The Impact of Testosterone Supplementation on Surgical Complications in Gender-Affirming Mastectomy: A Meta-Analysis

Abstract Background Patients seeking gender-affirming surgery are usually on hormone supplementation. We hypothesized that perioperative testosterone therapy increases hematoma following chest masculinizing surgery. Methods Meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies with perioperative hormone status and surgical outcomes were included. Patient characteristics, testosterone use, surgical details, and outcomes were extracted. Meta-analysis and pooled analysis using aggregated patient-level data were conducted. Results Fifteen studies were included, comprising 3,036 testosterone-treatment (TT) and 726 non-testosterone-treatment (NTT) patients. Overall complication rates were similar (11.08% vs. 9.80%; p = 0.29). Meta-analysis showed significantly higher hematoma in TT (OR 1.99, 1.19–3.34, p < 0.001). Other complications showed no significant differences: infection (OR 0.33 0.07–1.59), wound dehiscence (OR 0.68 0.04–11.06), seroma (OR 0.5 0.15–1.57), and venous thromboembolism (OR 0.20 0.0–10.42). Hematoma risk did not differ between patients who continued versus stopped testosterone (TT-C 8.73% vs. TT-S 7.80%; p = 0.54), or by cessation timing ( p = 0.60). Mixed-effects meta-regression found incision type was not a significant moderator of hematoma (QM (1) = 0.34, p = 0.56) among TT and NTT. Without stratifying by testosterone, hematoma rates were higher with limited incisions than extended incisions (11.96% vs. 6.5%; p < 0.01). Conclusions Testosterone therapy was associated with higher postoperative hematoma rates, while perioperative cessation did not reduce hematoma or overall complications. These findings support heightened perioperative awareness and vigilance for hematoma risk in patients receiving testosterone, while decisions regarding the timing of hormone therapy initiation should be carefully weighed against established mental health benefits. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .