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

Body Contouring as Gender-Affirming Surgery in Transgender Patients: A Systematic Review of the Current Literature

Background: There is an increasing demand for body contouring and gender-affirming surgeries, and so is the need to compare outcomes between techniques. Gender dysphoria is a discrepancy between gender identity and the sex assigned at birth. One way to address this is to perform procedures to enable patients to look according to their desired gender identity. Gaps in knowledge regarding the best approaches and which surgical techniques yield the most patient satisfaction remain. This article summarizes up-to-date studies, including upper and lower body contouring procedures. Methods: A systematic review was performed using terms related to body contouring in gender-affirming surgery for transgender patients. All articles included surgical and patient-reported outcomes following either chest or lower body contouring procedures. Results: 15 studies, including trans male chest wall contouring, trans female breast augmentation, and lower body contouring, with 1811 patients, fulfilled the inclusion criteria. The double incision (DI) techniques consistently resected more tissue and had better BODY Q scores than non-overweight patients. Bleeding was increased in periareolar, semicircular, and obese patients with DI techniques. Nipple depigmentation and sensation loss were more common with double-incision-free nipple graft techniques (DIFNG). Lower body contouring patients had average implant sizes bigger than 200 mL and reported 2 gluteal implant displacements, 1 exposure, and one rupture. Eight percent of patients who underwent large-volume fat grafting reported dissatisfaction due to fat reabsorption. Conclusions: The debate between the double incision and periareolar techniques continues. Variations of the DIFNG technique continue to be the most common approach; however, nipple depigmentation and loss of sensation are also more common with it. Regarding increased bleeding with periareolar techniques, there is still no evidence that hormonal therapy may be playing a role in it. For lower-body trans female contouring, implants could help with the longevity of contouring results in patients needing large-volume fat grafting. There is an increasing evaluation of gender-affirming body contouring patient-reported outcomes; however, there is still a need for a validated way to report satisfaction scores in lower body contouring. Validated surveys could help identify surgical candidates based on satisfaction patterns, specifically for transgender and non-binary patients.

Gender-Related Medical Experiences of Youth Who Have Detranstioned

People whose gender does not align with their sex assigned at birth can undergo a medical transition process, so their body reflects their gender. However, some people interrupt this process temporarily or permanently, which is often referred to as "detransition." Media coverage of detrans experiences tend to attribute this phenomenon to a lack of medical gatekeeping. However, research has shown detransitions are highly unpredictable. The aim of this article is to examine the medical experiences of youth who have detransitioned during various stages of the process from transition to today. Twenty-five interviews with 15-25-year-old youth who detransitioned were conducted. Thematic analysis led to the development of six themes: facing gatekeeping and invalidation during transition, accessing trans care, lacking adequate support during transition, finding support in detransition, lacking support in detransition, leaving the medical system. Our results question the usefulness of gatekeeping to prevent detransition and shows that it tends to erode the trust relationship between youth and practitioners and stifle gender exploration. Validation, support, information giving as well as exploration without constrain, or expectation of outcome seems to be a more helpful way forward to work with gender diverse youth.

Patient-Reported Outcomes on Subjective Nipple Sensation After Double-Incision and Periareolar Mastectomy for Chest Masculinization: Subjective Nipple Sensation After Chest Masculinization

ABSTRACT

We evaluated patient-reported outcomes to assess for patient and procedural factors associated with postchest masculinization subjective nipple sensation. Patients who underwent double-incision or periareolar mastectomies for chest masculinization by a single senior surgeon (2015-2019) were surveyed at 2 time points regarding postoperative nipple sensation and satisfaction, including patient-reported outcomes using BODY-Q modules (Q-Portfolio.org). Demographic, operative, and postoperative variables were obtained from medical records. Patients were stratified according to survey responses. Univariate and multivariate analyses were performed.Response rate was 42% for survey 1 and 22% for survey 2. Of the 151 survey 1 responders, 138 (91.4%) received double-incision mastectomies and 13 (8.6%) received periareolar mastectomies. Among Survey 1 responders, 84.6% periareolar patients and 69.6% double-incision patients reported "completely" or "a little" nipple sensation preservation, and the difference trended toward significance (P = 0.0719). There was a stepwise increase in proportion of patients reporting sensation with greater recovery time until response to survey 1. Obesity (P = 0.0080) and greater tissue removed (P = 0.0247) were significantly associated with decreased nipple sensation. Nipple satisfaction scores were significantly higher for patients reporting improved nipple sensation (P = 0.0235). Responders to survey 2 who reported greater satisfaction with nipple sensation were significantly more likely to report preserved sensitivity to light touch (P = 0.0277), pressure (P = 0.0046), and temperature (P = 0.0031). Preserved erogenous sensation was also significantly associated with greater satisfaction (P = 0.0018).In conclusion, we found that nipple sensation may be associated with postoperative nipple satisfaction. Operative techniques to optimize nipple sensation preservation may improve this population's postoperative satisfaction.

Female-to-Male Chest Surgery in Transgender Patients: A Comparison Between 2 Different Techniques and a Satisfaction Study in a Single Center

Background

Gender dysphoria is a distress caused by a mismatch between gender identity and the sex assigned at birth. About 0.5% of the population suffer from gender dysphoria, which represents 25 million people worldwide. Gender-affirming mastectomy is the most common procedure for female-to-male patients.

Objectives

The aim of this single-center retrospective study is to present the outcomes after mastectomy and to evaluate patient satisfaction using the BODY-Q questionnaire.

Methods

Several data regarding patient characteristics and surgery have been collected. A satisfaction survey has been sent to patients. Two groups, "NAC grafts" and "semicircular," have been compared for complications and satisfaction.

Results

A total of 103 patients have had a transgender mastectomy performed by 3 surgeons, representing 206 mastectomies. There were 5 wound infections (4.8%), 8 seromas (6.8%), 10 hematomas (6.8%), and 23 partial/total nipple areolar complex (NAC) necrosis (20.4%). The complication rates in this study are similar to others in the literature. Few studies express interest in patient satisfaction after this type of surgery and even fewer use a suitable questionnaire.

Conclusions

Transgender mastectomy is a safe and often necessary procedure to improve the quality of life of patients suffering from gender dysphoria. Nevertheless, there is currently no validated tool to assess postoperative satisfaction within this specific population group.

Level of Evidence 3

Double-incision mastectomy after reduction mammaplasty for persistent gender dysphoria: a case report

Most patients undergo just one type of gender-affirming top surgery, but some will have a double-incision mastectomy after reduction mammaplasty. We describe a 46-year-old transgender man who requested a flatter chest after undergoing reduction mammoplasty the previous year. We also provide three considerations to guide surgical decision-making in this situation.

Gender detransition: A critical review of the literature

Gender detransition is the act of stopping or reversing the social, medical, and/or administrative changes achieved during a gender transition process. It is an emerging phenomenon of significant clinical and social interest.

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 .

Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents

Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Targeted Nipple Areola Complex Reinnervation in Gender-affirming Double Incision Mastectomy with Free Nipple Grafting

Restoration of breast sensation has become an important goal in autologous and implant-based breast reconstruction after cancer-related mastectomy. Although gender-affirming mastectomy with free nipple grafting (FNG) results in similar sensory deficits, chest reinnervation concepts have not been applied to this procedure.

Methods

This article describes a novel technique to reinnervate the FNG in patients undergoing double incision gender mastectomy.

Results

Our technique differs from previously described reinnervation techniques in several aspects: (1) the donor axon count is maximized by preserving the third to fifth lateral cutaneous nerves for coaptation to the nipple areola complex, (2) the reinnervation approach varies and is based on patient anatomy, (3) the distal graft or donor nerve is split into fascicles to increase the reinnervation zone, and (4) the split fascicles are coapted to the dermatosensory peripheral nerve elements of the dermis.

Conclusion

Chest reinnervation is technically feasible in patients undergoing double incision gender mastectomy with FNG (please also see the video abstract).