The double subcutaneous mastectomy, also known as top surgery or chest reconstruction, is one of the main steps in female to male (FtM) gender transition. Transmen often consider it the most important surgery and the first one they undergo as it lets them live their own gender identity without the ambiguity caused by the shape of their chest. The mastectomy is considered a highly effective treatment for gender dysphoria and has a high post-op satisfaction rate not only for transgender patients but also for non-binary persons who find this surgery sufficient for their gender identity affirmation.
Generally speaking, a mastectomy is a surgery most often practiced in the oncologic field to excise breast tumors; there are several surgical techniques available and the procedure might remove different tissues based on the stage of the cancer. There could be excision of just the mammary gland, or the excision of areola and nipple too, up to the most serious cases which require the removal of all breast tissue plus the pectoralis major and minor muscles and axillary lymph node dissection (ALND or axillary lymphadenectomy).
Furthermore, a less radical form of mastectomy is practiced in few selected cases of patients with no cancer but with high risk of developing it due to their genetics and familiarity; in such cases it is called preventive or prophylactic mastectomy.
In this blog post though, we are going to talk about the specific case of the subcutaneous bilateral mastectomy in FtM transgender patients.
Surgical goals and different options in FtM Top Surgery
When performing a bilateral mastectomy or chest reconstruction, the surgeon will try to achieve the following five goals:
- Reduce the breast tissue
- Eliminate the intermammary cleft
- Remove the excess skin
- Reposition and resize the nipple and areola
- Minimize the scars on the chest
The choice of the surgical technique will depend upon the anatomical characteristics of the patient, such as the breast size and elasticity of the skin, and from the knowledge and experience of the surgeon.
Hormone replacement therapy with testosterone has minimal and irrelevant effect on breast size in FtM transgenders. This is also one of the reasons why HRT is not a criterion for having access to this surgery unlike other SRS procedures.
The different surgical options for the bilateral subcutaneous mastectomy are the following:
- Semicircular incision or hemi-periareolar incision or Webster’s technique or keyhole technique. This technique is performed by making a small incision along the border of the lower half of the areola.
- Transareolar incision. This technique was developed by Prof. Ivo Pitanguy, the father of Plastic Surgery, and is performed by making a horizontal incision that splits in half both the areola and the nipple.
- Double concentric periareolar incision or concentric circular incision. This technique is performed by making two incisions: one along the outer border of the areola to form a circle and a second circular incision larger than the first one.
- Extended concentric circular incision. This technique is performed like the circular incision with the addition of the resection of triangles of tissue which have the base on the outer circular incision, and in number and dimension dependent on the breast size and the ptosis grade.
- Free nipple graft technique. This technique is performed by making an incision around the areola and harvesting a full-thickness graft of the nipple areola complex; this graft is preserved in saline solution while the mastectomy is performed; once the breast tissue is removed, the nipple area complex is repositioned in the most appropriate location.
The indications for these procedures, based on medical papers, advise the use of the semicircular technique when breast size is small (A cup) and there is mild ptosis (grade I) with good skin elasticity.
The transareolar incision is advised for patients with the same characteristics outlined above (A cup, mild ptosis and good skin elasticity) who also require a nipple reduction.
The concentric circular incision is indicated for patients with B cups and ptosis grade I or II and good skin elasticity; it is also indicated for smaller breast sizes with moderate skin elasticity.
The extended concentric circular incision is indicated for patients with C cups and ptosis grade II, with moderate skin elasticity.
Lastly, the free nipple graft technique is indicated for patients with large volume breasts and moderate to severe ptosis (grade II or III) especially when skin elasticity is scarce. This technique makes the mastectomy possible also in case of large volume breasts but has the disadvantage of both leaving scars which are more visible and of adding the risk of discoloration and loss of sensation to the nipple and areola.
In short, the larger the volume of the breast to excise and the larger the amount of skin to excise and the lower the elasticity of the skin of the patient, the longer will be the surgical incision in order to have satisfactory results which in turn will lead to a more visible scar.
Risks and complications of FtM mastectomy
Among the possible risks and complications for the bilateral subcutaneous mastectomy there are the intraoperative and post-operative bleeding, infection, hematomas and seromas that might require surgical evacuation (but that are prevented with drainages and bandages). It is also possible the formation abscesses or the partial necrosis of the nipple as well as the risk of asymmetries or deformities due to excess tissue in the pectoral area. There is often need for a second corrective surgery to improve the aesthetic result (20-25% of cases). Hence, it is good to discuss this topic with the surgeon before undergoing the procedure. Lastly there might be the risk of areola and nipple discoloration and loss of sensation depending on the technique employed.
It is also important to remind that undergoing this surgery doesn’t completely prevent the possibility of developing breast cancer. The nipple areola complex (NAC) and part of the breast tissue are left intact in place, leaving behind tissue that can potentially evolve into cancer.
Further information on bilateral mastectomy in female to male transgenders
The mastectomy can also be performed paired with the hysterosalpingo-oophorectomy, by employing two surgical teams; this is done to decrease the number of times the patient is subject to general anesthesia to complete the transition as well as to decrease the number of hours spent in the OR.
Scars are visible for at least 8-12 months, then they slowly fade. It is important to follow the surgeon’s advices to minimize scarring. The use of silicone gel sheets for scar prevention may improve the final result.
Surgery lasts on average 1-2 hours, but it depends from the technique used and the anatomical characteristics of the patient. During the first few days it is normal to have decreased sensation in the chest area. The patient is discharged 1-3 days post-op and the sutures are removed after about 5-10 days. After that it is possible to get back to daily life, avoiding vigorous activities and heavy lifting. After about 4 weeks there should be no more restrictions.
The criteria to have access to the bilateral mastectomy as set by the Standards of Care 7th edition of the World Professional Association for Transgender Health (WPATH) are the following:
- Persistent and well documented diagnosis of Gender Dysphoria by a mental health professional.
- In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
- Age of majority in a given country.
- The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
There is no need to be taking the hormone replacement therapy with androgens to be eligible for this surgery.
These criteria do not apply for all those patients who undergo the mastectomy procedure for reasons other than the treatment of gender dysphoria.
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- Female-to-Male Gender Affirming Top Surgery: A Single Surgeon’s 15-Year Retrospective Review and Treatment Algorithm.
McEvenue G, Xu FZ, Cai R, McLean H – Aesthetic Surgery Journal, Dic 2017
- Principles of Transgender Medicine and Surgery – 2nd edition
Ettner R, Monstrey S, Coleman E – Routledge 2016
- Sex Reassignment Surgery in the Female-to-Male Transsexual
Monstrey SJ, Ceulemans P, Hoebeke P – Seminars in Plastic Surgery, Ago 2011