Chest-Wall Contouring Surgery in Female-to-Male Transsexuals: A New Algorithm

BACKGROUND: In female-to-male transsexuals, the first surgical procedure in their reassignment surgery consists of the subcutaneous mastectomy. The goals of subcutaneous mastectomy are removal of breast tissue, removal of excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. The authors present the largest series to date of female-to-male transsexuals who have undergone subcutaneous mastectomy. METHODS: A total of 184 subcutaneous mastectomies were performed in 92 female-to-male transsexuals, using the following five techniques: semicircular, transareolar, concentric circular, extended concentric circular, and free nipple graft. The technique used depended on the breast size and envelope, the aspect and position of the nipple-areola complex, and the skin elasticity. To best meet the goals of creating a normal male thorax, the authors have developed an algorithm to aid in choosing the appropriate procedure. RESULTS: The overall postoperative complication rate was 12.5 percent (23 of 184 subcutaneous mastectomies), and in eight of these cases (4.3 percent), an additional operative intervention was required because of hematoma, infection, and/or wound dehiscence. Despite this low complication rate, additional procedures for improving aesthetic results were performed on 59 breasts (32.1 percent). The semicircular and concentric circular techniques produced the highest rating of the overall result by patient and surgeon, whereas the extended concentric circular technique produced the lowest rating. CONCLUSIONS: Skin excess and skin elasticity are the key factors in choosing the appropriate technique for subcutaneous mastectomy, which is reflected in the algorithm. Although the complication rate is low and patient satisfaction is high, secondary aesthetic corrections are often indicated.