Abstract
Purpose:
Top surgery, or masculinization of the chest, is often the first and sometimes only procedure in gender-affirming surgery for transgender- and gender-diverse persons assigned female at birth. In recent years, there has been improved access to care for transgender individuals and increased demand for top surgery. Our aim was to investigate the degree of satisfaction with the postoperative outcome after top surgery in transgender men.
Methods:
Ninety transgender men who underwent top surgery between September 1, 2013 and August 31, 2018 were included. Patients were surveyed from 5 to 62 months after surgery. Participants' files were evaluated for complications, and 84 (response rate 93.3%) participants answered a questionnaire evaluating patient satisfaction postoperatively.
Results:
Patients were either satisfied or partially satisfied with the overall experience of undergoing surgery and the postoperative result in 90.5% of responses. Patients were very satisfied with their clothed appearance in 89.3% of responses, whereas only 44.1% were very satisfied with their nonclothed appearance and 46.4% partially satisfied. Patients were also very satisfied with postoperative scars in 47.6% of responses and nipple reconstruction in 48.8%. Only two patients expressed their regret.
Conclusion:
Satisfaction outcomes after top surgery are generally positive, especially in respect of clothed appearance, self-confidence, and self-acceptance.
Keywords: satisfaction, top surgery, transgender, transgender men, quality of life
Introduction
Background
An incongruence between assigned gender and one's gender identity or experienced gender can lead to significant distress and gender dysphoria.1 An increase in social awareness and access to treatment has meant an increase in referrals to Sexology clinics and to Plastic Surgery departments in Denmark. A “multidisciplinary care team” consisting of psychologists, psychiatrists, gynecologists, and plastic surgeons handle all aspects of treatment for transgenderism.2 Top surgery (masculinization of the chest and breast augmentation) is performed by plastic surgeons in several departments in Denmark, whereas bottom surgery (vaginoplasty, phalloplasty, and metoidioplasty) is performed by plastic surgeons at a single center. The gynecology department is responsible for female gonadectomy and hormone therapy.
Top surgery or masculinization of the chest, which is often the only surgery that transgender- and gender-diverse persons assigned female at birth undergo, can improve quality of life and decrease discomfort associated with gender dysphoria.3 Success of surgery is subjective and is influenced by many factors. In a previous study, based on the interviews of the same population as this study and authored by the same group, we investigated the prevalence of pain, sensory disturbances, and complications after top surgery to quantify the side effects.4 We found that 23 of 90 transgender men who underwent top surgery presented with persistent postsurgical pain at the time of the interview. The majority (90.1%) of these experienced only mild-to-moderate pain. None of the participants who reported pain had constant pain, and only half of the participants experienced pain monthly or less frequently than that. The majority of the participants who experienced pain did not need to use pain relieving medication, and for the few who did only Paracetamol (Acetaminophen) was used.4 These aspects are important to consider when evaluating the success of surgery. In this study, we investigated if patients' expectations were met, and gains from surgery justify eventual side effects. Understanding the factors that influence satisfaction is essential to improve preoperative information and managing expectations, as well as improve patient experience and end-result satisfaction.
Objective
The objective of this study was to evaluate self-reported satisfaction after top surgery in gender reassignment surgery.
Materials and Methods
Study design
This is a single-center, cross-sectional study using a telephonic questionnaire to evaluate overall satisfaction and satisfaction of cosmetic result, regarding scarring and nipple reconstruction retrospectively. Confidence and acceptance postsurgery, as well as regret and expectation, were also evaluated. Complications, persistent pain, and sensory disturbance have previously been evaluated.4
The study has been approved by the Danish Data Protection Agency: j.nr. 2012-58-0004, and by the local health data handling center: RH-2017-353. Informed consent was obtained from all participants.
Setting and participants
All transgender men who underwent top surgery as part of gender-affirming surgery between September 2013 and August 2018 at the Department of Plastic Surgery and Burns, Copenhagen University Hospital, Rigshospitalet, Denmark were assessed for eligibility. The study period is limited to 5 years due to Danish Health Legislation. Study participants were identified by combining the diagnostic code (International Classification of Diseases-10 F64.0) for transgender men and the surgical procedure code (Sundhedsstyrelsens Klassifikations System KHAD10) for mastectomy.
Exclusion criteria included death, emigration, previous extensive surgery of the breast, and previous treatment for cancer or other major disease. Two patients were excluded from the study, due to double registration. Patients were contacted between November 1, 2018 and January 15, 2019. Participation was voluntary. Nonresponders were also contacted by text and voice message. Of the 90 identified eligible participants, 84 responded to the questionnaire.
Two techniques were used to perform top surgery: periareolar incision or a horizontal incision and free nipple graft. Surgeries were primarily performed by four senior plastic surgeons. Five surgeries were performed by plastic surgery residents, supervised by the aforementioned surgeons.
Data sources and quantitative variables
A questionnaire (see Supplementary Data) based on the BREAST-Q (patient-reported outcome measure for breast surgery) questionnaire was constructed, using only questions that we found to be applicable for transgender men. The questionnaire included 23 questions on satisfaction of the postoperative result and the experience of surgery. These questions were part of a survey of 64 questions, which was used in another study on postoperative pain.4 All questions were asked with reference to the patient's chest after top surgery. The questionnaire also covered pre- and postsurgery expectations and regret. Questionnaires were read out to participants over the telephone.
Overall satisfaction was evaluated using questions on satisfaction of clothed and nonclothed appearance. Response options to these questions were either “very satisfied,” “partially satisfied,” “partially unsatisfied,” or “very unsatisfied.” If responses in the two items were congruent, overall satisfaction was registered with that response. In case of incongruent responses in the two items, the overall response was registered according to the least satisfied response.
This method of grouping responses was used with questions pertaining to scars and nipple appearance.
Participants were asked how satisfied they were with the appearance and placement of scars. Satisfaction with nipple appearance was questioned regarding placement on the chest, the placement compared with the contralateral nipple and the shape of the nipples.
Responses to questions on self-confidence, self-acceptance, and perceived acceptance from others were given as “all the time,” “most of the time,” “sometimes,” and “never.” These responses were grouped and evaluated according to the same method as described above.
Examples of questions on self-confidence include “How often do you feel confident?” and “How often do you feel confident about your body?” Participants were also asked to what degree they accepted their bodies postsurgery. Perceived acceptance from others was evaluated with questions about confidence in social contexts and attractiveness.
The participants were also asked if they were happy with their decision to undergo the operation, if they would choose to be operated once again and if, overall, it had been a positive experience for them. The questionnaire also evaluated if pre-surgical expectations were met and if the participants had regret about going through with the surgery.
Complications including hematoma, nipple necrosis, infection, and persistent postoperative pain were evaluated in this population, and these data are presented by Lang et al.4 In addition, we registered the need for scar correction postmastectomy. The need for tattooing of the nipple–areolar complex was used as an indicator of nipple necrosis.
Statistical analysis
Data have been presented descriptively with numbers and percentages, and for age and time since surgery, also with medians and ranges. Differences according to surgical procedure, body mass index (BMI; grouped as <18.5, 18.5–24.9, 25–25.9, and ≥30), and amount of tissue removed (divided into quartiles of grams removed: <331, 331–536, 537–859, and ≥860) were evaluated using two-sided chi-square test (or fisher's exact test if a cell had a count of ≤5) and reported as a p-value. Alpha was set at 0.05. Data analysis was performed using SAS 9.4 for Windows (SAS Institute, Cary, NC).
Results
Of the 90 eligible transgender men, 84 responded to the questionnaire (response rate 93.3%). Patients' age ranged between 18 and 53 years, with a median of 22.5 years. Time from operation to interview ranged between 5 and 62 months, with a median of 23 months (Table 1). Preoperative BMI ranged from 18.2 to 31.6, with median BMI of 23.5. The amount of breast tissue removed from one breast varied greatly from 24 to 1128 g, with a median of 269.5 g.
Table 1.
Demographics of Trans Men Who Have Undergone Top Surgery
| n (%) | |
|---|---|
| Total | 90 (100) |
| Total respondents | 84 (93.3) |
| Age, years | |
| 18–20 | 28 (31.1) |
| 21–30 | 42 (46.7) |
| 31–40 | 13 (14.4) |
| 41–50 | 6 (6.7) |
| >50 | 1 (1.1) |
| BMI | |
| <18.5 | 4 (4.9) |
| 18.5–24.9 | 56 (69.1) |
| 25–25.9 | 19 (23.5) |
| ≥30 | 2 (2.5) |
| Surgery | |
| Free | 67 (74.4) |
| Periareolar | 23 (25.6) |
| Year of surgery | |
| 2013 | 3 (3.3) |
| 2014 | 6 (6.7) |
| 2015 | 20 (22.2) |
| 2016 | 11 (12.2) |
| 2017 | 40 (44.4) |
| 2018 | 10 (11.1) |
| Amount of breast tissue removed (grams) | |
| <331 | 23 (28.4) |
| 331–536 | 21 (25.9) |
| 537–859 | 20 (24.5) |
| ≥860 | 20 (24.5) |
| Reoperations and complicationsa | |
| No complications | 73 (81.1) |
| Antibiotics | 7 (7.8) |
| Hematomab | 7 (7.8) |
| Tattoo | 4 (4.4) |
| Seroma | 2 (2.2) |
BMI and amount of tissue removed only recorded for respondents of questionnaire. BMI data missing for three patients.
Does not sum to 90 patients (100%); one patient received antibiotics and had a hematoma, one patient received antibiotics, had a hematoma, and was tattooed because of nipple necrosis.
Six patients were reoperated due to a hematoma, one was treated conservatively.
BMI, body mass index.
All questions from the questionnaire were asked with reference to the participants' chest in the previous week, irrespective of how far along they were in the gender-affirming process.
Patients were either satisfied or partially satisfied with the overall experience of undergoing surgery and the postoperative result in 90.5% of responses. Patients were very satisfied with their clothed appearance in 89.3% of responses, whereas only 44.1% were very satisfied with their nonclothed appearance and 46.4% partially satisfied. Overall satisfaction with postoperative scars and nipple reconstruction was both 82.1% (Table 2).
Table 2.
Overall Satisfaction and Satisfaction with Postoperative Scars and Nipple Reconstruction Among Patients Treated with Mastectomy in Gender Reassignment Surgery
| Overall satisfaction | |
| Satisfied | 37 (44.1) |
| Partially satisfied | 39 (46.4) |
| Partially unsatisfied | 7 (8.3) |
| Unsatisfied | 1 (1.2) |
| Appearance with clothes | |
| Satisfied | 75 (89.3) |
| Partially satisfied | 7 (8.3) |
| Partially unsatisfied | 1 (1.2) |
| Unsatisfied | 1 (1.2) |
| Appearance without clothes | |
| Satisfied | 37 (44.1) |
| Partially satisfied | 39 (46.4) |
| Partially unsatisfied | 7 (8.3) |
| Unsatisfied | 1 (1.2) |
| Satisfaction with postoperative scars | |
| Satisfied | 40 (47.6) |
| Partially satisfied | 29 (34.5) |
| Partially unsatisfied | 11 (13.1) |
| Unsatisfied | 4 (4.8) |
| Appearance of scars | |
| Satisfied | 41 (48.8) |
| Partially satisfied | 30 (35.7) |
| Partially unsatisfied | 10 (11.9) |
| Unsatisfied | 3 (3.6) |
| Placements of scars | |
| Satisfied | 60 (71.4) |
| Partially satisfied | 17 (20.2) |
| Partially unsatisfied | 6 (7.1) |
| Unsatisfied | 1 (1.2) |
| Satisfaction with nipple reconstruction | |
| Satisfied | 41 (48.8) |
| Partially satisfied | 28 (33.3) |
| Partially unsatisfied | 12 (14.3) |
| Unsatisfied | 3 (3.6) |
| Placement of nipples on thorax | |
| Satisfied | 71 (84.5) |
| Partially satisfied | 9 (10.7) |
| Partially unsatisfied | 4 (4.8) |
| Unsatisfied | 0 (0.0) |
| Placement of nipples according to each other | |
| Satisfied | 71 (84.5) |
| Partially satisfied | 10 (11.9) |
| Partially unsatisfied | 2 (2.4) |
| Unsatisfied | 1 (1.2) |
| Shape of nipples | |
| Satisfied | 45 (53.6) |
| Partially satisfied | 26 (31.0) |
| Partially unsatisfied | 10 (11.9) |
| Unsatisfied | 3 (3.6) |
Patients reported feeling confident after surgery in 90.5% of responses, while 79.8% reported self-acceptance and 64.2% perceived acceptance from others postmastectomy. Patients were completely satisfied with their decision to undergo surgery in 86.9% of responses and 61.9% of patients felt that their expectations were met, whereas 36.9% only partially agreed. Two (2.4%) regretted undergoing surgery (Table 3).
Table 3.
Self-Confidence, Self-Acceptance, and Perceived Acceptance from Others Among Patients Treated with Mastectomy in Gender Reassignment Surgery
| Self-confident | |
| Agree | 76 (90.5) |
| Disagree | 8 (9.5) |
| Self-acceptance | |
| Agree | 67 (79.8) |
| Disagree | 17 (20.2) |
| Perceived acceptance from others | |
| Agree | 52 (64.2) |
| Disagree | 29 (35.8) |
| Missing | 3 |
| Affirmation of choosing surgery | |
| Agree | 73 (86.9) |
| Partly agree | 9 (10.7) |
| Disagree | 2 (2.4) |
| Expectations were met | |
| Agree | 52 (61.9) |
| Partly agree | 31 (36.9) |
| Disagree | 1 (1.2) |
| Not regretting having surgery | |
| Agree | 78 (92.9) |
| Partly agree | 4 (4.7) |
| Disagree | 2 (2.4) |
Complications occurred in 23.3% of cases, which included papilla necrosis, hematoma, and infection. Six patients (7.8%) required reoperation due to hematoma. The occurrence of complications did not affect postoperative satisfaction (p=0.81).
Nine (10%) patients underwent scar correction after top surgery, and four (4.4%) patients required tattooing after nipple necrosis.
We found no statistically significant correlation between the two types of surgeries (masculinization of the chest with transverse incision and free nipple transplantation compared with a periareolar incision) and degree of satisfaction (p=0.10), scar satisfaction (p=1.00), nipple satisfaction (p=0.41), self-acceptance (p=0.08), and to which extent expectations were met (p=0.24; Table 4). There was also no statistically significant relationship between BMI and satisfaction (p=0.80), nor the amount of breast tissue removed and satisfaction (p=0.98).
Table 4.
Outcomes According to Technique Used in Mastectomy in Gender-Affirming Surgery
| Horizontal incision and free nipple graft | Periareolar | p* | |
|---|---|---|---|
| Overall satisfaction | 0.10 | ||
| Unsatisfied/partially unsatisfied | 4 (6.4) | 4 (19.1) | |
| Satisfied/partially satisfied | 59 (93.7) | 17 (80.9) | |
| Scar satisfaction | 1.00 | ||
| Unsatisfied/partially unsatisfied | 11 (17.5) | 4 (19.1) | |
| Satisfied/partially satisfied | 52 (82.5) | 17 (81.0) | |
| Nipple satisfaction | 0.41 | ||
| Unsatisfied/partially unsatisfied | 10 (15.9) | 5 (23.8) | |
| Satisfied/partially satisfied | 53 (84.1) | 16 (76.2) | |
| Self acceptance | 0.08 | ||
| Disagree | 10 (15.9) | 7 (33.3) | |
| Agree | 53 (84.1) | 14 (66.7) | |
| Expectations were met | 0.24 | ||
| Disagree | 1 (1.6) | 0 (0.0) | |
| Partly agree | 20 (31.8) | 11 (52.4) | |
| Agree | 42 (66.7) | 10 (47.6) |
χ2-Test was used when cell counts were not <5, otherwise Fisher's exact test was applied.
About 65.7% of patients who were completely satisfied after top surgery were surveyed 2 years postsurgery; 35.1% were surveyed 3 years postsurgery and 9.1% 1 year postsurgery.
Discussion
The aim of top surgery in transgender men is to masculinize the chest, alleviate gender dysphoria, and improve quality of life.5,6 This procedure is not only reserved for “female-to-male” persons, but it is also desired by nonbinary persons.
This study sets out to evaluate satisfaction after top surgery in transgender men, at a single plastic surgery center in Denmark. As in this study, other studies have shown high overall satisfaction postsurgery and a low incidence of regret.7–9 Many studies evaluate satisfaction using Likert scales for both patient and surgeon assessment of cosmetic outcome postsurgery.7–9 Validated questionnaires on body image and patient-reported outcomes are lacking for transgender individuals after top surgery. There are also few prospective studies that evaluate body image in this patient group.10–12 Agarwal et al. present significant improvement in body image and satisfaction after top surgery, using the BREAST-Q and Body Uneasiness Test.13 Klassen et al. present studies on the development of the BODY-Q (patient-reported outcome tool for weight loss and body contouring treatments) chest module and eventually the development of GENDER-Q (patient-reported outcome tool for adolescents and adults undergoing gender-affirming treatments), which is to be used as a patient-reported outcome measure for gender-affirming treatment.14,15 The BODY-Q is not specifically validated for transgender individuals, but it is a step closer to a patient-reported outcome tool for transgender patients. It is used in an explorative study by van de Grift et al., which shows that it can be useful for assessment in transgender patients.16
We observed a tendency toward higher satisfaction with the surgical outcome and self-acceptance after top surgery with transverse incision and free nipple transplant compared with periareolar incision, although the differences were statistically insignificant. The higher satisfaction could be related to the fact that the transverse technique is performed on patients with larger breast volume. These patients possibly experience greater gender dysphoria, and therefore benefit more from the surgery. Satisfaction with scarring and the nipple areolar complex is also generally high. We found a complication rate of 23.3% and a scar correction rate of 10%, which are in line with other studies.17,18
Patients with a higher BMI have an increased risk of postoperative complications, excess skin compared with patients with a lower BMI, and have decreased skin elasticity.19 In our study, we observed that patients with a low BMI (<18.5) and those with a high BMI (≥30) reported the greatest satisfaction. Patients with a lower BMI may have smaller breasts and are therefore usually more suited to a periareolar incision, and postsurgical scars are more discrete. Patients with a high BMI may have more breast tissue removed, which results in a greater change in their appearance. Although this dataset of limited size did not show a statistically significant difference between patient categories (BMI and amount of breast tissue removed), it is important to take this into consideration when planning the procedure and informing the patient about expected outcomes.
With the increasing access to gender reassignment surgery, the transgender population are, to a large extent, first-time users of the health care system. With increased exposure to the health care system, transgender individuals may request more involvement in decision-making, which could lead to more realistic expectations and better satisfaction postoperatively.19,20 It is also important for patients to be thoroughly informed preoperatively about surgical incision used for top surgery and expected scarring.20,21
Finally, the two patients who expressed regret also only partially agreed that their expectations were met. Even though the number of patients who expressed regret and dissatisfaction is low, it should be considered whether the surgery was premature. It is important that all aspects of the patients' expectations are discussed. This includes the cosmetic and physical result as well as the emotional effect the patient hopes the surgery will achieve.
Limitations
This study included a relatively small population of 90 participants with variation in follow-up time between participants. The questionnaire was constructed from parts of the BREAST-Q questionnaire that were relevant for transgender men, and therefore statistical analysis usually performed on the BREAST-Q score could not be done. This is a cross-sectional study, and therefore offers no insight into satisfaction preoperatively or time-dependent variations. To minimize recall bias, items in the questionnaire were evaluating participants' experiences within the week up to the survey. Risk of interviewer bias was addressed by reading the questionnaire to the participants, although variations in intonation, dialect, and speech speed might have affected the responses.
Conclusion
Satisfaction outcomes are generally positive, especially in respect of clothed appearance, while there is considerable proportion of participants who are only partially satisfied on other parameters. Self-confidence and self-acceptance outcomes are positive, but less convincing in respect of perceived acceptance from others. Whether this is due to surgical outcomes or social factors needs to be further investigated. The majority of patients affirm their decision to undergo surgery, although a small minority express regret. While this study only included 90 patients, we had a high response rate of >90% and have therefore gained insight into the experiences of almost all top surgery patients treated in our department. The results may be used to shape information given to future patients to ensure better understanding of expected outcomes, risks involved with surgery and improve satisfaction.
Supplementary Material
Acknowledgments
The authors thank Alessandro Venzo, MD (Rigshospitalet, Copenhagen, Denmark) for his contribution to expert advice on treatment and on the article, and Dorthe Myrholt, medical secretary (Rigshospitalet) for assisting with patient identification and extraction from the electronic patient database.
Abbreviation Used
- BMI
body mass index
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding received.
Supplementary Material
Cite this article as: Day DL, Klit A, Lang CL, Mejdahl MK, Holmgaard R (2023) High self-reported satisfaction after top surgery in gender-affirming surgery: a single-center study, Transgender Health 8:2, 124–129, DOI: 10.1089/trgh.2021.0091.
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