Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns

Abstract

Background: Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques.

Methods: Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups.

Results: In total, 490 patients underwent gender-affirming mastectomy during the study period. An estimated 96 patients underwent periareolar mastectomy, whereas 390 underwent double incision mastectomy. Demographics were similar between groups, and there were no differences in rates of hematoma (3.1% versus 5.6%, respectively; P = 0.90), seroma (33.3% versus 36.4%; P = 0.52), or revision procedures (14.6% versus 15.8% P = 0.84) based on technique.

Conclusions: Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.

Fig. 1.

Preoperative markings for double-incision mastectomy. The patient is marked in the standing position, with arms raised to help accentuate the inferior and lateral borders of the pectoralis muscle. The superior incision is marked straight across the inferior border of the pectoralis major and is angled superiorly toward the axilla to follow the inferolateral border of the pectoralis muscle. Reprinted with permission from Plast Reconstr Surg 2021;147:1288–1296.

Fig. 2.

The inferior incision is placed in the inferior pectoral shadow and not in the inframammary fold, which is often lower than the pectoral shadow. This is marked intraoperatively while pulling the breast parenchyma and skin flap superiorly on tension to estimate the closure. Reprinted with permission from Plast Reconstr Surg 2021;147:1288–1296.

Fig. 3.

Preoperative (A) and postoperative (B) photographs of a patient who underwent gender-affirming mastectomy with a periareolar technique.

Fig. 4.

Preoperative (A) and postoperative (B) photographs of a patient who underwent gender-affirming mastectomy with a double incision and free nipple graft technique.