Transgender Breast Surgery (Male-to-Female and Female-to-Male)

Introduction

Gender dysphoria, quite often referred to as gender identity disorder, is defined by an individual’s persistent discomfort with his or her own assigned sex. Individuals with gender identity disorder have a desire to live as members of the opposite sex and therefore often modify their primary and secondary sexual characteristics. Today there are many surgical and medical options for transsexual patients to transition into their desired gender.

Transsexual females are persons who were born with male anatomy and assigned to be male sex at birth, but the gender they associate with is female and vice versa for transsexual males. These individuals often undergo hormonal therapy and sex reassignment surgery to transition and alter their appearance in a way that aligns with their gender identity. The term “trans” or transgender female refers to a transexual woman and “trans” male refers to a transexual man; wheras the term “cis” or cisgender are individuals who identify with their assigned gender at birth.

Before any of these procedures or starting hormone therapy, a mental health evaluation is required. A psychiatrist must diagnose the individual with gender identity disorder. This evaluation rules out any endocrine disorders, psychosis, and mental health disorders. Once the patient is cleared by the psychiatrist, hormone replacement therapy is initiated before surgical intervention.

Many transgender male-to-female patients see breast development after long-term hormone replacement therapy. However, for those who desire larger breasts, breast augmentation is an alternative or supplemental option. Breast augmentation is the enlargement of breast by using silicone or saline implants to enhance the size and shape of the chest ( Fig. 25.1 ). The prosthesis is chosen to fit the contour of the breast by the surgeon according to the patient’s desired appearance. In some male-to-female patients, consideration of a tissue expander as a first step to develop a breast mound may be considered. The use of breast implants requires a thorough discussion with the patient and informing the patient that implants are not lifetime devices and thus often require further operations over one’s lifetime.

Transgender female-to-male patients usually seek bilateral mastectomy, which is the removal of the breast and the shaping of the male contoured chest. The technique chosen for this procedure depends on the amount of breast tissue present and the tissue elasticity. The breast parenchyma and fat can be removed through multiple incisions ranging from a periareolar incision to a double-incision mastectomy with free nipple graft.

Although hormone therapy is preferred for most gender reassignment procedures, it is not required for top surgery eligibility. Top surgery may be performed 6–12 months before bottom surgery, which includes vaginoplasty or metoidioplasty/phalloplasty; for some trans-individuals, top surgery may be the only surgical procedure throughout transition.

Indications and Contraindications

Augmentation mammaplasty for the transgender female patient is a commonly performed procedure. Despite the frequency with which the procedure is performed, there are very few articles that address this specifically in the published literature. For the transgender female patient seeking improvement of her chest appearance, it is incumbent on the treating physician to distinguish these operative indications from those of a cis-female patient seeking aesthetic or even reconstructive measures for breasts. Therefore, the treating physician should be knowledgeable of the World Professional Association for Transgender Health (WPATH) guidelines for top surgery in trans-female patients and should strictly adhere to the parameters outlined. The full extent of these guidelines exceeds the scope of this chapter; however, the surgeon should have a letter from a licensed mental health specialist who has an established relationship with the patient, and the patient should be on hormone therapy and living as the desired gender for at least 12 months. Adherence to these guidelines is important not only to ensure that the patient meets criteria from a gender dysphoric standpoint but also from a medico-legal standpoint for the surgeon.

Once the dysphoria is addressed and/or documented, surgical evaluation can proceed as standard for an augmentation mammaplasty. The indications for a subcutaneous mastectomy in transgender males follow the same guidelines as for trans-females with the exception of being on hormone therapy.

Preoperative Evaluations for Male-to-Female Transgender Patients

Most patients would have been on a feminizing hormone protocol before evaluation by a plastic surgeon for augmentation mammaplasty. These hormones generally result in some breast tissue growth, which is usually consistent with a Tanner stage 3 or 4 seen in adolescent girls. This development is usually not sufficient for the patient’s aesthetic desires and in our experience not sufficient for the patient to “pass” as the female gender, so it is important for the plastic surgeon to determine what are the patient’s aesthetic goals and expectations. Generally speaking, we have found that most trans-female patients desire a relatively larger appearance than most cis-females. The challenge with this, however, is that their tissue is usually less conducive to large volume (augmentations). We have found that virtual imaging has helped both the treating plastic surgeon and the patient come to a better understanding of the patient’s desired appearance. This also allows for better management of expectations preoperatively. After virtual imaging, we proceed with our routine breast/chest examination as we would for any patient desiring a change in appearance of the breasts, which includes assessing breast footprint (breast width), inframammary fold (IMF) level and symmetry, nipple-to-IMF distance both at rest and on stretch, sternal notch–to-nipple distance, nipple–areolar complex diameter, skin pinch, evaluation of underlying pectoralis muscle, and determination of preexisting ptosis. It is also important to evaluate for any abnormalities such as masses in the breast tissue and axilla, because, although rare, estrogen exposure in these patients can increase their risk for breast malignancy. There is limited literature regarding the risks and incidence of breast cancer in this population.

Depending on the patient’s body mass index, most differences are noted in the relatively less elasticity of the overlying skin envelope, as well as thinner superior pole tissue. The pectoralis major muscle is usually more developed in these patients as well. It is important to identify any asymmetry preoperatively, because it might be more pronounced postoperatively, leading to patient dissatisfaction.

The choice of prosthesis should be guided by patient preference after the risks and benefits of both silicone and saline are explained by the plastic surgeon. It has been our preference to proceed with silicone prostheses because of the softer postoperative texture ( Table 25.1 ). Textured implants have a risk of anaplastic large cell lymphoma (ALCL), so it is our practice to place smooth implants. Recent FDA recommendations are for ultrasound or MRI at 5-6 years postoperatively to look for a silent leak and then every 2-3 years in the asymptomatic patient.

TABLE 25.1

Implant Types for Breast Augmentation Procedure

	Saline filled	Silicone Gel
FDA approval	Yes, must be >18 years old	Yes, must be >22 years old
Filling	Saline water solution	Silicone gel
Volume	Volume can be adjusted during surgery	Filled before surgery
Surface of shell	Smooth or textured	Smooth or textured
Warranty	Manufacturer dependent	Manufacturer dependent

FDA, U.S. Food and Drug Administration.

Surgical Techniques

Relevant Surgical Anatomy

As mentioned earlier, the breast base width is important. This can be determined by applying pressure directly onto the nipple–areolar complex and determining the circular footprint created subcutaneously from the breast tissue that is present. The width of pectoralis muscle is also important, because some of these patients will undergo subpectoral prosthesis placement. This width is determined by measuring the horizontal distance from parasternal insertion of muscle fibers to the anterior axillary fold.

The underlying neurovascular supply to the breast tissue and nipple–areolar complex also should be taken into consideration. The innervation of the nipple–areolar complex comes from the lateral cutaneous branch of the fourth intercostal nerve. This is important when performing pocket dissection of the lateral-to-lateral pectoralis border. The blood supply to the breast and nipple–areolacomplex has been well documented in the past. Of importance, however, is that the second intercostal perforator from the internal mammary artery is frequently encountered when performing subpectoral pocket creation and can be a source for postoperative hematoma if not adequately controlled intraoperatively. The subpectoral pocket is the safest from a perfusion standpoint because the blood supply from the pectoral branch of the thoracoacromial artery is maintained.

Preoperative Markings

We begin by marking the midline by drawing a line from the sternal notch to the umbilicus. We then mark the native IMFs bilaterally. The native breast footprint is usually demarcated and outlined as described earlier. Depending on the thickness of the pectoralis muscle, we might have the patient adduct the shoulders to delineate the pectoralis border for preoperative markings as well.

Our standard approach is to use an IMF incision, because the preoperative nipple–areolar complex width of trans-females is usually not sufficient to allow periareolar prosthetic insertion. Transaxillary approaches to breast augmentation are well documented in the literature; however, in our experience, we think that better final contour and symmetry are better attained via an IMF approach.

Because of the larger sized implants that most of these patients desire, if an IMF incision is placed directly within the IMF, the problem of postoperative scar migration onto the breast might result. Therefore, we generally place our IMF incision at least 1 cm inferior to the native IMF, depending on the size of the implant being placed.

Surgical Exposure

Determination of the pocket placement is usually done preoperatively. For a very thick pectoralis muscle, a subglandular or subfascial approach might be more desirable, because the risk of postoperative animation deformities is minimized. Dual-plane III placement also can aid with prevention of that problem. Of note, the skin envelope is usually thinner in these patients, which conversely makes subglandular placement more tenuous from a post-operative standpoint. Because of this, it is our practice to perform subpectoral placement, with a dual-plane II release if necessary. We determine the need for dual-plane release depending on the extent of preoperative ptosis present.

Details of the Procedure

We begin by ensuring pneumatic compression stockings are in place before induction of anesthesia, because these patients are at a higher risk of venous thromboembolism. Typically patients are advised to hold estrogen 4 weeks preoperatively. Preoperative antibiotics are administered, usually consisting of vancomycin and cefazolin or clindamycin if penicillin allergy is present.

Ensure the patient is symmetrically supine on the operating table, with arms either abducted to 45 degrees or crossed over the abdomen, while padded and secured with tape or elastic wrap. The entire chest to umbilicus is prepared with povidone-iodine (Betadine) or chlorhexidine solution. Lidocaine 1% with epinephrine is infused into the intended incision sites bilaterally.

Incise through subcutaneous tissue down to the pectoralis fascia. Perform glandular release up to the nipple–areolar complex if the dual-plane II procedure is needed. Elevate and divide pectoralis insertions inferiorly starting laterally and extending medially to about the fourth interspace. Subpectoral pocket dissection is then performed with electrocautery according to the preoperative determination of breast footprint. Sizers are placed and the operative table back raised to determine adequacy of size and symmetry.

Once appropriate size is determined, 3-0 Vicryl sutures are placed through the fascia superiorly, fibrofatty tissue/rib periosteum inferiorly to facilitate pocket closure after implant placement. The implant pocket is then irrigated with betadine and then triple antibiotic solution of cefazolin (Ancef), bacitracin, and gentamicin (assuming no contraindications).

Implant is placed and 3-0 Vicryl sutures are then tied. 3-0 Monocryl and 4-0 Monocryl are then used to close both the deep and superficial dermis and cyanoacrylate glue is applied over the incision. A surgical support bra is placed finally.

Postoperative Care and Expected Outcomes

The surgical bra is usually the only dressing required postoperatively. Depending on vertical displacement of the implants, superior pole compression using foam tape or an elastic bandage can be used to apply gentle but constant downward pressure on the implants. Patients are usually instructed to avoid shoulder abduction beyond 45 degrees for the first 2 weeks, along with avoidance of strenuous activity and heavy lifting for 6 weeks. They are encouraged to ambulate as soon as possible postoperatively. Augmentation mammaplasty can be safely performed as an outpatient procedure; however, each patient should be risk stratified accordingly.

The literature does not support prolonged antibiotics; however, most plastic surgeons will administer postoperative oral antibiotics. We also administer a muscle relaxant to be used as needed (PRN) for the first 5 postoperative days.