Thursday, December 17, 2009

Chest Wall Contouring in Female-to-Male Transsexuals

I’ve been in solo practice for 19 years. I’m getting ready to do my first female-to-male (FTM) chest wall contouring. [Yes, I told the patient he was my first FTM though not my first mastectomy.]

I recalled having seen the fifth referenced article below and used it’s bibliography to find other articles which gave me nice tips on the “male” chest.  Here is the algorithm I scanned in from the fifth article.

In the normal female mastectomy, the inframammary fold is maintained. In the FTM chest-wall contouring mastectomy it is not. In the 5th article, it is explicitly pointed out: “The inframammary fold is always released, and this is an especially important maneuver for patients with large breasts.” Also,

Regardless of the technique chosen, we feel it is extremely important to preserve all of the subcutaneous fat when dissecting the glandular tissue from the flaps. This ensures thick flaps that produce a pleasing contour and do not subsequently become tethered to the chest wall. For the same reason, we preserve the pectoralis fascia and definitely do not perform liposuction at the anterior aspect of the breast. However, the judicious use of liposuction can occasionally be indicated laterally or to attain better symmetry at the end of the procedure.

Information on the male nipple gathered from the 4th reference below:

Measurements on the configuration of the nipple-areola complex revealed that 91 percent of the complexes were oval and only 7 percent were round.

Describing the localization of the nipple-areola complex on the thorax by various measurements, the average distance from sternal notch to nipple was 20 cm. The average horizontal distance from the midsternal line to the nipple was 11 cm and the average distance from the sternal notch to the xiphoid was 20 cm. (photo scanned in from 2nd article below)

Our results concerning the localization of the nipple with respect to the intercostal space showed that most of them were located in the fourth or the fifth intercostal space.

Our findings in a European population showed a slightly smaller nipple-areola complex, with a mean diameter of 23 mm for round complexes and 27:20 mm for an oval complex.

Marking tips for the concentric circle technique from the 2nd referenced article:

The vertical excess of skin is determined by comparing the distance (“ground” distance, not “air” distance) from the inframammary crease to a horizontal line 4 inches below the middle of the clavicle. This measurement is made over the fullest portion of the breast, and it is compared with the corresponding vertical distance measured over the sternum. The difference between these measurements, added to the diameter of the areola, determines the vertical height of the larger (outside) “circle.”

The horizontal excess of skin is determined by comparing the “ground” distance from the lateral border of the sternum to the anterior axillary line over the fullest portion of the breast with the corresponding horizontal distance at the level of the inframammary crease. The difference between these measurements, added to the diameter of the areola, equals the horizontal width of the larger (outside) “circle.”

The smaller (inside) circle is the periphery of the areola. The larger “circle” is placed concentrically outside the areolar circle.

If he allows, I’ll let you know how it all turns out as he heals.

REFERENCES

1. Chest-wall Contouring in Female-to-Male Transsexuals: Basic Considerations and Review of the Literature; Plastic. Reconstr. Surg. 96(2):386-391, August 1995; Hage, J. J. and Bloem, J. J.

2. Concentric circle Operation for Massive Gynecomastia to Excise the Redundant Skin; Plast. Recontr. Surg. 63(3):350-354, March 1979.; Davidson, B. A.

3. Transareolar Incision for Gynecomastia; Plast. Reconstr Surg. 38(5):414-419, November 1966; Pitanguy, I.

4. Configuration and Localization of the Nipple-areola Complex in Man; Plast. Reconstr. Surg 108(7):1947-1952, December 2001.; Beer, Gertrude M.; Budi, Srecko; Seifert, Burkhardt; Morgenthaler, Werner; Infanger, Manfred; Meyer, Viktor E.

5. Chest-Wall Contouring Surgery in Female-to-Male Transsexuals: A New Algorithm; Plast. Reconstr. Surg 121(3):849-859, March 2008; Monstrey, Stan; Selvaggi, Gennaro; Ceulemans, Peter; Van Landuyt, Koen; Bowman, Cameron; Blondeel, Phillip; Hamdi, Moustapha; De Cuypere, Griet

3 comments:

purplesque said...

Fascinating. I hope the surgery turns out really well. Good luck to you both! (I would love to know how it turned out if its okay with your patient)

Gizabeth Shyder said...

Fascinating, I agree. Can't wait to see patient satisfaction outcome.

StorytellERdoc said...

This was a great post! Something I know nothing about since we don't do this in the ER! LOL How did it go? I'm sure you will give the patient awesome results.

Enjoy your weekend!