Drain-Free Technique for Female to Male Gender Confirmation Chest Surgery Decreases Morbidity- Outcomes from 214 Consecutive Mastectomies

Purpose

The gold standard for treatment of gender dysphoria is a multimodal approach using medical and surgical techniques. We present 107 consecutive patients who underwent 214 mastectomies with free nipple grafts performed by a single surgeon with the use of progressive tension sutures to obviate the need for closed suction drainage. The aim of this paper is to compare morbidity in this group to previously published outcomes where drains were used.

Methods

A retrospective chart review was undertaken of all patients presenting to a single surgeon for gender confirming chest surgery. Patients presenting for gender confirmation surgery who did qualify for minimal scar techniques were excluded from this study. After approval was obtained from the Indiana University Institutional Review Board, a retrospective chart review was undertaken as well as a literature review, compiling data from previously published studies of mastectomy with free nipple graft for the transgender patient. Outcomes of this drain-free group were compared to historical data, where drains were known to have been be employed.

Chi-square and Fisher’s exact test were used for categorical data and statistical significance was set to the level of p < 0.05.

Results

119 patients presented for gender confirming chest surgery however 12 of these were excluded as they opted for minimal scar techniques.

107 patients underwent 214 mastectomies. The mean age of patients was 29 (17-66). 50(47%) were obese. 48 (45%) had 1 or more chronic medical co-morbidities with 15 (14%) diabetic patients. The mean body mass index was 31 (18-57). 31 (29%) of patients had a history of smoking. Average weight resected was 810g on right 812g on left range (98-4650). Mean operative time was 141 minutes (77-266). 86 (80%) of patients were discharged home the day of surgery and all admissions were planned.

The median pain score on the visual analogue pain scale on discharge from the recovery room was 4/10. Hematoma occurred in 1 (0.5%)mastectomy requiring acute return to the operating room. Infections occurred in 4 mastectomies (4%) with wound dehiscence in 3 mastectomies (3%). 2 (2%) mastectomies had partial nipple necrosis. 1 patient developed a symptomatic pneumothorax. There were 0 seromas. 5(5%) mastetcomies underwent secondary corrections including 4 “dog-ear” revisions and one Nipple revision. Median follow-up was 8 months.

Outcomes from this drain-free technique were compared to previously published reported outcomes of mastectomy with free nipple graft performed for gender confirmation. When compared to previously published series, (n=1334), the drain-free group had statistically significantly lower rates of hematoma (1/214 vs. 39/1334, p= 0.034) and acute reoperation (1/214 vs. 42/1334, p= 0.023). There was a shorter length of hospital stay in the drain-free group with a statistically significantly lower revision rate (6/214 vs.116/1334, p=0.0015).

Conclusion

FTM gender confirmation chest surgery can be safely offered using a drain-free technique. Compared to historical data the use of progressive tension sutures decrease the incidence of hematoma and the need for acute re-operation. They may also facilitate a shorter hospital stay and a decreased need for revision surgeries