A New Algorithm for Masculine Chest-Wall Contouring in 560 Trans-AFAB (Assigned Female at Birth) Patients: Clinical...

The preoperative plan is crucial in chest-wall contouring surgery. Choosing the right surgical technique may be challenging, especially when there are many variables to consider. Therefore, the senior author (GLR) described a novel and simpler preoperative algorithm which we used in our group of 560 trans-AFAB patients.

From 2016 to 2024, 560 consecutive trans-AFAB patients underwent top surgery with the new algorithm that uses the inferior border of pectoralis major muscle as a landmark to decide between three techniques: (1) Periareolar incision (PA), when the NAC is on the landmark, (2) hemi-periareolar incision (HP), when the NAC is above the landmark, and (3) double-incision technique with free nipple graft (DI) when the NAC is below the landmark. Complications, need for a touch-up, scar quality (through the Vancouver Scar Scale) and patient-reported outcomes (through TRANS-Q questionnaire) were analyzed.

The most used technique was DI (82.4%) followed by HP (11.4%) and PA (6.2%). Hematoma occurred in 10.8% of the patients but only 1.7% needed a reintervention in the operating room. We performed a touch-up procedure in 9% of the patients. The most prevalent VSS score was 1 registered in 38.4% of patients. The TRANS-Q questionnaire revealed that the large majority of patients showed an improvement after surgery (p value: 1.41 × 10^-16).

This simple but effective new algorithm can support surgical choices and maximize the aesthetic outcomes in trans-AFAB patients' chest-wall contouring. High patient satisfaction and good surgical outcomes evidence the efficacy of this algorithm.

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