Mastectomy for Female-to-Male Transsexuals: A Two Technique Algorithm

Background: Subcutaneous mastectomy for female-to-male transsexuals is usually the first operation in gender reassignment with a goal is to create a masculine appearing chest and remove all glandular breast tissue while minimizing scars.¹These patients often have more glandular tissue and significant ptosis compared to traditional subcutaneous mastectomy for gynecomastia. We present the largest series of subcutaneous mastectomies performed in female-to-male transgender patients reported in the literature to date.

Methods: A retrospective review of all subcutaneous mastectomies performed in transgender patients by a single surgeon was performed. Two techniques were used, a periareolar incision with a superiorly based nipple areolar pedicle or an incision at the inframammary fold with free nipple graft.  Approach used was based on breast size and degree of ptosis.

Results: Between January 2001 and July 2012, 912 subcutaneous mastectomies were performed on 456 patients, 223 periareolar and 233 amputation free nipple procedures.  Patients who underwent periareolar procedures had smaller breasts and less ptosis compared to amputation free nipple, 66.4% versus 6.9% had A cup sized breasts.  The overall complications rate was 18% consisting of 35 hematomas (7.7%), 23 seromas (5%), 11 infections (2.4%), 9 partial nipple necrosis (2.4%) and 4 other complications (0.9%).  The complication rate for the periareolar group was 20.2% and 15.9% in the amputation free nipple group.  There was no statistically significant difference in complications between the two groups.

	Keyhole	Double Incision
	n (%)	n (%)		P-value
Total	45 (20.2)	37 (15.9)		0.272
Hematoma	19 (8.5)	16 (6.9)		0.598
Seroma	15 (6.7)	8 (3.4)		0.135
Infection	6 (2.7)	5 (2.1)		0.470
Partial nipple necrosis	3 (1.2)	5 (2.1)		0.504

In patients with medium sized breasts (B or C cup) in which either procedure could be argued to be appropriate, there was no difference in overall complications (p=0.717) or hematomas (p=0.810). 

Conclusion: Subcutaneous mastectomies for chest contouring in female-to-male transsexuals can be performed with minimal complications if the appropriate technique is chosen.  When breast size and shape are carefully considered, both techniques have similar complication rates.  Our outcomes suggest that the indications for the periareolar technique can be broadened without increased complications.