Female-to-Male Chest Reconstruction: A Review of Technique and Outcomes

Patient-reported satisfaction and health-related quality of life after chest masculinization in transgender men using the BODY-Q Chest module and the 15D instrument

Chest masculinization is the most common surgical intervention in transgender men. Studies indicate good patient-reported postoperative satisfaction, but only recently has a patient-reported outcome instrument, the BODY-Q Chest module, been developed and validated for this patient group. This study aimed to evaluate postoperative patient-reported satisfaction and health-related quality of life (HRQoL) using the BODY-Q Chest module and the 15D after surgical chest masculinization in transgender men. The data comprised all patients receiving chest masculinization from 2005 to 2018. The patients were invited by letter to complete the BODY-Q Chest module and the 15D questionnaire in May 2020. Of the 220 patients invited, 123 completed the survey, resulting in a response rate of 56%. The median chest and nipple scores were 76 and 68 out of 100, respectively. The number of secondary corrections was negatively associated with the chest score (p value < 0.001). The 15D index score was lower compared with the age-standardized male population (p value < 0.001), but similar to the age-standardized female population. Psychiatric comorbidity was associated with lower 15D index scores (p value < 0.001). There were no statistically significant differences between the BODY-Q Chest module scores or the 15D index score among the different surgical techniques. The postoperative satisfaction with chest masculinization was good and in line with previous literature. HRQoL resembles that of the reference population. The periareolar technique is not associated with better satisfaction despite causing less scar burden. The negative association between the chest score and number of secondary corrections is unsettling and requires further examination in a prospective setting.

Review of Gender Affirming Mastectomy Surgery: Comparing Drains Versus No Drains

BACKGROUND

Gender-affirming mastectomy can improve mental health and gender expression. However, there is no consensus on routine drain usage in gender-affirming surgeries. The purpose of this study is to compare gender-affirming mastectomies with and without drains and review complications.

METHODS

An institutional review board-approved, retrospective review was performed to identify patients between 2017-2021 who had double-incision mastectomy, with or without nipple graft, and separated into drain and no-drain cohorts. Patient demographics, outcomes, and postoperative complications were analyzed, including unplanned return to the operating room, seromas, hematomas, postoperative infection, and postoperative antibiotic use. Univariate and multivariate analysis was performed.

RESULTS

There were 359 patients that had a gender-affirming mastectomy surgery between 2017 and 2021. The mean age was 26.1 years old, and mean body mass index was 27.4. There were 144 patients (40.1%) who had a drain, and 215 patients (59.9%) without a drain. For postoperative complications of all patients, there were 12 (3.3%) unplanned returns to the operating room, 18 seromas (5.0%), 26 hematomas (7.2%), 50 (13.9%) postoperative antibiotic use, and 4 postoperative infections (1.1%). There were no significant differences found between drain use for all postoperative complications, but no-drain use was significantly associated with less prescribed postoperative antibiotics compared to drain use (3.7% and 29.0%, respectively; P < 0.001).

CONCLUSIONS

Gender-affirming mastectomy surgeries are safe and effective treatment options. No-drain placement was not associated with increased postoperative complications. Surgeons may consider not prescribing routine postoperative antibiotics if using drains, and avoiding drains for gender-affirming mastectomies may be considered in selected individuals based on clinical judgment.

Peri-surgical imaging of intersex and gender diverse youths

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Masculinization of the Chest in Transmen with Large Breasts

Background and Objectives  Surgery to masculinize the chest is a frequently sought-after procedure by transmen who wish to conform their physical appearance to their gender identity. In our study, the outcomes of surgical masculinization comprising subcutaneous mastectomy through a modified elliptical incision, liposuction, reduced inert nipple-areola grafting, and quilting stitches were analyzed. Materials and Methods  Thirty-two transmen with large breasts and hypertrophied nipples and areolae underwent the above-mentioned masculinizing procedure in this prospective cohort study. Our statistically validated institutional aesthetic outcome assessment score (IAOAS) was used to analyze the outcomes at the end of the follow-up period. Results  The average period of follow-up was 24.5 months. The average final IAOAS was 23.1. The rate of complications was found to be associated with using breast binders. In all, 22 of 32 patients (68.75%) had an excellent outcome score, while 10 patients (31.25%) had a good outcome score ( p  = 0.025). Conclusion  Top surgery is crucial for transmasculine patients to achieve their desired gender identity as males. It is imperative that this procedure is performed to their complete satisfaction. Our single-staged comprehensive approach of subcutaneous mastectomy and liposuction with reduced inert nipple and areola grafts, which aids in a swift transition to a male role, is a prerequisite for bottom surgery at our institute.

Subcutaneous mastectomy in female-to-male transsexuals is associated with higher risk of postoperative bleeding complications

Introduction

Chest contouring or subcutaneous mastectomy (SCM) in female-to-male (FtM) transgender individuals is the primary surgery in the gender reassignment process. Many authors report high rates of postoperative bleeding in these patients and discuss a possible influence of preoperative hormone therapy. However, there is a lack of data on the analysis between different surgical techniques and postoperative bleeding risk.

Materials and Methods

In this retrospective study, we included 22 FtM transgender individuals who underwent bilateral SCM using 4 different techniques (44 breasts) between June 2014 and September 2023. Postoperative complications regarding surgical techniques and patient demographics were collected and analyzed.

Results

SCM with free nipple grafting was the most commonly used technique (n = 12, 54.5%). The mean operative time was 163.4 ± 49.2 minutes. There were no significant differences in operative time between the surgical techniques (p ≥ 0.20 in all cases). The rate of acute postoperative bleeding was 20.5% (n = 9). Acute postoperative bleeding occurred most frequently in patients who received a semi-circular incision for SCM. There was no significant difference in the rate of acute postoperative bleeding between the different surgical techniques. BMI, breast weight, and duration of surgery were not associated with the rate of acute complications (p > 0.17 in all cases).

Conclusions

Less invasive SCM techniques in FtM transgender individuals are associated with higher postoperative bleeding risk.

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

Outcomes of enhanced recovery protocols and tranexamic acid on double-incision versus periareolar gender-affirming mastectomy: A retrospective study of postoperative outcomes

INTRODUCTION

The effects of enhanced recovery protocols and use of tranexamic acid (TXA) to reduce postoperative complications after periareolar and double-incision (DIM) gender-affirming mastectomies have not been previously described. We sought to evaluate the efficacy of our ERP including use of liposomal bupivacaine [Exparel] in these cases, assess the efficacy of TXA in reducing postoperative complications, and compare need for revisionary surgery between periareolar and DI mastectomy techniques.

MATERIALS AND METHODS

A retrospective review from November 2017 to June 2022 was performed. Data were collected on patient demographics, operative data, and postoperative outcomes including complications and revisions. Morphine milligram equivalent was used to assess opioid use after surgery.

RESULTS

Overall, 260 patients were included: 240 (92.3%) patients in the DI and 20 (7.7%) patients in the periareolar group. Thirty-five (7.3%) breasts in the DIM group and five (12.5%) breasts in the periareolar cohort developed complications (p = 0.220). Significantly more breasts in the periareolar cohort developed hematomas (12.5% vs. 2.9%, p = 0.011). Sixteen (3.3%) breasts in the DIM group developed seromas. Significantly more breasts in the periareolar group required revisionary surgery (15.0% vs. 5.2%, p = 0.025). Patients who received intraoperative liposomal bupivacaine [Exparel] had fewer opioids intraoperatively (p = 0.019) and at discharge (p < 0.001). Use of TXA did not affect rates of complications including hematoma or seroma.

CONCLUSIONS

Overall, complication rates for periareolar and DIM are similar. However, the periareolar technique results in a significantly higher rate of hematomas and revisionary surgery. Use of intraoperative liposomal bupivacaine [Exparel] resulted in significantly lower opioid use. Lastly, use of topical TXA did not lower the risk of postoperative hematoma or seroma.

Impact of surgical technique on outcome measures in chest masculinization: A systemic review and meta-analysis

BACKGROUND

Among plastic surgeons, there are several conventional techniques for performing chest surgery. Research on surgical approaches has focused cis-gender patients with medical conditions, such as breast cancer or gynecomastia, but has never studied transgender populations. The aim of this study is to perform the first systematic review of gender-affirming surgery (GAS) in transgender populations and determine postoperative outcomes differences in relation to surgical technique.

METHODS

Two reviewers independently searched Medline, Embase, CINAHL, Web of Science, and Cochrane databases for studies published prior to 2021. Studies selected for inclusion were retrospective or prospective studies of adult transgender men undergoing GAS that utilized appropriate operative techniques and reported complications and/or patient-reported outcomes.

RESULTS

A total of 26 randomized controlled trials, including 40 distinct populations and 3055 patients, were identified. Surgical techniques compared double incision free nipple graft (DIFNG) (2053 patients [67.20%]), pedicled nipple techniques (PNT) (297 [9.72%]), and periareolar techniques (PAT) (705 [23.08%]). Pairwise analysis found the lowest complication rates associated with procedures utilizing DIFNG, followed by PNT, then PAT. Patients with PAT had significantly higher satisfaction scores than DIFNG.

CONCLUSIONS

This is the first systematic review to evaluate outcomes of chest surgery techniques among the transgender population. Results indicate significantly more complications for PAT compared to DIFNG or PNT. Analysis of patient-reported outcomes was limited due to heterogeneity in reporting.

[Thoracic reassignment surgeries]

Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.

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.

Cultural Competence in the Care of LGBTQ+ Patients: A Primer for Breast/Chest Centers

The number of individuals identifying as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) has doubled over the past 10 years, and this figure continues to rise. The LGBTQ+ community is diverse, encompassing a vast array of differences in gender identity and sexual orientation. Additionally, it is inclusive of people from all races, ethnicities, religions, and socioeconomic backgrounds. This intersectionality of identities and experiences impacts both access to health care and its delivery. Barriers to care for this population are multifactorial and include stigma, discrimination, bias, limited role models, issues with insurance coverage, lack of education and training for health care providers, and lack of research on LGBTQ+ health-related issues. Specific to breast cancer, the screening recommendations for this group are influenced not only by risk but also by gender-affirming hormonal and surgical therapies. This article will provide an overview of the LGBTQ+ population, review breast cancer screening compliance and recommendations, summarize the multitude of health disparities, and offer potential interventions to improve care delivery at the individual, facility, organizational, and health policy levels.

High Self-Reported Satisfaction After Top Surgery in Gender-Affirming Surgery: A Single-Center Study

Purpose

Top surgery, or masculinization of the chest, is often the first and sometimes only procedure in gender-affirming surgery for transgender- and gender-diverse persons assigned female at birth. In recent years, there has been improved access to care for transgender individuals and increased demand for top surgery. Our aim was to investigate the degree of satisfaction with the postoperative outcome after top surgery in transgender men.

Methods

Ninety transgender men who underwent top surgery between September 1, 2013 and August 31, 2018 were included. Patients were surveyed from 5 to 62 months after surgery. Participants' files were evaluated for complications, and 84 (response rate 93.3%) participants answered a questionnaire evaluating patient satisfaction postoperatively.

Results

Patients were either satisfied or partially satisfied with the overall experience of undergoing surgery and the postoperative result in 90.5% of responses. Patients were very satisfied with their clothed appearance in 89.3% of responses, whereas only 44.1% were very satisfied with their nonclothed appearance and 46.4% partially satisfied. Patients were also very satisfied with postoperative scars in 47.6% of responses and nipple reconstruction in 48.8%. Only two patients expressed their regret.

Conclusion

Satisfaction outcomes after top surgery are generally positive, especially in respect of clothed appearance, self-confidence, and self-acceptance.

Chest Wall Contouring in Transgender Men: A 20-Year Experience from a National Center

Several western countries have experienced a drastic increase of referrals to specialist gender services of transgender and gender-diverse people. Chest wall contouring is an important element in treatment of gender dysphoria. National data concerning this group have yet to be investigated. The aim of this study was to examine and evaluate the techniques and surgical outcome of chest wall contouring from the last 20 years from a single center in Norway.

Methods

This study is a retrospective review of all female-to-male patients who underwent chest wall contouring surgery at Oslo University Hospital between 2000 and 2020. Statistical analysis with comparison of techniques and evaluation of development over time was examined.

Results

In total, 333 patients underwent bilateral chest wall contouring, 209 (62.8%) with inframammary incision with free nipple graft (IM), and 124 (37.2%) with periareolar technique (PA). In 20 years, the average age decreased from 31 (19-68) to 24.9 years (17-61). Average body mass index was significantly lower in the PA-group than in the IM-group. Complication rate was 20.7%, with postoperative bleeding being the most frequent (9.6%). Revision surgery was required in 24.9% of the cases; periareolar technique required significantly more procedures.

Conclusions

The number of patients referred and operated on has increased drastically over a 20-year period. When comparing the techniques, the outcome concerning complications and revisions is at an acceptable level. Postoperative bleeding and revision surgery occur more often with the periareolar technique. There remains a knowledge gap concerning quality of life and satisfaction after surgery within this patient group.

Blood Pressure Challenge Reduces Hematomas in Gender-Affirming Mastectomy: A Retrospective Chart Review of 92 Consecutive Patients

BACKGROUND

Gender-affirming mastectomy is a common surgery for the treatment of gender incongruence and gender dysphoria and improves quality of life. Hematoma rates for gender-affirming double incision mastectomies are between 2.8% and 8.1%. This study aims to investigate the utility of a blood pressure challenge, whereby the patient's blood pressure is medically increased intraoperatively to reveal bleeding vessels that can be addressed with additional hemostasis before skin closure, to reduce postoperative hematoma.

METHODS

A retrospective chart review of patients who underwent gender-affirming double incision mastectomies over a 6-year period by a single surgeon was conducted. Surgeries were separated into a blood pressure challenge experimental group and a non-blood pressure challenge control group. Demographics, surgical characteristics, and postoperative complications were compared between the 2 cohorts using Pearson χ2, Fisher exact, t tests, univariate logistic regression, and multivariable logistical regression. Significance was established at P < 0.05.

RESULTS

A total of 92 patients (184 breasts) were included with 32 patients (64 breasts) in the control group and 60 (120 breasts) in the blood pressure challenge group. In the control group, there were 5 hematomas (7.81%) compared with 1 (0.83%) in the blood pressure challenge group (P = 0.02). On univariate logistical regression analysis, blood pressure challenge was the only variable significantly associated with hematoma (odds ratio, 0.1; 95% confidence interval, 0.01-0.63; P = 0.04). On multivariable logistical regression, after controlling for age, body mass index, smoking status, and mass of excised breast tissue, patients who underwent blood pressure challenge demonstrated lower hematoma rates (odds ratio, 0.08; 95% CI, 0.004-0.59; P = 0.04).

CONCLUSIONS

Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

Health State Utility Values in Patients Undergoing Chest Masculinization Surgery

BACKGROUND

Chest masculinization surgery is the most common gender-affirming procedure performed in transgender and gender-diverse individuals. While evidence on the health-related quality of life (HRQL) impact of chest masculinization is starting to emerge, data on health state utility values (HSUVs) associated with the surgery is largely missing. The objectives of this study were to estimate the HSUVs using EQ-5D for patients seeking chest masculinization surgery and assess the determinants of EQ-5D score at 6 months postoperatively.

METHODS

Patients seeking chest masculinization at a single community plastic surgery clinic by 2 surgeons completed 3 patient-reported outcome measures - EQ-5D-3L, Patient Health Questionnaire (PHQ)-9, and BODY-Q Chest module - preoperatively and postoperatively at 6 weeks and 6-months. Friedman test was used to assess the differences in PROM scores at the 3 timepoints. Simple and backward stepwise regression analyses of 6-month postoperative EQ-5D scores were performed.

RESULTS

A total of 113 patients (mean [SD] age, 25.7 [6.9] years) were included. The mean [SD] EQ-5D scores at preoperative, postoperative 6 weeks and 6 months were 0.81 [0.15], 0.84 [0.15] and 0.87 [0.12], respectively. Postoperatively, problems were most frequently reported in the dimensions "pain/discomfort" and "anxiety/depression". Preoperative PHQ-9 score was a predictor of 6-month postoperative EQ-5D scores following simple (p < 0.01) and backward stepwise linear regression analysis (p < 0.01).

CONCLUSION

Chest masculinization was associated with an improvement in overall HRL at 6 months postoperatively; however, this did not achieve statistical significance. Preoperative depression severity was a significant determinant of postoperative HRL. Consequently, additional support must be offered to patients who have a higher level of preoperative depression.

Mastectomy is a safe procedure in transgender men with a history of breast reduction

Little is known about the safety and surgical outcomes of mastectomy after breast reduction in the trans male population. Several concerns have been voiced that performing mastectomy with prior breast reduction surgery, increases the risk for complications and revision surgery. All transgender men with a history of breast reduction, who underwent a mastectomy at our center between 01-1990 and 01-2021 were identified from our hospital registry. A retrospective chart study was conducted recording surgical characteristics, surgical complications, revision surgery, and clinical follow-up. A total of 1362 subcutaneous mastectomies were performed between 01-1990 and 01-2021. A total of 36 (2.6%) individuals were included (35 bilateral and 1 unilateral breast reduction). The mean age at mastectomy was 37 ± 10 years, and the median time between breast reduction and mastectomy was 6.3 years (range 1.0-31.1). Most individuals underwent a Wise-pattern breast reduction (91%) and a double incision mastectomy with free nipple grafts (86%). Following mastectomy, one acute reoperation was performed because of hemorrhage (3%). Partial pedicled nipple necrosis was seen in 7% and (partial) non-take of nipple grafts in 4%. Scar revisions were performed in 9%, dogear corrections in 20%, and both nipple corrections, and contour corrections in 6%. When comparing the outcomes in literature for surgical complications, scar revision, contour correction or nipple areolar complex revision, no clear disadvantage seems to be present when performing mastectomy after breast reduction. Mastectomy is a safe procedure in transgender men with a history of breast reduction.

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

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

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Hematoma following gender-affirming mastectomy: A systematic review of the evidence

BACKGROUND

Hematomas are reported to be the most common immediate complication in patients undergoing gender-affirming mastectomy, with rates substantially higher than those associated with other types of breast surgery. This study sought to examine the breadth of current literature and provide evidence-based explanations regarding the development of hematomas in chest masculinizing surgery and technical considerations for reducing their incidence.

METHODS

A systematic review was conducted to identify all articles related to gender-affirming mastectomy published through September 2021. Literature search yielded 2,661 articles for screening, of which 20 met inclusion criteria. Themes from the selected articles were compiled to generate consensus statements qualified by associated level of evidence (LOE).

RESULTS

The rate of hematoma following gender-affirming mastectomy is reported in the literature ranging from 0% to 31.2%. The use of more limited, nipple-sparing incisions is associated with a higher hematoma rate than mastectomy with free nipple grafting (Level III). There is no conclusive evidence indicating any relationship between the use of masculinizing hormones and the incidence of hematoma (Level IV). Factors such as body mass index (Level III) and breast size (Level III) were not found to influence hematoma risk, though nicotine use (Level IV) was significantly associated with the incidence of hematoma.

CONCLUSIONS

Hematoma is a known complication following gender-affirming mastectomy. The use of limited incision approaches has the strongest association with an increased risk of hematoma. There is no evidence indicating an association between hormone use (i.e., testosterone) and hematoma incidence. Future studies are needed to better define factors, interventions, and protocols to reduce the rate of hematoma.

LEVEL OF EVIDENCE

III.

Overview of Medical Management of Transgender Men: Perspectives from Sri Lanka

Transgender medicine is an evolving field of medicine due to the rising awareness of individuals with a non-binary gender identity. Individuals with nonconforming gender identities have been on the rise in many societies and it is becoming an increasingly discussed issue. Their management is multidisciplinary, which includes mental health, endocrine therapy, and surgery. Although their general healthcare needs are similar to those of the general population, special considerations in primary and preventive care are also necessary in relation to the gender-affirming medical issues. Their quality of life is largely affected by psychological, social, and economic difficulties they face due to acceptance issues in the society and healthcare. This review explores the primary care, medical, and surgical management of transgender men with perspectives from Sri Lanka.

Double-sided Nipple-areola Complex Marker for Masculinizing Chest Surgery

In addition to chest contour and incision placement, nipple-areola complex size, orientation, and position is a primary concern of patients undergoing masculinizing chest surgery with free nipple grafting for gender dysphoria or gynecomastia. The author has developed a double-sided nipple-areola complex harvest and inset marker that facilitates graft healing in an optimized masculine orientation.

Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze?

BACKGROUND

Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity.

METHODS

Transgender and cisgender participants were enrolled and shown images of surgery naïve chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image.

RESULTS

Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naïve: 802 vs. 395 ms; p = 0.02, masculinized: 940 vs. 692 ms, p = 0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391 ms; p = 0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847 ms; p = 0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59 ms; p = 0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p < 0.05).

CONCLUSIONS

This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

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.

Hockey stick incision: a modified technique for chest wall masculinization

Background

Chest wall masculinization is often performed for transgender men in order to address gender dysphoria. Peri-areolar and double-incision mastectomy with free nipple grafts, are the most common techniques employed in chest masculinization surgery, but are limited by their relative inconsistency and inefficiency in reconstructing a natural anterior contour that comprehensively resembles that of a cis-masculine chest. The purpose of this study is two-fold. The first is to describe the "hockey stick" approach, which expands on the widely performed double-incision mastectomy to the axilla, with an additional step of revising lateral chest wall folds of tissue excess. This technique is scalable to the degree of pre-operative excess tissue on the anterior and lateral chest wall. The second is to compare the "hockey stick" incision to existing reconstructive options, with respect to clinical outcomes and patient satisfaction.

Methods

Patients who received chest masculinization surgery at Yale-New Haven Hospital were included. A retrospective chart review, comprising demographic variables, procedural details, and post-operative events, was conducted. Selected modules from a validated survey instrument, the BODY-Q, were measured. Patients were classified by body mass index and incision, which included peri-areolar, inframammary fold, and "hockey stick" incision by date.

Results

Twenty-seven of 73 (37.0%) participants completed the full survey and were included in the analysis. The "hockey stick" incision had comparable patient satisfaction and post-operative outcomes, compared to peri-areolar and double-incision mastectomy with free nipple graft techniques. Greater BMI patients had a higher incidence of wound dehiscence, compared to other weight classifications.

Conclusions

The "hockey stick" incision is a readily performed, effective surgical technique for building a cis-masculine appearing chest in transgender men with efficient and predictable outcomes. While performed in patients with higher BMI, the "hockey stick" confers equivalent patient satisfaction and clinical outcomes to peri-areolar and double-incision mastectomy.

Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes

Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.

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.

A Three-Step Technique for Optimal Nipple Position in Transgender Chest Masculinization

BACKGROUND

The ideal position of the nipple-areola complex (NAC) in the transgender population can be a challenge to determine.

OBJECTIVES

The authors sought to determine the best location and aesthetics of the female to male NAC.

METHODS

Patients who underwent female to male mastectomy with free nipple grafting were included. NAC position is confirmed utilizing a vertical coordinate at the level of the 4th rib near the border of the pectoralis muscle and a horizontal coordinate determined by dividing each unilateral chest into vertical thirds from midline to anterior axillary line laterally. The NAC position is confirmed at the junction of the middle and lateral third. Symmetry is ensured bilaterally by creating a triangle and transposing it side to side; the base lies from sternal notch to inframammary fold in the midline and the apex is adjusted to the NAC. A 24-question survey utilizing a 5-point Likert scale was distributed postoperatively to assess the patient's thoughts about their chest, nipples, scar, and overall experience with the gender affirmation process.

RESULTS

Thirty-one patients were included in this study. Eighteen patients responded to the postmastectomy survey, all of whom were highly satisfied with the aesthetic result postoperatively. All patients felt comfortable with their exposed chest. Nipple location was particularly highly received with 100% satisfaction rate (mean Likert score, 4.72). Nipple size and shape received a mean Likert score of 4.17 and 3.89, respectively.

CONCLUSIONS

The triple confirmation technique is an easy, reproducible method to guide the surgeon in relocation of the NAC.

LEVEL OF EVIDENCE: 4

Female-to-Male Transgender Chest Contouring: A Systematic Review of Outcomes and Knowledge Gaps

PURPOSE

The number of gender affirmation surgeries performed in the United States is increasing. Frequently, chest contouring is the first surgery for female-to-male transgender patients; it fosters assimilation into the new gender role with a desired sense of masculinity. Creating an aesthetic male chest requires adjustment of breast tissue volume, proper nipple-areolar complex placement, and abolishment of the inframammary fold. Although much has been published on various techniques and outcomes, there is no consensus on how to approach transmale top surgery. We have reviewed the most up-to-date literature and in so doing have uncovered significant knowledge gaps.

METHODS

An electronic literature review was performed. PubMed search keywords included combinations of "female-to-male," "transgender surgery," "chest contour," and "nipple-areolar complex." Articles were included if the patients were transgender female to male.

RESULTS

Our literature search yielded 67 unique articles, 22 of which met our inclusion criteria. A total of 2447 unique patients were analyzed. The articles discussed aspects of chest surgery in female-to-male transsexuals including mastectomy and nipple aesthetics. Relevant data trends were extracted and subsequently investigated.

DISCUSSION

Female-to-male transgender patients often undergo chest contouring as their initial gender affirmation surgery. As the surgical treatment of gender dysphoria continues to grow, it is imperative for plastic surgeons to understand the surgical options and associated outcomes for transmasculine top surgery. Future research is needed to improve patient selection, surgical decision making, and patient-reported outcomes for different chest contouring techniques. In addition, there is a significant knowledge gap for the ideal nipple-areolar complex shape, size, and location.

The Nipple Split Sharing vs. Conventional Nipple Graft Technique in Chest Wall Masculinization Surgery: Can We Improve Patient Satisfaction and Aesthetic Outcomes?

BACKGROUND

Double incision mastectomy with free nipple grafts (DIFNG) offers more flexible nipple-areola complex (NAC) resizing and repositioning in transmale and gender non-conforming individuals. The cis-male NAC has a smaller diameter, oval shape and lateral position. If nipple grafts are performed without having these considerations, aesthetics can be dissatisfying. We aim to describe the nipple split sharing technique during chest wall masculinization surgery comparing surgical, patient-reported outcomes (PRO) and aesthetic results with the conventional technique.

METHODS

This was a retrospective review of transmale patients who underwent DIFNG from January 2017 to January 2019. The cohort was divided into two groups: conventional and the splitting technique. Demographics, intraoperative and postoperative outcomes were recorded. In addition, PRO using Body-Q scale and aesthetic results using a Likert-based scale were analyzed.

RESULTS

Thirty-four patients (68 breasts) underwent DIFNG. A total of 32 breasts underwent the split nipple reconstruction approach, whereas 36 underwent conventional technique. Median patient age and BMI in the nipple sharing and conventional technique groups were 27 years and 35.4 kg/m², and 24 years and 32.2 kg/m², respectively. Differences on postoperative complications were not statistically significant. Patient satisfaction on nipples' module was 90.7% vs. 58.1% in the nipple sharing vs. conventional technique, respectively (p < 0.05). The nipple's masculine aspect, size, contour, position and scars were aesthetically superior to the split approach (p < 0.05).

CONCLUSION

Double incision mastectomy with nipple split sharing technique has good aesthetic outcomes, a low complication rate and high patient satisfaction. It is a great surgical alternative to improve aesthetics in chest wall masculinization surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Breast Surgery.

A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients

BACKGROUND

Increasingly more nonbinary patients are obtaining better access for gender-affirming chest surgery (top surgery), representing an important subset of patients who undergo such surgery.

OBJECTIVE

We review our experience at gender-affirming chest surgery in nonbinary versus transmasculine patients in an integrated health care setting.

METHODS

We performed a retrospective study of nonbinary and transmasculine patients who underwent gender-affirming chest surgery from May 1, 2012, to December 27, 2017.

RESULTS

There were 111 nonbinary patients and 665 transmasculine patients included in the final analyses. Nonbinary patients were more likely to seek more than 1 surgical consultations than transmasculine patients (24.3% vs 1.7%, respectively, P < 0.0001). More nonbinary patients (17.3%) indicated nipple sensation to be important relative to their transmasculine counterparts (0.4%, P < 0.0001). Fewer nonbinary patients were on testosterone before surgery (33.64%) in comparison to transmasculine patients (86.14%, P < 0.0001). When only prior reduction mammaplasty or top surgery were considered, nonbinary patients (8.1%) were more likely than transmasculine patients (3.5%) to have had a prior chest surgery. When evaluating patients who did not have prior chest surgery before undergoing top surgery at our institution (n = 721), rates of major complications, minor complications, as well as revisions, were comparable between nonbinary and transmasculine patients.

CONCLUSIONS

This study demonstrated that more nonbinary patients requested nonflat chests relative to their transmasculine counterparts. Both groups in our sample displayed comparable rates of complications after top surgery.

Outcome Measures in Gender-Confirming Chest Surgery: A Systematic Scoping Review

BACKGROUND

The aim of this scoping review was to provide an overview of outcome measures in gender-confirming chest surgery.

METHODS

A comprehensive literature search was performed in PubMed, EMBASE, CINAHL, PsycINFO, Scopus and the Cochrane Library to find studies evaluating gender-confirming chest surgery in a non-cis gender population. The systematic scoping review followed the PRISMA extension for scoping reviews. Data were charted for outcome measures including complications, reoperations, revision surgery, aesthetic outcome and patient-reported outcome measures.

RESULTS

Our search yielded 849 records, which were screened on title, abstract and full text. Of these, 47 were included in the review. Feminising gender-confirming chest surgery was evaluated in 11 studies, and masculinising gender-confirming chest surgery was evaluated in 39 studies. Clinician-reported outcome categories were used in 40 studies and included complications, reoperation, revision surgery and aesthetic outcome. Categories of patient-reported outcomes were used in 29 studies and included aesthetic outcome, functional outcome and mental health parameters. The summary of outcome domains and classifications showed that there are large variations in outcome evaluation between studies. Although several studies reported on similar outcome categories, there was a high level of heterogeneity of domains and classifications of outcomes.

CONCLUSIONS

Evaluation of outcomes in gender-confirming chest surgery showed large variations in reporting, and further streamlining of reporting is therefore required to be able to compare surgical outcomes between studies.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes

BACKGROUND

Chest reconstruction ('top surgery') is an important component of transition in the transmasculine population that can substantially improve gender incongruence. The aim of this study was to evaluate the demographic characteristics, surgical technique, and postoperative outcomes following transmasculine chest surgery.

METHODS

Using ICD codes, we identified all cases of gender-affirming transmasculine chest surgery from the ACS NSQIP database (2010-2017). CPT codes were used to categorize patients by reconstructive modality: reduction versus mastectomy (± free nipple grafting [FNG]). Univariate analysis was conducted to assess for differences in demographics, comorbidities, and postoperative complications. Multivariable regression analysis was used to control for confounders.

RESULTS

A total of 755 cases were identified, of whom 591 (78.3%) were mastectomies and 164 (21.7%) were reductions. No significant differences were noted in terms of age or BMI. Mastectomies had shorter operative times, but similar length of stay compared to reductions. Rates of postoperative complications were low, with 4.7% (n = 28) of mastectomies and 3.7% (n = 6) of reductions experiencing at least one all-cause complications. Postoperative complication rates were not statistically different between mastectomy with (3.4%) and without (5.6%) FNG. After controlling for confounders, there was no difference in terms of risk of all-cause complications between reduction and mastectomy, with or without FNG.

CONCLUSION

Mastectomy and reduction mammaplasty are both safe procedures for chest reconstruction in the transmasculine population. These results may be used to encourage shared decision making between patient and surgeon such that the reconstructive modality of choice best aligns with the desired aesthetic outcome.

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.

Modified Treatment Algorithm for Pseudogynecomastia After Massive Weight Loss

BACKGROUND

Pseudogynecomastia is the increased aggregation of fatty tissue in the area of the male breast with resultant female appearance. Two forms can appear: pseudogynecomastia after massive weight loss (pseudogynecomastia obese [PO]) and pseudogynecomastia, which is caused only by adipose tissue (pseudogynecomastia fat). For PO, only the Gusenoff classification with corresponding operative treatment options exists. However, this classification is limited by the fact that it underestimates the extensive variability of residual fat tissue and skin excess, both crucial factors for operative planning. For this reason, we propose a modification of the treatment algorithm for the Gusenoff classification based on our results to achieve more masculine results.

MATERIALS AND METHODS

A total of 43 male patients with PO were included in this retrospective study (grade 1a, n = 1; grade 1b, n = 1; grade 2, n = 17; grade 3, n = 24). Forty-two mastectomies with a free nipple-areola complex (NAC) transposition (grades 2 and 3) and 1 with a subcutaneous mastectomy (grade 1a) with periareolar lifting were performed. A retrospective chart review was performed to obtain data regarding age, body mass index, body mass index loss, weight loss, reason for weight loss, comorbidities, nicotine, and additional procedures, postoperative sensitive on the NAC transplants and complications.

RESULTS

None of the free-nipple grafts were lost. Forty (95%) of 42 patients with mastectomy had a resensitivity on the NAC.

CONCLUSIONS

For pseudogynecomastia, the treatment algorithm of the Gusenoff classification should be modified and adapted according to our recommendations to achieve more optimal masculine results.

Early Experiences With the Buttonhole Modification of the Double-Incision Technique for Gender-Affirming Mastectomies

BACKGROUND

Little has been published about transmasculine and nonbinary gender-affirming mastectomies, particularly for patients with skin excess who desire reliable vascularity and sensation to the nipple-areolar complex. In this case series, we describe our experiences with the "buttonhole technique."

METHODS

This was a retrospective case series of all consecutive patients who had a buttonhole mastectomy by a single surgeon. This technique maintains the nipple-areolar complex on a dermal pedicle rather than using a free nipple graft.

RESULTS

Seventeen patients were included, with ages ranging from 21 to 49 years (median, 28 years). There were no major complications. Four patients had minor complications and/or required revision.

CONCLUSIONS

The buttonhole technique should be considered for transmasculine and nonbinary patients with skin excess who are concerned about nipple vascularity and sensation.

Chest and facial surgery for the transgender patient

In conjunction with social transition, hormones, and counseling, gender-affirming surgery (GAS) is a key component in the treatment gender dysphoria. Gender affirming surgeries can be divided into genital surgery (phalloplasty, metoidioplasty, oophorectomy, vaginoplasty, and orchiectomy) and non-genital surgeries. The non-genital surgeries for transmasculine individuals include chest masculinization and body contouring. For transfeminine individuals, they include breast augmentation, and facial feminization. Chest masculinization eliminates the need for binding and improves overall confidence and quality of life. Choice of technique depends on body habitus and patient preference. For transfeminine individuals, some breast growth can be achieved with the use of estrogen over the course of 1-2 years, but many still require breast augmentation for breasts that are proportionate to their frame. Facial surgery for transfeminine patients is highly effective in changing classic masculine anatomic features to feminine norms. The most common of these procedures include forehead contouring, rhinoplasty, lip lift, mandible angle reduction, genioplasty and chondrolaryngoplasty. These non-genital surgeries are critical to treating gender dysphoria in transgender and gender non-binary individuals. Further research with standardized and validated assessments of patient reported outcomes is needed to fully understand long term effects on quality of life and gender dysphoria.

Female-to-Male Gender-Affirming Chest Reconstruction Surgery

There is an increased demand for gender affirmation surgery. Chest contouring, or "top" surgery, is especially important in the female-to-male (FtM) transgender population. This Continuing Medical Education (CME) article critically appraises the available literature on top surgery to allow plastic surgeons to understand current practices and determine the best surgical technique using a decision algorithm and the patient's preoperative anatomy and characteristics. Because a single best surgical approach does not exist due to significant variance in preoperative patient anatomy, and in order to provide a useful framework for decision making, surgical approaches described are categorized as: approach 1-remote incision procedures without skin excision; approach 2-procedures with periareolar skin excision; and approach 3-mastectomy procedures with skin excision other than periareolar skin excision. Decision algorithms that help determine the most suitable surgical technique for individual patients are reviewed. Data on complication rates and patient satisfaction will improve informed consent discussions and create realistic patient expectations.

Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men

BACKGROUND

A primary goal in chest wall reconstruction ("top surgery") for trans men is achieving a symmetric, aesthetically pleasing position of the reconstructed male nipple-areola complex.

METHODS

The senior author's (A.H.) technique for component nipple-areola complex creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March of 2015 to October of 2016.

RESULTS

The average patient age was 30.64 years, and the average body mass index was 28.54 kg/m. Eighty-two percent of the sample received preoperative testosterone therapy, and average operative time was 2 hours 59 minutes. Average overall mastectomy specimen weight was 627.80 g, average length of hospital stay was 0.96 days, and average follow-up duration was 19.02 months. Complications occurred in five patients (10 percent), including seroma (4 percent), cellulitis (2 percent), hematoma (2 percent), and suture granuloma (2 percent). Only five patients (10 percent) underwent postoperative revision to adjust nipple-areola complex size, projection, or symmetry. Twenty-eight patients (56 percent) underwent secondary revisions, including scar revisions (56 percent), liposuction (12 percent), and fat grafting (2 percent).

CONCLUSION

The use of a modified nipple flap and free areola graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male nipple-areola complex in a safe and effective manner.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Creation of an Aesthetic Male Nipple Areolar Complex in Female-to-Male Transgender Chest Reconstruction

BACKGROUND

Female-to-male chest wall reconstruction is becoming more common, but while there is a growing body of the literature describing technique and algorithms, little detail is written on methods for creating a male appearing nipple areolar complex (NAC) from a female NAC utilizing free nipple graft techniques. Incorrect positioning of the NAC on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation.

METHODS

With this paper, we present techniques for nipple grafting to achieve improved male appearing NACs, as well as a simple, reproducible method for appropriate placement of the NAC relative to the borders of the pectoralis muscle. To validate our technique, we performed photographic analysis of 64 NACs in 32 volunteers with BMI of 25 or less.

RESULTS

The anatomic study determined the cis-male nipple to be positioned on average 2.5 cm medial to the lateral border of the pectoralis muscle and 2.4 cm above the inferior pectoralis insertion. This supports our surgical technique of positioning the NAC in relation to the pectoralis borders rather than previously advocated anatomic landmarks. We also present reliable techniques for creating a round or horizontally oval final NAC shape as well as a composite grafting technique for cases of large papillae.

CONCLUSIONS

Our anatomic study supports placement of the male NAC relative to lateral and inferior borders of the pectoralis muscle. Nipple grafting techniques presented allow for a simple and reproducible method of creating an aesthetic male NAC shape in female-to-male transgender chest reconstruction.

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 .