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Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 25-28

Evaluation of concentric periareolar subcutaneous mastectomy outcomes in transsexual patients during 2016–2017 in Iran: A clinical study

1 Department of Plastic and Reconstructive Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Midwifery, Medical Branch of Tehran, Islamic Azad University, Tehran, Iran

Date of Submission26-Jan-2019
Date of Acceptance09-Mar-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Omid Etemad
Department of Plastic and Reconstructive Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_10_19

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Background: Transsexual (TS) people are those who assigned one sex at the birth but identified their gender in what society considers the opposite direction. Studies showed that gender reassignment surgery (GRS) had greatly improved the quality of life in TS patients. Materials and Methods: We studied 20 patients who had legally the permission of being underwent the sex reassignment surgery in Imam Khomeini Hospital Complex of Tehran, Iran. For all patients, concentric periareolar subcutaneous mastectomy was performed. The patients were followed up for 1 year and the results were evaluated. Results: Our findings show an acceptable scar formation after 1 year of the sex reassignment surgery. There was only one complication which was managed conservatively. About 90% of patients were satisfied from the results of surgery, and no one was less/unsatisfied. The average score of nipple sensation was 7.9 and no changes in nipple pigmentation was observed. Conclusion: Concentric periareolar mastectomy is probably a good technique of subcutaneous mastectomy in female to male GRS in patients with small and medium size of the breast and poor skin elasticity. The result scar in this method is acceptable and gives the patients a good feeling of having male chest.

Keywords: Sex reassignment surgery, subcutaneous mastectomy, transsexual

How to cite this article:
Rahmati J, Etemad O, Mohammadi NM. Evaluation of concentric periareolar subcutaneous mastectomy outcomes in transsexual patients during 2016–2017 in Iran: A clinical study. Turk J Plast Surg 2020;28:25-8

How to cite this URL:
Rahmati J, Etemad O, Mohammadi NM. Evaluation of concentric periareolar subcutaneous mastectomy outcomes in transsexual patients during 2016–2017 in Iran: A clinical study. Turk J Plast Surg [serial online] 2020 [cited 2020 Jul 12];28:25-8. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/25/274433

  Introduction Top

Transsexual (TS) people are those who assigned one sex at the birth but identified their gender in what society considers the opposite direction. According to a study in 2017, the incidence rate of transsexualism and the annual average of demands were 2.5 in 100,000 and 130 inhabitants, respectively.[1]

In 1989, a group of physiologists and psychologists laid down a guideline to select the best candidate of gender reassignment surgery (GRS).[2] Subsequently, studies have shown a significant improvement in symptoms of depression, psychological stability, and social and sexual life postoperatively.[3],[4],[5]

Studies showed that GRS had greatly improved the quality of life in TS patients.[6],[7],[8] Mammoplasty increases self-confidence and improves body image and better gender identification among female-to-male (FTM) TS people.[6]

According to this fact that hormonal therapy has limited effect on breast size, subcutaneous mastectomy includes the surgical excision of gland tissue helps to create male chest anatomy in FTM candidates.[9] Following the hysterectomy and subcutaneous mastectomy in GRS, vaginectomy, reconstruction of the horizontal part of urethra, scrotoplasty, and penile reconstruction will be performed.[9],[10],[11] For these patients, the objective is to find a technique in which we minimize the chest-wall scar, reducing and proper positioning of nipple and areola, and obliterate the inframammary fold.[11],[12] Some authors believe that skin excess determines the appropriate GRS technique.[11],[12],[13]

There are different techniques which are being used in GRS.[13],[14],[15],[16],[17] Among these methods, we chose a technique with minimum resulting scars and maximum access to the breast tissue. In concentric periareolar technique, reducing and positioning of the areola will be obtained to remove the excess skin.[11] On the other hand, this method leads to desirable scars because of confining it to the circumference of the areola.

In this study, we evaluated 20 patients who underwent concentric periareolar subcutaneous mastectomy surgery after obtaining the legal permission of sex reassignment surgery according to the preexamination tests in Iran.[18] All patients were followed up for 12 months. The probable need for revision surgery was explained for each patient before the surgery.

  Materials and Methods Top

A 28-year-old GRS candidate was chosen among the patients who have received the legal permission of this procedure in Hospital Complex of Iran. Informed consent and photography were taken for each candidate. The surgery was started under the general anesthesia. Two circular incisions with the diameters of 2.5–3 cm and 4–4.5 cm (depends on the size of the breast which was 75B with body mass index [BMI] of 19 in our case) were created around the nipple areolar complex (NAC). Marking the site of surgery was done, and a schematic drawing of this step is shown in [Figure 1].
Figure 1: Marking the site of surgery

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De-epithelialization of the space between two incisions with the diameter of 1–1.5 cm was performed. Breast tissue was excised from pectoral muscle fascia by maintaining 1 cm thickness of tissue under the NAC to avoid tension occurrence. It is shown in [Figure 2].
Figure 2: Mastectomy and conserving the nipple areola complex

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After hemostasis achieved, the closed-suction drain was placed in the area, and purse string was obtained using 4-0 nonabsorbable suture in the borderline of the outer circle of the skin. Finally, the skin and subcutaneous tissue was closed using absorbable suture as shown in [Figure 3].
Figure 3: Closing the purse string and placing the drain at the end of surgery

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After dressing up the surgical site, patients must wear compression garment. The drains were removed when the drainage was <30 cc/day. Finally, NAC was examined to evaluate the blood circulation. The follow-up continued for 1 year after the surgery and results were collected by evaluating the satisfaction, scar formation, nipple sensation, and need of revision.

  Results Top

During 2016–2017, 20 patients underwent sex reassignment surgery using concentric periareolar subcutaneous mastectomy in Imam Khomeini hospital complex in Iran. We monitored our patients for 1 year. Moreover, our findings are as follows:

  • Satisfaction: The satisfaction was rated as “very satisfied,” “satisfied,” and “not satisfied.” Among 20 patients, who underwent the GRS in Imam Khomeini Hospital Complex of Iran, 19 of them (95%) were “very satisfied” and “satisfied” from the result of surgery. These data are tabulate in [Table 1]
  • Scar formation: After 1 year of surgery, an acceptable scar was remained in the site of mastectomy
  • Nipple sensation: We considered sensation score as a quantitative variable varies between 0 and 10 in where 0 and 10 indicates no sensation and good sensation, respectively. This evaluation was done by superficial and deep breast touch by a doctor. After 1 year from the GRS, the average score of nipple sensation was 7.9
  • Complications: Hematoma occurred in one patient, and there was no other complication among other patients in our study. Hematoma was managed conservatively
  • Need for secondary correction: During 1 year from the surgery, three patients needed revision because of contour deformity occurrence. Liposuction was performed for one of them, and two of them underwent the excess breast skin removal.

[Figure 4] shows a pre- and post-operative photography of one the patients.
Table 1: Satisfaction from the results of surgery

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Figure 4: Preoperative (a) and postoperative (b) photos

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  Discussion Top

Mastectomy in TS people who are the candidates of GRS plays an important role in esthetic purposes to make a male chest with minimal scar. There are many different techniques which are used to achieve this aim.[6],[7],[9],[10],[11],[12],[13],[19] For smaller breast and elastic skins, the semicircular technique which was first described by Webster is deployed.[11] The resultant scar in this technique is acceptable.[14] In the cases with small breasts and large prominent nipple, the Trans-areolar Technique is used. This procedure allows us to resect a specific amount of nipple, but the result scar on NAC may be remained.[15] In patients with large and ptotic breasts, the free nipple graft technique is preferred.[13],[17],[20] Long residual scars, changes in pigmentation, and sensation of NAC and the risk of incomplete graft take are some disadvantages of this method.[11] Because of confining the scar to the circumference of the areola, concentric circular technique has aesthetic results in these patients. This method also allows us to positioning and reducing the areola.[16] A same method called the extended concentric circular technique is used for correcting wrinkling resulted by large difference between the inner and outer circles.[11] The result scar may extend horizontally onto the breast skin. Selecting the proper technique depends on the size of breast tissue and the degree of ptosis. In order to avoid depression deformity, we must save a small amount of mammary tissue. Furthermore, the pectorals major muscle fascia must be preserved to be fixed with fascia.[9] Hematoma should be controlled and supervised during the follow-up.

Subcutaneous mastectomy allows us to conserve the nipple areola skin and gives the surgeon maximum access to the breast tissue.[21] The resultant scars are also acceptable and have aesthetic effects in making male-chest for TS patients who are candidates of FTM GRS.

There are many studies in which subcutaneous mastectomy outcomes are evaluated. In a study by Matton and Anseeuw on 202 patients, the rate of complication was 5%, and the patients who needed secondary corrections of areola, scar, and chest contouring were 8.9%, 12.6%, and 17.8%, respectively.[22]

Cameron et al. studied 97 patients who were candidates of TGS subcutaneous mastectomy with a 5-year follow-up period.[23] Totally, five major complications were reported. Furthermore, there was an indication of some minor complications included hypertrophic scarring, deformities, and pigmentation changes of the nipple grafts.

In the study of Kääriäinen et al., 57 patients underwent the GRS.[24] Chest-wall contouring surgery was performed for these patients and among them, one-third of the patients experienced postoperative complications; 14%, 28%, and 15.8% needed scar, contour, and the nipple corrections, respectively. In this study, the rate of complication occurrence was larger than in ours; and it may have a relation with the method of the surgery.

Eighty-eight patients underwent FTM sex reassignment surgery by Fredrick and his colleagues using subcutaneous nipple-sparing mastectomy technique. Eighty-three patients were satisfied from the results of surgery, and there were no complications.[25] In our study, we experienced complications in three patients, and we need more study to prevent it for the future cases.

Top and Balta reported the occurrence of complications in 13.4% of patients among 52 patients who underwent the subcutaneous mastectomy FTM surgery using Webster semicircular, concentric circular, vertical, and apron flap methods.[10] The rate of complication was 13.4%, and the results showed that all patients were satisfied from the esthetic results of the surgery. They choose the technique of the surgery according to breast size, degree of skin excess, skin elasticity, chest width, nipple areola complex size and position; while in our study, all patients were selected among the patients with average BMI of 21 and average breast size of 78 to perform concentric periareolar subcutaneous mastectomy.

Among 20 patients in our study, 90% of them were satisfied from the results of the surgery; there was only one patient who experienced hematoma, but no necrosis, pigmentation changes in nipple and hypertrophic scar were observed. The scar remained in the site of surgery was acceptable in all patients. During 1 year from the surgery, three patients needed revision because of contour deformity occurrence. Liposuction was performed for one of them, and two of them underwent the excess breast skin removal.

We need more studies to eliminate the complications of this surgical technique and also, evaluating the various aspects of subcutaneous mastectomy methods.

  Conclusion Top

Concentric periareolar mastectomy is probably a good technique of subcutaneous mastectomy in FTM GRS. That is because of giving the surgeon maximum access to the breast tissue and possibility of repositioning and reduction of nipple areola complex. Furthermore, the result scar in this method is acceptable and gives the patients a good feeling of having a male chest. The elimination of postoperative complications and scar formation needs the experience of a plastic surgeon. Finally, it should be considered that choosing the proper method of surgery is a critical step in these patients and it may help us to prevent the occurrence of complications postoperatively. Our study was performed in Imam Khomeini Hospital Complex of Tehran, Iran.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Becerra-Fernández A, Rodríguez-Molina JM, Asenjo-Araque N, Lucio-Pérez MJ, Cuchí-Alfaro M, García-Camba E, et al. Prevalence, incidence, and sex ratio of transsexualism in the autonomous region of Madrid (Spain) according to healthcare demand. Arch Sex Behav 2017;46:1307-12.  Back to cited text no. 1
Meyer W, Bockting O. The Standards of Care (SOC) for Gender Identity Disorders. 6th Edition, Netherland, Harry Benjamin International Gender Dysphoria Association; 1989. p. 1-27.  Back to cited text no. 2
Moshtagh N. Are there only two genders? Baztab Danesh J Cogn Brain Behav 2007;1:32-4.  Back to cited text no. 3
Cohen-Kettenis PT, Gooren LJ. Transsexualism: A review of etiology, diagnosis and treatment. J Psychosom Res 1999;46:315-33.  Back to cited text no. 4
Cohen-Kettenis P, Yolundal M, Stephanie H, Peggy T. Adolescent with gender identity disorder who were accepted or rejected for sex reassignment surgery-a prospective follow up study. Am Acad Child Adolesc Psychiatry 2001;40:472-81.  Back to cited text no. 5
Richards C, Barrett J. The case for bilateral mastectomy and male chest contouring for the female-to-male transsexual. Ann R Coll Surg Engl 2013;95:93-5.  Back to cited text no. 6
Wolter A, Diedricson J, Scholz T, Arenz Landwehr A, Liebau J. Sexual reassignment surgery in female-to-male transsexual. J Plast Reconstr Aesthet Surg 2015;68:184-91.  Back to cited text no. 7
Zeluf G, Dhejne C, Orre C, Nilunger Mannheimer L, Deogan C, Höijer J, et al. Health, disability and quality of life among trans people in Sweden-a web-based survey. BMC Public Health 2016;16:903.  Back to cited text no. 8
Namba Y, Watanabe T, Kimata Y. Mastectomy in female-to-male transsexuals. Acta Med Okayama 2009;63:243-7.  Back to cited text no. 9
Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics. Balkan Med J 2017;34:147-55.  Back to cited text no. 10
Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg 2011;25:229-44.  Back to cited text no. 11
Hage JJ, Bloem JJ. Chest wall contouring for female-to-male transsexuals: Amsterdam experience. Ann Plast Surg 1995;34:59-66.  Back to cited text no. 12
Lindsay WR. Creation of a male chest in female transsexuals. Ann Plast Surg 1979;3:39-46.  Back to cited text no. 13
Webster JP. Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg 1946;124:557-75.  Back to cited text no. 14
Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr Surg 1966;38:414-9.  Back to cited text no. 15
Davidson BA. Concentric circle operation for massive gynecomastia to excise the redundant skin. Plast Reconstr Surg 1979;63:350-4.  Back to cited text no. 16
Kluzák R. Sex conversion operation in female transsexualism. Acta Chir Plast 1968;10:188-98.  Back to cited text no. 17
Levine SB. Psychiatric diagnosis of patients requesting sex reassignment surgery. J Sex Marital Ther 1980;6:164-73.  Back to cited text no. 18
Berry MG, Curtis R, Davies D. Female-to-male transgender chest reconstruction: A large consecutive, single-surgeon experience. J Plast Reconstr Aesthet Surg 2012;65:711-9.  Back to cited text no. 19
Hoopes JE. Surgical construction of the male external genitalia. Clin Plast Surg 1974;1:325-34.  Back to cited text no. 20
Matton G, Anseeuw A, Subcutaneous mastectomy, indications and techniques. Acta Chir Bleg 1987;87:120-8.  Back to cited text no. 21
Cregten-Escobar P, Bouman MB, Buncamper ME, Mullender MG. Subcutaneous mastectomy in female-to-male transsexuals: A retrospective cohort-analysis of 202 patients. J Sex Med 2012;9:3148-53.  Back to cited text no. 22
Cameron JA, Cleland AJ, Maraccini RL, Cunningham BL, Buckley MC. Trsnsgender subcutaneous mastectomy for gender affirmation. Plast Reconstr Surg Glob Open 2016;4:160-1.  Back to cited text no. 23
Kääriäinen M, Salonen K, Helminen M, Karhunen-Enckell U. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg 2017;106:74-9.  Back to cited text no. 24
Frederick MJ, Berhanu AE, Bartlett R. Chest surgery in female to male transgender individuals. Ann Plast Surg 2017;78:249-53.  Back to cited text no. 25


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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