Population with Gender Incongruence and Healthcare Needs

Medical assistance for transgender patients should provide integral, specialized care across all stages-initial intake, outpatient follow-up, hormone therapy, clinical and surgical procedures, and postoperative monitoring. This continuum of care is typically delivered by a multidisciplinary team-composed of psychiatrists, endocrinologists, gynecologists, urologists, and plastic surgeons, among others-to support the patient’s needs and decision-making in its full complexity.¹

Improvement in Dysphoria and the Importance of Surgical Procedures

Numerous studies^2,5,10 report that transgender individuals frequently experience discrimination, stigma, and abuse. Alarmingly, 41% of transgender people report having attempted suicide-compared with 1.6% of the general pop-ulation-and 56% have been diagnosed with depression at some point (approximately 4 times the rate for the general population), while 38% have been diagnosed with anxiety (50% higher than the general rate).⁴

In the present case series, 8 out of 34 patients (23.53%) had a history of anxiety or depressive disorder and the same number were classified as being overweight, which is often linked to anxiety and depression.

One study¹¹ demonstrated that, 1 year after surgery, 96% of the patients reported feeling comfortable with their bodies in the workplace, and 43% felt comfortable exposing their bodies in public settings such as pools and beaches. These findings underscore the functional and psychological benefits of masculinizing chest surgery for this population.

Collectively, the data affirms that plastic surgery plays a pivotal role in gender affirmation, aiding individuals in aligning their phenotype with their identity and thereby contributing to a reduction in gender dysphoria and societal prejudice.

On Binders and Social Media

Many transgender men use compressive bandages-com-monly known as binders-to flatten breast tissue and reduce the discomfort and social stigma associated with chest fullness.^12,13 However, binders can be uncomfort-able and may lead to pain, skin infections such as derma-titis, restricted upper-limb mobility, and breathing difficulties.^12,13

Given the discomfort of prolonged binder use, many transgender men deliberately display their postoperative scars as symbols of pride and community identity.¹⁰ In the current study, for example, one patient who qualified for the smaller-scar periareolar technique chose instead the double-incision approach-with its more prominent scarring-as a form of personal expression.

This celebration of surgical scars extends into social media platforms (Instagram, Facebook etc.), in which posts tagged with #topsurgery, #ftm, and #transmen foster engagement and dialogue about masculinizing chest surgery. In this way, the linear scars of the chest become emblematic badges of individual triumph and collective solidarity.

Preoperative Preparation and Surgical Techniques

The periareolar technique yields small, well-concealed scars but has limited applicability, being suitable only for patients with small, non-ptotic breasts and good skin quality.¹⁴ For medium-to-large breasts or those with ptosis, the double-incision approach with free NAC grafting was chosen. Commonly called the smile technique due to the curved shape of the final inframammary scars resembling a smiling mouth, this method was the most frequently performed. Its advantages include excellent surgical exposure, relative technical ease, and low rates of revision surgery. The main drawbacks are long inframammary scars-which may extend laterally along the thoracic wall-and potential changes to the areolae, including contour irregularities and reduced sensation.^5,7,15

Description of the Double-Incision Technique with Free NAC Grafting

The patient is marked in an orthostatic position (►Fig. 5). A midline is drawn from the sternal notch to the umbilical scar, checking for any umbilical deviations to avoid affecting the remaining markings. The IMF is outlined bilaterally (this marking typically follows the inferior border of the pectoralis major muscle [PMM]). Next, this marking is transposed to the upper part of the breast, providing a preliminary outline of the dermoglandular tissue to be removed and the skin flap to be preserved.

Bilateral oblique markings are made from the umbilical scar to the anterior axillary pillar, which in most patients runs tangent to the lateral border of the PMM, similar to descriptions made by other authors.^16,17 Subsequently, a dashed line is drawn from the medial third of the clavicle to the NAC.

Areas for liposuction, most commonly in the preaxillary or lateral thoracic regions, may be demarcated. It should be emphasized that the main skin flap areas should generally not undergo liposuction. Urinary catheterization is avoided, as the surgical time is limited to approximately 3 to 4 hours, and the procedure may cause discomfort for the patient due to genital exposure inconsistent with their phenotype. Anti-biotic prophylaxis with cephalosporin is administered ap-proximately 30 minutes before the surgical incision.

The procedure begins with infiltration of a 0.9% saline solution and adrenaline (1:500 thousand) into the incision areas and lipodystrophy regions (axillary and lateral thoracic areas). After waiting approximately 7 minutes, liposuction is performed in the marked areas using a 4.0 cannula.

Next, the areolar grafts are harvested. For large areolas, the option is to perform dual resection of the areolar segment: the areola and nipple are resected and grafted separately.

After harvesting, the incision begins at the upper breast marking, aiming at complete removal of the NAC, as in cases of small breasts with large NACs, this could result in upward displacement of the fold incision. During mastectomy, an approximate thickness of 1.0 to 1.5 cm should be maintained in the superior flap to preserve proper vascularization and innervation without damaging the subdermal plexus, mini-mizing the risk of flap ischemia. To standardize the flap, excess subcutaneous tissue is resected with Metzenbaum scissors to avoid irregularities.

The lower incision follows, which may be made directly at the IMF or slightly above it in cases of very low-set breasts. Rigorous hemostasis is performed, and the cranial and caudal skin flaps are approximated.

The scar is typically oriented horizontally in the central portion of the chest. In the lateral portion, a more curvilinear line is preferred, mimicking the angle of the lateral border of the PMM, like that proposed by other authors.¹⁸ Connecting the scars in the sternal region is avoided, although it may be necessary in cases of large breasts or significant ptosis.

Regarding NAC reconstruction, the symmetrical positioning of the new NAC, its dimensions, and characteristics are fundamental to construct an esthetically-pleasing masculine chest.^18-20 Grafting is preferred over an inferior pedicle dermal flap, as the latter requires maintaining more breast tissue for viability, which may result in excess volume in the breast region and an unsatisfactory outcome.

The literature indicates that approximately 91% of male areolas have an oval shape, with an approximate size of 1.5 x 2.5 cm.^6,21,22 However, the devices available on the market to mark areolas are essentially round, designed based on the shape and size of female NACs.

Given that the standard male NAC has a different configura-tion, using commercially-available areolotomes, which were designed according to female anatomy, produces areolas with configurations distinct from those typically observed in men. Additionally, when grafted, NACs tend to elongate vertically due to skin tension and stretching, further distorting their shape.^6,23 In this context, other authors⁶ have advocated specific adaptations after conventional circular skin marking, essen-tially flattening the original marking (reducing the vertical diameter and increasing the lateral extension). It is believed that this approach works with skin tension forces and traction vectors, avoiding less realistic results caused by a vertically elliptical shape. Thus, a pair of elliptical areolotomes (measur-ing 1.7 x 2.3 cm and 1.8 x 2.6 cm) made of stainless steel was designed and developed, based on the proportions of male areolas and craniocaudal traction forces. Thus, after harvesting and grafting in an oval shape, the goal is to maintain this appearance horizontally; or, when significant scar contraction occurs, the NAC evolves into a rounded shape, which is also esthetically pleasing and well-accepted by patients.

Regarding NAC positioning, it is located approximately 2.0 cm medially to the lateral border of the PMM and approximately 2.0 cm superiorly to its inferior insertion (where the IMF incision is placed). Generally, the NAC lies tangential to the oblique thoracic line initially marked and approximately 11 to 12 cm from the midsternal line. For patients with large areolas, the option is to harvest the areolar and nipple segments separately, enabling individual grafting of each component of the complex. For this, the areolar tissue is thinned, and the nipple tissue is left slightly thicker while also reducing its size.

Suction drains are left in the breast pocket for approxi-mately 5 to 7 days and removed when the output is lower than 50 mL in 24 hours. Sutures are made with polyglactin sutures in the subcutaneous layer (deep layer: 3.0; and superficial layer: 4.0) and with monofilament nylon in the skin (4.0) and graft (5.0). The NAC graft dressing consists of a first layer of cellulose mesh soaked in essential fatty acids, followed by gauze under negative pressure covered with a transparent plastic dressing. This dressing is removed after approximately 5 to 7 days, and daily dressings with fatty acid-soaked gauze are recommended.

For postoperative care, the use of antithrombosis stockings for 15 days and a chest binder for 45 days is advised. Anti-coagulants are not prescribed. The NAC graft sutures are removed around 10 to 12 days postoperatively, and the remain-ing sutures are kept for 20 to 30 days. Return to activities is gradual: driving and resuming normal activities are allowed after 3 weeks, and physical activities, after 6 weeks.

Peer Evaluation of Results

In the peer evaluation of the outcomes, the results were classified as excellent (25; 36.76%), very good (29; 42.65%) and good (14; 20.59%). The P_O was of approximately 0.735, and the Cohen Kappa coefficient, of approximately 0.60, indicating moderate to substantial inter-rater reliability.