Female-to-Male Gender Affirming Top Surgery: A Single Surgeon's 15-Year Retrospective Review and Treatment Algorithm

Background: Mastectomy, referred to here as "Top Surgery," is an important surgical step for female-to-male (FTM) transgender patients. The goal is to excise breast tissue and create a masculine chest contour. Despite the rising demand for Top Surgery, debate still exists regarding how to select the most appropriate surgical technique to optimize aesthetic outcomes safely. Objectives: To determine the safety profile and aesthetic outcome of one surgeon's 15-year FTM Top Surgery experience. To provide an algorithm for FTM surgery technique selection based on this experience. Methods: A retrospective chart review was performed on 679 FTM patients (1358 mastectomies) undergoing Top Surgery from October 2001 to July 2016. The author's Top Surgery algorithm utilizes two techniques, "Keyhole" and "Double Incision Free Nipple Graft (DIFNG)," based on breast ptosis, inferior vertical skin pinch, and skin elasticity. Demographic data, operative details, complications, and reoperations along with their reasons were collected and analyzed. Results: Of the 679 patients, 15.3% underwent Keyhole and the remaining 84.7% underwent DIFNG procedure. The total complication rate was 18.1% and the total reoperation rate was 11.2% and these rates were shown to decrease over time. The two techniques differed significantly (P < 0.001) in operating time (136 vs 102 min), breast weight excised (215 vs 638 g), and complication rate (33 vs 16%). The aesthetic rating of results was 4.6/5 for Keyhole and 3.7/5 for DIFNG. Conclusions: Safe and aesthetically pleasing results were achieved using this simplified algorithm. Experience with FTM techniques can decrease complication and reoperation rates over time.