Female-to-Male Gender-Confirming Drainless Mastectomy May Be Safe in Obese Males

BMI Is Not Associated With Chest-Specific Body Image, Complications, or Revisions in Gender-Affirming Mastectomy: A Single-Center Cross-Sectional Study

OBJECTIVE

To analyze the impact of Body Mass Index (BMI) on clinical and patient-reported outcomes following gender-affirming mastectomy (GM).

BACKGROUND

BMI is a barrier for obese patients seeking GM despite increasing evidence that it is safe in this population. Currently, little is known about the impact of BMI on chest-specific body image and satisfaction after GM.

METHODS

This single-center, cross-sectional study included individuals 18 years and older who underwent GM between 1990 and 2020 and were at least 2 years postoperative. Patient-reported chest-specific body image was measured using the BODY-Q and Gender Congruence and Life Satisfaction chest subscales. Satisfaction was measured using the Holmes-Rovner Satisfaction with Decision scale. Clinical and demographic variables were identified from the chart review. Bivariate analysis was performed to determine whether BMI was associated with chest-specific body image, satisfaction, and complications within 30 days or revisions in GM.

RESULTS

Two hundred twenty-seven individuals meeting eligibility criteria were contacted to participate and 137 responded (60.4% response rate). The mean age was 29.1 (SD=9.0), and mean BMI was 30.9 (SD=8.0), with 26.4% (N=60) of the cohort having a BMI>35. Chest-specific body image and satisfaction with the decision did not vary by BMI or breast resection weight. Complications and revisions were not associated with BMI.

CONCLUSIONS

Individuals undergoing GM reported high rates of satisfaction after GM regardless of BMI. Complication and revision rates did not vary significantly by BMI or breast resection weight. Surgeons should re-evaluate the role BMI plays in patient selection and counseling for GM.

Topical Tranexamic Acid and Chest Masculinization Surgeries-Impact on Postoperative Hematoma Incidence

Introduction

Postoperative hematoma requiring intervention occurs more frequently in chest masculinization surgeries than in other types of breast surgeries, with incidences ranging from 0.7% to 13.2% per patient. Although there is increasing evidence that topically applied tranexamic acid (TXA) effectively reduces postoperative bleeding in breast surgeries, its impact on masculinization surgeries is understudied.

Aims

Examining the significance of topical TXA in reducing postoperative hematoma in chest masculinization surgeries.

Methods

This retrospective cohort comprises female-to-male transgender and non-binary patients who underwent chest masculinization at Helsinki or Tampere University hospitals between 2018 and 2024. Topical TXA (20 mg/ml, 25 ml per breast) was incorporated into routine use in October 2022, replacing the previous practices; Helsinki mainly operated without TXA, whereas Tampere routinely used intravenous (i.v.) TXA.

Results

A total of 198 patients undergoing chest masculinization surgery were included. Among them, 9 (4.5%) major hematomas occurred. The need for reoperation due to postoperative hematoma was lower in the topical TXA (3.2%, 2 out of 63 patients) and i.v. TXA (3.4%, 2 out of 58 patients) groups compared to the non-TXA group (6.5%, 5 out of 77 patients). Subpectoral incisions (71.2%, 141 patients) resulted in a 5.0% hematoma rate, whereas periareolar incisions (28.8%, 57 cases) had a 3.5% hematoma rate.

Conclusions

Our study suggests that topical and i.v. TXA effectively reduce postoperative bleeding in chest masculinization surgeries, with similar outcomes between the 2 methods. Albeit our results lack statistical significance and they support the potential benefit of prophylactic TXA use in hematoma reduction.

Body Mass Index and Complication Rates Among Patients Undergoing Gender-Affirming Surgeries: An Analysis of the National Surgical Quality Improvement Project Database

PURPOSE

To determine the relationship between body mass index (BMI) and complication rates among patients undergoing gender-affirming surgeries (GAS).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2021. Patients who underwent a GAS were identified using International Classification of Diseases Ninth (ICD-9) and Tenth (ICD-10) codes. Current Procedural Terminology (CPT) codes were organized within 6 GAS subgroups: masculinizing top, masculinizing bottom, feminizing top, feminizing bottom, head and neck, and voice procedures. BMI was classified as underweight, healthy weight, overweight, or obese classes I-III using the Center for Disease Control and Prevention ranges. Demographic data included sex, age, race, and ethnicity. Descriptive statistics were used to characterize the study sample, and hierarchical logistic regression was used to examine the association between GAS, BMI, and surgical complications.

RESULTS

Among the 6771 cases, the majority had a BMI categorized as healthy weight (33.5%) or overweight (30.5%). Smaller proportions had obesity class I (18.6%), class II (8.4%), or class III (6.2%); 1.9% were underweight. BMI was not a significant predictor of complications among those undergoing masculinizing and feminizing top surgeries or head and neck surgeries. Among participants undergoing masculinizing bottom surgery, those with class 1 obesity were 70% less likely to have surgical complications compared to those with a healthy weight. For those undergoing feminizing bottom surgeries, participants with class 1 obesity were 3.3 times more likely to have surgical complications compared to those with a healthy weight.

CONCLUSION

BMI is commonly used to determine GAS eligibility, yet its utility in predicting complications is uncertain. Healthcare providers should consider the patient's overall health status when assessing GAS eligibility rather than relying on BMI alone.

High BMI as risk factor in mastectomy in transmasculine individuals: a retrospective matched case-control study

Introduction: Obesity as a risk factor in gender-affirming surgery is a hot topic. Though obesity is considered a risk factor for certain surgical complications, BMI cutoffs may be a barrier to surgical care for transgender individuals. Material and methods: All transgender individuals that underwent gender-affirming mastectomy in our center were retrospectively identified from a departmental database. Every transgender individual with a BMI > 34kg/m2 was matched 1:1 to an individual with a BMI between 18 and 25 kg/m2, based on: surgical technique, surgeon, smoking, resection weight (+/-150 grams), and comorbidity such as diabetes and cardiovascular diseases. A retrospective chart study was conducted, recording demographics, surgical characteristics, short- and long-term complications and reoperations. Complications were ordinally categorized according to the Clavien-Dindo (CD) classification. Outcomes of groups were compared. Results: A total of 53 individuals with BMI > 34 who underwent mastectomy were matched to 53 non-obese individuals according to the abovementioned matching criteria. A total of 44 (83%) non-obese individuals had a complication-free trajectory, versus 23 (43%, p < 0.01) in the obese group. Seroma occurred more frequently in obese individuals (n = 16 (30%) vs 2 (4%), p < 0.01). Looking at de CD rating system, obese individuals experienced more complications overall (p < 0.01). However, complications were mostly CD grade I or II. Secondary surgical chest contour corrections were performed in 9 (17%) obese versus 2 (4%) non-obese individuals. CD grade III complications occurred in 10 (18%) obese individuals and in 4 (8%) non-obese individuals. There were no grade CD grade IV or V complications. Conclusion: Mastectomy in individuals with obesity seems safe with regard to major complications. However, minor complications and revision surgery are significantly more frequently present in these individuals. Preoperative counseling should focus on the higher risk on complications and reoperations.

Association of High Body Mass Index With Postoperative Complications After Chest Masculinization Surgery

PURPOSE

Body mass index (BMI) requirements for transgender and nonbinary patients undergoing chest masculinization surgery (CMS) are not standardized and based on small sample sizes. This is the largest and first national retrospective study to determine the association between BMI and postoperative complications.

METHODS

The National Surgical Quality Improvement Program 2012-2020 was queried for CMS patients. The primary outcome was incidence of at least one complication within 30 days. Secondary outcomes were incidence of major and minor complications. Body mass index (in kilograms per square meter) was categorized as category 0 (<30), 1 (30-34.9), 2 (35-39.9), 3 (40-44.9), 4 (45-49.9), and 5 (≥50). Logistic regression was used to evaluate the association between BMI and outcomes.

RESULTS

Of 2317 patients, median BMI was 27.4 kg/m 2 (interquartile range, 23.4-32.2 kg/m 2 ). Body mass index range was 15.6 to 64.9 kg/m 2 . While increasing BMI was significantly associated with greater odds of at least one complication, no patients experienced severe morbidity, regardless of BMI. Patients with BMI ≥50 kg/m 2 had an adjusted odds ratio [aOR, 95% confidence interval (CI)] of 3.63 (1.02-12.85) and 36.62 (2.96->100) greater odds of at least one complication and urinary tract infection compared with nonobese patients, respectively. Patients with BMI ≥35 kg/m 2 had an adjusted odds ratio (95% CI) of 5.06 (1.5-17.04) and 5.13 (1.89-13.95) greater odds of readmission and surgical site infection compared with nonobese patients, respectively.

CONCLUSIONS

Chest masculinization surgery in higher BMI patients is associated with greater odds of unplanned readmission. Given the low risk for severe complications in higher BMI individuals, we recommend re-evaluation of BMI cutoffs for CMS patients.

Body mass index and benign breast surgeries: a survey of plastic surgeons’ knowledge and attitudes

Background

The academic literature has not arrived at a consensus on the importance of body mass index (BMI) as an indicator of surgical feasibility and risk. This study evaluates board-certified plastic surgeons' and trainees' knowledge, experiences, and concerns around performing benign breast surgeries in high-BMI patients.

Methods

An online survey instrument was developed and shared with plastic surgeons and plastic surgery trainees from December 2021 to January 2022.

Results

There were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). For respondents who had BMI guidelines for performing benign breast surgeries, the median maximum BMI was 35 for all procedures. Most respondents supported or strongly supported their BMI guidelines.The majority of respondents indicated that they tended to have less training and experience in performing benign breast surgeries on high-BMI patients compared to those with BMI <30. Most respondents indicated that they were less satisfied with the results of these procedures on high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher.

Conclusions

Respondents indicated that the risks of complication, more frequent need for surgical revisions, and unsatisfactory outcomes were their greatest concerns when conducting chest surgeries among high-BMI patients. Given that most surgeons practice in settings where high-BMI patients are excluded from procedure access, further research is needed to assess the extent to which these concerns reflect actual outcome differences.

Non-typhoidal Salmonella soft-tissue infection after gender affirming subcutaneous mastectomy case report

We present a case of a 32-year-old transgender male who underwent chest masculinization, complicated by purulent soft tissue infection of bilateral chest incisions. Cultures tested positive for non-typhoidal Salmonella, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa. Herein, we discuss multiple factors contributing to the complexity of treating this patient's clinical course.

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 .

Medical considerations in the care of transgender and gender diverse patients with eating disorders

Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.

The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory.

OBJECTIVES

The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures.

METHODS

We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes.

RESULTS

Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.

CONCLUSIONS

Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.

Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns

Background:

Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques.

Methods:

Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups.

Results:

In total, 490 patients underwent gender-affirming mastectomy during the study period. An estimated 96 patients underwent periareolar mastectomy, whereas 390 underwent double incision mastectomy. Demographics were similar between groups, and there were no differences in rates of hematoma (3.1% versus 5.6%, respectively; P = 0.90), seroma (33.3% versus 36.4%; P = 0.52), or revision procedures (14.6% versus 15.8% P = 0.84) based on technique.

Conclusions:

Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.

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.

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.

Surgical and patient-reported outcomes following double incision and free nipple grafting for female to male gender affirmation: does obesity make a difference?

BACKGROUND

The efficacy of chest wall contouring in alleviating symptoms of gender dysphoria in transmale and nonbinary patients is well established. As the popularity and indications for these procedures continue to increase, more surgeons are performing these surgeries on obese patients. The aim of this study was to investigate the association of obesity on postoperative and patient-reported outcomes.

METHODS

A retrospective chart review was performed for 97 consecutive masculinizing mastectomies by a single surgeon using the double incision and free nipple graft technique (DIFNG). Surgical outcomes were collected using electronic records and patient-reported outcomes using BODY-Q questionnaires.

RESULTS

DIFNG mastectomies were performed in 97 patients from 2016 to 2019, of which 43(44%) were obese and 54(56%) were non-obese. The average follow-up time was 62(12 - 112) months in obese patients and 61(10 - 127) months in non-obese patients. There was no difference in minor and major complication rates between non-obese and obese patients [minor: 4(7%) vs 5(12%), p = 0.19) and major: 0(0%) vs 1(2%), p = 0.46]. BODY-Q data was available for 33(77%) of obese and 43(80%) of non-obese patients. There was no difference in scores for each module of the BODY-Q between obese and non-obese patients (p>0.05).

CONCLUSION

Chest wall contouring using the DIFNG technique continues to be safe and effective for the management of gender dysphoria in transmale and nonbinary patients. Considering that obese patients have comparable surgical and patient-reported outcomes as non-obese patients, it is our practice to routinely offer the DIFNG technique to healthy obese patients with BMI's between 30 and 40.