Case 29 Gender Transition (Female-to-Male)
29.1 Description
Grade II breast ptosis, oval and moderately enlarged nipple-areolar complexes (NACs), bilateral lateral chest adiposity
Bilateral chest and abdominal hair growth
Asymmetry in shoulder height
29.2 Work-Up
29.2.1 History
Duration of social transition as male
Use and duration of masculinizing hormone therapy
Use of breast binding
Importance of nipple sensation
History of hypertrophic scarring or keloids
Weight stability
Medical comorbidities
Psychiatric history and any established relationship with a mental health professional
History of smoking
Family history or personal history of breast cancer
29.2.2 Physical Examination
Perform chest examination to evaluate
Volume of glandular tissue
Skin quality and amount of excess skin
Grade of breast ptosis, position of NAC in relation to the IMF
Dimensions of the NAC
Masses, discharge, or lymphadenopathy
Chest wall contour and axillary tissue excess
29.2.3 Pertinent Imaging or Diagnostic Studies
Breast imaging, if any abnormality is noticed on examination
29.3 Consultations
Mental health professional: Should be involved throughout the preoperative and postoperative process
Endocrinologist or primary physician: Coordinating hormone therapy and follow-up
29.4 Patient Counseling
Effects of masculinizing hormone therapy on the chest
Testosterone increases muscle mass, decreases fat mass, and increases hair and acne
Inherent differences between male and female chests relevant to top surgery
The male chest is wider with more pectoral muscle development, areolae are smaller, and distance between the nipple and inframammary crease is shorter
Effects of binding: Loss of skin elasticity
Goals of surgery
Removal of breast tissue, address excess skin, reduction and proper positioning of the NAC, elimination of the inframammary fold (IMF), and aesthetic chest wall scars
Expectations for surgery
Clear understanding of the limitations and benefits of each surgical technique
Counseling on smoking cessation, if appropriate
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