Abstract
Background and Aims:
Chest-wall contouring surgery is an important part of the gender reassignment process that contributes to strengthening the self-image and facilitating living in the new gender role. Here, we analyze the surgical techniques used in our clinic and report the results.
Material and Methods:
Female-to-male transgender patients (n = 57) undergoing chest-wall contouring surgery at Tampere University Hospital between January 2003 and April 2015 were enrolled in the study. Breast appearance was evaluated and either a concentric circular approach or a transverse incision technique was used for mastectomy. Patient characteristics and data regarding the technique and postoperative results were collected and analyzed retrospectively.
Results:
In addition to the transgender diagnosis, 40.4% of the patients had another psychiatric diagnosis. For mastectomy, a concentric circular approach was used in 50.9% and a transverse incision approach in 49.1% of the patients. In the transverse incision group, 21.4% of the patients underwent pedicled mammaplasty and 78.6% mastectomy with a free nipple–areola complex graft. Compared with the transverse incision group, breasts were smaller (p < 0.001) and body mass index value was lower in the concentric circular group (p = 0.001). One-third of the patients had complications (hematoma, infection, seroma, fistula, or partial necrosis of nipple–areola complex) and the reoperation rate was 8.8%. Hematoma was the most frequent reason for reoperation. Corrections were required for the scar in 14.0% of the patients, the contour in 28.0%, the areola in 15.8%, and the nipple in 5.3%. Secondary corrections were needed more often in the concentric circular (55.2%) than in the transverse incision group (25.0%; p = 0.031).
Conclusions:
The larger the breast, poorer the skin quality, and greater the amount of excess skin, the longer the required incision and resulting scar is for mastectomy of female-to-male patients. Hematoma is the most common reason for acute reoperation and secondary corrections are often needed.
Keywords
Introduction
As a result of hormonal treatment male-to-female (MtF) patients often get small size breasts. Enlargement of these hormone-induced breasts is usually not regarded as indicated in the public healthcare. The situation is equal compared to women who desire enlargement of small sized breasts. However, breast augmentation in MtF transgender patients improves satisfaction with breasts and increases psychosocial and sexual well-being (1). In female-to-male (FtM) patients, mastectomy is often the first, and sometimes the only, procedure performed in gender reassignment surgery (2–6). The breast is a prominent feminine feature, and thus poses a significant social handicap for trans men. The aim of mastectomy is to achieve a masculine chest wall contour to facilitate living in the new gender role (7, 8).
Various mastectomy techniques for FtM patients are reported (2–7, 9, 10). Characteristics such as the size of the breast, the degree of ptosis, quality, and amount of excess skin influence the selected technique. It is also important to consider the general body habitus and the differences between female and male mammary and chest anatomy. Operative techniques include semicircular, transareolar, concentric circular, and extended concentric circular approaches, inferior pedicled mammaplasty, and mastectomy with a free nipple–areola complex (NAC) graft. Liposuction can be combined with any of the techniques (4–6). During surgery, most of the glandular tissue and excess skin are removed, the nipple and areola are reduced and re-positioned, and the inframammary fold (IMF) is obliterated.
The aim is to achieve aesthetically the best possible contour of a male chest with the fewest scars (2–6). Corrective operations to improve the aesthetic results may be needed later. The importance of skin excess and elasticity is emphasized when selecting the most appropriate technique for the mastectomy. Increasing the length of the scar may be necessary to achieve the best chest contour and avoid secondary corrections. Study results vary with regard to which techniques are associated with a higher rate of secondary aesthetic corrections and the rate of necessary corrections (2–6).
Gender reassignment surgery for transgender patients began in the mid 1990s in Finland. Chest-wall contouring surgery is performed in several hospitals. There are no published national data regarding this patient group and the number of international studies is also limited. In the present study, we analyzed the chest-wall contouring surgery techniques used for FtM transgender patients at Tampere University Hospital. Our aim was to determine the factors that guided the method selection and to analyze how the selected technique affected the results, complication rate, and need for secondary aesthetic correction.
Material and Methods
Transgender patients that underwent chest-wall contouring surgery at Tampere University Hospital from January 2003 until April 2015 were enrolled in the study. The clinical data were collected and analyzed retrospectively. The study was approved by the Ethics Committee of Tampere University Hospital. A total of 57 FtM patients were included in the study. Two MtF patients were operated during the study period. These patients were excluded from the study. All patients underwent the initial operation at Tampere University Hospital. Patients having prior chest-wall contouring surgery at another hospital were excluded from the study.
The size of the breast and degree of ptosis, skin quality, amount of excess skin, and the general body habitus were considered. As this is a retrospective study, information on skin elasticity and the amount of excess skin were not precisely recorded for all patients. For the analyses, FtM patients were divided into three groups according to the size of the breast and degree of ptosis: those with small (A cup) breasts and no or mild ptosis; those with medium-sized (B cup) breasts and mild to moderate ptosis; and those with large (C cup or bigger cup) breasts and moderate to severe ptosis.
According to the surgical approach used for mastectomy, FtM patients were further divided into two groups. The first group included patients in whom a concentric circular approach was used (Fig. 1). The location of the inner circle was defined according to the extent of the planned areolar reduction. The outer circle was marked according to how much skin would be excised and how the NAC would be repositioned. The area between marked circles was de-epithelized and access to the glandular tissue was gained through an inferior incision close to the outer circle. The mammary gland was removed except for a small amount of tissue left under the NAC to maintain good shape. A purse–string suture was used to match the outer circle with the inner circle of the wound and to achieve the planned areolar size. The size of the areola was adjusted to between 2 and 3 centimeters. The second group included patients that underwent a transverse incision in the IMF (Fig. 2). Either pedicled mammaplasty or mastectomy with a free NAC graft was used in this group.
Mastectomy of a FtM transgender patient performed with concentric circular approach: A) preoperative planning and B) postoperative result after 2.5 years. A fistula has been marked in the left NAC and was excised.
Mastectomy of a FtM transgender patient performed with a transverse incision and free NAC grafts: A) preoperative planning and B) postoperative result after 3 months. A small dog ear on the right side was excised later.
In both the concentric circular and transverse incision groups, the nipple was reduced if necessary. Liposuction was combined with some of the procedures based on the individual physician’s decision. Water jet-assisted liposuction using a Body-Jet® system (Upviser Oy, Human Med, Germany) was performed at the beginning of the procedure for hydrodissection. Compression garments were used for 4–6 weeks after surgery.
Patient characteristics and data on the size and ptosis of the breast, selected surgical technique, complications, postoperative results, and secondary aesthetic corrections were collected and analyzed. In addition, data on other psychiatric diagnoses and hormonal treatment were recorded and analyzed. Statistical analyses of the data were performed with Fisher’s exact test and the Mann–Whitney test using IBM SPSS Statistics, Version 23.0.
Results
A psychiatric diagnosis in addition to the transgender diagnosis was applied to 40.4% of the FtM patients, and the diagnosis was depression in 82.6% of the patients. None of the patients had undergone genital surgery, and thus mastectomy was the first procedure in the surgical reassignment process. In total, 93.0% of the patients underwent hormonal treatment. Most of the patients (84.2%) were discharged from the hospital within 1 day after surgery. The mean follow-up time after surgery was 4.1 years (range 0.5–12.5).
Most of the patients were basically healthy. Three of the patients had asthma, one had hypertension, one had hypercholesterolemia, and one had coronary artery disease. At the time of the clinical evaluation, 19.2% of patients smoked and they were strongly encouraged to quit smoking prior to the operation. A concentric circular approach was used for the mastectomy in 50.9% of the FtM patients and a transverse incision approach was used for 49.1% of the patients. Mean patient age in the concentric circular and transverse incision groups was 22.8 and 24.4 years (median 22 and 21.5 years), respectively. The mean body mass index (BMI) value was 22.5 (median 22.3) in the concentric circular group and 26.6 (median 25.5) in the transverse incision group. The median BMI value in the transverse incision group was significantly higher than that in the concentric circular group (p = 0.001).
The duration of hormonal treatment tended to be longer in the concentric circular approach group compared with the transverse incision group (p = 0.056). Hormonal treatment lasted less than 6 months for 13.8% of the patients and more than 6 months for 82.8% of the patients; 3.4% of the patients received no hormonal treatment. In the transverse incision group, hormonal treatment lasted for less than 6 months in 35.7% and more than 6 months for 53.6% of the patients; 10.7% of the patients received no hormonal treatment.
The breasts were small in 75.9% of patients in the concentric circular group and medium-sized in 24.1%. There were no large breasts in this group. The distribution between these categories differed significantly from that in the transverse incision group (p < 0.001). In the transverse incision group, 7.1% of the breasts were small, 53.6% were medium-sized, and 39.3% were large. In the transverse incision group, 21.4% of the patients underwent a pedicled mammaplasty and 78.6% of the patients underwent mastectomy with a free NAC graft. Liposuction was performed for 58.6% of the patients in the concentric circular group and for 14.3% in the transverse incision group. Postoperative complications are reported in Table 1 and did not differ significantly between the concentric circular and transverse incision groups (p = 1.000). Altogether, 15.8% (9/57) of the FtM patients had a hematoma; five of the nine patients required operative hematoma evacuation and all of these belonged to the concentric circular group. No other surgery in the acute phase due to complications was necessary.
Post-mastectomy complications in the FtM group (n = 57).
NAC: nipple–areola complex.
Secondary aesthetic correction was required for 40.4% of the FtM patients. Each underwent one secondary aesthetic operation except for three patients who required two corrective operations. The need for a secondary aesthetic operation differed significantly between the operative groups; 55.2% of the patients in the concentric circular group and only 25.0% of the patients in the transverse incision group required correction (p = 0.031). The shape of the breast, size, and shape of the areola, and size of the nipple and scar were corrected in the secondary operation according to the need (Table 2). In the transverse incision group, secondary aesthetic correction was performed in 33.3% of the patients that underwent pedicled mammaplasty and in 22.7% that underwent the free NAC graft technique. The duration of hormonal treatment differed between patient groups having secondary corrections and those without. Hormonal treatment lasted less than 6 months for 13.0% and more than 6 months for 87.0% of the patients who underwent secondary corrections. In the patient group with no corrective operations performed, hormone treatment lasted less than 6 months for 32.4% and more than 6 months for 55.9%; 11.8% of the patients received no hormonal treatment.
Secondary aesthetic corrections performed in the FtM group (n = 57).
NAC: nipple–areola complex.
Secondary aesthetic correction was significantly more common in FtM patients with complications after primary surgery (68.4%) than in FtM patients without complications (26.3%; p = 0.004). All the patients with complications after the primary surgery required secondary aesthetic correction.
The aesthetic results regarding the size and shape of the areola were documented in the medical records of 47 FtM patients. In the concentric circular group, the size and shape of the areola of 54.5% patients was considered good when compared to 84.0% in the transverse incision group (p = 0.053). Information regarding the aesthetic result of the scar was found in medical records of 51 FtM patients. The aesthetic results of the scar were considered to be good in 61.5% of the patients in the concentric circular group and in 36.0% in the transverse incision group, but the difference between groups was not statistically significant (p = 0.095).
Discussion
Chest-wall contouring surgery is an important part of the gender reassignment process, improving self-image and facilitating living in the new gender role. In our study, mastectomy was the first procedure in the surgical reassignment process of FtM patients. The most common mastectomy techniques described in the literature are the concentric circular approach, inferior pedicle mammaplasty, and mastectomy with a NAC graft, and some modifications of these (2–7, 10). In our study, the two main techniques used were the concentric circular approach and the transverse incision technique (pedicled mammaplasty or mastectomy with a free NAC graft). The technique selected was consistent with previous studies (2–6). The larger the breast, poorer the skin quality, and greater the amount of excess skin, the longer the required incision and scar.
A significant proportion of the patients in our study had another psychiatric diagnosis besides the transgender diagnosis, usually depression. Gender reassignment reportedly improves psychologic well-being, functional ability, and social relationships (10–13). Hormonal treatment seems to have a positive effect on mental health (11, 14). Depression was not evaluated after surgery in the present study. Nevertheless, chest-wall contouring surgery together with hormonal treatment most likely reduces the symptoms of depression.
Patients in the transverse incision group were significantly more obese, which is a logical finding. Obese patients are more likely to have bigger breasts, thus requiring longer mastectomy scars. The duration of hormonal treatment also tended to be shorter in the transverse incision group compared with concentric circular approach group. This may be explained by the fact that breasts are bigger in this group. This causes greater impairment in psychosocial and sexual well-being and may lead patients seek treatment more quickly.
We found liposuction very beneficial for performing hydrodissection prior to the mastectomy and for helping to contour the chest wall in the concentric circular patient group. Mastectomy with a free NAC graft was performed more often in the patients included in the present study than in some previous studies (2–4). Cregten-Escobar et al. (5) used this technique to the same extent and Berry et al. (6) used this technique even more often than in our study. Our experience is that it is easier to achieve good chest wall contour and reposition the NAC using this technique compared with pedicled mammaplasty in larger breasts with ptosis.
One-third of the FtM patients had some postoperative complications (hematoma, infection, seroma, fistula, or partial necrosis of NAC). Complication rates in other studies were smaller and varied between 11.0% and 12.5%, but the reoperation rates of 4.3%–10.4% were consistent with our rate of 8.8% (3–6). In both previous studies and our study, hematoma was the most frequent reason for reoperation in the acute phase.
The rate (40.4%) of secondary aesthetic revisions was quite high in our study, although most of the patients required only one correction. In previous studies, the corresponding rate varied between 9.0% and 40.4% (3–6). The need for corrections was 1.4%–19.6% for scars, 5.5%–25.5% to improve the contour, and 2.0%–13.0% for NAC. These values are smaller or consistent with our results. Based on our results, secondary corrections were needed significantly more often when the concentric circular technique was used and the need for revision was lower if the mastectomy was performed with a free NAC graft. Monstrey et al. (3) reported the highest revision rate (60.0%) when the extended concentric circular technique was used. Wolter et al. (4) found the highest incidence (11.2%) of required corrections if inferior pedicled mammoplasty was used. Cregten-Escobar et al. (5) also reported that secondary corrections were more often needed when using pedicled techniques and less often needed when mastectomy with a free NAC was performed.
We found that patients with complications in the acute phase had a significantly higher need for secondary aesthetic corrections than patients without complications. Surgical complications may impair the healing process, leading to a less favorable aesthetic outcome. In our experience, creating an areola with a good size and shape is more challenging when using the concentric circular technique and the transverse incision technique produces larger scars. A limitation of the study is that a thorough patient satisfaction survey was not performed, and therefore more far-reaching conclusions regarding patient satisfaction cannot be drawn.
In summary, the concentric circular approach, often combined with liposuction, was mainly used as the mastectomy technique for small or medium-sized breasts and the transverse incision technique was mainly used for medium-sized or large breasts. The need for secondary aesthetic corrections was quite high, albeit only one operation per patient was mainly needed. Better selection of the most appropriate technique for each patient and careful avoidance of complications could decrease the need for correction. Published algorithms could help to improve the process of technique selection process (3, 4). Excessive attempts to avoid scars may compromise the shape of the breast. On the other hand, despite achieving a good shape using longer incisions, the patient may be dissatisfied with the scars. The importance of considering the patient’s feelings about the scars and the requirements for achieving a very good breast shape when choosing the operative technique cannot be overemphasized.