Addressing The Grey Zone In Gender Affirming Mastectomy: Outcomes And Technique Choice In Fischer Grade 2 Patients
Darius Balumuka, MBChB, Kelsi Krakauer, B.S., Juliana Hansen, M.D..
Oregon Health and Science University, Portland, OR, USA.
PURPOSE: Choice of surgical technique in gender-affirming mastectomy (GAM) can be challenging for Fischer grade 2 patients. In grade 1 the periareolar (PA), and in grade 3 the double incision with free nipple graft (DIFNG) are usually chosen. The decision is more challenging in grade 2 patients where the PA fails to address the skin and the DIFNG is rather extensive. To expand options for this sub-population we have developed two novel techniques, Batwing and Nipple Sparing Double Incision (NSDI). A decision algorithm is included in our work.
METHODS: Single-surgeon retrospective chart review of GAM outcomes (complications, aesthetic revisions) between 2014 and 2021 for Fischer grade 2 patients.
RESULTS: 444 patients underwent GAM, 51 (11%) of which were a Fischer grade 2. 21 patients (5%) were classified as 2A and 30 (6.8%) were classified 2B. The surgical techniques used were PA (20%), Batwing (39%), NSDI (24%) and DIFNG (10%). Four patients developed hematoma requiring take-back for a complication rate of 7.8%. Complication rates for Batwing, NSDI, and PA were 10%, 8% and 7.7% respectively. 12 patients (24%) opted for minor aesthetic revisions under local anesthesia; PA (31%), Batwing (10%), NSDI (17%). There were no complications or revisions recorded in the DIFNG group.
CONCLUSION: In Fischer grade 2 patients, the Batwing and NSDI techniques provide better exposure, allow for better control of NAC position and have a lower aesthetic revision rate than the PA technique with a comparable complication rate. Our algorithm accounts for Fischer grade, unique patient characteristics and desires.
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