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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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2
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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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3
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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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4
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Tettamanzi M, Ziani F, Rodio M, Arrica G, Muratore G, Manconi A, Trignano C, Beatrici E, Liperi C, Rubino C, Trignano E. Retrospective Study on Optimizing Breast Augmentation Outcomes in Transgender Patients: A Comprehensive Analysis of Tumescent Local Anesthesia Technique. Aesthetic Plast Surg 2024:10.1007/s00266-024-03922-5. [PMID: 38459382 DOI: 10.1007/s00266-024-03922-5] [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: 12/16/2023] [Accepted: 02/09/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Tumescent local anesthesia (TLA) involves the infusion of a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While the use of TLA in sub-glandular augmentation mammoplasty has been documented, we present a modified TLA approach for primary sub-muscular breast augmentation in transgender patients based on our experience over the past years. METHODS Between the years 2014 and 2021, we performed primary sub-muscular breast augmentation on 20 transgender patients under TLA and conscious sedation. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Initially, the solution was infiltrated between the pectoral fascia and the mammary gland, and subsequently, during the surgery, under the pectoralis major muscle. RESULTS The average volume of tumescent solution infiltrated during TLA was 740 mL per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia. Patients experienced no pain or discomfort during the preoperative infiltration or surgical procedure. Reoperations due to short-term complications never occurred. We observed a major complication rate of 5%, represented by 1 hematoma. Long-term complications comprised one case of implant dislocation and one occurrence of dystrophic scar formation. No cases of capsular contracture needing reoperation, asymmetry, and implant rupture occurred. In total, one individual (5%) requested larger implants. Follow-up time ranged from 30 days to 1 years. CONCLUSIONS Overall, augmentation mammaplasty is a valuable choice for transgender women aiming to enhance their feminine characteristics and alleviate gender dysphoria. It is imperative for patients to conduct thorough research, grasp the potential pros and cons, and consult experienced healthcare professionals in transgender care. Additionally, tumescent local anesthesia (TLA) has proven to be a safe and efficient method for sub-muscular breast augmentation, providing effective pain control with minimal postoperative complications, resulting in high patient satisfaction. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Matilde Tettamanzi
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy.
| | - Federico Ziani
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Manuela Rodio
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Giovanni Arrica
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Giovanni Muratore
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Anna Manconi
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Claudia Trignano
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Edoardo Beatrici
- Department of Urology, Humanitas Research Hospital - IRCCS, Milan, Italy
| | - Corrado Liperi
- Intensive Care Unit, Emergency Department, AOU Sassari, Sassari, Italy
| | - Corrado Rubino
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Emilio Trignano
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
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5
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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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6
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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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7
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Moses JD, Schall TE, Campo-Engelstein L. Unjust Discrimination Between Cisgender and Transgender Gender-Affirming Care. Ann Intern Med 2023. [PMID: 37399563 DOI: 10.7326/m23-0704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Affiliation(s)
- Jacob D Moses
- Institute for Bioethics and Health Humanities, University of Texas Medical Branch, Galveston, Texas (J.D.M., L.C.)
| | - Theodore E Schall
- Berman Institute of Bioethics and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (T.E.S.)
| | - Lisa Campo-Engelstein
- Institute for Bioethics and Health Humanities, University of Texas Medical Branch, Galveston, Texas (J.D.M., L.C.)
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8
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Jolly D, Boskey ER, Ganor O. Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries. Ann Surg 2023; 278:e196-e202. [PMID: 35762604 DOI: 10.1097/sla.0000000000005512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Divya Jolly
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, MA
| | - Elizabeth R Boskey
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
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9
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Barger BT, Pakvasa M, Lem M, Ramamurthi A, Lalezari S, Tang C. Non-typhoidal Salmonella soft-tissue infection after gender affirming subcutaneous mastectomy case report. Case Reports Plast Surg Hand Surg 2023; 10:2185621. [PMID: 36926352 PMCID: PMC10013424 DOI: 10.1080/23320885.2023.2185621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
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.
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Affiliation(s)
- Branden T Barger
- School of Medicine, University of California, Riverside, CA, USA
| | - Mikhail Pakvasa
- Department of Plastic and Reconstructive Surgery, University of California, Orange, CA, USA
| | - Melinda Lem
- School of Medicine, University of California, Irvine, CA, USA
| | - Aishu Ramamurthi
- Medical College of Wisconsin, Affiliated Hospitals, Inc., Graduate Medical Education, Milwaukee, WI, USA
| | - Shadi Lalezari
- Department of Plastic and Reconstructive Surgery, University of California, Orange, CA, USA
| | - Cathy Tang
- Department of Plastic and Reconstructive Surgery, University of California, Orange, CA, USA
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10
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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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11
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Mehra G, Boskey ER, Ganor O. The Quality and Utility of Referral Letters for Gender-Affirming Surgery. Transgend Health 2022; 7:497-504. [PMID: 36644120 PMCID: PMC9829156 DOI: 10.1089/trgh.2021.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Purpose The World Professional Association for Transgender Health (WPATH) recommends referral by a mental health professional for gender-affirming chest and genital surgeries. However, several transgender health guidelines propose an informed consent model of care to respect patient autonomy. This research aimed to understand, characterize, and asses the quality of information gathered through referral letters for patients consulting for gender-affirming surgeries. Methods A retrospective review of electronic medical records (EMRs), including referral letters from behavioral health (BH) and primary care providers (PCPs), was conducted for patients seeking chest or genital surgery by a single surgeon between 2017 and 2019. Data were abstracted manually and included medical and gender history and documentation of WPATH-recommended surgical criteria. Results A total of 233 patient records, including 171 PCP letters and 231 BH letters, were reviewed. With respect to documentation of surgical criteria, 92% of BH letters documented a diagnosis of gender dysphoria, 63% ability to provide informed consent, and 51% management of BH comorbidities. More than half of individuals with chronic physical health conditions did not have those conditions documented in their referral letters. Similarly, BH letters often failed to document BH diagnoses endorsed by patients. For example, while 80% of patients endorsed a diagnosis of anxiety, more than half did not have it documented in their letters. Overall, greater than half of diagnoses across BH conditions were only documented as present in the EMR. Conclusion Referral letters only variably documented WPATH-recommended surgical criteria and did not reliably document physical and mental health comorbidities. Our research suggests that multidisciplinary pre-surgical assessment may be more useful than referral letters in some settings.
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Affiliation(s)
| | - Elizabeth R. Boskey
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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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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13
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Brownstone LM, DeRieux J, Kelly DA, Sumlin LJ, Gaudiani JL. Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based. Transgend Health 2021; 6:121-124. [PMID: 34414267 DOI: 10.1089/trgh.2020.0068] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Lisa M Brownstone
- Counseling Psychology, University of Denver, Morgridge College of Education, Denver, Colorado, USA
| | - Jaclyn DeRieux
- Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California, USA
| | - Devin A Kelly
- Counseling Psychology, University of Denver, Morgridge College of Education, Denver, Colorado, USA
| | - Lanie J Sumlin
- Eating Disorder Care, Denver, Colorado, USA.,School of Education and Human Development, Counseling Psychology and Counselor Education, University of Colorado, Denver, Colorado, USA
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14
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Current Trends in Facial Feminization Surgery: An Assessment of Safety and Style. J Craniofac Surg 2021; 32:2366-2369. [PMID: 34054085 DOI: 10.1097/scs.0000000000007785] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Facial feminization surgery (FFS) plays an instrumental role in the process of gender affirmation. These procedures are becoming increasingly appreciated for their ability to improve patient satisfaction and gender identity in a way that alleviates gender dysphoria and improves the quality of life. Despite the recent surge in popularity across the US, the current literature lacks evidence on the safety profile of combined facial feminization procedures. Our goal was to determine the safety profile of facial feminization procedures registered on a national surgical database. METHODS Patients with a primary diagnosis of gender dysphoria undergoing facial surgical procedures were identified from the National Surgical Quality Improvement Program database between the years 2013 and 2018. Demographic characteristics along with 30-day postoperative complications were recorded. Logistic regression models adjusted for confounders were used to determine the independent predictors of postoperative complications. RESULTS A cohort of 77 patients who underwent a total of 220 procedures was identified. The number of patients undergoing surgery per year increased from three (3.9%) in 2013 to 41 (53.2%) in 2018, a 13.6-fold increase. The most commonly performed procedure was forehead contouring/frontal sinus setback, performed on 52 patients (67.5%), followed by orbital contouring (n = 37, 48%), rhinoplasty (n = 34, 44%), mandibuloplasty (n = 34, 44%), chondrolaryngoplasty (n = 27, 35.1%), genioplasty (n = 11, 14%), brow lift (n = 9, 11.7%), cheek augmentation (n = 9, 11.7%), and lip lift (n = 7, 9.1%). The number of patients who underwent 5 or more procedures in a single anesthetic event was 41 (53.2%). The complication rate was 3.9%. Univariate analysis suggested an association between older age and postoperative morbidity (P < 0.02). However, this was not found to be an independent predictor on multivariate analysis adjusted for confounders (P < 0.083). Additionally, an increase in operative time and the number of procedures performed during a single anesthetic were not independent predictors of 30-day postoperative complications (P < 0.317 and P < 0.19, respectively). CONCLUSIONS FFS can be safely performed and has a low risk of postoperative morbidity. The number of patients seeking FFS surgery has risen exponentially, with the highest demand seen for the reconstruction of the upper facial third. These findings should guide expectations for patients seeking FFS, as well as for plastic surgeons looking to perform multiple procedures per anesthetic event.
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15
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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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16
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Stowell JT, Zavaletta VA, Carroll EF, Grimstad FW. Multidisciplinary approach to imaging for gender-affirming surgery: engaging surgeons, radiologists, and patients to ensure a positive imaging experience. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:610. [PMID: 33987308 DOI: 10.21037/atm-20-6431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Medical imaging plays an integral role in the preoperative evaluation and postoperative management of transgender and gender diverse (TGD) patients who pursue gender-affirming surgery. Radiology department encounters can be a source of anxiety for patients of any demographic, including TGD patients. Although most imaging modalities are considered "non-invasive", certain imaging procedures and other aspects of the radiology encounter could be considered quite invasive to the TGD patient. The TGD patient may be worried that the imaging examination will have to address anatomy that they feel does not align with their gender identity, or reveal some abnormality or disheartening complication of their surgery. Simultaneously, the patient must also navigate potentially uncomfortable interactions with other patients in department waiting rooms, restrooms, and changing facilities as well as with radiology staff. As the referral source to imaging facilities, providers should advocate on behalf of their TGD patients. Referring providers should work with imaging facilities to ensure their patients will receive inclusive and affirming care and not be subject to discomfort on the part of gender identity or expression. Proactive and regular communication among radiology facilities, patients, and referring providers will ensure appropriate and sensitive care for this vulnerable population. A positive imaging experience can improve patient outcomes and the relationship between healthcare providers and the TGD community they serve.
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Affiliation(s)
- Justin T Stowell
- Department of Radiology, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Vaz A Zavaletta
- Department of Radiology, Division of Interventional Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Frances W Grimstad
- Division of Pediatric and Adolescent Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
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17
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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: 16] [Impact Index Per Article: 5.3] [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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18
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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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19
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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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