Female-to-Male Gender-Affirming Chest Reconstruction Surgery

Mastectomy for Individuals with Gender Dysphoria Younger Than 26 Years: A Systematic Review and Meta-Analysis

BACKGROUND

Gender dysphoria (GD) refers to psychological distress associated with the incongruence between one's sex and one's gender. In response to GD, birth-registered female patients may choose to undergo mastectomy. In this systematic review, the authors summarize and assess the certainty of the evidence about the effects of mastectomy.

METHODS

We searched MEDLINE, Embase, PsycINFO, Social Sciences Abstracts, LGBTQ+ Source, and Sociological Abstracts through June 20, 2023. We included studies comparing mastectomy to no mastectomy in birth-registered patients younger than 26 years with GD. Outcomes of interest included psychological and psychiatric outcomes, and physical complications. Pairs of reviewers independently screened articles, abstracted data, and assessed risk of bias of the included studies. We performed meta-analysis and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

We included 39 studies. Observational studies ( n = 2) comparing mastectomy to chest binding provided very low-certainty evidence for the outcome of GD. One observational study comparing mastectomy to no mastectomy provided very low-certainty evidence for the outcomes of global functioning and suicide attempts, and low-certainty evidence for the outcome nonsuicidal self-injury (adjusted OR, 0.47; 95% CI, 0.22 to 0.97). Before-and-after ( n = 2) studies provided very low-certainty evidence for all outcomes. Evidence from case series ( n = 34) studies ranged from high to very low certainty.

CONCLUSIONS

Case series studies demonstrated high-certainty evidence for the outcomes of death, necrosis, and excessive scarring; however, these are limited in methodologic quality. In comparative and before-and-after studies, the evidence ranged from low to very low certainty.

[Gender-Affirming Top Surgery for Gender Incongruence/Dysphoria: A Literature Review and Alignment with the New German S2k Guidelines on Mastectomy and Breast Augmentation]

"Top surgery", which refers to gender-affirming chest procedures, is one of the most common surgeries for individuals with gender incongruence (GI). These surgeries include breast augmentation or mastectomy and aim to align the physical appearance with gender identity. This review is based on the newly published German S2k guideline "Surgical Measures for Gender Incongruence" and offers a comprehensive overview of current breast surgery techniques and relevant literature.A literature analysis was conducted based on data from PubMed from 1973 to July 2024. The analysis included 122 studies on gender-affirming chest surgeries for individuals with GI. The core statements were extracted and summarized.Gender-affirming chest surgeries, including both breast augmentation and mastectomy, generally lead to significant improvements in the well-being of individuals. Breast augmentations often involve silicone implants or autologous fat grafting. Mastectomies for chest flattening aim to create a smooth, masculine-contoured or neutral chest while preserving nipple sensation. The choice of surgical technique largely depends on breast size, the degree of ptosis, and skin elasticity. Patient satisfaction with the surgical outcomes is consistently high, underscoring the importance of these procedures.This review provides a comprehensive overview of current surgical techniques for chest surgeries in individuals with gender incongruence. With the growing number of transgender and non-binary patients, clear surgical guidelines are increasingly important to meet the high demands and address complex anatomical challenges. The new German S2k guideline, developed by German experts from various participating disciplines, supports this need. The high patient satisfaction with surgical outcomes underscores the significance of these procedures for improving quality of life.

Techniques for Preserving the Nipple Areolar Complex in Chest Masculinization for All Chest Sizes

Current literature on gender-affirming top surgery techniques predominantly focuses on achieving optimal binary male aesthetic outcomes. However, goals for surgery are unique, and preservation of the nipple-areolar complex (NAC) for aesthetics and sensation can be of primary importance to patients. This paper provides an algorithm for preserving the NAC based on chest size and native NAC position. Written consent was obtained for all before and after patient photos. Photos were taken as part of patient care and documentation from one surgeon at Women's College Hospital in Toronto, Canada, between January 2020 and March 2022. Four techniques are highlighted in detail in this report: (1) keyhole (subcutaneous) mastectomies, (2) periareolar mastectomies, (3) nipple-preserving double-incision mastectomies, and (4) inverted T mastectomies. Current literature for top surgery focuses primarily on double-incision mastectomies with free nipple grafts or a smaller subset of periareolar and keyhole mastectomies. We have outlined several techniques to preserve the NAC, and an algorithm has been recommended based on chest size and preoperative NAC position. NAC preservation is possible for most chest sizes when performing masculinizing chest surgeries. The algorithm we have described provides guidance for surgeons to choose which technique to use based on the patient's breast volume, ptosis, and NAC position to preserve the entire NAC.

Patient-reported and Clinical Outcomes following Gender-affirming Chest Surgery: A Comparison of Binary and Nonbinary Transmasculine Individuals

Background

Nonbinary individuals assigned female at birth are increasingly presenting for gender-affirming chest surgery (GCS). However, little is known about psychosocial outcomes in this group. We compare patient-reported and clinical outcomes after GCS between nonbinary and binary transmasculine individuals who underwent GCS.

Methods

We performed an institutional retrospective chart review. Demographic information, medical comorbidities, history of gender-affirming medical care, operative details, and complications were collected and compared between nonbinary and binary patients. Two validated patient-reported outcomes measures, the Gender Congruence and Life Satisfaction (GCLS) scale and the chest dysphoria measure were administered postoperatively.

Results

A total of 281 patients were included, of which 40.6% (114) identified as nonbinary and 59.4% (167) identified as binary transgender men. Fewer nonbinary patients used testosterone (P < 0.001). Nonbinary patients underwent a wider variety of masculinizing chest operations than binary patients, with fewer nonbinary patients electing for free nipple-areolar complex grafts (P < 0.001) and more nonbinary patients undergoing breast reduction (P = 0.001). A total of 137 (48.7%) patients responded to postoperative surveys. Nonbinary and binary respondents had comparable scores on the overall GCLS (P = 0.86), GCLS chest subscale (P = 0.38), and chest dysphoria measure (P = 0.40). The absence of nipple-areolar complex grafts was associated with higher GCLS chest scores (P = 0.004).

Conclusions

Nonbinary individuals have similarly positive outcomes following GCS compared with binary individuals. Surgeons should be aware of greater medical and surgical heterogeneity in this population and seek to understand individual patients' goals and priorities.

Masculinizing Mammoplasty for Female-to-Male Transgenders: 10 Years' Experience

BACKGROUND

Masculinizing mammoplasty is a surgical procedure frequently performed in transmale individuals. Despite providing a positive impact for the patient, this surgery has high rates of complications and revisions. In cases requiring a double incision, there are advantages in using an inferior pedicle when possible.

METHODS

This was an observational study. Outcomes and complications were analyzed in 104 patients operated on by the author using three techniques: concentric periareolar surgery, double incision with an areola graft, and double incision with an inferior areolar pedicle. The Breast-Q questionnaire adapted for transgender males was applied.

RESULTS

The responses of the adapted Breast-Q questionnaires demonstrated high scores regarding quality of life and satisfaction. The rates of complications and surgical revisions were 24.3 and 25.6%, respectively, with no significant difference between the techniques. The most common complication was hematoma (13.6%), which was positively associated with the use of testosterone. Ischemia of the nipple-areola complex was present in 8.7% of the operated breasts. When using the inferior pedicle, areola ischemia occurred more often when the nipple-fold distance was greater than 8 cm.

CONCLUSIONS

Quality of life, satisfaction, complications, and revisions were comparable to those observed in the literature. Hematoma was the most frequent complication, and an association with the use of testosterone was observed. When a double incision is indicated, the inferior pedicle is more advantageous than the areola graft; however, it should be used when the distance between the nipple and the inframammary fold is 8 cm or less.

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 .

Genital gender-affirming surgery trends in Germany: Total population data with 19,600 cases from 2006 to 2022

PURPOSE

To delineate the current trends regarding gender-affirming surgeries (GAS) in Germany.

METHODS

Analysis of German hospital quality reports from 2006 to 2022 was conducted using the reimbursement.info tool. The German procedure classification (OPS) codes 5-646.0 for masculinizing- and 5-646.1 for feminizing surgery were assessed to identify GAS. Linear regression models were utilized for the analysis and depiction of current trends.

RESULTS

A total of 19,632 gender-affirming procedures were performed during the study period with an exponential increase over the years. Masculinizing surgeries increased from 246 in 2006 to 1291 cases in 2022 (increase by 424%; p < 0.001). The highest annual increase of 37.2% in numbers was from 2018 to 2019 (from 1235 to 1694 cases). Feminizing surgeries increased from 180 cases in 2006 to 799 procedures in 2022 (increase by 343%; p < 0.001). The cases increased most between 2015 and 2016 from 277 to 502 cases (81.2%). The number of hospitals offering these surgeries expanded from 24 in 2006 to 29 in 2022 (21% increase; p < 0.001).

CONCLUSION

This study demonstrates an exponential growth in numbers feminizing and masculinizing of GAS performed each year in Germany. Furthermore, a discernible trend emerges with a propensity for concentration of procedures within selected high-caseload centers across Germany.

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

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

Nipple reduction using the mushroom flap technique for male transgender

Nipple reduction is a well-established procedure that is widely used and can improve the self-confidence of male transgender individuals. The nipple reduction procedure in male transgender individuals differs from that in cisgender females due to a greater disparity in postoperative nipple sizes compared to preoperative sizes. Flaps used in male transgender nipple reduction should be simple to avoid skin necrosis. We present the nipple reduction of a 25-year-old male transgender patient using the mushroom technique. A 6 mm circular line was drawn at the most prominent part of the apex of the nipple. Another circular line was created at the base of the nipple. The skin and subcutaneous tissue were removed. The original diameter of the nipple was reduced. The two circular lines were re-approximated and sutured. Both right and left nipple height was 7 mm, and the width of the right and left nipple was 12 and 13 mm, respectively. The new nipple height and width of both sides at six months postoperative were 3 mm and 6 mm, respectively. The nipples were healed uneventfully, and the patient reported high satisfaction and self-confidence. This method can be used as a promising alternative to previously described techniques.

Factors influencing intraoperative conversion from double- to single-incision mastectomy with free nipple grafts in 352 transgender and non-binary patients

BACKGROUND

Double-incision mastectomy (DIM) with free nipple grafts (FNG) is a common technique employed in gender-affirming mastectomy (GAM), but is associated with a high scar burden. Intraoperatively, the surgeon may opt for a single-incision mastectomy (SIM) along the inframammary folds (IMF) to optimize aesthetic outcomes. This study sought to identify factors predictive of intraoperative conversion.

METHODS

From February 2018 to November 2022, TGNB patients who underwent GAM at a single institution were retrospectively reviewed. Data regarding patient characteristics, perioperative details, postoperative complications, and aesthetic satisfaction were collected.

RESULTS

A total of 352 patients were identified. Median age and body mass index (BMI) were 25.0 years (IQR: 9.0) and 28.5 kg/m2 (IQR: 8.5), respectively. Most patients received IMF incisions (n = 331, 94.0%); of whom, 66 (19.9%) underwent intraoperative conversion from DIM to SIM with FNG. Larger breast cup-size (p < 0.001) and a greater degree of ptosis (p = 0.002) preoperatively were significantly associated with intraoperative conversion to SIM. There was no significant association between intraoperative conversion and the ratio of intermammary distance to the width of the chest wall (p = 0.086). Overall complication rates were significantly higher among patients with diabetes mellitus (p = 0.015) and a greater degree of ptosis (p = 0.018). 77.8% (n = 274) of patients were satisfied with their aesthetic outcome. NPWT usage was associated with higher rates of aesthetic satisfaction (83.6% vs. 77.8%; p = 0.005).

CONCLUSION

Patients with larger breast cup size and greater degree of ptosis should be counseled preoperatively that they may be at a higher risk of conversion to a singular incision.

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.

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.

Sexual Function in Post-surgical Transgender and Gender Diverse Individuals

Surgical treatment for gender dysphoria consists of facial, chest, and genital surgery. Chest and genital gender affirmation surgeries alter the form and function of the native organs. This can have a profound impact on sexual function for transgender and gender- diverse individuals. In this article, the authors will discuss the impacts that chest and genital gender affirmation surgeries can have on sexual function.

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.

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

Quantifying Nipple-Areolar Complex Shape and Location After Transmasculine Top Surgery: A Study of Postoperative Photographs Posted on Social Media and Surgeons' Professional Websites

Purpose

The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions.

Methods

In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed.

Results

We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012).

Conclusion

Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.

A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today

The University of Michigan has played an important role in advancing gender-affirming surgery programs in the United States. The University of Michigan was home to a little-known gender identity clinic shortly after the opening of the first such clinic at Johns Hopkins. Since 1995, the University of Michigan Comprehensive Services Program (UMCGSP) has been continually offering surgical services to transgender and gender diverse patients. Here, we present the history of both programs, drawn from program documents and oral history, and explore their implications for the future sustainability of gender-affirming surgery programs. The original gender identity clinic opened in 1968, and operated in a multidisciplinary fashion, similar to other clinics at the time. Eventually, the clinic was closed due to disinvestment and lack of sufficient providers to maintain the program, problems which are being increasingly recognized as barriers for similar programs. The modern program, UMCGSP is perhaps the longest continually running gender-affirming surgical program at an academic center. In spite of challenges, key investments in education, statewide community engagement, and the development of a comprehensive care model have helped UMCGSP avoid the pitfalls of the earlier clinic and remain relevant throughout its nearly 30-year history. In the face of rising challenges to gender-affirming care in the United States, much can be learned from the sustainability of the UMCGSP. Institutions seeking to maintain gender-affirming surgery programs should ensure the availability of comprehensive care and promote the education of the health care workforce.

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.

A New Surgical Technique for Female-to-Male Top Surgery: The Posterioinferior Pedicle (PIPe) Approach

INTRODUCTION

Most of the time, female-to-male (FtoM) chest surgery involves mastectomy techniques and free transplantation of the nipple-areola complex. With the increasing prevalence of gender dysphoria and the demand for female-to-male gender reassignment surgery, the need for FtM top surgery is also rising. To meet this demand, we present a new approach: the PIPe technique, based on a fasciocutaneous flap with a posteroinferior pedicle.

MATERIALS AND METHODS

All patients with FtoM gender dysphoria undergoing surgery using the posteroinferior pedicle flap technique in the Plastic Surgery Department at Rennes University Hospital Center were included. The procedure involved extensive liposuction of the lower internal and external mammary quadrants, followed by liposuction of deep tissues in the upper quadrants, except in the pedicle area. After removing skin from the lower quadrants down to the dermis and de-epithelializing the posteroinferior pedicle flap, the thoracic flap was lowered and the areola transposed.

RESULTS

From July 2022 to March 2023, fifteen patients underwent surgery, and their results were collected prospectively. The average age was 25 years, the mean weight was 76.6 kg, and the average BMI was 28.1 kg/m2. The average operating time was 102 min, and the mean weight excised was 459.5 g. The average length of hospital stay was 3.3 days, and the drainage duration was 2.4 days. No major complications were reported, and there were no cases of reintervention or recurrence.

CONCLUSIONS

Our study presents a novel surgical approach utilizing the posteroinferior pedicle technique. Its key benefit lies in the preservation of neurovascular function, which makes it an attractive option for patients seeking to retain nipple sensitivity. This procedure is reliable, reproducible, and recommended as a first-line treatment for grade II and III gynecomastia due to its low rate of major complications and favorable functional and aesthetic outcomes.

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 .

Gender-Affirmative Surgery: A Collaborative Approach between the Surgeon and Mental Health Professional

SUMMARY

Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in the Standards of Care, international guidelines that help inform clinical decision-making. Historically, mental health care professionals (MHCPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as understanding of gender identity evolves, so does the relationship between the MHCP and the surgeon. The role of the MHCP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and the health care team. This article discusses the evolution of the relationship between the MHCP and the surgeon and provides insight into the history of this relationship.

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.

Targeted Nipple Reinnervation in Gender-affirming Mastectomy Using Autologous Nerve Graft

Our team recently described targeted nipple reinnervation (TNR) during female-to-male gender-affirming mastectomy with free nipple grafting using either direct nerve coaptation or nerve allograft. The goals of TNR are to improve sensation (including erogenous sensation) and prevent numbness, paresthesias, chronic pain, and phantom sensation. Here, we describe our modified technique, which has evolved to use autologous intercostal nerve branches as donor nerves for reinnervation if direct nerve coaptation cannot be achieved. During TNR, the T3-T5 sensory branches are preserved and coapted to the repositioned nipple-areolar complex (NAC). In patients with donor nerves that were not adequate in length to allow for direct coaptation, autologous intercostal nerve branches were not used for coaptation (branches present along the chest wall that would otherwise be lost) or one of the T3-T5 branches were harvested. An end-to-end nerve repair between the autograft and donor nerves was done, and the donor nerve/autograft complex was coapted to the NAC. Targeted muscle reinnervation was performed after autograft harvest to prevent neuroma formation. TNR with intercostal nerve autograft is technically feasible in female-to-male gender-affirming mastectomy with free nipple grafting when direct coaptation is not possible. Chest reinnervation using autologous intercostal nerve branches as donor nerves is another option for reinnervation when the nerves are too short for direct coaptation. Because the collection of long-term data is ongoing, the effectiveness of NAC reinnervation using our technique will be described in a future publication.

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.

Perioperative Care of Transgender and Gender-Diverse Patients: A Biopsychosocial Approach

Transgender and gender-diverse (TGD) people endure numerous physical and mental health disparities secondary to lifelong stigma and marginalization, which are often perpetuated in medical spaces. Despite such barriers, TGD people are seeking gender-affirming care (GAC) with increased frequency. GAC facilitates the transition from the sex assigned at birth to the affirmed gender identity and is comprised of hormone therapy (HT) and gender-affirming surgery (GAS). The anesthesia professional is uniquely poised to serve as an integral support for TGD patients within the perioperative space. To provide affirmative perioperative care to TGD patients, anesthesia professionals should understand and attend to the biological, psychological, and social dimensions of health that are relevant to this population. This review outlines the biological factors that impact the perioperative care of TGD patients, such as the management of estrogen and testosterone HT, safe use of sugammadex, interpretation of laboratory values in the context of HT, pregnancy testing, drug dosing, breast binding, altered airway and urethral anatomy after prior GAS, pain management, and other GAS considerations. Psychosocial factors are reviewed, including mental health disparities, health care provider mistrust, effective patient communication, and the interplay of these factors in the postanesthesia care unit. Finally, recommendations to improve TGD perioperative care are reviewed through an organizational approach with an emphasis on TGD-focused medical education. These factors are discussed through the lens of patient affirmation and advocacy with the intent to educate the anesthesia professional on the perioperative management of TGD patients.

UK recommendations for the management of transgender and gender-diverse patients with inherited cancer risks

As the rate of people openly identifying as transgender or gender diverse (TGD) is increasing, UK cancer genetics services are seeing growing numbers of TGD patients. Lack of appropriate clinical guidelines and a scarcity of robust data about the impact of gender-affirming treatments on cancer risk has led to uncertainty of how best to support TGD patients, and inequity in standards of care. To address this gap, the UK Cancer Genetics Group and Central & South Genomic Medicine Service Alliance facilitated a 2-day meeting to develop national consensus to support the management of TGD patients with inherited cancer risks. Key stakeholders from a broad range of clinical specialties, patients advocates, and those with lived experience discussed and voted on recommendations for best practice. The consensus was reached on topics including family history questionnaires, pedigrees, clinical information, breast tissue management, gynaecological and prostate management, patient pathways, and education. Further work is required to reach consensus on the breast screening recommendations for TGD patients assigned female at birth who have had masculinising chest surgery. Here we present a summary of the processes used to reach consensus, and the recommendations from this meeting.

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

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

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.

Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents

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

How to do the Pisces mastectomy for female-to-male top surgery

Gender-affirming mastectomy ('top surgery') is one of the most commonly requested and performed procedures in the transgender and non-binary population. The goal of female-to-male (FtM) surgery is to treat gender dysphoria by creating an aesthetically pleasing male chest, achieved by removing excess breast tissue and skin, and repositioning and resizing the nipple-areola complex. We present a modification of the double-incision, mastectomy with free nipple graft (DIFNG) technique that we have called the ‘Pisces’ mastectomy as it is common for fish to exhibit gender fluidity. With some imagination, the skin excision could also be considered fish-shaped. This technique achieves the goals of surgery, provides good access for haemostasis and decreases the need for revision surgery by adequate removal of ‘dog ears’ medially and laterally.

Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents

Background

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

Methods

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

Results

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

Conclusion

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

Pathological Evaluation of Breast Specimens in Transgender Chest Masculinization: Incidental Findings and Effect of Prior Chest Binding and Androgen Therapy in 74 Consecutive Patients

Background: The rate of masculinizing chest surgery for gender affirmation continues to increase. With a paucity of literature on pathological evaluation of breast specimens in this patient population, there is a need for these data and for protocols on the handling of these specimens. 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 (J.D.K.). Inclusion criteria were any patient with sex assigned female at birth who underwent removal of breast and/or nipple areolar complex tissue for gender affirmation. Patient demographics were recorded. Bilateral breast tissue was sent for routine pathology in all cases and findings were recorded. A p-value of <0.05 was considered significant. Results: Seventy-four consecutive patients and 148 breast specimen reports were identified from a database and included in the study. The mean age was 26 years (15-49). Thirty-nine patients had a known history of chest wall binding and 60 patients had undergone preoperative androgen therapy. There was no invasive or in situ carcinoma found in any breast tissue specimens. Thirty-four patients had a benign lesion in one or both breast specimens. Atypical lobular hyperplasia was found in one patient's specimen. A history of chest wall binding was not correlated with any benign lesions (p=0.79) or stromal fibrosis (p=0.94). A history of testosterone use was not correlated with any benign lesions (p=0.35) or stromal fibrosis (p=0.20). Conclusions: The prevalence (1.4%) of significant breast pathology and of benign findings (46%) in our study closely correlates with the rates in the literature. We found no correlation between significant breast pathology or benign lesions and a history of chest wall binding or preoperative androgen therapy. We recommend all breast specimens removed during chest masculinization surgery be sent for pathological evaluation.

Analysis of Nipple-Areola Complex Localization Using Male Cadavers: Considerations for Gender-Affirming Surgery

Background

Masculinizing chest reconstruction is the most common gender-affirming surgery in transgender males. Despite the current literature's acknowledgment of the vital role that proper placement of the nipple-areola complex (NAC) plays in a masculine chest contour, there is still much debate regarding the best anatomical landmarks to achieve the desired result.

Objectives

The primary aim of this study is to determine which landmarks for NAC placement can be applied across diverse body types and aid surgeons in creating a masculine chest.

Methods

Twenty-five formaldehyde-embalmed male cadavers were analyzed by conducting various measurements of the NAC, nipple, and surrounding bony and muscular landmarks to identify the most consistent landmarks for proper NAC placement. Linear regression analyses were run to determine how the distance between nipple to respective landmarks varied based on antemortem body mass index (BMI), height, weight, and age.

Results

The measurements for the inferior and lateral borders of the pectoralis major muscle (PMM) displayed the least amount of variance of all the anatomical landmarks studied. Additionally, there was no significant change in these pectoral measurements with varying BMI, height, weight, or age, indicating that these measurements are reliable landmarks for NAC placement across various body types. The average NAC placement in relation to the inferior and lateral borders of PMM was around 2.5 and 2.0 cm, respectively.

Conclusions

Our cadaveric analysis indicates that aesthetically pleasing masculine chest results can be produced consistently across varying body types when adhering to a simple pectoral approach in NAC placement.

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.

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

Background:

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

Methods:

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

Results:

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

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

Conclusion:

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

with low complication rates.

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

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

Gender affirming medical care of transgender youth

The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.

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

Background:

Mastectomy is a commonly requested procedure in the transmasculine population and has been shown to improve quality of life, although there is limited research on safety. The aim of this study was to provide a nationwide assessment of epidemiology and postoperative outcomes following masculinizing mastectomy and compare them with outcomes following mastectomy for cancer prophylaxis and gynecomastia correction in cisgender patients.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017 was queried using International Classification of Diseases and Current Procedural Terminology codes to create cohorts of mastectomies for 3 indications: transmasculine chest reconstruction, cancer risk-reduction (CRRM), and gynecomastia treatment (GM). Demographic characteristics, comorbidities, and postoperative complications were compared between the 3 cohorts. Multivariable regression analysis was used to control for confounders.

Results:

A total of 4,170 mastectomies were identified, of which 14.8% (n = 591) were transmasculine, 17.6% (n = 701) were CRRM, and 67.6% (n = 2,692) were GM. Plastic surgeons performed the majority of transmasculine cases (85.3%), compared with the general surgeons in the CRRM (97.9%) and GM (73.7%) cohorts. All-cause complication rates in the transmasculine, CRRM, and GM cohorts were 4.7%, 10.4%, and 3.7%, respectively. After controlling for confounding variables, transgender males were not at an increased risk for all-cause or wound complications. Multivariable regression identified BMI as a predictor of all-cause and wound complications.

Conclusion:

Mastectomy is a safe and efficacious procedure for treating gender dysphoria in the transgender male, with an acceptable and reassuring complication profile similar to that seen in cisgender patients who approximate either the natal sex characteristics or the new hormonal environment.