Feminizing Top Surgery: Outcomes of a Safe and Effective Procedure in a Single Academic Institution
Feminizing top surgery by means of silicone-based breast augmentation is a gender affirming surgery to create a more feminine-appearing chest. Sometimes ancillary procedures as mastopexy, liposuction of the axillary area, scoring to the gland to correct tuberous breast or reduction of the NAC are performed simultaneously to achieve an optimal esthetic result. The purpose of this study is to assess the outcomes of the top surgeries performed on transfemale patients at Mayo Clinic, Rochester-Minnesota, from 2017 to 2022.
Methods/Technique:
An IRB approved, retrospective chart review of patients undergoing feminizing top surgery performed at Mayo Clinic, Rochester, Minnesota, from 2017 to 2022, was conducted. Patient's demographics and surgical outcomes were gathered. A survival analysis was performed to obtain the time to event complication rate and time to event for other gender affirming surgeries, as additional demographic information.
Results/Complications:
A total of 46 patients (92 breasts) underwent gender affirming breast augmentation operated over 5 years included in this study. Forty-five patients (98%) identified as females, the mean age was 39 years old (SD ±15.082; 18.984 - 73.958), thirty-six patients (78%) identified as white, three (7%) as Asian, two (4%) as African American, one (2%) as American Indian. Nineteen (41%) patients had a normal BMI (Body Mass Index) at the time of the surgery, ten (22%) were overweight, 12 (26%) were obese and 5 (11%) were extremely obese. Forty-four (96%) did not have smoking history; twenty-five (54%) reported alcohol consumption; five (5%) had hypertension; twelve (26%) presented dyslipidemia and two (4%) had diabetes. Thirty-nine (87%) patients had hormone therapy prior to surgery and thirty (65%) had previous gender affirming surgeries: nineteen (41%) had vaginoplasty, ten (22%) had facial feminization surgery and one (2%) had tracheal shaving. Overall, three patients (7%) had simultaneous gender affirming procedures from which two (67%) were vaginoplasty and one (33%) had a tracheal shave.
All patients underwent implant-based breast augmentation. Eighty-eight implants (96%) were silicone with a mean implant volume of 289 ml (SD ±95.212 ;140 - 520). The planes for implant placement were seventy-four breasts (82%) subglandular, fourteen (16%) subfascial, and two (2%) subpectoral via. Seventy-six breasts (81%) got an inframammary fold (IMF) incision and eight (10%) a periareolar incision. The mean length of the IMF incision was 5.3 cm (SD ±1.08; 4 - 7). In twenty-two, ancillary procedures were performed: fourteen (15%) had scoring of the mammary gland for tuberous breast features correction, four (4%) had mastopexy, two (2%) had NAC reduction and two (2%) had liposuction. None required a staging procedure using tissue expander or fat grafting.
A survival analysis for major complications showed a median postoperative follow up of 372 days (pending quartiles), only four patients (8.7%) presented complications that underwent surgical intervention and were the following: n=2 hematomas required evacuation; n=1 displacement that required capsulotomy, ADM placement and implant exchange; and n=1 capsular contracture that required capsulotomy and implant exchange. At 1 month follow up, the probability of a complication having occurred was 2.15% (95% CI of 0 - 5.05%) At one year follow up, the probability of a complication having occurred was 8.05% (95% CI of 0.72 - 14.84%). Only 4 patients (8.7%) presented minor complications: n=1 mild palpable fluid under right nipple, n=1 mild rippling in medial aspect of breast, n=1 surgical site infection resolved in less than 2 weeks and n=1 full thickness wound dehiscence. A total of 3 patients (6.5%) underwent further revision: from which one (2%) was non-surgical for hypertrophic scar management with laser and corticosteroid injection; and two (4.3%) surgical for volume augmentation with implant exchange: one from 345 to 700cc and the other from 235 to 330cc.
The probability for a subsequent facial feminization surgery to have occurred at 6 months follow up is of 5.6% (95% CI: 0 - 12.7%) and at one year follow up is of 0.5% (95% CI: 0 - 19.3%). Meanwhile, the probability for a subsequent vaginoplasty to have occurred at 6 months follow up is of 34.2% (95% CI: 11.4 – 51.15%) and at one year follow up is of 84.8% (95% CI: 57.2 – 94.6%).
Conclusion:
Breast augmentation with implants is a safe procedure to achieve feminization of the breast with an exceptionally low rate of complications.