Mastectomy in Transgender and Cisgender Patients: A Comparative Analysis of Epidemiology and Postoperative Outcomes

Trends in Top Surgery Patient Characteristics, Wound Complications, and CPT Code Use by Plastic Surgeons: A Decade-Long Analysis

BACKGROUND

Gender-affirming top surgery is becoming increasingly common, with greater diversity in the patients receiving top surgery. The purpose of this study was to examine national trends in patient demographics, characteristics, wound complication rates, and concurrent procedures in patients receiving gender-affirming top surgeries.

METHODS

Patients with gender dysphoria who underwent breast procedures, including mastectomy, mastopexy, breast augmentation, or breast reduction by a plastic surgeon between 2013 and 2022, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. These procedures were considered to be gender-affirming "top surgery." Univariate analyses were performed to examine trend changes in the patient population and types of additional procedures performed over the last decade.

RESULTS

There was a 38-fold increase in the number of patients who received top surgery during the most recent years compared to the first 2 years of the decade. Significantly more individuals receiving top surgery in recent years were nonbinary (P < 0.01). There was a significant decrease in percentage of active smokers (P < 0.01) while there was an increase in percentage of patients with diabetes (P = 0.03). While there was a significant increase in the number of obese patients receiving top surgery (P < 0.01), there were no differences in postoperative wound complications between the years. Significantly more patients received additional procedures (P < 0.01) and had about a 9-fold increase in distinct number of additional CPT codes from 2013-2014 to 2021-2022.

CONCLUSIONS

Our study found that there has been (1) a significant increase in the number of top surgery patients from 2013 to 2022 overall and (2) a particular increase in patients with preoperative comorbidities, such as a higher body mass index and diabetes. Understanding current and evolving trends in patients undergoing surgical treatment for gender dysphoria can inform individualized care plans that best serve the needs of patients and optimize overall outcomes.

Understanding Public Perceptions of Nipple and Scar Characteristics After Chest Wall Masculinization Surgery

BACKGROUND

Surgical chest masculinization procedures, especially gender-affirming top surgery (GATS), are becoming increasingly prevalent in the USA. While a variety of surgical techniques have been established as both safe and effective, there is limited research examining ideal aesthetic nipple appearance and incision scar pattern. This study employs patient images to understand the public's perception on top surgery outcomes when adjusting for BMI ranges and Fitzpatrick skin types.

METHODS

Images from RealSelf modified via Adobe Photoshop depicted various scar types and nipple-areolar complex (NAC) sizes/positions. A Qualtrics survey was distributed utilizing Amazon Mechanical Turk. Statistical analysis was performed through JMP Pro 17 for ordinal and categorical values, with a p value less than or equal to 0.05 statistically significant.

RESULTS

A moderately sized and laterally placed NAC was preferred. A transverse scar that resembles the pectoral border between the level of the inframammary fold and pectoral insertion was deemed most masculine and aesthetic. Majority of results demonstrated that this is unaffected by Fitzpatrick skin types. Increased BMI images impacted public preferences, as a nipple placed farther from the transverse incision (p = 0.04) and a transverse scar position closer to the IMF was preferred in higher BMI patients.

CONCLUSIONS

An understanding of the most popular NAC and scar choices, as well as how these factors may differ when considering a Fitzpatrick skin type or BMI categorization was attained. This validates the importance of patient-centered approach when employing surgical techniques in GATS. Future studies intend to obtain reports from actual patients considering GATS.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable.

Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.

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.

Masculinizing chest wall gender-affirming surgery: Clinical outcomes of 73 subcutaneous mastectomies using the double-incision and semicircular incision techniques

Masculinizing chest wall gender-affirming surgery is an important element in the treatment of gender dysphoria. In this study, we report an institutional series of subcutaneous mastectomies and aim to identify the risk factors for major complications and revision surgery. A retrospective review of consecutive patients who underwent primary masculinizing top surgery via subcutaneous mastectomy at our institution through July 2021 was performed. Demographics and clinical characteristics were recorded as well as major complications and revision surgeries. Time-to-event analyses were performed to assess predictors of major complications and revision surgery. Seventy-three consecutive patients (146 breasts) were included. The mean age and the mean body mass index were 25.2 ± 7 years and 27.6 ± 6.5 kg/m2, respectively. The mean follow-up time was 7.9 ± 7.5 months. None of the patients had a history of chest wall radiation or breast surgery. Double incision with free nipple grafting was the most common technique (n = 130, 89%), followed by periareolar semicircular incision (n = 16, 11%). The mean resection weight was 524.7 ± 377.7 g. Concomitant suction-assisted lipectomy was performed in 48 (32.9%) cases. The rate of major complications was 2.7%. Revision surgery was performed in 8 (5.4%) cases. Concomitant liposuction was significantly associated with a lower rate of revision surgery (p = 0.026). Masculinizing chest wall gender-affirming surgery is a safe procedure with a low rate of revision. Concomitant liposuction significantly reduced the need of revision surgery. Future studies utilizing patient-reported outcomes are still required to better assess the success of this procedure.

Transgender and gender-diverse youth: an update on standard medical treatments for gender dysphoria and the sociopolitical climate

PURPOSE OF REVIEW

Transgender and gender-diverse (TGD) youth experience a discordance between their binary sex assigned at birth and gender identity. All TGD youth benefit from compassionate care delivered by clinicians who are informed in matters of gender diversity. Some of TGD youth experience clinically significant distress, termed gender dysphoria (GD), and may benefit from additional psychological support and medical treatments. Discrimination and stigma fuel minority stress in TGD youth and thus many struggle with mental health and psychosocial functioning. This review summarizes the current state of research on TGD youth and essential medical treatments for gender dysphoria. These concepts are highly relevant in the current sociopolitical climate. Pediatric providers of all disciplines are stakeholders in the care of TGD youth and should be aware of updates in this field.

RECENT FINDINGS

Children who express gender-diverse identities continue to express these identities into adolescence. Medical treatments for GD have a positive effect on mental health, suicidality, psychosocial functioning, and body satisfaction. The overwhelming majority of TGD youth with gender dysphoria who receive medical aspects of gender affirming care continue these treatments into early adulthood. Political targeting and legal interference into social inclusion for TGD youth and medical treatments for GD are rooted in scientific misinformation and have negative impacts on their well being.

SUMMARY

All youth-serving health professionals are likely to care for TGD youth. To provide optimal care, these professionals should remain apprised of best practices and understand basic principles of medical treatments for GD.

Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries

OBJECTIVE

To determine if and how race impacts the 30-day outcomes of gender-affirming chest surgeries.

BACKGROUND

Little is currently known about how race may affect the outcomes of gender-affirming surgeries.

METHODS

We analyzed data from the National Surgical Quality Improvement Program (NSQIP) database of 30-day complications of gender-affirming chest surgeries from 2005 to 2019. All participants had a postoperative diagnosis code for gender dysphoria and at least one procedure code for bilateral mastectomy, bilateral breast reduction, or bilateral augmentation mammoplasty. Differences by racial group were analyzed through Pearson χ 2 and multivariate logistic regression.

RESULTS

There were no racial differences in the all-complication rates for both transmasculine and transfeminine individuals undergoing gender-affirming chest surgeries. Black patients undergoing masculinizing procedures were significantly more likely to experience mild systemic [adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.02-4.65] and severe complications (aOR: 5.63, 95% CI: 1.99-15.98) when compared with White patients. Patients of unknown race had increased odds of experiencing severe complications for masculinizing procedures compared with White patients (aOR: 3.77, 95% CI: 1.39-10.24). Transmasculine individuals whose race was unknown were 1.98 times more likely (95% CI: 1.03-3.81) to experience an unplanned reoperation compared with White individuals. Black transfeminine individuals were 10.50 times more likely to experience an unplanned reoperation (95% CI: 1.15-95.51) than their White peers.

CONCLUSIONS

Although overall complications are uncommon, there is evidence to suggest that there are racial disparities in certain 30-day outcomes of gender-affirming chest surgeries.

Comparing Scrotoplasty Complication Rates in Transgender and Cisgender Men: An ACS NSQIP Study

While masculinizing gender-affirming genital surgeries may include scrotoplasty, there has been limited research on the safety and outcomes of scrotoplasty among transgender men. We compared scrotoplasty complication rates between cisgender and transgender patients using data from the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database. Data was queried between 2013 and 2019 for all patients with procedure codes for scrotoplasty. Transgender patients were identified through a gender dysphoria diagnosis code. T-tests and Fisher's exact test were used to identify any differences in demographics, operative characteristics, and outcomes. The primary outcomes of interest were demographic factors, operative details, and surgical outcomes. A total of 234 patients were identified between 2013 and 2019. Fifty were transgender and 184 were cisgender. Age and BMI were significantly different between the two cohorts, such that the cisgender cohort was older (M _trans = 38 years (SD:14), M _cis = 53 years (SD: 15)) and had higher BMI than the transgender cohort (M _trans = 26.9 (SD: 5.5), M _cis = 35.2 (SD: 11.2)). Cisgender patients also had poorer overall health (p = 0.001), and were more likely to have hypertension (p = 0.001) and diabetes (p = 0.001). Race and ethnicity did not vary significantly between the cohorts. Operative details differed significantly between cohorts, such that transgender patients had a longer operating time (M _trans = 303 min (SD: 155), M _cis = 147 min (SD: 107)) and fewer transgender patients had a simple scrotoplasty (p = 0.02). The majority of gender-affirming scrotoplasties were performed by plastic surgeons (62%) whereas the majority of cisgender scrotoplasties were performed by urologists (76%). Despite these demographic and pre-operative differences, the number of patients who underwent complex scrotoplasty experiencing any of the tested complications did not differ by gender. Our results support scrotoplasty as a safe procedure for transgender patients, with no significant differences in outcomes between transgender and cisgender 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.

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 .

Histopathologic Features of Breast Tissue From Transgender Men and Their Associations With Androgen Therapy

OBJECTIVES

To assess the histopathologic features of breast tissue of transgender men (TM) undergoing gender-affirming bilateral mastectomies in relation to androgen therapy (AT).

METHODS

We reviewed 374 transgender bilateral mastectomy cases from 2017 to 2020. Of these, 314 (84.4%) patients received preoperative AT. We compared these with 127 cases of cisgender females undergoing elective breast reduction.

RESULTS

Breast specimens from TM on AT, compared with cisgender women, showed a median higher gross percentage of fibrous tissue (P < .001), reduced lobular density (P = .004), higher amount of lobular atrophy (P < .001), and lower incidence of cysts (P < .001), apocrine metaplasia (P < .001), calcifications (P < .001), columnar cell change (P = .002), and atypia (P = .003). Each additional month of AT was associated with a 2% decrease in the odds of having nonapocrine cysts (P = .02), a 5% decrease in the odds of having usual ductal hyperplasia (P = .007), and a 0.14% decrease in median lobular density (95% confidence interval, -0.18 to -0.05).

CONCLUSIONS

In this study, breast specimens from TM, particularly with a history of AT, had a higher proportion of fibrous tissue, fewer lobules, and a higher degree of lobular atrophy than cisgender females. Rare cases of atypia were not predicted by preoperative imaging or gross findings, supporting routine microscopic evaluation of these specimens.

[Topical Application of Tranexamic Acid in Subcutaneous Mastectomy Wounds in Female-to-male Transgender Patients]

INTRODUCTION

Tranexamic acid (TXA) is an antifibrinolytic drug that can be used to treat and prevent bleeding. Its application in plastic and reconstructive surgery has been very limited to date. To our knowledge, there is a lack of published data on the topical application of TXA in transgender patients undergoing subcutaneous mastectomy.

METHODS

We performed a retrospective data analysis of female-to-male transgender patients who underwent subcutaneous mastectomy. A total of 22 patients were treated with topical TXA, while 29 patients served as controls. The primary endpoint was the amount of wound secretion in the first 48 hours after surgery. Secondary endpoints were the duration of drainage and the occurrence of postoperative bleeding.

RESULTS

Within the first 48 hours, the TXA group had an average drain volume of 97±50 ml compared with 180±111 ml in the control group (p<0.01). There was a significantly lower flow rate over the entire period in the group of TXA patients (113±86 ml vs. 265±197 ml). The time of drains in situ was 2.3±0.7 days in TXA patients, while the drains in the control group were in place for an average of 3.4±1.3 days (p<0.01). In the group of patients treated with TXA, there was a tendency towards a lower number of postoperative bleeding and haematoma (9vs. 17%).

DISCUSSION

There was a significant reduction in the amount of drain fluid within the first 48 hours and over the entire period after topical application of TXA. Also there was a reduction in the length of time patients had a drain in place in the TXA-treated patients. This study demonstrated a significant advantage for the topical application of TXA in subcutaneous mastectomy in female-to-male transgender patients.

Current Practices in the Pathologic Assessment of Breast Tissue in Transmasculine Chest Surgery

BACKGROUND

No guidelines exist regarding management of breast tissue for transmasculine and gender-nonconforming individuals. This study aims to investigate the experiences and practices regarding perioperative breast cancer risk management among the American Society of Plastic Surgery (ASPS) surgeons performing chest masculinization surgery.

METHODS

An anonymous online 19 question survey was sent to 2517 US-based ASPS members in October 2019.

RESULTS

A total of 69 responses were analyzed. High volume surgeons were more likely from academic centers (OR 4.88 CI 1.67 - 15.22; p=0.005). Age ≥40 (85.5%, n=59) and family history of breast cancer in first-degree relatives (68.1%, n=47) or family with a diagnosis before age 40 (71.0%, n=49) were the most common indications for preoperative imaging. 27.5% (n=19) of the respondents routinely excise all macroscopic breast tissue, with 30.4% (n=21) routinely leaving breast tissue. 73.9% (n=51) of respondents routinely send specimens to pathology. There was no significant correlation between surgical volume or type of practice and odds of sending specimens to pathology. High patient costs and patient reluctance (39.1%, n=27, and 35.3%, n=24, respectively) were the most often cited barriers for sending specimens to pathology. 8.7% (n=6) of respondents have found malignant or premalignant lesions in masculinizing breast specimens.

CONCLUSION

Large variation was found among surgeons' perioperative management of chest masculinizing surgery patients regarding preoperative cancer screening, pathologic assessment of resected tissue, and postoperative cancer surveillance. Standardization of care and further studies are needed to document risk, incidence, and prevalence of breast cancer in the transmasculine population before and after surgery.

Reproductive Organ Pathology of Individuals Undergoing Gender-Affirming Surgery

As gender-affirming surgeries become more routine, it is increasingly important for pathologists to recognize the expected histologic changes seen in various tissues secondary to gender-affirming hormone therapy. For example, exogenous testosterone-related squamous atrophy or transitional cell metaplasia of the cervix may be confused for high-grade squamous intraepithelial lesion. In addition to distinguishing between benign and dysplastic/malignant features, pathologists should be mindful of the phrasing of their reports and aim to use objective, nongendered language.

Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents

Background

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

Methods

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

Results

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

Conclusion

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

Prostatic metaplasia and pilar differentiation in gender-affirming mastectomy specimens

With the increasing practice of gender-affirming mastectomy as a therapeutic procedure in the setting of gender dysphoria, there has come a profusion of literature on the pathologic findings within these specimens. Findings reported in over 1500 patients have not included either prostatic metaplasia or pilar metaplasia of breast epithelium. We encountered both of these findings in the course of routine surgical pathology practice and therefore aimed to analyze these index cases together with a retrospective cohort to determine the prevalence, anatomic distribution, pathologic features, and associated clinical findings of prostatic metaplasia and pilar metaplasia in the setting of gender-affirming mastectomy. In addition to the 2 index cases, 20 additional archival gender-affirming mastectomy specimens were studied. Before mastectomies, all but 1 patient received testosterone cypionate, 6/22 patients received norethindrone, and 21/22 practiced breast binding. Prostatic metaplasia, characterized by glandular proliferation along the basal layer of epithelium in breast ducts, and in one case, within lobules, was seen in 18/22 specimens; 4/22 showed pilar metaplasia, consisting of hair shafts located within breast ducts, associated with squamoid metaplasia resembling hair matriceal differentiation. By immunohistochemistry, prostatic metaplasia was positive for PSA in 16/20 cases and positive for NKX3.1 in 15/20 cases. Forty-three reduction mammoplasty control cases showed no pilar metaplasia and no definite prostatic metaplasia, with no PSA and NKX3.1 staining observed. We demonstrate that prostatic metaplasia and pilar metaplasia are strikingly common findings in specimens from female-assigned-at-birth transgender patients undergoing gender-affirming mastectomy. Awareness of these novel entities in the breast is important, to distinguish them from other breast epithelial proliferations and to facilitate accrual of follow-up data for better understanding their natural history.

Pain Control After Mastectomy in Transgender Patients: Ultrasound-guided Pectoral Nerve Block II Versus Conventional Intercostal Nerve Block: A Randomized Clinical Trial

Background

Mastectomy is sometimes performed in transgender patients, which may damage the regional nerves such as the pectoral and intercostobrachial nerves, leading to postoperative pain. An ultrasound-guided nerve block can be used to track and block the nerves properly.

Objectives

This study aimed to compare the ultrasound-guided type-II pectoral nerve block with the blind (conventional) intercostal nerve block (ICNB) for pain control after breast tissue reconstruction surgery in transgender patients.

Methods

In the present single-blind randomized clinical trial, 47 patients were randomly divided into two groups: (A) Ultrasound-guided type-II pectoral nerve block (n = 23) and (B) blind intercostal nerve block (n = 24). After nerve block in both groups, pain intensity at 3, 6, 12, and 24 hours after surgery, upper limb paresthesia, frequency of nausea and vomiting, shortness of breath, hematoma, and the length of hospital stay were assessed.

Results

Patients who received the ultrasound-guided type-II pectoral nerve block had a greater reduction in pain intensity (24 h after surgery), opioid use (24 h after surgery), nausea, vomiting, and hospital stay than those who received ICNB, whereas the recovery time did not differ between the study groups.

Conclusions

The pectoral nerve block under ultrasound guidance, compared to the intercostal nerve block, in transgender patients can reduce the required dosage of opioids within 24 hours, pain intensity within 24 hours after surgery, the incidence of postoperative nausea, and vomiting, and the hospital stay of patients.

Combined Mastectomy and Laparoscopic Hysterectomy with Salpingo-Oophorectomy in Transgender Men: a Cohort Study

There are few data on complications with gender affirming surgery. The aim of this study was to assess peri- and postoperative complications of laparoscopic hysterectomy and mastectomy performed in a single sitting in transgender men. Assessment of intra- and postoperative complications in a series of 65 transgender men (mean age 27, range 18–47) undergoing concomitant mastectomy and laparoscopic hysterectomy with salpingo-oophorectomy. Mean operating time was 292 ± 47 min. Thirty-four (52%) patients experienced complications: 28 (41%) DINDO grade I, 0 DINDO grade 2, 6 (11%) DINDO grade III. The six grade 3 complications consisted of 5 hematomas requiring evacuation after mastectomy and 2 vaginal tears requiring transvaginal repair. Three patients were readmitted within 30 days, all for postoperative bleeding/hematoma. In transgender men, performing laparoscopic hysterectomy and mastectomy at a single sitting has a modest rate of perioperative complications, and may improve resource utilization.

Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based

Body mass index (BMI) requirements for gender affirmation surgery (GAS) are ubiquitous and vary across providers. Requirement variation is not surprising given little data to suggest an association between BMI and GAS outcomes. Implementation of subjective BMI requirements limits access to GAS and negatively impacts patient health and safety. We outline the literature on BMI and GAS outcomes, discuss clinical utility of GAS, and summarize dangers of prescribing weight loss as a prerequisite for surgery. We propose that providers use empirically supported indices of health and comorbidity instead of BMI to determine surgical eligibility for all patients considering GAS.

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.

A review of gender affirmation surgery: What we know, and what we need to know

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.

Chest Masculinization Technique and Outcomes in 72 Double-incision Chest-contouring Procedures with Free Nipple Grafting

Background:

Chest masculinization for gender affirmation is the removal of breast tissue and excess skin, often with repositioning of the nipple areola complexes to achieve a male-appearing chest. A double-incision technique with free nipple grafting (FNG) is the preferred method for trans men with large, ptotic breasts. The authors present the outcomes of 72 consecutive chest masculinization cases using this technique.

Methods:

A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (JDK). Patients who underwent masculinization by concentric circle or liposuction-only techniques were excluded. Potential risk factors for complications were analyzed with Chi-square and logistic regression techniques. P < 0.05 was considered significant.

Results:

Seventy-two patients underwent bilateral mastectomy with free nipple grafting. There were 6 major complications resulting in return to operating room, re-admission, or need for interventional procedure. These included 4 hematomas, 1 infection, and 1 hospital admission for shortness of breath and pain.

Minor complications treated conservatively included 3 seromas, 1 instance of delayed wound healing, 1 case of superficial thrombophlebitis, and 4 hypertrophic scars. Eleven patients experienced nipple areolar complex complications. Four patients underwent revision surgery. Nicotine use was associated with a higher rate of hematoma (χ2: 9.95, P = 0.007). Later operative date, a surrogate for experience, was associated with decreased return to the operating room (Odds ratio: 0.99, P = 0.025).

Conclusion:

Double-incision chest contouring with free nipple grafting provides good chest contour for transgender men,

with low complication rates.

Classification of Transgender Man's Breast for Optimizing Chest Masculinizing Gender-affirming Surgery

The purpose of mastectomy for the female-to-male transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique; these have generally been based on the degree of breast ptosis and the quality and elasticity of the skin. We present a series of subcutaneous mastectomies operated on by 1 surgeon during the last 2 decades. Based on our experience, we suggest a classification system for selecting surgical technique.