Abstract
Introduction: Gender-affirming mastectomy is frequently performed in transmasculine individuals. The aim of this study is to describe surgical and demographic trends and outcomes in a large group of individuals undergoing this procedure.
Materials and methods: All individuals who underwent gender-affirming mastectomy from 01-1990 to 01-2023 in our center were identified. A retrospective chart study was conducted, recording medical history, use of medication including hormones, puberty suppression, surgical history, preoperative chest characteristics, BMI at surgery, surgical technique, concurrent surgical procedures, resection weight, complications and re-operations. Procedural, demographic and surgical trends were analyzed.
Results: A total of 2030 individuals were included of whom 1350 (67%) underwent double incision, 551 (27%) donut, 67 (3%) peri-areolar, 55 (3%) batwing and 7 (<1%) another mastectomy technique. A steep increase of performed mastectomies was observed in recent years. The mean age of people undergoing this procedure is increasingly lower. Surgical trend analysis showed: an increase in the use of the double incision technique, a smaller chest was deemed eligible for donut mastectomy and a less frequent use of a pedicled nipple-areolar complex. Postoperative bleeding that required a reoperation under general anesthesia occurred in 142 (7.0%) individuals (6.3% after double incision, 7.1% after donut, 14.9% after peri-areolar and 12.8% following batwing mastectomy). One or multiple surgical corrections were performed in 19.9% after double incision, 31.2% after donut, 14.9% after peri-areolar and 32.7% following batwing mastectomy. The median clinical follow-up time was 3.2 years (IQR 0.6-6.4).
Discussion: The frequency of performed mastectomy procedures has increased drastically over recent years. Specific surgical and demographic trends were identified.
Keywords: Transgender, mastectomie, top surgery, gender dysphoria, chest masculinization, complications
Introduction
There is an increase in transmasculine individuals who seek medical and surgical care for their gender dysphoria (Al-Tamimi et al., 2020). Gender-affirming mastectomy is frequently performed in this population. It has a positive effect on body attitude, satisfaction, self-esteem and body image-related quality of life (Bustos et al., 2021; van de Grift et al., 2016). Throughout the years, different techniques have been employed for chest masculinization (Ammari et al., 2019). Generally speaking, someone with a large, ptotic chest is a candidate for double-incision mastectomy, whereas someone with a smaller chest, with little or no ptosis and good skin quality, may be candidate for other techniques such as donut, batwing or keyhole mastectomy. Each technique has its’ own (dis)advantages and surgical indications.
Over the years, many (smaller) studies were published on surgical outcomes after gender-affirming mastectomy. Reported postoperative hematoma rates vary from 5-20%. Nipple-sparing mastectomy techniques are associated with a higher hematoma rate and revision surgery.
In this article, a high-volume, single-center case series of transmasculine individuals who underwent gender-affirming mastectomy is described. Demographics and surgical trends are analyzed as well as postoperative outcomes.
Materials and methods
Setting
The Amsterdam University Medical Center (AUMC), previously known as VU University Medical Center, is a well-known (surgical) healthcare provider for transgender individuals in The Netherlands. For each individual that opts for a gender-affirming surgical procedure, psychological eligibility is assessed by qualified psychologists, appropriately trained in mental health and experienced in the assessment of gender dysphoria, through multiple counseling sessions, according to the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (Coleman et al., 2022). Individuals were deemed medically and psychologically ‘fit-for-surgery’ by multidisciplinary consultation. Our multidisciplinary team consists of psychologists, psychiatrists, endocrinologists, plastic surgeons, urologists and gynecologists. Gender-affirming mastectomy is covered by health insurances nation-wide, including most secondary corrections. In the study time period, a total of 12 plastic surgeons performed gender-affirming mastectomies.
Surgical (contra)indications
In our center, individuals who want to opt for gender-affirming mastectomy are preoperatively screened by a plastic surgeon or physician assistant. Based on chest size, skin elasticity, ptosis, surgeon experience and preferences and individual preferences, a choice for mastectomy technique is made (Monstrey et al., 2008). Obesity (BMI > 35 kg/m2) currently is a (relative) contra-indication for this procedure in our institution, however the procedure can be performed in selected cases with BMI > 35, after extensive counseling. Individuals are advised to refrain from smoking, but it is not a strict contra-indication for this type of surgery. Some may opt for simultaneous gynecological surgery, meaning (total laparoscopic) hysterectomy with or without bilateral salpingo-oophorectomy. Before 2020, the minimum age to undergo this procedure was 18 years. since 2020, the minimum age is 16 years.
Peri-operative procedure
Preoperative marking is performed on a standing or sitting-upright individual. The surgical procedure is performed under general anesthesia and in supine position, both arms alongside the body. The resection specimens are routinely sent for histopathological examination (van Renterghem et al., 2018). A subcutaneous redon drain is placed on each side. A postsurgical compression vest is worn for six postoperative weeks. When the perioperative course is uncomplicated, individuals are discharged the day after surgery after drain removal. When full-thickness nipple grafting is performed, tie-over dressing is applied, which is removed at the outpatient clinic at day 5-7 after surgery. Scheduled postoperative outpatient visits are typically planned at 5-7 days (after mastectomy with free nipple grafting) or 2-3 wk (after mastectomy with pedicled nipple-areolar complex), and 6 wk after surgery.
Identification of study participants
All individuals who underwent gender-affirming mastectomy between 01-1990 and 01-2023 were retrospectively identified from a departmental database. Individuals provided written informed consent for storage of their anonymous data in the departmental database. Some individuals were described in previous research (Cregten-Escobar et al., 2012; Elfering et al., 2020; van de Grift et al., 2017).
Retrospective chart study
A retrospective chart study was conducted, recording medical and surgical history, use of medication including hormones, history of puberty suppression, history of intoxications (smoking, alcohol abuse or drug abuse), preoperative chest characteristics, BMI at surgery, surgical technique, concurrent surgical procedures, ablative resection weight, complications and re-operations. An overview of all predefined complications, classified according to the Clavien-Dindo classification, is presented in Appendix 1.
Statistical analyses
Descriptive statistics were used to analyze demographics and surgical outcomes. For Gaussian continuous variables, means ± standard deviations were presented. For non-Gaussian variables medians and ranges. Chi square test was used to compare surgical outcomes and reoperations between mastectomy techniques. Univariate analysis of preoperative risk factors for complications and reoperations was performed for the study group as a whole. Subgroup analyses were performed based on the most prevalent surgical techniques.
Ethical statement
The study protocol was approved by the institutional medical ethical committee (METC 2014322). All individuals are treated according to the current Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (Coleman et al., 2022).
Results
A total of 2030 consecutive transmasculine individuals were retrospectively identified and included in this study. Group demographics are depicted in Table 1.
Table 1.
Demographics of included individuals.
| Total number of included individuals | 2030 |
|---|---|
| Individual characteristics | |
| Median age at surgery, (IQR) | 21.7 (19.0-27.4) |
| Age at surgery, grouped, n (%) 16-18 (minor) 18-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 >60 |
129 (6.4%) 617 (30.4%) 614 (30.2%) 269 (13.3%) 141 (6.9%) 99 (4.9%) 55 (2.7%) 53 (2.6%) 29 (1.4%) 12 (0.6%) 12 (0.6%) |
| History of puberty suppression, n (%) | 535 (26.1%) |
| Use of testosterone at time of surgery, n (%) | 1841 (90.7%) |
| History of smoking and/or current smoker, n (%) | 764 (37.6%) |
| Self-reported history of drug abuse n (%) Marihuana XTC Cocaine Psychedelics Heroine Crack cocaine |
257 (12.7%) 19 (0.9%) 16 (0.8%) 8 (0.4%) 6 (0.3%) 1 (<0.1%) |
| Anatomic characteristics | |
| Mean BMI ± SD | 24.6 ± 4.3 |
| BMI, grouped, n (%) <18 18-25 25-30 30-35 >35 |
24 (1.2%) 1224 (60.3%) 507 (25.0%) 253 (12.5%) 22 (1.1%) |
| Estimated breast size (cup), n (%) A B C D >D |
476 (23%) 606 (30%) 457 (23%) 314 (15%) 177 (9%) |
| History of breast reduction n (%) | 38 (1.9%) |
| History of breast augmentation n (%) | 3 (0.1%) |
| Surgical characteristics | |
| Bilateral or unilateral mastectomy, n (%) Bilateral Unilateral* |
2028 (99.9%) 2 (0.1%) |
| Mastectomy technique, n (%) Double incision Free nipple grafting Pedicled nipple-areola complex Without nipple replacement because of BRCA-gene positivity Without nipple replacement because wish of individual Donut Peri-areolar Batwing Other techniques Liposuction Regnault B Wise-pattern Vertical scar |
1350 (66.5%) 1286 (95.2%) 62 (4.6%) 1 (0.1%) 1 (0.1%) 551 (27.1%) 67 (3.3%) 55 (2.7%) 7 (0.3%) 4 (0.2%) 1 (<0.1%) 1 (<0.1%) 1 (<0.1%) |
| Simultaneous procedures n (%) Mastectomy alone Mastectomy with hysterectomy with/without oophorectomy Mastectomy with abdominoplasty |
1766 (87.0%) 262 (12.9%) 2 (0.1%) |
Both because of history of breast cancer and previous unilateral oncological mastectomy.
BMI, Body Mass Index; SD, Standard Deviation; BRCA, gene BReast Cancer gene.
Demographic trend analysis
A steep increase of performed mastectomy procedures was observed, starting in 2012. Before 2012, less than 50 procedures were performed yearly. In recent years, over 200 procedures were performed each year (Figure 1). A rise of individuals with a history of puberty suppression was observed, starting from 2005 (Figure 2). In recent years, the percentage of individuals undergoing mastectomy with a history of puberty suppression ranged between 20-40% per year. Fewer individuals were on testosterone treatment at time of mastectomy, 79% in 2022 compared to 100% in the years 2000s. The median age at mastectomy has decreased over the last years (Figure 3). A total of 121 individuals aged between 16 and 18 years underwent mastectomy, since the moment we started performing mastectomy procedures in this age category.
Figure 1.
Number of mastectomy procedures in transmasculine individuals depicted per year.
Figure 2.
Percentage of transmasculine individuals per year with a history of puberty suppression (blue) and on testosterone treatment at time of mastectomy (orange) depicted per year.
Figure 3.
Median age and interquartile ranges of individuals undergoing mastectomy per time unit.
Surgical trend analysis.
Between 1990 and 2000, donut mastectomy was the most frequently performed mastectomy technique. After this time period, double incision mastectomy was performed most frequently (Figure 4). Double incision mastectomy now constitutes approximately 70% of cases. Currently, in our institution, donut mastectomy is performed solely in small chests with no or little ptosis, which is in concordance with current insights in recent literature (Cregten-Escobar et al., 2012; Monstrey et al., 2008). This is reflected by the mean resection weight per resection specimen for donut mastectomy procedures over the years, which declined (Figure 5). Donut mastectomy in large chests and/or significant ptosis may provide a suboptimal result with the need for (multiple) surgical corrections (Cregten-Escobar et al., 2012).
Figure 4.
Mastectomy Sub techniques depicted as percentage of total performed procedures over the years, grouped over 5-year time periods.
Figure 5.
Mean resection weight per breast for donut mastectomy procedures over the years.
Identification of technical trends also revealed trends that have passed. The use of concomitant liposuction during mastectomy was popular in the time period 2005-2010. Afterwards, this was rarely performed. The use of a pedicled nipple-areolar complex was frequent in the time period between 2001 and 2006. In subsequent years, full-thickness skin grafting of the nipple was performed.
Surgical outcomes
An overview of postoperative complications is presented in Table 2. Postoperative bleeding that required a reoperation under general anesthesia occurred in 142 (7.0%) individuals. Analyzed according to different surgical techniques, postoperative bleeding occurred in 86/1350 (6.3%) individuals after double incision mastectomy, 39/551 (7.1%) individuals after donut mastectomy, 10/67 (14.9%) after peri-areolar mastectomy and 7/55 (12.8%) following batwing mastectomy. One or multiple surgical corrections were performed in 451 (22.2%) individuals (247/1350 (19.9%) after double incision, 172/551 (31.2%) after donut, 10/67 (14.9%) after peri-areolar and 18/55 (32.7%) following batwing mastectomy. The median clinical follow-up time was 3.2 years (IQR 0.6-6.4). An overview of performed surgical corrections is presented in Table 3.
Table 2.
Overview of postoperative complications, subdivided per mastectomy technique.
| Double incision (n = 1350) |
Donut (n = 551) |
Peri-areolar (n = 67) |
Batwing (n = 55) |
p-value | |
|---|---|---|---|---|---|
| Immediate complications | |||||
| Postoperative bleeding, for which return to theatre | 86 (6.3%) | 39 (7.1%) | 10 (14.9%) | 7 (12.8%) | 0.018 |
| Early complications | |||||
| Hematoma For which punction For which incision and drainage |
6 (0.4%) 11 (0.8%) |
- 4 (0.7%) |
- - |
- - |
NS |
| Wound dehiscence Conservative management |
18 (1.3%) | 12 (2.2%) | – | – | NS |
| Surgical site infection, for which oral antibiotics | 7 (0.5%) | 3 (0.5%) | – | – | NS |
| Seroma, for which punction | 90 (6.7%) | 43 (7.8%) | 2 (3.0%) | 2 (3.6%) | NS |
| Infected seroma | 10 (0.7%) | 1 (0.2%) | – | – | NS |
| Necrosis of pedicled nipple Partial necrosis Total necrosis |
6/62 (9.7%) 2/62 (3.2%) |
9 (1.6%) 4 (0.7%) |
- - |
2 (3.6%) 3 (5.5%) |
<0.01 |
| Non-take of nipple graft Partial non-take Total non-take |
13/1286 (1.0%) 6/1286 (0.5%) |
n/a n/a |
n/a n/a |
n/a n/a |
n/a |
| Late complications | |||||
| Scar hypertrophy Silicone gel sheeting Corticosteroid injection Laser therapy |
24 (1.8%) 22 (1.6%) 4 (0.3%) |
7 (1.3%) 5 (0.9%) 2 (0.4%) |
- - - |
1 (1.8%) - - |
NS |
| Keloid | 2 (0.1%) | – | – | – | NS |
| Post-mastectomy pain syndrome | – | 1 (0.2%) | – | – | NS |
Table 3.
Overview of surgical corrections, subdivided per mastectomy technique.
| Double incision (n = 1350) | Donut (n = 551) | Peri-areolar (n = 67) | Batwing (n = 55) | p-value | |
| Reoperations | |||||
| No secondary corrections, n (%) | 1103 (81.1%) | 379 (68.8%) | 57 (85.1%) | 37 (67.3%) | <0.01 |
| Dogear correction, total, n (%) 1 dogear correction, local anesthesia 1 dogear correction, general anesthesia Multiple dogear corrections |
153 (11.3%) 94 (7.0%) 56 (4.1%) 3 (0.2%) |
8 (1.5%) 7 (1.3%) 1 (0.2%) - |
- - - - |
1 (1.8%) - 1 (1.8%) - |
<0.01 |
| Surgical contour correction, total, n (%) Dermolipectomy Liposuction/lipofilling Excision of remaining glandular tissue |
74 (5.5%) 63 (4.7%) 9 (0.7%) 2 (0.1%) |
70 (12.7%) 29 (5.3%) 26 (4.7%) 15 (2.7%) |
6 (9.0%) 3 (4.5%) 3 (4.5%) |
6 (10.9%) 5 (9.1%) 1 (1.8%) |
<0.01 |
| Scar correction, total 1 scar correction local anesthesia 1 scar correction general anesthesia 2 scar corrections >2 scar corrections |
28 (2.1%) 10 (0.7%) 14 (1.0%) 2 (0.1%) 2 (0.1%) |
107 (19.4%) 37 (6.7%) 48 (8.7%) 13 (2.4%) 9 (1.6%) |
4 (6.0%) 3 (4.5%) 1 (1.5%) - - |
11 (20%) 3 (5.5%) 7 (12.7%) 1 (1.8%) - |
<0.01 |
| Correction nipple, n (%) | 9 (0.7%) | 26 (4.7%) | 3 (4.5%) | 1 (1.8%) | <0.01 |
Univariate analyses identified surgical technique as risk factor for postoperative bleeding (OR 1.31, p = 0.035, 95%CI 1.02-1.68) and as risk factor for surgical scar corrections (OR 2.20, p = 0.001, 95%CI 1.80-2.69). All other characteristics did not predispose significantly to postoperative bleeding. When analyzing only the double incision mastectomy group, higher BMI was a predictor of reoperations in general (p < 0.001, OR 1.49, 95%CI 1.20-1.84), such as dogear surgery (p = 0.001, OR 1.51, 95% CI 1.17-1.95) and other secondary contour corrections (p = 0.035, OR 1.47, 95%CI 1.03-2.09). Also, high BMI was a predictor of seroma (p = 0.032, OR 1.4, 95%CI 1.03-1.94) When analyzing only the donut mastectomy group, breast size was a predictor of reoperations in general (p < 0.001, OR 1.60, 95% CI, 1.58-1.62).
Discussion
Much like many other gender-affirming surgical procedures, the frequency of performed mastectomy procedures has increased drastically over (recent) years (Al-Tamimi et al., 2020). In fact, the mastectomy procedure is the most frequently performed procedure in our transgender population.
In recent years, mastectomies were predominantly performed in young adults. In the period 2020–2022 80% of individuals were under 25 years old at time of mastectomy. The current population undergoing mastectomy is increasingly younger. In the Netherlands, up until 2020, mastectomy was generally performed after the age of 18. But since 2020, and in line with international literature, individuals in the age category 16-18 are also be deemed eligible for this procedure (Olson-Kennedy et al., 2018). In this time period (since 2020), 129 of them underwent mastectomy. This group is closely monitored to check on their postoperative satisfaction, possible regret and quality of life.
When considering puberty-blocking hormones and testosterone treatment, approximately 20% of individuals had a history of puberty suppression in 2023. Before 2017/2018, individuals were indicated for a mastectomy procedure after at least 12 months of testosterone use. Afterwards, a policy change was instituted that this was no longer necessary. A recent fall in individuals using testosterone treatment was observed, which may be caused by (1) the wish to start testosterone treatment after the mastectomy procedure or (2) the wish not to use testosterone hormones at all as it may not provide the desired effects on the individual.
Over the years, a shift was observed in our center from donut mastectomy as the default mastectomy technique to the double incision mastectomy technique. The difference in risk on postoperative bleeding is lower when compared to earlier publications of our team8, and this is in line with current literature (Bekisz et al., 2022; Rifkin et al., 2022). Differences in outcomes between the techniques can mainly be found in secondary correction rate (18.9% for double incision mastectomy, 31.2% for donut mastectomy). Individuals who undergo donut mastectomy have a higher secondary surgical correction rate, which is mainly due to secondary contour corrections and scar corrections (Table 3). For donut mastectomy, chest size, estimated by weight of the resection specimen, was a predictor of reoperations in general. In concordance with that, in recent years, a stricter indication for donut mastectomy was employed. This practically means that only small chests with no ptosis are deemed eligible for donut mastectomy. Donut mastectomy in medium to moderately large chests with some or more ptosis may lead to an undesirable cosmetic outcome and a high percentage of secondary revision procedures. Though double incision mastectomy comes with bigger scars, the scar can be placed anatomically in the pectoral shadow and the surgeon can shape the chest under direct vision (Kamali et al., 2021; Salibian et al., 2021).
A total of 262 individuals underwent the combined procedure of a mastectomy with hysterectomy with/without oophorectomy. In 2007, this combined procedure was introduced as treatment option. In 2018-2019 this option was chosen by 15-20% of individuals. In 2020-2022, the combined procedure was less frequently performed, which may be due to (1) COVID restrictions and the effect it had on operation room availability, (2) waiting list issues for the simultaneous procedure, and some chose to undergo the procedures separately, (3) the availability of a singular gynecological procedure that combines robot-assisted colpectomy and hysterectomy with/without oophorectomy and (4) less frequent request to undergo hysterectomy and/or oophorectomy in general. This underlines that the surgical path of the individual is not only influenced by personal preferences, but also by the offered pallet of (combined) procedures. In a recent study by Elfering et al., it was stated that the combined procedure led to a higher risk of hematoma and re-operations when compared to the mastectomy only procedure (Elfering et al., 2020). However, in this study, on a higher number of individuals, there was no increased bleeding risk in the combined procedure, which could be explained by the larger group studied and the exclusion of other centers in this study.
Currently, double incision mastectomy is performed standardly with free nipple grafting at our center. An advantage of the pedicled nipple-areolar complex is some preservation of sensation. As it is not a skin graft, graft take problems are not observed. However, choosing a too thin or narrow pedicle may lead to inadequate vascularization and subsequent (partial) necrosis, while choosing a too thick pedicle may lead to contour deformities, which is undesirable. These (dis)advantages should be discussed before the procedure with each individual to determine which is most suitable for the individual and practice shared-decision making.
Strengths of this study are the vast population that was studied, the completeness of data, provided definitions of complications, and the uniqueness of the position of our hospital in national transgender surgical healthcare, which makes it ideally suitable for trend analysis. Limitations of this study are the retrospective nature and that data from a single center was included. International research collaborations are being formed to assess data on mastectomy surgery and outcomes on a broader scale.
Appendix 1.
Used definitions of complications are listed below:
Immediate complication: adverse event occurring within the first 24 hours postoperatively.
Early complication: adverse event occurring between 24 hours to 3 weeks postoperatively.
Late complication: adverse event occurring 3 weeks to years postoperatively.
Postoperative bleeding: Bleeding, that may lead to swelling and/or pain. Management: Return to theater for hemostasis (Clavien-Dindo 3b).
Hematoma: Swelling after 24 hours after mastectomy based on the accumulation of hematoma, for which punction (Clavien-Dindo 1) or incision and drainage (Clavien-Dindo 1 or 3b).
Wound dehiscence: Separation of previously approximated surgical wound edges that was managed noninvasively (Clavien-Dindo 1)
Surgical site infection: for which oral antibiotics (Clavien-Dindo 2)
Seroma: postoperative accumulation of serous fluid for which punction (Clavien-Dindo 1)
Infected seroma: Infection of this fluid, that may lead to swelling, pain, redness and/or fever. Management: Antibiotic treatment (Clavien-Dindo 2) and punction or incision and drainage (Clavien-Dindo 3b).
Partial or total necrosis of pedicled nipple: inadequate vascularization of the pedicled nipple-areolar complex that may be partial or total. Management: Conservative wound management (Clavien-Dindo 1).
Partial or total non-take of nipple graft. Management: Conservative wound management (Clavien-Dindo 1).
Scar hypertrophy. Management: Treatment may consist of silicone gel sheeting, corticosteroid injection and/or laser therapy.
Keloid: Abnormal proliferation of scar tissue. Management: Varies.
Post-mastectomy pain syndrome: A type of chronic neuropathic pain disorder.
Appendix 2. Percentage of mastectomy procedures where liposuction was used additionally for chest contouring
Funding Statement
The author(s) reported there is no funding associated with the work featured in this article.
Disclosure statement
No potential conflict of interest was reported by the authors.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
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