Female to Male Transgender Breast Surgery

Ann R. Schwentker

DEFINITION

Transgender person: individuals who identify with a gender that is distinct from their assigned sex at birth.
Gender dysphoria: emotional stress caused by differences between a person’s assigned sex and his/her gender identity.
Transition: a period of formal transformation of one’s gender identity that may include changing name, clothing, preferred pronouns, gender-affirming hormones, and/or surgery.
Female to male, trans man: a person assigned female gender at birth who identifies as male.
Male to female, trans woman: a person assigned male gender at birth who identifies as female.

ANATOMY

The anatomy may vary widely, depending on the patient’s body habitus.
All patients have excess glandular breast tissue. Other factors that influence surgical planning include the following:
- Whether or not there is areolar enlargement
- Nipple position
- The amount of skin excess

PATIENT HISTORY AND PHYSICAL FINDINGS

The World Professional Association for Transgender Health (www.wpath.org) has published a Standards of Care manual that should be consulted in determining an individual’s suitability for surgery. In particular, it is desirable that patients be supported by a mental health professional to manage their dysphoria.
Thorough breast exam including any masses, asymmetry, nipple/areolar size and position, ptosis, and skin excess.
The importance of nipple sensation to the patient should be assessed. All available techniques may reduce or eliminate nipple sensation and erectile function¹ and make breastfeeding impossible, which may dissuade some patients.

IMAGING

Any masses should be imaged and worked up as for a female with a breast mass.
Patients who above age 45 should have a preoperative mammogram. It is not possible to remove 100% of breast tissue with this procedure, and patients should discuss with their medical doctors whether postoperative mammograms are necessary.

NONOPERATIVE MANAGEMENT

Many patients begin transitioning by wearing binders. These can cause chafing and intertrigo, which should be treated prior to surgery.
Patients may experience significant breast gland involution after starting testosterone therapy. Although this is not sufficient to avoid surgery, it may alter the surgical plan in smallbreasted patients.

SURGICAL MANAGEMENT

Insurance coverage for transgender surgery is variable. Comorbidities that may increase the chance of insurance coverage for surgery include the following:
- Breast cancer, breast mass, or BRCA positivity
- Fibrocystic disease with documented intractable pain
- Intertrigo
- Symptoms of macromastia

Preoperative Planning

Patients with small areolae and very small (A cup) breasts may be candidates for periareolar mastectomy.
If there is significant skin excess, a breast amputation will almost always be preferable.

Positioning

The patient is positioned supine with the arms at 90 degrees and securely wrapped to arm boards (FIG 1). The table is placed so that the patient can be moved to a seated position during surgery.