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

Nipple-Preserving Inferior-Ellipse Mastectomy: A New Technique for Gender-Affirming Top Surgery

SUMMARY

The 2 most common techniques for gender-affirming mastectomy are the double-incision free nipple graft and periareolar techniques. However, some patients are not well suited for either technique. When the nipples are high and on the pectoralis muscle, but there is marked breast tissue and skin redundancy, a double-incision free nipple graft would land the incision above the pectoral shadow, but a periareolar approach would not adequately remove the excess skin. In these patients, a nipple-preserving inferior-ellipse incision allows for appropriate chest contouring, leaving the nipple position unchanged and placing the incision in the pectoralis muscle shadow. A retrospective review identified all consecutive patients undergoing nipple-preserving inferior-ellipse mastectomy by the senior author (R.B.-L.). Indications were patients with moderate glandular tissue, skin excess, and a high nipple-areola complex (NAC) above the inferior border of the pectoralis major. Sixteen patients underwent inferior-ellipse mastectomy and were included. Mean follow-up was 203 days. Two patients (14%) required revision of the NAC. There was no partial or complete NAC loss. One patient (7%) developed postoperative seroma, which resolved with aspiration. For patients with moderate glandular tissue, excess skin in the inferior pole, and NAC position above the inferior border of the pectoralis major, the nipple-preserving inferior-ellipse mastectomy technique achieves excellent chest contour.

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.

Nonbinary and Transgender Male Patient Preferences for Gender-Affirming Top Surgery

BACKGROUND

This study aimed to identify patient preferences and outcomes of chest masculinization surgery in patients identifying as nonbinary versus transgender (trans-) males.

METHODS

Patients who underwent chest masculinization (2003-2022) were included. Demographics, medical comorbidities, surgical approaches, complications, secondary procedures, and BODY-Q chest module survey responses were compared between cohorts.

RESULTS

Three hundred two patients were included. Thirteen percent identified as nonbinary and 87% as trans-male. The most common surgical approach in both groups was double incision with free nipple-areola graft (63% vs 71%, P = 0.33). Nonbinary patients more frequently opted for double incision without free nipple areola graft compared to trans-male patients (18% vs 2.7%, P < 0.001). Other unique surgical requests of nonbinary patients included nipple areola preservation and small breast mound preservation (5.2%) and balance between losing bulk and achieving a more androgynous appearance (5.3%). The survey response rate was 31% (93/302). Both groups reported improved quality of life postoperatively (P = 0.16). Three nonbinary patients elected not to keep their nipple-areola complexes (P = 0.005). Trans-male patients were more likely to report having a male chest as very important for their gender identity (82% vs 95%, P = 0.043). Nonbinary patients were less likely to prefer small nipples (82% vs 95%, P = 0.033) and 18% stated that they preferred no nipples (vs 2.7% trans-male patients, P < 0.001).

CONCLUSIONS

Nonbinary patients have distinct surgical preferences regarding nipple-areola complexes. Chest masculinization planning can differ for this group of patients compared to their trans-male counterparts.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

NO LEVEL ASSIGNED

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

The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth

PURPOSE

Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB).

METHODS

In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr).

RESULTS

We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group.

CONCLUSION

Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.

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-Affirming Mastectomy: Psychosocial and Surgical Outcomes in Transgender Adults

BACKGROUND

Limited literature exists examining the effects of gender-affirming mastectomy on transmasculine and nonbinary patients that is prospective and uses validated survey instruments.

STUDY DESIGN

The psychosocial functioning of transmasculine and nonbinary patients was compared between patients who underwent gender-affirming mastectomy and those who had not yet undergone surgery. Participants were enrolled in a single-site, combined study of surgical and psychosocial outcomes, including a cross-sectional cohort of preoperative and postoperative patients, as well as separate prospective cohort. Participants completed the BREAST-Q psychosocial and sexual well-being modules, the BODY-Q satisfaction with chest and nipples modules, the Body Image Quality of Life Inventory, the Transgender Congruence Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 scale before and after surgery. We also examined how patient demographic factors correlated with postoperative surgical and psychosocial outcomes.

RESULTS

A total of 111 transmasculine and nonbinary patients 18 to 63 years of age (mean ± SD 26.5 ± 8) underwent mastectomy and were included in the study. All were included in the cross-sectional cohort, and 20 were enrolled in the prospective cohort. More than one-third (34.2%) of patients were nonbinary. After surgery, psychosocial and sexual well-being, satisfaction, body image-related quality of life, and gender congruence were increased (p < 0.001) in both cohorts, and depression (p < 0.009 cross-sectional), and anxiety (p < 0.001 cross-sectional) were decreased. The most common adverse event was hypertrophic scarring, which occurred in 41 (36.9%) participants.

CONCLUSIONS

In this study of transmasculine and nonbinary adults, gender-affirming mastectomy was followed by substantial improvements in psychosocial functioning.

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.

[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.

Preoperative breast imaging and histopathological findings in chest contouring surgery on transmen

BACKGROUND

Chest contouring is the most common surgical procedure transmen receive. Only a few articles discuss the importance of preoperative imaging and postoperative histopathological analysis of excised breast tissue. We studied the findings of preoperative breast imaging and the results of postoperative histopathological analysis in a clinical setting.

MATERIALS AND METHODS

Data from 220 patients were collected retrospectively from 2005 to 2018. Preoperative imaging modalities and their findings were recorded and classified according to the American College of Radiology Breast Imaging Reporting and Data System. The histopathological findings in breast specimens were categorized based on the World Health Organization Classification of Breast Tumors (5th edition).

RESULTS

Preoperative imaging was performed in 133 (60.5%) patients. Patients in the ultrasound-only group were younger (mean age 22.8) than the other groups (mammogram (MGR) 37 years and MGR+US 35.5 years). Preoperative imaging results were normal in 131 (98.5%) patients. Two patients needed further evaluation. Histopathological results were available on 206 (93.6%) patients. The most common histopathological findings were fibrosis (67.5%), atrophy (34.3%), and chronic mastopathy (14.5%). There were no high-risk or malignant findings.

CONCLUSIONS

The need for further examinations based on routine preoperative imaging was low (1.5%). Therefore, more individualized patient selection for preoperative imaging is justified. There were no high-risk or malignant findings in histopathological analysis, and the occurrence of benign findings was similar to that reported in previous studies. Despite our findings, based on current knowledge, histopathological examination of excised breast tissue can still be recommended. Therefore, future studies are needed to define clear guidelines.

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.

Defining sexual dimorphism in masculinizing chest surgery using 3-dimensional imaging

There is no consensus on the ideal scar location and inframammary fold (IMF) placement in the gender-affirming double-incision mastectomy technique. Recent advances in imaging technology have facilitated noninvasive investigations into anatomic variability, in many cases, obviating the traditional approach of cadaveric dissection to answer anatomic questions. A better understanding of chest wall sexual dimorphism may allow surgeons who perform gender-affirming procedures to achieve more natural-appearing results. A total of 60 chests were analyzed using either cadaveric dissection (n = 30) or virtual dissection with 3-dimensional (3-D) reconstructions of computed tomography (CT) images (n = 30) using the Vitrea® software. Chest proportions were recorded using each technique, correlating surface anatomy with muscular and bony landmarks. Cadaveric and 3-D radiography chest analysis revealed that natal male chest walls are, on average, wider and longer than natal female chest walls. The pectoralis major muscle dimensions and the location of its insertion were not found to significantly differ between male and female chests. The male nipple-areolar complex (NAC) tended to be narrower in length and width, with a less projecting nipple than the female NAC. Finally, the IMF was found to lie over the interspace between the fifth and sixth rib in both male and female chests. Our findings confirm natal male and female IMF are positioned between the 5th and 6th ribs. This fact affirms the senior author's technique of masculinizing the chest, keeping the masculinized IMF at approximately the same level as the natal female IMF and following the pectoralis major muscle edges to define the resulting scar in a way that differs from previously reported techniques.

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.

Masculinizing and defeminizing gender-affirming surgery

Transmasculine transgender and gender-diverse individuals may request gender-affirming surgery, standalone or in addition to other interventions. The choices and preferred outcomes of surgery can be highly individual. Besides surgeons' technical skills and patient physique, professionals in this field should be able to cooperate with other disciplines and with patients. The most requested surgery is masculinizing chest surgery, aiming to create a masculine chest with minimal scarring. For genital surgery, metoidioplasty refers to the procedure where the hypertrophic clitoris is released and possibly a scrotum is created from local labia flaps, whereas phalloplasty refers to a procedure in which a neophallus is created from a flap. Possible other surgeries include hysterectomy/oophorectomy, colpectomy, and the implants of scrotal or erection prostheses. In order to guide patients and clinicians, standardized outcome measures as well as evidence-based decision aids have been developed. Such aids, in combination with collaborative medical and psychosocial care, may further leverage the long-term outcomes of these surgeries.

Breastfeeding grief after chest masculinisation mastectomy and detransition: A case report with lessons about unanticipated harm

An increasing number of young females are undergoing chest masculinsation mastectomy to affirm a gender identity and/or to relieve gender dysphoria. Some desist in their transgender identification and/or become reconciled with their sex, and then revert (or detransition). To the best of our knowledge, this report presents the first published case of a woman who had chest masculinisation surgery to affirm a gender identity as a trans man, but who later detransitioned, became pregnant and grieved her inability to breastfeed. She described a lack of understanding by maternity health providers of her experience and the importance she placed on breastfeeding. Subsequent poor maternity care contributed to her distress. The absence of breast function as a consideration in transgender surgical literature is highlighted. That breastfeeding is missing in counselling and consent guidelines for chest masculinisation mastectomy is also described as is the poor quality of existing research on detransition rates and benefit or otherwise of chest masculinising mastectomy. Recommendations are made for improving maternity care for detransitioned women. Increasing numbers of chest masculinsation mastectomies will likely be followed by more new mothers without functioning breasts who will require honest, knowledgeable, and compassionate support.

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.

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

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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.

The Incidence of Breast Cancer After Gender-Affirming Mastectomy in Transmen

BACKGROUND

The incidence of breast cancer in transmale patients and their continued risk after gender-affirming mastectomy (GAM) has not been well established. Plastic surgeons who offer GAM are often one of the few medical professionals sought out by this population, placing them in a unique position to not only deliver surgical care but also improve access to preventative cancer care.

METHODS

We reviewed the senior author's experience with GAMs over the past 5 years for any incidence of breast cancer noted after or at time of surgery. We subsequently performed a thorough review of the literature for cases of breast cancer in transmen, to provide a comprehensive overview of screening, therapy, and postoperative surveillance practices.

RESULTS

We identified 2 cases of breast cancer (ages 49 and 54 years) found on routine examination of pathology specimens after GAM at our institution. Both patients had been taking hormone therapy for the past 1 year. Pathology specimen revealed low-grade estrogen receptor-/progesterone receptor-positive ductal carcinoma in situ in 1 patient, and estrogen receptor-/progesterone receptor-positive invasive ductal carcinoma in the other. Both patients were referred to oncology for appropriate treatment, and both elected to continue their exogenous hormone therapy for personal reasons.Review of the literature demonstrated 36 other cases of documented breast cancer in transmen. Sixty-seven percent (24) were found after GAM, and of those, 50% were incidentally found on pathology specimen. At least 50% were found to be either estrogen-, progesterone-, or androgen receptor-positive cancers. At least 17% of cases documented continued use of masculinizing hormone therapy after cancer diagnosis.

CONCLUSIONS

Most documented cases of breast cancer in transmen were diagnosed after gender-affirming surgery, which would suggest residual breast tissue does pose some risk for breast cancer. In addition, those diagnosed with cancer may elect to continue exogenous testosterone therapy despite potential added risks with hormone-receptor positivity. These cases highlight the need for agreement in current screening practices, surgical recommendations, and continuation of masculinizing hormone therapy.Plastic surgeons have the unique opportunity to educate these patients on appropriate breast cancer-related surveillance both before and after chest surgery.

The Effect of Preoperative Gender Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation

BACKGROUND

Many providers require cessation of gender affirming hormone therapy (GAHT) for transgender patients prior to undergoing masculinizing chest surgery due to concern for increased adverse events in the presence of exogenous hormones. Evidence has suggested that continuation of GAHT for certain patients may be safe for gender affirming procedures.

OBJECTIVES

To compare adverse event rates in GAHT cessation versus GAHT continuation in patients undergoing masculinizing chest surgery.

METHODS

This multicenter, retrospective study included patients at the Cleveland Clinic and MetroHealth System who underwent masculinizing chest surgery between 2016 and 2020.

RESULTS

There were 236 patients who met inclusion criteria. Of these, 172 (72.9%) discontinued testosterone GAHT prior to surgery (T-GAHT cessation), and 64 (27.1%) patients continued testosterone GAHT prior to surgery (T-GAHT continuous). Mean (SD) age at surgery was 25 (8) years, and mean (SD) BMI was 29.5 (6.6). Average duration of testosterone therapy was 18 months (range 0-300). There was no significant difference in tobacco use (p=0.73), diabetes (p=0.54), thrombophilia (p=0.97), or history of thromboembolism (p=0.39). Most patients underwent double incision free nipple graft technique (77.9%). There was no significant difference in surgical time (p=0.12), intraoperative complications (p=0.54), or postoperative complications (p=0.34). The most common complication was postoperative bleeding/hematoma (7.2%). Other complications included seroma (2.1%), infection (1.3%), and nipple graft failure (0.4%). There were no thromboembolic complications.

CONCLUSIONS

There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively versus patients who undergo GAHT cessation for masculinizing chest surgery.

Long-Term Changes in Free Nipple Graft Morphology and Patient-Reported Outcomes in Gender-Affirming Mastectomies

BACKGROUND

After gender-affirming mastectomies with free nipple grafts, satisfaction with nipples tends to fall short behind chest outcomes. This might be related to changes in nipple areolar complex (NAC) dimensions over time. Therefore, the aim of this study is to establish the long-term changes in NAC morphology and compare these to cisgender male NAC outcomes.

MATERIALS

An observational, cross-sectional study was performed. Data from two prospective cohorts were collected: (1) transgender men after a mastectomy with free nipple grafts and (2) cisgender men (reference sample). Demographics and 3-D images were collected for both groups. NAC measurements were performed on the 3-D images at 4 time points (7-, 30-, 90- and 365-days postoperative) in transgender men and once in cisgender men. Furthermore, the BODY-Q (nipple module) was administered postoperatively at 30-, 90- and 365-days in transgender men.

RESULTS

In total, 67 transgender and 150 cisgender men were included. NAC width and height in trans men changed from 21.5 mm (±2.7) to 23.8 mm (±3.9, p<0.001) and 16.2 mm (±2.5) to 14.7 mm (±3.0, p=0.01) within a year, respectively. On average, the NACs increasingly rotated 21 degrees in the latero-caudal direction (p<0.001). The mean NAC width and height in cisgender men were 28.1 mm (±5) and 20.7 mm (±4), being significantly larger than in transgender men. Satisfaction for size, shape and flatness decreased significantly after postoperative day 30 (p=<0.05) in transgender men.

CONCLUSIONS

Morphology of and satisfaction with the NACs in transgender men significantly changed over time. Understanding and incorporating these differences into pre-operative counseling and surgical planning might help increase 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 .

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.

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

Background:

Mastectomy and chest-wall contouring is the most common gender confirmation surgery. With increasing prevalence of transgender individuals, there is a demand for better surgical outcomes and aesthetic results. Our aim was to evaluate surgical techniques used and assess modifications in gender confirmation mastectomies at Karolinska University hospital in Stockholm, Sweden.

Methods:

A retrospective cohort study was performed on 464 patients undergoing gender confirmation mastectomies in our department between 2009 and 2018. Patient demographics, psychiatric comorbidity, surgical method, and outcome were analyzed. Follow-up was at least one year.

Results:

The most frequently used surgical technique for gender confirmation mastectomies was double incision with free nipple graft (243 patients, 52.4%), followed by periareolar incision (113 patients, 24.4%) and semicircular incision (67 patients, 14.4%). The double incision technique and periareolar technique were associated with 18.9% and 28.3% complications, 3.3% and 12.4% acute reoperations, 28.4% and 65.5% secondary revisions, respectively. The double incision technique increased from being used in 17.8% of all mastectomies during 2009–2013 to 62.9% during 2014–2018, while periareolar incision decreased from 43.0% to 18.5%.

Conclusions:

The current study describes a successful transition of surgical technique from periareolar incision to double incision with free nipple graft in gender confirmation mastectomy, leading to significant improvements in the overall outcome with fewer complications, less acute reoperations and less secondary corrections. Hence, we consider the double incision with free nipple graft technique to be the favored technique in the vast majority of cases in female-to-male chest wall contouring.

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.

Transgender and Gender-nonbinary Patient Satisfaction after Transmasculine Chest Surgery

Supplemental Digital Content is available in the text.

Background:

Transmasculine chest surgery is the most common surgery performed in transmasculine patients, with high overall acceptance and low postoperative complication rates. Trends have shown clear improvement in quality of life and satisfaction. However, to the best of our knowledge, overall patient satisfaction after transmasculine chest surgery and associated factors are largely unknown. The aim of this study is to estimate the overall patient satisfaction in transgender men and nonbinary population after transmasculine chest surgery and to assess associated factors.

Methods:

A systematic review was conducted by searching literature in several databases. Meta-analyses of prevalence with a random-effect model for overall and subgroup prevalence were performed. Meta-regression, publication bias, and sensitivity analyses were conducted.

Results:

A total of 1052 transmasculine patients underwent any type of transmasculine chest surgery. The pooled overall postoperative satisfaction was 92% [95% confidence interval (CI) 88–96%]. In the subgroup metanalysis, patient satisfaction after periareolar mastectomy was 93% (CI 88%–97%) and after mastectomy with or without free nipple grafting was 90% (CI 84%–95%). Patient satisfaction for studies with mean follow-up >1 year was 91% (CI 83%–97%) and for mean follow-up of 1 year or less was 93% (CI 89%–96%).

Conclusions:

This study shows a high level of satisfaction in transmasculine chest surgery for both techniques, which remain stable over time. Also, our results show that this procedure impacts patient satisfaction beyond chest appearance and surgical outcomes. This corroborates its broad acceptance and the improvements in the standard of care, and decision-making approach.

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.

The ideal location of the male nipple-areolar complex: A pinpointing algorithm

Background

In the treatment of gender dysphoria, appropriate nipple-areola complex (NAC) positioning is essential for achieving a natural appearing male chest after subcutaneous mastectomy. An accurate predictive model for the ideal personalized position of the NAC is still lacking. The aim of this study is to determine the anthropometry of the male chest to create individualized guidelines for appropriate NAC positioning in the preoperative setting.

Materials and methods

Cisgender male participants were recruited. Multiple chest measurements were manually recorded. Best subset regression using linear models was used to select predictors for the horizontal coordinate (nipple-nipple distance; NN) and vertical coordinate (sternal notch-nipple distance; SNN) of the NAC. Internal validation was assessed using bootstrapping. Furthermore, a cohort of transgender men who had received a mastectomy with replantation of nipples according to current practice was identified. Comparison testing between the algorithm and standard practice was performed to test the limitations of standard practice.

Results

One hundred and fifty cis male participants were included (median age: 26, IQR: 22-34 years). Four predictors were found to predict NN (age, weight, chest circumference (CC), anterior-axillar fold to anterior-axillar fold (AUX-AUX)) and reads as follows: NN = 4.11 + 0.035*age + 0.041*weight + 0.093*CC + 0.140*AUX-AUX Two predictors were found to predict SNN (NN and weight), and reads as follows: SNN = 7.248 + 0.303*NN + 0.072*weight. Both models performed well (Bootstrapped R2: 0.63 (NN), 0.50 (SNN)) and outperformed previous models predicting NAC position. Ninety-six transgender men were eligible for evaluation of current practice and showed an average placement error of -0.9 cm for NN and +2.2 cm for SNN.

Conclusion

The non-standardized approach of NAC repositioning results in a significant error of nipple placement. We suggest that the two predictive models for NN and SNN can be used to optimize NAC positioning on the masculinized chest wall.

Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1884926.

Power-assisted Liposuction and a Single Incision Pull-through Technique for Top Surgery: A Case Report

Various treatment approaches exist for female-to-male subcutaneous mastectomy, also known as “top surgery.” The most commonly performed techniques for patients with decreased volume of breast tissue, no ptosis, and good skin elasticity continue to involve areolar or periareolar incision. Here, we report a case of a 17-year-old patient who underwent top surgery performed through power-assisted liposuction and a non-areolar single-incision “pull-through” technique. Operative management included initial liposuction for contouring of adipose tissue. Surgical subcision of excess breast tissue adherent to the subdermal plane was then performed and removed with a grasp-and-pull motion using the pull-through technique. We obtained a favorable result with low scar burden, preserved nipple sensation, and no nipple contracture. No complications were reported. This procedure is limited for patients with small breast size (A cup, <100 grams of glandular tissue per side), minimal to no ptosis, appropriate nipple size and position, soft fibroglandular tissue, and good skin elasticity.

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

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

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

Crowdsourcing the Ideal Nipple-Areolar Complex Position for Chest Masculinization Surgery

Chest masculinization surgery is increasing in prevalence. However, the ideal location of the nipple-areolar complex (NAC) is unknown. Our purpose was to determine the most aesthetically favorable male NAC position for use in chest masculinization through crowdsourcing.

Patient-reported satisfaction and quality of life after trans male gender affirming surgery

Background: Trans male gender affirming surgery is becoming more available resulting in an increase in patients undergoing these procedures. There are few reports evaluating the outcomes of these procedures in the transgender population. This study was performed to provide patient-centric insight on self-image and other concerns that arise during surgical transition. Methods: A 22-question survey was sent to 680 trans male patients. The survey was broken down into the following sections: demographics, timing and type of surgical procedures, self-image, sex/dating life, social life, employment, co-existing psychiatric morbidity, and common issues faced during the surgical transition. Results: A total of 246 patients responded (36% response rate). Most patients (54%) waited 1-2 years after starting their transition before having a surgical procedure, and 10% waited longer than 6 years. In regard to self-image, sex/dating life, and social life there was a significant improvement (p < 0.001) after undergoing gender affirming surgery. Patients reported significantly less difficulty with employment after having gender affirming surgery (p < 0.001). If present, the following psychiatric morbidities were self-reported to have a statistically significant improvement after surgery: depression, anxiety, substance abuse, suicidal ideation, panic disorder, social phobia, and obsessive-compulsive disorder (P < 0.003). Conclusion: It is important to provide patients, surgeons, and insurance companies with expected outcomes of gender affirming surgery along with the potential risks and benefits. Post-surgical trans male patients reported a significant improvement in overall quality of life. Initial hesitations to having surgery such as regret and potential complications were found to be non-issues. Additional research should be done to include more patients with phalloplasties, trans females, and nonbinary identifying patients.

Immediate Targeted Nipple-Areolar Complex Reinnervation: Improving Outcomes in Gender-affirming Mastectomy

Supplemental Digital Content is available in the text.

Female-to-male mastectomy often renders the chest skin and nipple–areolar complex (NAC) insensate. We propose a new technique of preserving the intercostal nerves and using them to reinnervate the NAC after mastectomy.