We thank Bertrand et al. for elaborating on the optimal measure with which to evaluate chest wall masculinizing surgery in transgender individuals.
The authors clearly point out the different anatomical situation and technical considerations of this population compared with other groups undergoing chest wall contouring surgery. Although agreeing on the relevance of a dedicated measure with which to assess postoperative satisfaction, we take a somewhat different approach compared with Bertrand et al. 1
In our opinion, postoperative patient-reported outcome measures should best be based on concepts that are experienced to be relevant by the individuals themselves. Traditionally, health care professionals assume what is important to patients when designing outcome measures of treatments, including patient-reported outcome measures. Recent reviews have shown the large number of concepts and self-developed measures that were used to assess the outcomes of gender-affirming operations.
However, some concepts that were hypothesized by clinicians to be important may not be relevant to satisfaction and quality of life to patients, and vice versa. 2
The development of the BODY-Q Chest Module (among other “Qs”) followed international guidelines for instrument development that emphasizes the use of qualitative methods to ensure that the scales measure concepts that matter to patients from their perspective.
Postoperative chest sensation was assumed to be among the factors that influence chest satisfaction. Some transgender men mentioned nipple sensation during the interviews, and we included an item in the field-test scale to measure this concern. However, this item performed extremely poorly in the psychometric analysis and was therefore dropped. 3 This finding is illustrated in 4 Figure 1, which shows the item characteristic curves for the nipple sensation and shape items (the latter were included in the final scale). The dots representing the class intervals for shape satisfaction—among the other satisfaction items—follow the item characteristic curves well. That the sensation item does not can be explained, as the included items ask about appearance, whereas the nipple item asks about sensation. Fig. 1.:
Rasch outcomes assessment of nipple sensation and satisfaction with chest shape. The
curved lines represent the expected scores for each item ( above, nipple sensation; below, satisfaction with chest shape). The closer the dots follow the item characteristic curve, the better the fit of the observed data to the predictions of the Rasch model.
In the study referred to,
we asked 50 postoperative transgender men whether they missed certain items in the scale, contributing to their quality of life. No comments on chest sensation were made by any of the participants. 5
We do agree with Bertrand and colleagues on the importance of continuously improving patient-reported outcome measures for this group based on the latest clinical and societal developments and on other relevant measures. Currently, an international consortium is working on the development of the GENDER-Q, a comprehensive measure with both generic modules along with modules for specific surgical and nonsurgical gender-affirming treatments.
In the process of development, a literature review and review of existing measures inform the patient interviews. For example, the BREAST-Q and FACE-Q will be assessed to determine their content validity for chest feminization (surgery) or facial (dis)satisfaction. Lastly, we emphasize the importance of the systematic collection of objective outcome data, such as surgical complications, standardized measurement of chest sensation, or clinician-reported aesthetic success, and to relate those measures to subjective patient-reported outcome measure data. We invite global partners to collaborate in the field testing of the preliminary version of the GENDER-Q to maximize generalizability and clinical use. 6 Disclosure
Dr. Klassen is a co-developer of the BODY-Q and would receive a share of the license revenues if used in a for profit study. The remaining authors have no financial disclosures to report.
Tim C. van de Grift, M.D., M.Sc., Ph.D. Mark-Bram Bouman, M.D., Ph.D., F.E.C.S.M. Department of Plastic, Reconstructive, and Hand Surgery Amsterdam University Medical Center Amsterdam Public Health Institute Amsterdam, The Netherlands
Anne F. Klassen, B.A., D.Phil(Oxon.) Department of Pediatrics McMaster University Hamilton, Ontario, Canada Margriet G. Mullender, M.B.A., Ph.D. Department of Plastic, Reconstructive, and Hand Surgery Amsterdam University Medical Center Amsterdam Public Health Institute Amsterdam, The Netherlands REFERENCES
1. Bertrand B, Perchenet AS, Philandrianos C, Casanova D, Cristofari S. Subcutaneous mastectomy improves satisfaction with body and psychosocial function in trans men: Findings of a cross-sectional study using the BODY-Q chest module. Plast Reconstr Surg. 2019;144:144e–145e.
2. Andréasson M, Georgas K, Elander A, Selvaggi G. Patient-reported outcome measures used in gender confirmation surgery: A systematic review. Plast Reconstr Surg. 2018;141:1026–1039.
3. U.S. Food and Drug Administration. Patient-reported outcome measures: Use in medical product development to support labeling claims. Guidance for industry. Available at:
. Accessed November 23, 2015.
4. Klassen AF, Kaur M, Poulsen L, et al. Development of the BODY-Q chest module evaluating outcomes following chest contouring surgery. Plast Reconstr Surg. 2018;142:1600–1608.
5. van de Grift TC, Elfering L, Greijdanus M, et al. Subcutaneous mastectomy improves satisfaction with body and psychosocial function in trans men: Findings of a cross-sectional study using the BODY-Q chest module. Plast Reconstr Surg. 2018;142:1125–1132.
6. Klassen AF, Kaur M, Johnson N, et al. International phase I study protocol to develop a patient-reported outcome measure for adolescents and adults receiving gender-affirming treatments (the GENDER-Q). BMJ Open 2018;8:e025435.
, discussing material recently published in the Letters to the Editor Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the
Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the
Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.