Subcutaneous mastectomy

Subcutaneous mastectomy in sex reassignment surgery (from female to male) is the first intervention performed within the sex reassignment process. The main objective is to remove the mammary gland while minimizing incisions and scars.

Transsexualism (either male to female, or vice versa) is a gender identity disorder, characterized by dissatisfaction and discomfort with the anatomical sex, and the patient’s desire to live and be accepted as an individual of the opposite sex. The anatomically assigned sex and the social roles culturally assumed for that sex cause them great suffering. The comprehensive management of these patients includes medical treatment, surgical interventions and psychological support. It has to be guided and directed by a multidisciplinary team, integrated by specialists from different fields such as endocrinologists, plastic surgeons, psychologists, psychiatrists, etc.

What is mastectomy in sex reassignment?

Subcutaneous mastectomy in these patients is an extremely important intervention, since it allows achieving a flat thorax, the characteristic male torso configuration, and greatly facilitates the integration of these individuals as persons of the opposite sex. The procedure consists of removing all the breast tissue, and also the skin in case it is excessive. Sometimes it is necessary to reposition the nipple-areola complex, since in certain large, ptosic breasts with excess skin, the nipple is too low.

Generally speaking, there are several types of intervention, depending on the size and shape of the breasts.

Types of mastectomy procedures

Liposuction

If the breasts are small and with little glandular component. In these cases the skin itself is retracted and an adequate chest contour is achieved with a less aggressive intervention.

Liposuction with subcutaneous mastectomy through inferior hemiareolar incision

Combines liposuction with excision of the glandular component through a small inferior hemiareolar incision.

Subcutaneous mastectomy and excess skin removal

On occasions when the breast is large and/or ptosic it may be necessary in addition to performing a subcutaneous mastectomy, to perform an excision of excess skin with a reduction pattern, which is designed according to the patient’s characteristics (it can be periareolar skin resection, lateral triangles to the areola, or a true breast reduction pattern).

Areola grafting

Occasionally, if the breast is very large or ptosic, an areola graft may be necessary to reposition it.

The difficulties to be faced especially in the course of this surgery is that the breasts are usually of considerable volume, and that the skin is usually in excess and has lost its elasticity. On the other hand, compressive breast bandages, sometimes used by patients to camouflage their breasts prior to surgery, also have a negative effect on excess skin and skin elasticity. The hormonal treatment to which these patients are subjected is also a point to be taken into account as it has effects on healing.

Details to keep in mind if you are thinking of having a mastectomy:

• Smoking is a relative contraindication, since it affects the healing capacity.
• Subcutaneous mastectomy is an operation to be performed in an operating room under general anesthesia.
• It is a safe intervention and we can foresee concrete results.
• The patient is usually admitted for 24 hours, and can return to normal life in 1-2 weeks.
• The rate of complications is not frequent, although if they appear, they may be hematoma (1%), infection (1%), or alterations in the healing process (4%).
• This surgery shows high rates of patient satisfaction, both psychosocial and self-image.

In conclusion, mastectomy in the context of masculinization of the female thorax plays a relevant role in the process of gender change, not only because it is the point of no return, but also because it is the first surgical intervention that these patients undergo, and its correct intervention will depend to a large extent on the sex change process being as less traumatic as possible.

It is a complex surgical procedure, and decisions regarding the choice of the intervention must be made based on the physical examination of the patient, its characteristics in terms of tissues, breast size, glandular and adipose composition. The patient must know about the procedure he/she is going to undergo, so he/she must be adequately informed and oriented, and he/she must give his/her free consent.

On the other hand, mastectomy in the context of the sex reassignment process is only one of the multiple interventions that these patients undergo, and therefore it must be properly coordinated by a multidisciplinary team. This procedure can be performed alone or in conjunction with oophorectomy (removal of the ovaries), or even in some cases with genital sex reassignment, although experts generally recommend that these procedures be performed in at least two surgeries.

In short, if you are thinking of undergoing an intervention of this type, consult your trusted plastic surgeon. Remember that this intervention must be performed by expert hands specialized in this field. The “SECPRE” or “Spanish Society of Plastic and Reconstructive Surgery”, a society that brings together the specialists in plastic surgery in this country, whose values include excellence, quality and safety in the performance of plastic and aesthetic surgery, offers you a list of professionals who practice the specialty of Plastic, Aesthetic and Reconstructive Surgery in your province. Check that your surgeon has the specific qualifications in Plastic, Reconstructive and Aesthetic Surgery to operate with the greatest guarantees and without running unnecessary risks.