Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy.

[INTRODUCTION] Subcutaneous mastectomy is one of the first steps in sexual reassignment in female-to-male transsexuals (FTMTS). The main goal is to masculinize the chest by removing the female contour. In this study, we introduce an algorithm to facilitate choosing the appropriate mastectomy technique depending on morphological aspects.

[PATIENTS AND METHODS] The records of 173 patients (346 mastectomies) from January 2008 to December 2013 were retrospectively reviewed. The authors conducted four different surgical techniques depending on breast volume, grade of ptosis and skin elasticity. The outcome parameters such as complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and surgical correction rate were obtained and related to the employed technique.

[RESULTS] From January 2008 to December 2013, we performed 346 mastectomies, of which 48 breasts (13.9%) were treated by a semicircular incision in combination with water-jet-assisted liposuction, 66 breasts (19.1%) by an additional circumferential mastopexy, 170 breasts (49.1%) by an inferior pedicled mammaplasty and 62 breasts (17.9%) by mastectomy with free nipple grafting. The mean operation time lasted 103.6 min. The overall complication rate was 11.8%. Secondary revisions were necessary in 9%. Of the patients, 88% rated the aesthetic results as "very good" or "good." Nipple sensitivity was rated as "very good" or "good" in 80.3% of the breasts.

[CONCLUSION] FTMTS are a well-informed patient population and therefore increasingly more demanding for aesthetic outcomes. If possible, the most scar-saving procedure should be preferred. With ascending degrees of ptosis, a larger skin envelope and lesser elastic skin, an extended-incision technique is required. The presented surgical algorithm facilitates the selection of the appropriate mastectomy technique and shows a high patient satisfaction with the aesthetic result, a preservation of nipple sensitivity and a low rate of complications and secondary aesthetic corrections.