Mastectomy in transgender patients: The experience of a Portuguese reference center

Abstract

Gender-affirming mastectomy represents a fundamental procedure in the transition process for transgender patients, substantially contributing to psychosocial well-being. This study presents the 13-year experience of the only reference center in Portugal and aims to analyze surgical techniques, outcomes, complications and patient-reported satisfaction following chest wall masculinization.

A retrospective review was conducted of all trans men who underwent gender-affirming mastectomy between October 2011 and December 2024. Surgical techniques were selected based on breast size, ptosis and skin elasticity. Demographics, operative details, complications, and revision procedures were recorded, and postoperative satisfaction was assessed.

A total of 87 patients underwent chest wall masculinization surgeries, including 174 mastectomies. Inframammary mastectomies with nipple-areolar complex grafts were performed in 55%, concentric periareolar in 34%, and hemiperiareolar in 9.2% of cases. Mean body mass index was higher in the inframammary group (25.8 vs. 22.8 kg/m²; p < 0.001). The overall complication rate was low. Hematoma occurred in 13%, hypertrophic scarring in 11% (significantly associated with inframammary technique; p < 0.05), and no infections were recorded. Secondary revision surgery was required in 8.0% of patients. Among survey respondents (47%), the mean satisfaction score was 8.5/10, with no reports of regret.

Gender-affirming mastectomy is a safe and effective procedure that provides significant aesthetic and psychosocial outcomes. Individualized surgical technique selection based on anatomical features yields high patient satisfaction and low complication rates.

Introduction

According to the 2024 Statistical Report by the Portuguese Ministry of Youth and Modernization, there has been a growing trend in gender changing in civil registration records, including the subsequent change of first name. Since the law allowing this change took effect in 2011, 3034 individuals have undergone gender transition in Portugal.¹ The number of transgender individuals pursuing medical and surgical treatment has risen in recent years.^2,3 Nevertheless, the number of unreported cases is believed to be significantly higher.⁴

Gender-affirming surgery aims to reshape the body to align an individual’s physical characteristics with their self-identified gender.⁵ Mastectomy is often the first surgical procedure performed in trans men and, in some, the only surgical intervention performed.^4,6

Transmasculine chest surgery has been shown to improve quality of life, enhance self-esteem, and optimize interpersonal relationships for trans men.^3,7, 8, 9, 10, 11 The goal of this surgery is to create a masculine-appearing chest by removing breast tissue, reducing excess skin, repositioning the nipple-areola complex (NAC), and eliminating the inframammary fold, all while minimizing scarring.^5,8,11,12

Some surgical mastectomy techniques and treatment algorithms have been described, depending on the patient’s body morphology. These procedures include hemiperiareolar, transareolar and concentric circular mastectomies (with or without lateral extensions), as well as inferior pedicle based and inframammary mastectomies.^7,13

In October 2011, the Genitourinary and Sexual Reconstruction Unit was established at Coimbra University Hospital Center. It is currently the national reference unit for gender reassignment and is responsible for providing comprehensive healthcare to transgender individuals. This unit offers multidisciplinary care throughout the transition process, with a team that includes specialists in plastic surgery, gynecology, urology, endocrinology, psychiatry and psychology.

The unit follows the World Professional Association for Transgender Health (WPATH) Guidelines. Patients undergoing gender-affirming interventions must be diagnosed with gender dysphoria, as assessed and documented by two independent psychiatrists. They must be over 18 years of age and any medical or psychiatric comorbidities should be well-controlled or absent. Additionally, these patients must complete a minimum period (12 months) of medically oriented hormonal therapy before undergoing any surgical procedure.

This study aims to present for the first time the experience of the only Portuguese reference center for gender-affirming surgeries, specifically chest wall masculinization, since its beginning until December 2024. Our goal is to highlight the different surgical techniques used, acute and secondary revision procedures performed, and patient-reported outcomes while providing a unique national perspective on outcomes over several years in Portugal, adding to the existing literature on gender-affirming chest surgery.

Materials and methods

After receiving approval from the Coimbra University Hospital Center Ethics Committee, we conducted a retrospective review of the clinical records of all trans men who underwent gender-affirming mastectomy at our institution between October 2011 and December 2024. The inclusion criteria consisted of transgender patients who had undergone mastectomy with at least 3 months of follow-up. Patients who had prior chest wall contouring surgery at other hospitals were excluded.

The data collected included age, body mass index, medical and surgical history, medication, smoking status, date of surgery, type of procedure, operation time, hospital stay, complications and need for a revision procedure.

The surgical technique used for the mastectomy (hemiperiareolar, concentric periareolar, or inframammary with NAC grafts) was selected based on the breast size, degree of ptosis, amount of excess skin, and skin elasticity of the patient. Trans men with small breasts (A cup), no or mild ptosis, and minimal skin excess were offered a hemiperiareolar mastectomy (Figure 1). Those with medium-sized breasts (B cup), mild ptosis, and mild skin excess were offered a concentric periareolar mastectomy (Figure 2). Patients with larger breasts (C cup or greater) and moderate to severe ptosis were offered an inframammary mastectomy with NAC grafts (Figure 3).

Figure 1.

Example of a subcutaneous mastectomy with a hemiperiareolar approach, before the surgery (above) and 1 year postoperatively (below).

Figure 2.

Example of a subcutaneous mastectomy with a periareolar concentric approach, before the surgery (above) and 1 year postoperatively (below).

Figure 3.

Example of a subcutaneous mastectomy with free nipple-areolar complex graft, before the surgery (above) and 1 year postoperatively (below).

Patients were contacted either by telephone or during clinical appointments to obtain informed consent. After consent was obtained, a self-administered online questionnaire was sent to each patient via email. The questionnaire included two items: (1) whether the patient regretted undergoing surgery, and (2) their assessment of the aesthetic outcome of the mastectomy. For the latter, a 10-point Likert scale was used, with 1 indicating “poor” and 10 indicating “excellent” results. Participation was voluntary, and all responses were collected anonymously without any form of compensation.

Statistical analyses of the data were performed with Mann-Whitney, Fisher and Chi-Square tests using IBM SPSS version 31.

Results

From October 2011 to December 2024, we performed chest masculinization surgeries in 87 patients, representing a total of 174 glandular resections. None of the patients had undergone previous genital surgery. The mean age was 29.5 years (range, 18–51). All patients were undergoing hormonal treatment at the time of the surgery. Regarding medical history, 9 patients were diagnosed with depression, 6 with asthma, and 2 with hypothyroidism. At the time of the surgery, 38% of the patients were active smokers (Table 1).

Table 1.

Sample characteristics.

	Value (%)
Age, years - Mean - Range	29.5 18–51
Body mass index, kg/m2 - Mean - Range	24.4 17.8–39.5
Preoperative hormone therapy	87 (100)
Active smoking	33 (38)
Co-existing comorbidities - Asthma - Allergic rhinitis - Diabetes mellitus - Dyslipidemia - Hypothyroidism - Autoimmune hepatitis - Hepatitis C - Epilepsy - Depression - Bipolar disorder	6 (6.9) 1 (1.1) 1 (1.1) 3 (3.4) 2 (2.3) 1 (1.1) 1 (1.1) 1 (1.1) 9 (10) 1 (1.1)
Surgical techniques - Liposuction - Hemiperiareolar - Concentric periareolar - Inframammary with NAC graft	1 (1.1) 8 (9.2) 30 (34) 48 (55)

NAC: nipple-areola complex.

An inframammary approach with full thickness NAC grafts was used in 48 (55%) patients, a concentric circular technique was performed in 30 (34%) patients, and a hemiperiareolar approach was used in 8 (9.2%) patients. In 1 (1.1%) patient, we chose liposuction as the sole procedure due to the presence of a small amount of breast tissue with predominance of fat (Table 1).

The mean BMI was 25.8 kg/m² in the inframammary mastectomy group and 22.8 kg/m² in the periareolar concentric and hemiperiareolar group. The mean BMI in the inframammary group was statistically higher than in other mastectomy types (p < 0.001).

The mean operation time for chest wall masculinization surgeries was 90 min and the mean length of hospital stay was 3.5 days.

Hematoma occurred in 11 patients (13%), all of whom required surgical drainage. This complication did not differ significantly between the inframammary and the periareolar or hemiperiareolar approaches (p = 0.54). Other complications included complete NAC necrosis (1.2%), partial NAC necrosis (8.1%), suture dehiscence (2.3%), seroma (2.3%), NAC depression (3.5%), dog ears (7.0%) and hypertrophic scars (11%). The last complication was the only one that showed a statistically significant difference in the inframammary group (p < 0.05). Smokers demonstrated approximately 3.7-fold higher odds of NAC necrosis compared to non-smokers (OR = 3.71), even though the difference in NAC necrosis between groups did not reach statistical significance (p = 0.09). Patients did not present any infection. Further details are presented in Table 2.

Table 2.

Post-operative complications of mastectomies.

	Hemiperiareolar and periareolar group (n = 38)	Inframammary with NAC graft group (n = 48)
Hematoma, n (%)	4 (11)	7 (15)
NAC necrosis, n (%) - Complete - Partial	1 (2.6) 2 (5.3)	0 (0.0) 5 (10)
Seroma	1 (2.6)	1 (2.1)
Incomplete integration of NAC grafts, n (%)	Not applicable	3 (6.3)
Suture dehiscence, n (%)	1 (2.6)	1 (2.1)
NAC depression, n (%)	3 (7.9)	0 (0.0)
Hypertophic scars, n (%)	0 (0.0)	9 (19)
Skin and/or fat surplus, n (%)	1 (2.6)	0 (0.0)
Dog ears, n (%)	0 (0.0)	6 (13)
Infection, n (%)	0 (0.0)	0 (0.0)

NAC: nipple-areola complex.

A total of 13 revision procedures were performed in 7 trans male patients (8.0%). These included conversion to an inframammary approach (from concentric periareolar) and other additional revisions involved lipofilling of retroareolar area in 3 patients, dog-ear excision in 5, and scar revision in 1 patient (Table 3). There were no statistically significant differences in revision surgeries among different surgical techniques.

Table 3.

Secondary corrections performed after mastectomies.

	Hemiperiareolar and periareolar group (n = 38)	Inframammary with NAC graft group (n = 48)
Conversion to another mastectomy approach, n (%)	1 (2.6)	0 (0.0)
Lipofilling of retroareolar area, n (%)	3 (7.9)	0 (0.0)
Liposuction, n (%)	1 (2.6)	0 (0.0)
NAC reconstruction/revision, n (%)	2 (5.3)	0 (0.0)
Scars revision, n (%)	0 (0.0)	1 (2.1)
Dog ear excision, n (%)	0 (0.0)	5 (10)

NAC: nipple-areola complex.

Patient satisfaction with the overall result was assessed in 41 patients (47%). The remaining patients could not be reached by phone or email, and one had committed suicide. The average satisfaction score for the overall result was 8.5 (on a scale from 1 = poor to 10 = excellent). The score range was 3 to 10. The mean satisfaction score among patients who underwent inframammary mastectomy was 8.6, while the periareolar and hemiperiareolar group scored 8.7. There was no statistically significant difference between groups (p = 0.8). None of the patients reported regretting the surgery (Table 4).

Table 4.

Patients satisfaction outcomes.

	Hemiperiareolar and periareolar group (n = 19)	Inframammary with NAC graft group (n = 22)
Satisfaction score - Mean - Range	8.7 3–10	8.6 4–10
Regret of surgery, n (%)	0 (0.0)	0 (0.0)

NAC: nipple-areola complex.

Discussion

The goal of chest wall masculinization surgery is to create an aesthetic and harmonious male chest with minimal scarring while satisfying the patient.^14,15 The procedure may appear similar to mastectomy in gynecomastia, however it is usually more difficult due to a higher breast volume that includes the axillary tail of Spence; moreover, poorer skin elasticity and a greater degree of ptosis are often present due to the common use of chest binders and hormonal therapy.14, 15, 16, 17

Preoperative evaluation is crucial in choosing the surgical technique, which should always be individualized.^14,16,18 Breast size, degree of excess skin and ptosis, and skin elasticity are the most important factors in selecting the optimal mastectomy technique.¹⁸

Several algorithmic surgical approaches have been published, such as the one proposed by Monstrey et al. which includes options such as semicircular, transareolar, concentric circular, extended concentric approach, and the NAC graft technique.¹³ More recently, Wolter et al. developed another algorithm to aid in selecting the appropriate surgical technique based in breast size, degree of ptosis, and skin quality. In ascending order, he proposed liposuction followed by hemiperiareolar or concentric periareolar mastectomy, inferior pedicled mammaplasty, and mastectomy with NAC graft.¹⁵

In our department, the first gender-affirming surgery performed in trans male patients is always the chest wall masculinization procedure. The choice of the surgical technique is left to the surgeon’s discretion and it is based on the breast size, degree of ptosis, amount of excess skin and skin elasticity, which is consistent with several studies.^14,15,19

Our mastectomy options include hemiperiareolar, concentric periareolar, and inframammary approaches with NAC grafting. Regardless of the specific surgical technique employed, we always discuss the procedure thoroughly with the patient, particularly the aspects regarding the anticipated position and quality of the resulting scar. We consider this step to be essential for managing expectations and enhancing postoperative satisfaction.

A substantial proportion of patients in this study presented with psychiatric comorbidities, predominantly depression, consistent with findings reported in previous studies.^20,21 Patients who underwent mastectomy with NAC grafts were significantly more likely to be obese. This association can be explained by the presence of larger and more ptotic breasts; in these cases, we consider the inframammary approach to provide the most favorable outcomes.

The reported incidence of hematoma following gender-affirming mastectomy ranges from 0% to 31% in the literature.²² In our study, hematoma was the most common short-term complication, occurring in 13% of cases. Some studies have reported a higher frequency of hematomas with small-incision approaches compared to techniques with greater exposure.^13,18,22,23 However, we did not observe this trend, as the occurrence of hematoma did not differ significantly between inframammary and periareolar/hemiperiareolar approaches.

The reported rate of infections following transgender mastectomy is generally low. Miszewska et al. reported an infection rate of 4.8%.¹⁹ In our series, no infections were observed, which may be attributed to rigorous aseptic preoperative and intraoperative protocols, including the use of prophylactic antibiotics. Postoperative antibiotics are not routinely administered in our center.

Hypertrophic scarring was the most frequently reported long-term complication (11%) and occurred exclusively in patients who underwent inframammary mastectomy, with a statistically significant difference. This finding is consistent with other studies reporting a higher incidence of hypertrophic scarring in this patient group.⁷

Secondary aesthetic revisions occurred in 8.0% of cases, comparable to previously published data.^15,24 There were no significant differences observed between the various mastectomy approaches.

Patient-reported satisfaction with the aesthetic outcome was high, with mean scores of 8.6 in the inframammary group and 8.7 in the hemiperiareolar and concentric periareolar groups. No significant differences were found between groups, consistent with the systematic review by Bustos et al. which reported high and stable satisfaction levels for both periareolar mastectomy and NAC graft approaches.¹² In our cohort, no patient reported regretting the surgery. These positive outcomes confirm that chest masculinization surgery has substantial benefits for the well-being and self-esteem of trans male patients, highlighting its strong psychosocial impact beyond purely aesthetic considerations.^3,7, 8, 9, 10, 11

Limitations of our study include the lack of preoperative-to-postoperative comparisons and the fact that patients completed the survey at different postoperative times. In our opinion, it would be valuable to include an external plastic surgeon to independently evaluate and compare the preoperative and postoperative results. Additionally, our survey was not a validated tool, and the response rate was only 47%.

Conclusions

Gender-affirming mastectomy is a safe and effective procedure that substantially enhances the well-being and self-esteem of trans male patients. Individualized surgical planning, based on breast size, degree of ptosis, and skin characteristics results in high patient satisfaction, low complication rates and minimal need for secondary revisions. These findings highlight the significant psychosocial impact of chest masculinization surgery beyond its aesthetic benefits. Further prospective multicenter studies using standardized, validated assessment tools are warranted to more comprehensively evaluate these procedures.

Ethical approval and consent to participate

This study obtained approval from the Coimbra University Hospital Center Ethics Committee. Informed consent was obtained from all participants prior to data collection, in accordance with the Declaration of Helsinki. Patients gave permission to use of their clinical information and photographic material pertaining the present study.

Funding source

No funding was involved in the present study.

Declaration of competing interest

No conflict of interest to declare.