Female-to-Male Gender-Affirming Chest Reconstruction Surgery

Abstract

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

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

“…Of note, a 2018 Continuing Medical Education article on various techniques in masculinizing chest reconstruction reported rates of hematoma formation in masculinizing chest reconstruction that ranged between 4.5% and 33%. 41 It is possible that, given larger numbers, this difference in rates would be statistically, if not necessarily clinically, significant. If so, it may be due to the differences in technique used for transmasculine chest reconstruction.…”

“…As expected, BMI and smoking were identified as independent predictors of postoperative complications in our study. The association between BMI and postoperative complications has been extensively documented, including studies on mastectomy for transgender chest reconstruction, 30,41 cancer prophylaxis, 49 and gynecomastia. 44 Smoking has also been shown to adversely impact outcomes following risk-reduction mastectomy.…”

Facial Masculinization from Procedures to Payment: A Review

“…6 The breadth of gender-affirming surgeries has increased in recent years. The most common among transgender men include chest masculinization (removal of breast tissue, contouring of pectoralis major muscle 7 ), metoidioplasty (creation of neophallus using clitoral growth 8 ), and phalloplasty (creation of a neophallus using an autologous tissue flap 8 ). 7 According to the 2015 U.S. Transgender Survey, of the 8037 respondents who identified as transgender men, 97% had undergone or desired chest masculinization surgery, 27% metoidioplasty, and 22% phalloplasty.…”

Hockey stick incision: a modified technique for chest wall masculinization

“…In doing so, an improved sense of self-confidence, safety, psychological well-being, and sexual satisfaction (9-14) may be conferred. These considerations are addressed through several mechanisms: (I) removal of breast tissue and excess skin, (II) appropriate reduction in size and placement of the nipple-areolar complex to a more typical masculine position, (III) elimination or diminishment of the inframammary fold, (IV) minimization of anterolateral chest skin/fat folds, and (V) low complication/revision rates and efficiency of the procedure (15)(16)(17)(18)(19). While the appropriate reconstruction details vary among individual patients, chest masculinization surgery is performed in order to achieve an aesthetic result that resembles a cis-masculine chest.…”

“…These approaches include the semicircular peri-areolar, otherwise known as the "keyhole mastectomy," mastectomy with peri-areolar skin excision, trans-areolar, concentric circular extended concentric circular, and inferior pedicle tunnelized nipple-areolar complex (NAC) (21)(22)(23)(24)(25)(26). Choice of technique principally depends on patient-specific characteristics, which include overall body habitus, position of the NAC, breast volume, skin envelope, grade of ptosis, and skin elasticity (15,24,27).…”