Transgender Subcutaneous Mastectomy for Gender Dysphoria: A Single Surgeon's 5-Year Experience

Purpose:

As insurance coverage changes, subcutaneous mastectomy for female to male gender confirmation is becoming an increasingly popular surgical procedure¹.  At our institution, we have an extensive history of providing transgender health care and recognize the many challenges to achieving a masculine looking chest: pectoralis muscle shape, skin laxity, location of the inframammary fold, lateral thoracic rolls, nipple size and characteristics. The goal of our study was to critically evaluate our surgical approach by analyzing the aesthetic and clinical outcomes of subcutaneous mastectomies performed for female to male gender confirmation.

Methods and Materials:

Following IRB approval, a retrospective chart review was performed to identify patients having undergone bilateral subcutaneous mastectomies for gender confirmation.  Per our standard protocol, all patients had a preoperative diagnosis of gender dysphoria documented by a licensed mental health practitioner, met World Professional Association for Transgender Health criteria², and many were advised to have a preoperative mammogram. Demographics and outcomes data were collected and analyzed. Aesthetic results were evaluated by a blinded plastic surgeon.

Results:

From 2010-2015, 97 patients were identified who met our criteria, for a total of 194 mastectomies. The average age was 29 years (range 15-61), average BMI was 30 (range 20-54), and average specimen weight was 708 grams per breast (range 86-2702).  The vast majority received full thickness nipple grafts (170/194). Eighty (82%) patients were on perioperative Testosterone. The average follow up was 98 days (range 0-1288). The aesthetic outcomes improved with surgeon experience. We had a total of 5 major complications which led to secondary surgical procedures: 2 hematomas requiring operative evacuation, and 3 seromas necessitating drain placement. One patient was diagnosed with breast cancer on screening mammography and was excluded. Minor complications included hypertrophic scarring, standing cone deformities, and pigmentation changes of the nipple grafts. There were no deaths or perioperative venous thrombosis.

Conclusions:

Despite the recent increase in mastectomies performed annually¹, there is still no consensus on surgical method.  With appropriate preoperative screening, patient selection and surgical technique, bilateral subcutaneous mastectomies for female to male gender confirmation surgery can be a safe, highly satisfying procedure. We wish to share our pearls (preoperative marking, patient positioning, DVT prophylaxis, surgical approach, nipple placement, etc) to attain functional and cosmetically appealing outcomes.