contraction (range 0.0-5.6%), asymmetry (3.6%), hematoma (range 0.0-2.9%), infection (range 0.0-0.9%) and implant rupture (0.7%), CONCLUSION: Implant-based breast augmentation is a safe procedure in transgender individuals.
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Affiliation(s)
- Isha Sijben
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Floyd W Timmermans
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Oren Lapid
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Mark-Bram Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Wouter B van der Sluis
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands.
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22
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Bekeny JC, Zolper EG, Manrique OJ, Fan KL, Del Corral G. Breast augmentation in the transgender patient: narrative review of current techniques and complications. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:611. [PMID: 33987309 PMCID: PMC8105870 DOI: 10.21037/atm-20-5087] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 01/29/2021] [Indexed: 11/06/2022]
Abstract
Gender-affirming surgery (GAS) is often a crucial step during the journey to identity actualization for transgender patients. Surgical breast augmentation, or "top surgery", is frequently cited as the most important and sometimes only gender-affirming procedure sought by transfeminine patients. The breast augmentation process is remarkably similar in transgender and cisgender patients. However, there are unique guidelines, anatomic considerations, and contextual issues for the transgender patient population that must be taken into account by providers to achieve optimal outcomes. The aim of this review is to outline the current state of breast augmentation for transfeminine patients. We walk through our suggested pre-surgical evaluation, breast augmentation options, and post-surgical care. In the preoperative period, providers must establish a positive provider-patient relationship that allows for thorough history taking, physical examination, and goal setting. Providers must be able to select an appropriate implant, incision location, and operative plane to balance patient desires and pre-existing anatomic characteristics in transfeminine patients. Postoperatively, the provider must address acute and chronic needs to allow for continued satisfaction and safety. After reading this review, we aim for providers to be well-equipped to provide the highest quality breast augmentation care for their transfeminine patients. As research into best practices for breast augmentation in transfeminine patients continues to develop, we expect that surgical practice will continue to evolve.
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Affiliation(s)
- Jenna C. Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Elizabeth G. Zolper
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
- MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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23
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Akhavan AA, Sandhu S, Ndem I, Ogunleye AA. A review of gender affirmation surgery: What we know, and what we need to know. Surgery 2021; 170:336-340. [PMID: 33741180 DOI: 10.1016/j.surg.2021.02.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature. METHODS PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized. RESULTS Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery. CONCLUSION Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.
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Affiliation(s)
- Arya Andre Akhavan
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Shabaaz Sandhu
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Idorenyin Ndem
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Adeyemi A Ogunleye
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC.
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24
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Decuypere F, De Wolf E, Vyncke T, Claes K, Monstrey S, Buncamper M. Male-to-female gender affirmation surgery: breast reconstruction with Ergonomix round prostheses. Int J Impot Res 2021; 33:720-725. [PMID: 33723376 DOI: 10.1038/s41443-021-00425-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 02/11/2021] [Accepted: 02/26/2021] [Indexed: 11/09/2022]
Abstract
People with gender dysphoria are becoming more prevalent and more universally accepted. Social, hormonal, and surgical gender transition are able to substantially improve their quality of life. Various gender affirmation surgery (GAS) options are available to address gender dysphoria in the male-to-female (MtF) population, including facial and chest feminization, body contouring, and genital surgery. While hormone replacement therapy may result in some degree of breast development, it is often insufficient to effectively result in an adequate female-like breast contour. The creation of a female chest is generally the first surgical step in the transition. The primary aim of this manuscript is to describe the surgical technique with ergonomix round prostheses used at our high-volume GAS center and to point out how anatomical differences between trans-female and cis-female patients impact surgery. Furthermore, we provide an overview of the demographic data and postoperative outcomes.
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Affiliation(s)
- Fien Decuypere
- Department of Plastic and Reconstructive Surgery, Gent University Hospital, Ghent, Belgium.
| | - Edward De Wolf
- Department of Plastic and Reconstructive Surgery, Gent University Hospital, Ghent, Belgium
| | - Tom Vyncke
- Department of Plastic and Reconstructive Surgery, Gent University Hospital, Ghent, Belgium
| | - Karel Claes
- Department of Plastic and Reconstructive Surgery, Gent University Hospital, Ghent, Belgium
| | - Stan Monstrey
- Department of Plastic and Reconstructive Surgery, Gent University Hospital, Ghent, Belgium
| | - Marlon Buncamper
- Department of Plastic and Reconstructive Surgery, Gent University Hospital, Ghent, Belgium
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25
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Tirrell AR, Abu El Hawa A, Bekeny JC, Del Corral G. Outcomes in chest feminization patients with a history of illicit hormone use and silicone injections. Breast J 2021; 27:352-358. [PMID: 33578450 DOI: 10.1111/tbj.14178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 01/22/2023]
Abstract
Transfeminine patients facing barriers to gender confirming surgery sometimes pursue illicit feminization procedures such as "street" hormones and silicone injections. These procedures often yield complications and disfigurement, making surgeons and insurance companies wary of secondary breast reconstruction. This clinical series assesses illicit treatment among our transfeminine breast surgery patients and describes the presentation, surgical approaches, and outcomes of each patient. A retrospective review of transfeminine patients who underwent chest feminization surgery with a single provider between March 2018 and March 2020 identified patients with a history of illicit hormones or silicone injections. Demographics, comorbidities, preoperative diagnoses and symptoms, surgical details, and postoperative outcomes were collected. Patients were contacted for a follow-up survey concerning outcomes and satisfaction. Of the 41 transfeminine patients reviewed, eight (19.5%) had previous illicit treatment. Seven (17.1%) used non-prescribed hormones, and three (7.3%) received silicone breast injections. Two patients presented with symptoms from silicone injections; the remaining were asymptomatic. Six patients underwent subglandular breast augmentation, one had a reduction mammoplasty, and one underwent an implant exchange. Only one patient had postoperative complications that healed without surgical intervention. This series emphasizes the need to assess the prevalence of silicone injections and illicit hormone use among transgender chest feminization patients. The use of these substances was relatively high in our population compared to national averages; however, there is a low risk of postoperative complications. Providers may perform breast surgery in patients with a history of illicit augmentation practices after careful evaluation and surgical planning.
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Affiliation(s)
- Abigail R Tirrell
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Areeg Abu El Hawa
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
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26
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Use of the Subfascial Plane for Gender-affirming Breast Augmentation: A Case Series. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3362. [PMID: 33564588 PMCID: PMC7858195 DOI: 10.1097/gox.0000000000003362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/11/2020] [Indexed: 11/27/2022]
Abstract
Transgender women seeking gender-affirming breast augmentation often present with differences in preoperative chest measurements and contours in comparison with cisgender women. These include a more robust pectoralis muscle and limited glandular tissue, raising important considerations in determining the optimal anatomical plane for implantation. Abundant literature has described advantages and drawbacks of the available planes for breast augmentation in cisgender women. Certain drawbacks may be more pronounced for transgender women, given their distinct anatomy. The subfascial plane offers lower complication rates than the subglandular plane when using smooth implants, and avoids implant animation and displacement associated with the subpectoral plane. To our knowledge, existing studies have not yet addressed this discussion in the transfeminine population. The goal of this article is to highlight potential benefits of the subfascial plane for gender-affirming breast augmentation, utilizing a case series of 3 transfeminine patients, and to review the literature on surgical techniques and outcomes in this population.
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27
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Triple Negative Breast Cancer in a Male to Female Transgender Patient: A Case Report and Literature Review. Adv Radiat Oncol 2020; 5:1083-1089. [PMID: 33083671 PMCID: PMC7557203 DOI: 10.1016/j.adro.2020.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 11/22/2022] Open
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28
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Bekeny JC, Zolper EG, Fan KL, Del Corral G. Breast augmentation for transfeminine patients: methods, complications, and outcomes. Gland Surg 2020; 9:788-796. [PMID: 32775269 DOI: 10.21037/gs.2020.03.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gender-affirming procedures are critical steps in helping transgender patients reach identity actualization and maximal quality of life. Although there are many techniques for gender-affirming care, surgical breast augmentation, or "top surgery," is often cited as the most important-and sometimes only-procedure sought by transfeminine patients. Unfortunately, years of individual and systemic prejudice placed barriers between transgender patients and the healthcare providers needed to affirm gender identity. Policy has recently begun to change as research proving the safety, need, and outcomes of breast augmentation in transfeminine patients dismantles long-established systemic inequalities. With this change, more patients are seeking knowledgeable and respectful providers who can address their unique gender-affirming needs. Overall, breast augmentation in transfeminine patients is technically similar to procedures performed in cisgender peers, but with significant considerations. The most common method of augmentation relies on breast implants, since removable prostheses, exogenous hormones, and fat grafting alone often produce unsatisfactory results. Special attention needs to be directed towards anatomic differences in transgender versus cisgender patients in order to achieve optimal size and position of the breast and nipple-areolar complex. Complications for transfeminine patients undergoing breast augmentation are rare, and complication rates are equivalent with cisgender peers who pursue similar procedures. Short- and long-term benefits to quality of life have been well-documented. The aim of this review is to give providers the technical knowledge concerning breast augmentation options, pre-surgical evaluation, post-surgical care, and special considerations in transfeminine patients so that provider and patient can have a successful, respectful partnership in reaching gender-affirming goals.
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Affiliation(s)
- Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Elizabeth G Zolper
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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29
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Latack K, Adidharma W, Nolan IT, Crowe CS, Sowder LL, Satterwhite T, Morrison SD. Staying on Top of Breast Implant Illness: An Analysis of Chest Feminization Experiences. Plast Reconstr Surg 2020; 145:885e-886e. [PMID: 32221263 DOI: 10.1097/prs.0000000000006691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Kyle Latack
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Widya Adidharma
- Section of Plastic Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Mich
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, N.Y
| | - Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | | | | | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
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