Top surgery, excision of the female glandular breast tissue and shaping of a male chest, is often the first surgical procedure performed on female-to-male (transmasculine) transgender individuals. This marks the beginning of the surgical transition into a masculine phenotype, thereby facilitating a physical cohesiveness with gender identity. The psychological and aesthetic impact of this operation can be profound and lasting.1,2 With the expansion of health insurance coverage to include gender affirming surgery in the United States, subcutaneous mastectomy for transmasculine individuals has increased. Despite the increase in the number of procedures performed, there is a paucity of outcome literature on the topic.
In 1979, Davidson published his concentric circumareolar technique for gynecomastia, which later was modified by Hage and Bloem and applied to transmasculine top surgery.3,4 This technique allowed a concomitant nipple-areola complex reduction and at the same time removing excess skin. Based on his early experience, Hage and Bloem proposed four fundamental considerations for chest wall contouring in the transmasculine individual: (1) aesthetic correction of contour and elimination of the inframammary fold, (2) resection of excess skin and resulting scars, (3) proper reduction and positioning of mamilla and areola, and (4) minimization of chest wall scars.4,5 After these initial publications, several authors presented modifications, some of which were less extensive, using only a semicircular or transareolar approach, and some that were more involved, using an extended circumareolar incision.4–10 At a certain breast size, no circumareolar technique will sufficiently reduce the skin envelope; thus, most authors advocate for a double-incision mastectomy with a free nipple graft.4–8,10
In 2008, Monstrey et al. published a series of 92 patients who underwent top surgery and proposed an algorithm in which patients were divided into five different surgical approaches depending on their cup size, ptosis grade, and skin elasticity. This article summarized the five most commonly used techniques, described an algorithm, and demonstrated its application based on breast type.7 In our experience, five different surgical approaches can be overwhelming when discussing options with the patient. Furthermore, some techniques, such as the extended circumareolar incision, leave the patient with a less-than-ideal scar. In our experience, there are two techniques that deliver consistent results, the double incision with free nipple graft and the circumareolar technique. We developed the Fischer grading scale to classify patients and guide the surgeon’s application of the best technique based on the patient’s chest anatomy. This grading scale is similar to the Simon gynecomastia grading scale but accounts for higher glandular volume, ptosis, and skin elasticity from chronic binding. We believe this approach expands on the algorithm published by Monstrey et al.7
In this article, we present our grading scale and the outcome of the largest cohort of top surgery published to date. We demonstrate that application of this grading system can help determine which patients will benefit from a double incision and free nipple graft, with the primary endpoint being need for aesthetic revisions. This can help surgeons better select the appropriate technique for an individual breast type, thereby improving the outcome and possibly decreasing the need for aesthetic revisions. Furthermore, irrespective of the technique applied, the grading system will help classify patients, guide the discussion of surgical technique with the patient, and allow outcomes to be compared between surgeons.
PATIENTS AND METHODS
We reviewed our database and identified all transmasculine individuals undergoing bilateral mastectomy performed by the senior surgeon (B.F.) between 2006 and 2015. Demographic data collected included age, body mass index, smoking status, preexisting diabetes, use of testosterone, and months of social transition (Table 1). Only patients with follow-up of greater than 42 days were included. Looking at revisions, we included only the patients with a follow-up of greater than 180 days. All patients were classified using the Fischer grading system (Table 2). Outcome data collected included technique used, postoperative complications, and need for aesthetic revision. Complications were defined as hematoma, seroma, surgical-site infection, and nipple necrosis (Table 3). Revisions were categorized as liposuction, direct excision of skin/fat, scar revision, nipple-areola complex revision, and conversion from circumareolar incision to double incision (Table 4). All patients older than 40 years underwent screening mammography within 1 year before the surgical procedure with free nipple graft. Testosterone was discontinued 2 weeks before surgery. The seventh version of the Standards of Care set forth by the World Professional Association for Transgender Health was followed. This includes a letter from a mental health provider confirming readiness for surgery. Approval from the University of Maryland Medical Center Institutional Review Board was obtained before data collection.
Using IBM SPSS Version 22.0 (IBM Corp., Armonk, N.Y.), descriptive statistics were computed for both total sample size and for each type of procedure group (circumareolar incision versus free nipple graft). Continuous variables were expressed as mean ± SD, and categorical variables were expressed as frequencies and percentages.
To identify significant mean differences across the two types of procedures (circumareolar incision versus free nipple graft), t tests were used for the continuous variables; chi-square analyses were used for the categorical variables. Further subgroup analysis of the Fischer grade 2B patients was performed using chi-square analysis. Statistical significance was defined as a value of p < 0.05.
The Fischer grading system is a modification of the Simon gynecomastia grading scale, which accounts for skin laxity, glandular volume, and degree of ptosis (Figs. 1 through 9).11
A Fischer grade 1 patient has minimal glandular tissue, no skin laxity, and with the nipple-areola complex above the inframammary fold. A Fischer grade 2A patient has moderate glandular tissue, little to no skin laxity, with the nipple-areola complex above the inframammary fold. A Fischer grade 2B patient has moderate glandular tissue, increased skin laxity, with the nipple-areola complex at or below inframammary fold. A Fischer grade 3 patients has significant glandular tissue, irrespective of skin laxity, with the nipple-areola complex below the inframammary fold. A Fischer grade 4 patients has a deflated breast with significant skin laxity and the nipple-areola complex below the inframammary fold.
It is important to understand that a Fischer grade 2A patient may well have more breast volume than a grade 2B patient. It is the amount of skin laxity and nipple-areola complex position that defines the distinction.
The senior author (B.F.) uses two different techniques for transmasculine mastectomy: the circumareolar technique and the free nipple graft technique.
For the circumareolar technique, the size of the nipple is marked in an oval shape measuring 2 × 3 cm with the goal of mirroring the male phenotype (Fig. 10). The area from the 9-o’clock to 3-o’clock position is deepithelialized to avoid disrupting the dermal blood flow to the nipple. A full-thickness incision is made from the 3-o’clock position to 9-o’clock position, through which the mastectomy is performed. The inferior flap is kept thin, and care is taken to disrupt the inframammary fold using electrocautery. The superior flap is kept thicker, taking care to leave at least 2 cm of subcutaneous tissue behind the nipple-areola complex, thereby preserving the blood supply and preventing a saucer deformity. Liposuction can be used to feather and contour laterally. A 15-French drain is placed in the subcutaneous pocket and the incision is closed in layers. Then, 3-0 polydioxanone pursestring suture is applied.
Free Nipple Graft Technique
For the free nipple graft technique, in the preoperative area, the incision is marked (Fig. 11). Using a pinch test, it is ensured that the site of the nipple excision can be encompassed in the transverse closure. The lateral border of the pectoralis major is identified and the incision begins 2 cm below this lateral margin. The incision is carried along the inferior border of the pectoralis major muscle and not necessarily following the infra mammary fold. Medially, the incision should stop two fingerbreadths from the midline. The new nipple position is marked at the junction of the lateral two-thirds of the clavicle and one to two fingerbreadths above the incision.
The nipple is removed full thickness, the superior incision is made, and the superior flap is elevated. Through this incision, the subcutaneous mastectomy is performed with the breast parenchyma left attached to the inferior flap. The superior flap is then put under tension, and the ability to close the incision is confirmed. The inferior cut then completes the mastectomy. The incision is closed in layers over a 15-French closed suction drain. The patient is then brought up into seated position to confirm nipple position. The mastectomy flap is then deepithelialized and the nipple graft is thinned and sutured into place using 5-0 fast absorbing plain gut. Liposuction is used to contour the lateral chest wall and medially to thin any potential dog-ears.
Between January of 2006 and December of 2015, 1686 consecutive subcutaneous mastectomies were performed on 843 patients. Five hundred forty-eight patients were excluded from the study because of inadequate follow-up. Of the 295 that were included, 109 (37 percent) were treated using a circumareolar incision and 186 (63 percent) were treated using a free nipple graft technique. Using the Fischer grading system, the majority of patients were either grade 2B (28.5 percent) or grade 3 (45.1 percent) (Table 2). Follow-up ranged from 42 to 2947 days, with a mean of 297 days.
Patients that underwent free nipple graft surgery were statistically significantly more likely to be older (mean, 27.7 years versus 30.1 years) and have a higher body mass index (mean, 23.0 kg/m2 versus 29.0 kg/m2) than patients undergoing the circumareolar incision technique. There was no statistical difference in the months of social transition, smoking, use of testosterone, or incidence of diabetes (Table 1).
The overall complication rate was 18 percent, consisting of hematomas (6.8 percent), seromas (5.1 percent), infections (1.7 percent), and partial nipple necrosis (3.1 percent). The complication rate was 21.1 percent for the circumareolar incision group and 16.1 percent for the double-incision group, with hematoma being the most common complication in both groups. Overall, there was no statistically significant difference in complications between the two groups; however, as expected, there was a trend toward more complications in the circumareolar incision group (Table 3).
Of the 843 patients, 171 had a follow-up of greater than 180 days and were included in the analysis of aesthetic revisions. Of those 171 patients, 67 (39.1 percent) had some type of revision, either a minor procedure or a surgical revision in the operating room (Table 4). Eight of the 67 patients (11.9 percent) had two separate revisions. Forty-three percent of patients undergoing revisions had two to four different types of revision procedures. A total of 171 revisions were performed in these 67 patients (Table 4). The incidence of revision between the two groups was not statistically significant; however, there was a trend toward more revisions in the circumareolar incision group (46.5 percent versus 34 percent). When a circumareolar incision is chosen in a grade 2B breast, the likelihood for a revision is statistically significantly higher than when a free nipple graft is chosen (75 percent versus 33.3 percent) (Table 5 and Fig. 11). Also, not surprisingly, there was a trend toward higher revision rates for grade 4 when a circumareolar incision was chosen (13.3 percent versus 7.4 percent). Only one patient in the entire cohort was converted from the circumareolar incision technique to the free nipple graft technique.
For many transgender individuals, surgery can be the definitive treatment in transition to their affirmed gender.1,2 In 2014, Medicare lifted the 30-year ban on gender affirming surgery. Commercial insurance companies have also come to recognize the value of surgical treatment. Thus, more patients are able to undergo top surgery. Top surgery is the most frequently performed surgical intervention in the transmasculine population. It is important for surgeons to understand the difference between chest masculinization and a female mastectomy. Beyond minimizing and camouflaging the scars, the goals of surgery are more akin to those of gynecomastia surgery: to flatten the chest, and to reduce and shape the nipple to mimic the male phenotype. However, in contrast to gynecomastia surgery where liposuction alone may be used for a small breast, liposuction is rarely effective as the sole surgical method in top surgery because of the higher percentage of glandular tissue and ptosis present. The degree of ptosis is particularly marked in patients with decreased skin elasticity from years of breast binding.4,5,7 It should also be mentioned that in a transgender mastectomy, a significant amount of actual glandular tissue is excised. This has consequences, as the abundant blood supply to the genetic female breast tissue may lead to higher rates of hematoma compared with gynecomastia surgery.
Achieving optimal and durable results requires attention to breast shape, volume, and skin redundancy. As stated previously, a patient’s individual breast size is a major determining factor when selecting the appropriate surgical technique. The circumareolar technique is typically indicated for patients with smaller breasts, whereas the double-incision technique is indicated for patients with larger breasts. Compared with the algorithm established by Monstrey et al., we used only two techniques, the circumareolar technique and the free nipple graft technique.
Selection of the surgical technique is dictated by the patient’s desire and phenotype. In our cohort, almost all Fischer grade 1 and 2A patients were treated using the circumareolar technique, and most grade 3 and 4 patients were treated using the free nipple graft technique. Selection of surgical technique in Fischer grade 2B patients is more challenging; 45.9 percent of grade 2B patients (n = 50) were treated with the circumareolar incision technique. We demonstrated that grade 2B patients who underwent the circumareolar technique had a higher revision rate (48.6 percent) compared with grade 2B patients that underwent the free nipple graft technique (20 percent) (Table 5). Use of the circumareolar technique in grade 2B and grade 4 patients is often patient driven. Based on our results and the increased acceptance of the free nipple graft, we are strongly advocating using the free nipple graft for grade 2B and 4 patients. If the patients insist on a circumareolar technique, they are counseled about the likely need for additional skin removal and revision of the nipple-areola complex.
The revision rate in the literature is reported to be between 9 and 46 percent.5,8,10,12,13 Our overall aesthetic revision rate is 39.1 percent (circumareolar incision, 46.5 percent; free nipple graft, 34 percent), which is close to the 32 percent reported by Monstrey et al.7 and 40.4 percent reported by Cregten-Escobar et al.8 Our revision rate is higher than in some studies because we include small revisions that can be performed under local anesthesia in the office.
There is a trend toward the use of the free nipple graft technique in older patients and in patients with a higher body mass index. Although statistically not significant, there was a slightly higher incidence of hematomas in the circumareolar incision group compared with the free nipple graft group. This is consistent with the results of Cregten-Escobar et al. and Monstrey et al. and makes sense, as proper hemostasis is more difficult through the smaller incision.7,8
The overall complication rate (18 percent) in our large retrospective study is comparable to the rates published in other series of transmasculine top surgery. It is difficult to compare complication rates between studies, as each study included different variables and used different surgical techniques. Monstrey et al. included the same variables that we did and had an overall complication rate of 12.5 percent.7 The overall hematoma rate reported in the literature ranges from 5.4 to 11.8 percent. Cregten-Escobar et al. have the second largest cohort of patients (n = 202) and report an overall hematoma rate of 9 percent, which is higher than in our study (6.8 percent).8 The hematoma rate is higher in patients undergoing transareolar mastectomy without skin resection (21 percent). Monstrey et al. had a similar hematoma rate (20 percent) when using this technique. For marketing purposes and in select patients with very little glandular tissue, this technique is certainly appealing, but hemostasis is technically challenging. Because of the high rate of hematomas, the inability to reduce the nipple-areola complex, and the minimal morbidity of a circumareolar incision, we do not offer this technique to our patients.
All of our procedures were performed as outpatient surgery, whereas in Europe, most patients are admitted for an inpatient stay. Cregten-Escobar et al. advocate keeping the patient for 4 days in the hospital until the dressings are removed.8 With similar morbidity and reoperation rates, we demonstrate that these procedures can be performed safely and effectively in an outpatient setting.
A shortcoming of the current study is that it does not quantify patient satisfaction and measurable quality-of-life outcomes. Overall acceptance of the free nipple graft technique seems to have increased based on social media and anecdotal surgeon experience. Monstrey et al., with a limited response rate, suggested a similar trend in their article. Based on our results, we have changed our practice and encourage grade 2B and 4 patients to have a free nipple graft.
Our outcomes are comparable to those in the literature and we have shown that these procedures can be performed safely in an outpatient setting. Our grading scale classifies patients and helps the surgeon select a surgical technique. We show a clear trend toward a higher rate of aesthetic revisions in Fischer grade 2B patients when a circumareolar incision is selected over a free nipple graft technique.
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