Practice Patterns in Transgender Mastectomy Performed By Plastic Surgeons
Methods/Technique: A nineteen-question anonymous survey was distributed to all American Society for Aesthetic Plastic Surgery physician members. Subjects were polled on their qualifications, number of cases performed monthly, pre-operative risk factor and screening practices, details of operation, histopathologic analysis patterns, payer mix, and total charges. Descriptive statistics were performed on the data to convey survey results.
Results/Complications: To date, forty-nine plastic surgeons completed the survey. 78.3% of surgeons were in private practice. While 81.4% of respondents did have a pre-operative breast cancer screening routine, most screening was based on pre-operative mammography, with most mammograms only being ordered in cases of patients greater than age 40 or with significant risk factors (56.9% and 33.3% respectively). 11.8% require screening clearance by a breast surgeon, primary care provider, or oncologic surgeon. 5.9% of respondents used a breast cancer risk assessment tool during clinic visits. 19.6% did not screen for breast cancer in any way. Only 5.8% of surgeons performed oncologic resections, and only 17.3% oriented surgical specimens for pathology. Yet, 70.6% of respondents send specimens for pathology review. 72.5% identified their payer mix as self-pay. 15% of respondents include the patient in decisions regarding sending specimens to pathology and other testing that may influence final cost to the patient. 54.7% of respondents agree or strongly agree that more thorough national guidelines are needed for gender affirming top surgery.
Conclusion: While most respondents perform some type of pre-operative screening, offer pre-operative mammography, and send surgical specimens to pathology, there is wide variation in actual practice pattern. Few respondents use screening tools aside from mammography. While most respondents send specimens to pathology, few orient their specimens, which can negatively influence pathology localization and further breast cancer specific treatments if necessary. Although rare, there is evidence that incidental breast cancer or high-risk lesions are detected during the preoperative and operative period. This evidence combined with the wide variation in screening and pathology review patterns, suggests a need for protocoled screening and pathology guidelines for all surgeons performing this procedure. Although this sample predominantly represents a private, self-pay practice environment, this study provides insight into practice patterns that may differ from academic practice, or insurance covered payer mixes. Further data will need to be gathered in other practice environments and from specialties such as breast and general surgeons to more fully characterize practice patterns in transgender mastectomy.