Masculinizing Chest Wall Gender Affirming Surgery: Clinical Outcomes of 73 Subcutaneous Mastectomies Using the Double-Incision and Semicircular Incision Techniques

Goals/Purpose: Masculinizing chest wall gender affirming surgery is an important element in the treatment of gender dysphoria. Thanks to the recent regulations in the government funded health care programs such as Medicare and Medicaid that allow the insurance coverage of masculinizing top surgery, the number of procedures performed in the United States has significantly increased over the past several years. In this study, we report a series of subcutaneous mastectomies from a single academic center and aim to identify risk factors for major complications and revision surgery.

Methods/Technique: A retrospective review of consecutive patients who underwent primary masculinizing top surgery via subcutaneous mastectomy at our institution through July 2021 was performed. Demographics and clinical characteristics were recorded as well as major complications and revision surgeries. Time-to-event analyses using Cox regression models were performed to assess predictors of major complications and revision surgery.

Results/Complications: Seventy-three consecutive patients (146 breasts) operated over 4.5 years were included in this study. The mean age and the mean BMI were 25.2±7 years and 27.6±6.5 kg/m2, respectively. Twenty-four (32.9%) patients had a history of smoking. One (1.4%) patient had hypertension and 9 (12.3%) patients had dyslipidemia. The mean follow-up time was 7.9±7.5 months. None of the patients had a history of chest wall radiation or breast surgery. Double-incision with free nipple grafting was the most common technique (n=130, 89%), followed by periareolar semicircular incision (n=16, 11%). The mean resection weight was 524.7±377.7 grams. Concomitant suction-assisted lipectomy was performed in 48 (32.9%) cases. The rate of major complications was 2.7% (surgical site infection, n=1; hematoma that required evacuation, n=3). Revision surgery was performed in 8 (5.4%) cases which included standing cone excision (n=4) and nipple debulking (n=4). The average time-to-revision surgery was 13.6 months (SD: 7.5 months) in these patients. In addition, steroid injection was done to address hypertrophic incision scar in 1 (0.7%) case. Univariate time-to-event analysis demonstrated that having a concomitant liposuction was significantly associated with lower rate of revision surgery (p=0.026).

Conclusion: Masculinizing chest wall gender affirming surgery is a safe procedure with a low rate of revision. Concomitant liposuction significantly reduced the need of revision surgery. Future studies utilizing patient-reported outcomes are still required to better assess the success of this procedure.