Patient Satisfaction Following Top Surgery: A RealSelf Analysis Using Advanced Natural Language Processing

Abstract

Background:

Chest masculinization (top) surgery nearly tripled from 2016 to 2020 and is often the only gender-affirming procedure for transgender men. Outcomes are highly variable and operator-dependent, with limited research evaluating them from the patient’s perspective. This study examined the impact of specific surgical metrics and procedure costs on patient-reported outcomes following top surgery.

Methods:

RealSelf.com was queried for patient reviews. Extracted variables included procedure date, overall satisfaction, procedure cost, and written reviews. An artificial intelligence (AI) natural language processing tool was used for sentiment quantification from 0 to 1. Two authors analyzed sentiment on nipple–areolar complex (NAC) position, NAC quality, scar position, scar quality, and chest contour. Analysis of variance and Mann-Whitney U tested sentiment differences and cost comparisons, whereas the Pearson correlation analyzed cost–sentiment relationships.

Results:

A total of 350 (96.42%) of 363 reviews were satisfactory, with an indication of “worth it” and mean sentiment score of 0.80. Worth it ratings had significantly higher median AI-generated positive sentiment scores than "not worth it" ratings (0.91 versus 0.56, P < 0.001). Additionally, patients had a mean satisfaction rate of 92% for the 5 surgical outcomes, with NAC positioning and quality being most influential. Procedure costs were not significantly different, nor did they demonstrate any correlation with satisfaction.

Conclusions:

Chest masculinization surgeons can optimize patient satisfaction by focusing on key features, particularly related to NAC features and scars. The cost of this procedure did not significantly influence patient satisfaction. Practitioners can benefit from AI language tools to effectively analyze patient feedback and implement rapid improvements in their practice.

Takeaways

Question: How do key surgical components and procedure costs influence patient-reported outcomes following chest masculinization surgery?

Findings: This study analyzed 363 RealSelf.com patient reviews on chest masculinization surgery using a hybrid human–artificial intelligence (AI) sentiment analysis. We found that 96.42% of patients rated the procedure as “worth it.” Nipple–areolar complex (NAC) position and quality were the most significant factors influencing satisfaction, whereas procedure cost had no significant impact on outcomes.

Meaning: This study highlights the aspects of chest masculinization surgery that matter most to patients, emphasizing the importance of NAC quality over procedure cost, while introducing AI as a valuable tool for analyzing patient experiences.

INTRODUCTION

The demographic landscape of gender identity in the United States is changing, with approximately 1.6 million individuals self-identifying as transgender as of 2021.¹ This shift is paralleled by a surge in gender-affirming medical procedures, especially those involving chest masculinization (ie, top surgery). Within the span of just 4 years (2016–2020), the number of top surgery procedures performed nearly tripled.^2,3 The 2015 US Transgender Survey highlighted that approximately 36% of transgender men had undergone chest masculinization surgery. Moreover, 61% expressed interest in undergoing this procedure in the future, which may be attributed to the psychosocial distress caused by identifying as men while having breasts and resorting to cumbersome chest binders.^4,5

Top surgery is a pivotal component of the female-to-male transition process and has been linked to substantial improvements in reducing gender dysphoria and enhancing overall quality of life.^6,7 In fact, it is frequently the sole gender-affirming intervention pursued by transmasculine individuals. A recent single-center study conducted in Denmark demonstrated high patient satisfaction with postsurgical outcomes and a low rate of individuals expressing regret.⁸ However, it is noteworthy that the study participants expressed more satisfaction with their clothed appearance and less so with their unclothed appearance. Given the exponential increase in top surgery procedures, it is important to understand the components that determine surgical outcomes from patients’ perspectives.^9,10 This knowledge will pave a clearer path for surgeons to improve and advance their gender-affirming care.

Although previous studies have investigated patient satisfaction with top surgery, to our knowledge, no study has yet used a large patient-centered database to evaluate patient-reported outcomes following the procedure. The objective of this study was to analyze patient sentiment following top surgery through a hybrid human–artificial intelligence (AI) analysis of RealSelf, a large and widely used medical review online platform, and to identify how patient-reported outcomes are influenced by key surgical components as well as procedure costs.

METHODS

RealSelf.com is an online community platform that allows patients to provide testimonials following cosmetic procedures.¹¹ Alongside these reviews, patients can grade procedures as "worth it" or "not worth it" and provide their own preoperative and postoperative photographs. In this study, a web scraper application was used to extract all relevant tabular data in regard to chest masculinization surgery, including date of procedure, price, written reviews, and its associated worth it versus not worth it score as a proxy of overall satisfaction.¹² To objectively evaluate patients’ perspectives on masculinizing top surgery, an AI natural language processing tool was used to conduct sentiment analysis, otherwise known as opinion mining, on patient reviews.¹³ Here, a neural network categorized written reviews into positive or negative sentiments with a corresponding numerical sentiment score from 0 to 1 (Table 1). Separately, 2 independent investigators (A.S. and J.V.) recorded and analyzed all written reviews, focusing on 5 key surgical components: nipple–areolar complex (NAC) position, NAC quality, scar position, scar quality, and chest contour. For each of these components, reviews were categorized into 1 of 3 distinct groups: satisfied, dissatisfied, or neutral. Interrater reliability was evaluated using Cohen kappa. Analysis of variance testing was conducted to identify significant differences in sentiment scores across all surgical outcomes. Furthermore, nonparametric Mann-Whitney U tests were conducted to compare median procedure costs between patients who were overall satisfied with the procedure verses those who were overall dissatisfied. Finally, the Pearson correlation tests were used to determine if a relationship existed between cost of the procedure and sentiment scores.

Table 1.

Example of RealSelf Reviews and AI-generated Sentiment Analysis

RealSelf Review	AI-generated Sentiment	Sentiment Score
“I had a bilateral mastectomy with a peri-areolar incision around the nipple … and I am very happy to have made that decision. My results are near perfect with unnoticeable scarring—one of my top priorities—and a nice contour (also a high priority) …”	Positive	0.99
I went to see Dr. Top* for female-to-male top surgery (breast reduction and nipple grafting). It seemed like she treated my surgery like a breast reduction for a cis woman rather than creating a masculine chest shape like she said she was going to. My chest is still at least a B or C cup and I have huge, protruding nipples … She claimed that the surgery she did for my nipples was exactly how it was supposed to be and that it was normal for top surgery. I told her that I’d personally been with several friends who got top surgery whose doctors were able to create flat nipples with a tiny bump in the middle …	Negative	0.19

^*Renamed for anonymity.

RESULTS

Across 363 available reviews for masculinizing top surgery, 350 (96.42%) patients rated the procedure as worth it, indicating an overall satisfactory outcome. Paralleling these testaments, opinion mining reported a mean sentiment score of 0.80. Of the 13 reviews not rated worth it, 5 were classified as not worth it, and 8 as not sure. One not worth it review was positive. Among the not sure reviews, 2 expressed negative sentiment, 5 reviewed consultation experiences, and 2 were positive. (See appendix, Supplemental Digital Content 1, which displays a table showcasing sample comments and their corresponding ratings as provided by the commenters, https://links.lww.com/PRSGO/E79.) Patients also had a mean satisfaction rate of 92% for all 5 surgical outcomes extracted from the reviews. Analysis of variance testing demonstrated that satisfaction in each of the 5 surgical outcomes had a significant effect on sentiment scores, with NAC position and quality having the largest effect sizes (Table 2). Cohen kappa measured 0.87, ensuring high interrater reliability between investigators.

Table 2.

Mean Surgical Outcome Scores in Satisfied and Dissatisfied Patients^*

Key Metric	Satisfied	Dissatisfied	Effect Size	P
NAC position, mean (SE)	0.87 (0.01)	−0.46 (0.21)	0.443	<0.001
NAC quality, mean (SE)	0.83 (0.02)	−0.49 (0.19)	0.439	<0.001
Scar position, mean (SE)	0.85 (0.01)	−0.44 (0.23)	0.412	<0.001
Scar quality, mean (SE)	0.85 (0.02)	−0.40 (0.26)	0.379	<0.001
Chest contour, mean (SE)	0.83 (0.03)	−0.30 (0.27)	0.332	<0.001

^*As determined for each outcome during the extraction and quantification of patient reviews.

Patients with a worth it rating of the procedure had significantly higher median AI-generated sentiment scores compared with patients with a not worth it rating (0.91 versus 0.56, P < 0.001). Among satisfied patients with a worth it rating, the median cost of surgery was $7900 (interquartile range: $5950–$10,000). This was not statistically significant (P = 0.927) from the median cost of surgery of $8705 (interquartile range: $7000–$9500) for dissatisfied patients with a not worth it rating (Fig. 1). Furthermore, the Pearson testing did not show any significant correlation between price and sentiment scores (r = 0.11, P = 0.199).

Fig. 1.

Chest masculinization procedure costs between satisfied and dissatisfied patients.

DISCUSSION

Chest masculinization surgery can be broken down into several components that determine overall surgical outcomes. However, it is essential to understand these components from the perspective of patients to optimize results and patient satisfaction. To bridge this gap, we designed our study to describe patient-reported outcomes by evaluating specific components and determining their influence on overall sentiment. The results of our study can serve as an aid for gender-affirming plastic surgeons to optimize their outcomes in chest masculinization.¹⁴ Our analysis indicates a high level of overall satisfaction among patients who have undergone top surgery, highlighting the positive impact of the procedure on body image perception for female-to-male transgender individuals. The finding that 96.42% of patients rated the procedure as worth it, whereas the opinion mining reported a mean sentiment score of 0.80, was clear evidence for the presence of richer insights of patient perspectives beyond the binary rating score alone. By extracting the influence of individual surgical components, we revealed that NAC position and quality have the largest influence on patient satisfaction. Similarly, generating sentiment scores allowed for correlational testing with procedure costs, which were not significant.

Using AI for sentiment analysis has previously been described in the literature as an effective process to digest patient reviews.^15,16 Our analysis took this approach one step further and implemented a hybrid approach incorporating both AI-powered and human analysis. This methodology not only facilitated statistical analysis between reviews and surgical components but also eliminated potential reviewer subjectivity when scoring patient reviews. Additionally, previous literature has identified cost of surgery as a major barrier to patients seeking gender-affirming surgery.^17,18 This cost barrier may ultimately influence patients on where and by which surgeon they elect to have their chest masculinization, which may have an impact on their perceived quality of the procedure.^19,20 However, our findings revealed that the cost of surgery did not significantly differ between patients with overall satisfaction and dissatisfaction. This supports preceding studies showing that patient satisfaction is not contingent on the cost of the procedure, but rather on other factors such as surgical technique or postoperative care.²¹ Recognizing this and not feeling obligated to opt for the most expensive options can alleviate financial concerns for individuals seeking top surgery who disproportionately face financial insecurity, unemployment, and educational and/or housing discrimination.^22,23 Moreover, given that NAC position and quality were the most influential factors, careful consideration must be placed on determining the NAC size, shape, and location to achieve a natural masculine appearance. This may entail making the NAC more elliptical rather than round, placing it more laterally on the chest wall in a slanted angle, and possibly reducing the projection and diameter of the nipple.^24–28 It is also important not to underresect the breast tissue because this may lead to a chest contour that is fuller or more uneven than what the patient expects following a top surgery.^29,30 Additionally, the aesthetic result of the scar position and quality also plays a critical role in overall satisfaction. Optimizing scar outcomes should be achieved by carefully selecting procedure techniques most suitable to each patient, such as incisions along the inframammary fold, inverted-T, or periareolar incisions to minimize scar visibility. Thoughtful closing, selection of sutures, and patient counseling on scar care can also aid with optimizing long-term results.^29,31 From our analysis, a positive aesthetic outcome from the patient’s perspective typically consists of a well-hidden scar with symmetrical bilateral volume reduction (Fig. 2). Ultimately, top surgery should be planned in a shared decision-making style, ensuring discussion of NAC characteristics and accounting for each patient’s individual habitus and goals.

Fig. 2.

Top surgery results from RealSelf reviews.

Although this study offerred valuable insights into patient satisfaction with top surgery, it is important to acknowledge a few limitations. First, the analysis relied on patient reviews sourced from RealSelf.com, which may not provide a fully representative sample of individuals who have undergone top surgery. The user base of RealSelf may consist of individuals who are more inclined to share their positive experiences, potentially leading to selection bias. The absence of explicit demographic and regional data in our analysis introduces limitations in the generalizability of the findings. Without these data, it is challenging to identify whether specific subgroups or regions experience varying levels of satisfaction with chest masculinization surgery. For example, geographic variations in access to experienced surgeons, regional attitudes toward gender-affirming care, or socioeconomic factors might impact patient satisfaction. Future research should strive to incorporate demographic and regional variables to provide a more comprehensive understanding of patient satisfaction and assess whether outcomes vary significantly by these factors. Moreover, the timing of reviews in relation to the date of surgery was not consistently reported, making it difficult to analyze the impact of timing on patient sentiment. This limitation is notable, as satisfaction can vary significantly depending on whether a review was written during the early postoperative period or after full recovery. Consequently, the study may have missed input from patients who hold more neutral sentiments or have chosen not to share their experiences online. However, reviewers on RealSelf may elect to remain anonymous, thereby increasing the odds that patients with neutral or negative experiences will be just as likely to report their experiences as those with positive experiences. Additionally, the insufficient access to explicit demographic data further limited examination of potential variations or subgroup differences in patient satisfaction. However, available patient reviews originated from different regions across the United States, promoting a fairly diverse study population. Another limitation of this study is the reliance on self-reported cost estimates from RealSelf, which may not accurately reflect the true cost of surgery. However, the focus of our analysis was not to quantitatively assess cost variations but rather to explore whether patient satisfaction was influenced by the reported cost of their surgery. Future studies using verified cost data could further validate these findings. Furthermore, our study primarily focused on surgical outcomes specifically related to NAC and scarring, as well as the cost of the procedure. Nonetheless, it is important to acknowledge that there may be other factors playing a role in patient satisfaction levels that we did not analyze. For example, physician and staff demeanor, along with postoperative care, have been found to play a significant role in other plastic surgery procedures.^32,33 Future research can build upon these findings by investigating these additional variables as well as conducting comparative studies between patient- and provider-reported outcomes to better understand the level of congruency in perceived outcomes.

Our study held significant implications for both patients and surgeons. In addition to ensuring adequate symmetrical volume reduction, surgeons performing chest masculinization procedures must also emphasize proper NAC handling and placement. This entails shared decision-making with each patient, as well as assessing how the NAC changes with variations in patient positioning. Moreover, our analysis indicates that cost of chest masculinization is not correlated with patient-reported outcomes, which should relieve pressure on competitive pricing strategies. Interestingly, surgeons can also benefit from the analysis of patient reviews using AI natural language processing quantification tools, which offer reliable and immediate feedback on patient satisfaction levels.^32,34 By analyzing their reviews, surgeons can gain valuable insights into the factors that contribute to positive patient experiences and outcomes, as well as a better understanding of common themes and areas of concern reported by patients.

CONCLUSIONS

The findings of our study substantiate previous literature reporting high satisfaction rates (96.42%) with chest masculinization surgery. Additionally, it contributes a more detailed understanding of the specific components that influence patient-perceived outcomes. Most notably, we found that there is a significant association between patient satisfaction and the positioning and quality of the NAC. Patient satisfaction, however, was not affected by the cost of the procedure. Plastic surgeons should strive to engage in discussions with patients preoperatively, specifically addressing features that their patients would desire in their neo-NACs. In addition, plastic surgeons should also consider using an AI natural language processing tool as a more comprehensive way to understand patient sentiment, which may ultimately assist them in analyzing reviews of their own practice.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.