Introduction
The most common techniques applied to transgender men for masculinizing chest surgery include subcutaneous mastectomy via a periareolar incision and inframammary mastectomy with free nipple grafting. Regardless of approach chosen, the goals of masculinizing chest surgery are to sculpt a natural appearing masculine chest matched to the patient's body habitus with pectoral definition. Unfortunately, there is no consensus approach to surgical planning.[1-5] Surgical technique is dependent not only on the plastic surgeon's individual experience and patient-specific preferences, but also on evaluation of the patient's preoperative body habitus, breast size and shape, and skin quality.
The preoperative chest may be simplified into four components: the breast and subcutaneous tissue, the skin envelope, the nipple and finally the resulting incision.[5] To achieve a masculine chest shape, removal of the breast glandular tissue is required. This is distinctly different in regard to anatomy, goals, and execution from mastectomy performed for breast cancer as well as subcutaneous mastectomy performed for gynecomastia. Depending on breast tissue volume, preoperative ptosis, and skin elasticity, the skin envelope may require significant reduction for a taut, aesthetic male chest. The nipple-areola complex (NAC) likewise requires resizing, reshaping, and repositioning to match masculine proportions within the constraints of its blood supply. Finally, incisions and skin reduction should create scars with the least conspicuous size, position, and orientation.
With the number of considerations and constraints possible, a myriad of technique refinements and algorithms have been proposed; all can fit into two general categories of techniques. In smaller, less ptotic breasts, a single incision per breast designed around or through the NAC can be used to perform a subcutaneous mastectomy with a crescentic or donut-shaped skin excision. However, this approach is more difficult to apply larger ptotic breasts, as it is difficult to anatomically reposition the nipple and also achieve the necessary skin envelope reduction. In these cases, two incisions are necessary per breast. The glandular tissue and subcutaneous fat is removed and recontoured through a primary inframammary incision, and the nipple is brought through a separate oval incision. If it is not possible to transfer the NAC based on a vascular pedicle, free nipple grafting is also an option.
The procedure itself generally takes 2-4 hours, depending on technique used. Most patients require an overnight or short hospital stay.[1] General anesthetic is used. Surgical drains, left in place until a postoperative clinic visit, are the norm. The authors' preference is to use drains and compressive dressing or garment for the duration of 1-2 weeks.
In general, complications are rare for transgender men undergoing masculinizing chest surgery. Early reoperation is required in 4-9% of patients, usually for hematoma evacuation and infection, with a 12% overall complication rate.[1,2] Postsurgical complications are divided into those presenting early (within 2 weeks postoperatively) and late (after two to four weeks). Limited data specific to transgender masculinizing chest surgery are not as robust as data published for reduction mammoplasty and male gynecomastia surgery, so data on surgical complications are supplemented with data abstracted from the more extensive literature available in these fields.
Postoperative care in the primary and urgent care setting
Most early complications, although rarely life-threatening, should be expeditiously directed to the attention and experience of the operative plastic surgeon. Certain early complications (specifically hematoma, seroma, and nipple complications) can cause lasting aesthetic deformities that would be avoidable with timely intervention.
Delayed complications and specific areas of aesthetic dissatisfaction also merit referral to a surgeon. The most common complaints are related to postoperative scarring, contour deformities, and nipple appearance or discoloration. The process of healing and remodeling over the course of a year should be reinforced with patients. Prior to consideration for elective revision, patients should be medically, psychologically, and socially stable, and have realistic expectations.
Skin flap and incisional complications and scarring
Masculinizing chest surgery requires resection of redundant skin and soft tissue through surgical elevation of thin skin flaps. As a result, the blood supply to these skin flaps is tenuous.[6] This results in early complications, presenting as some degree of wound separation, delayed wound healing, or skin flap necrosis, with an estimated incidence of about 5 percent in the breast reduction population.[7]
Risk factors for early incisional and skin flap complications include high BMI (>30), hypertension, prior breast incisions, and amount of breast tissue resected. Perhaps the most important factor and one that is also modifiable for non-emergent surgery is preoperative smoking.[7,8] Patients should be counseled to stop completely for 4 weeks prior to surgery, and given the difficult nature of cessation of smoking, should consider quitting before even being referred for this type of surgery.
Unacceptable scarring, as a delayed complication, is also of concern to transgender men. A goal of surgery is to minimize the appearance of scars and optimizing their placement. Delayed wound healing results in a wide, abnormally pigmented scar that is more noticeable than the ideal fine line scar. In general, scarring from surgical incisions can be improved with some basic tenets of postsurgical wound care. Firstly, reduction of mechanical stress and tension across the wound by following postsurgical activity restrictions is paramount to reducing scar width. Tension across the incision can result in minute wound disruptions, causing excessive or widened scar formation. Patients should be counseled that incisions predictably look the worst in the early stage of healing, up to 10 weeks postoperatively, before they begin to remodel over the next several months up to one year. Hyper- or hypopigmentation can also result in a more noticeable scar during this time of remodeling. We therefore recommend sun avoidance, or strong sunblock applied over a healed incision for the first year postoperatively. Scar compression has also been found to reduce hypertrophic scarring, although the mechanism is not known. This can take the form of gentle scar massage (beginning no earlier than 2 weeks postoperatively), taping, or silicone gels and sheets.[9] Surgical scar excision and revision is sometimes necessary if scar care fails to improve the appearance to an acceptable level.
Hematoma / seroma
Hematomas occur in approximately 1-2% of all breast reduction patients postoperatively, and usually present early after surgery.[8] The incidence has been reported as high as 5-11% among certain subgroups of transgender patients.[1-3] Hematomas can be prevented with meticulous surgical hemostasis and optimization of medical comorbidities (coagulopathies, hypertension, and stopping ongoing anticoagulation and certain herbal medications). A hematoma presents as asymmetric swelling and pain, sometimes accompanied by ecchymoses. In general, most hematomas need to be evacuated because of the physical pressure they can exert on the taut skin envelope, which can compromise skin flap viability and can also cause postoperative chest deformities. Other complications can include calcification or infection of the hematoma. Usually upon surgical re-exploration and evacuation, no discrete bleeding vessel is ever identified. Small liquefied hematomas can be aspirated or drained percutaneously.
Seromas and oil cysts are fluid collections that occur at the surgical site that are usually preemptively drained by placement of closed suction drains during the operation, combined with adherence to a postsurgical pressure garment. Occasionally, these collections can persist or recur after surgical drains are removed, and need to be drained to prevent skin flap or incisional compromise. Timing of surgical drain removal is dependent on drain output, and should be a decision made in conjunction with the surgeon.
Large oil cysts result from fat necrosis, which can cause contour irregularities and calcifications over time. These are addressed by aspiration and/or surgical revision.
Infection
Infection is a rare early complication after masculinizing chest surgery.[1,8] Usually this will present as localized cellulitis, and can usually be treated with a short course of oral antibiotics. An underlying fluid collection may need to be drained if it is associated with a persistent postsurgical infection.
Nipple-areola-complex and nipple graft complications
Whether the Nipple-Areola-Complex is preserved on a dermal pedicle, as in subcutaneous mastectomy, or it is taken as a free graft, there are associated early and late complications related to nipple healing. Decreased nipple sensitivity, numbness, or paresthesias are expected outcomes for both methods. Patients report varying degrees of sensory recovery over time with both techniques. Both techniques result in some degree of hypopigmentation, reduction in nipple projection, and the rare complication of nipple loss; with these risks being more pronounced with free grafting. Careful adherence to postoperative instructions and nipple dressings can help assure good results with either technique,[1,2] with described overall nipple loss rates at 1% or less. It is important to distinguish between full thickness nipple necrosis and expected superficial skin slough in these postoperative patients.[6]
Nipple reconstruction and revision procedures may be required to restore the appearance of the nipple. Nipple position and size can also be adjusted during a secondary procedure. Usually these are minor procedures than can be accommodated once the initial healing phase is complete.
Contour irregularities
Minor chest wall contour deformities or asymmetry, including redundant tissue found at the end of incisions (dog ears), represented the most common reasons for patients seeking secondary chest wall surgery in multiple published series.[3,6] These can be excised as an outpatient procedure. Additionally, other contour deformities or asymmetries can be addressed with liposuction or fat grafting.
Overall operative revision rate for aesthetic improvement was reported as high as 32% in large published series of masculinizing chest surgery.[2]
Breast cancer risk
Transgender men should be counseled that androgenic hormonal therapy and chest wall contouring procedures (including subcutaneous mastectomy) do not obviate the risk of breast cancer development, particularly among those patients who are at greater risk for breast cancer due to family history. Chest wall contouring, with inherently different goals and techniques, as well as abundant intersurgeon variability in regard to technique, should not be considered a risk-reducing procedure. The presence of residual breast tissue has been acknowledged independently by various surgical authors describing various techniques.[1,3,6] Since the approaches to cosmetic mastectomy differs from those used in the management of breast cancer, all patients undergoing chest surgery should have baseline mammography to prevent an unexpected intraoperative or surgical pathology finding. Ongoing screening for breast cancer after subcutaneous mastectomy is discussed elsewhere in these guidelines.
References
- Wolter A, Diedrichson J, Scholz T, Arens-Landwehr A, Liebau J. Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy. J Plast Reconstr Aesthetic Surg JPRAS. 2015 Feb;68(2):184-91.
- Monstrey S, Selvaggi G, Ceulemans P, Van Landuyt K, Bowman C, Blondeel P, et al. Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm. Plast Reconstr Surg. 2008 Mar;121(3):849-59.
- Berry MG, Curtis R, Davies D. Female-to-male transgender chest reconstruction: a large consecutive, single-surgeon experience. J Plast Reconstr Aesthetic Surg JPRAS. 2012 Jun;65(6):711-9.
- Cregten-Escobar P, Bouman MB, Buncamper ME, Mullender MG. Subcutaneous mastectomy in female-to-male transsexuals: a retrospective cohort-analysis of 202 patients. J Sex Med. 2012 Dec;9(12):3148-53.
- Hage JJ, van Kesteren PJ. Chest-wall contouring in female-to-male transsexuals: basic considerations and review of the literature. Plast Reconstr Surg. 1995 Aug;96(2):386-91.
- Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011 Aug;25(3):229-44.
- Henry SL, Crawford JL, Puckett CL. Risk factors and complications in reduction mammaplasty: novel associations and preoperative assessment. Plast Reconstr Surg. 2009 Oct;124(4):1040-6.
- Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr Surg. 2015 Oct;136(4):531e - 44e.
- Broughton G, Rohrich R. Wounds and scars. Sel Read Plast Surg. 2005;10(7).