Top surgery for gender affirmation

Introduction

Gender affirmation surgery is an important step in the life journey of some gender diverse individuals (the term ‘re-assignment’ is no longer used and is considered harmful). Top (chest/breast) surgery is the most commonly pursued type of gender affirming surgery due to its visibility and the relative perception of this anatomical area as a gender marker. On the other hand, only a portion of these individuals will go ahead with bottom surgery, which has a great range, from hysterectomy and oophorectomy to metoidioplasty or phalloplasty.

Top surgery refers mainly to either breast augmentation or bilateral mastectomies with chest wall reconstruction for transwomen and transmen, respectively.

There appears to have been an exponential demand for these types of operations worldwide in recent years. There has been an almost 30% increase in the number of referrals to our unit over the last 3 years. This has resulted in increased waiting times and opening of a discussion on establishment of a subspecialty training programme for those interested in these types of procedures.

Indications for surgery: Adapted from WPATH SoC7 (the standards of care 8 have been published in September 2022 but are yet to be adopted fully by the NHS):

• 1.

  Persistent, well-documented gender dysphoria;

• 2.

  Capacity to make a fully informed decision and to consent for treatment;

• 3.

  Age of majority in a given country (if younger, follow the standards of care (SOC) for children and adolescents);

• 4.

  If significant medical or mental health concerns are present, they must be reasonably well controlled.

Hormone therapy is not a pre-requisite for female-to-male (FtM) top surgery. Although not an explicit criterion, it is recommended that male-to-female (MtF) patients undergo feminising hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose of this is to maximise breast growth in order to obtain better surgical (aesthetic) results.

There is also specific guidance on what an appropriate referral should include as part of an individual being considered for surgery. All the above should be in place, not as a means of gatekeeping, but rather to ensure informed consent, and emphasise the irreversibility of these procedures.

Most surgeons worldwide will require a single referral from a specialist (psychiatrist, psychologist or specialist counsellor) for a trans person and two separate referrals for non-binary individuals. Most NHS specialist surgical units in the UK require two independent referrals for any individual to be considered for surgery from one of the gender identity clinics in the NHS. It is important to note that there are health systems in the world where a specific transgender informed consent model is considered and promoted.

As with any other type of surgery, a multidisciplinary approach should be the target of any unit regularly performing these types of procedures. It is preferable to always involve a team of surgeons and other professionals (physiotherapists, therapists and others) in order to be able to offer the best option to the trans persons seeking top surgery.

Currently FtM top surgery is offered free of charge in the NHS. Waiting times for any trans-related healthcare pathway are outside any other pathway targets set by the NHS for any other healthcare issue. The time between general practitioner (GP) referral to the Gender Identity service to the operating table for top surgery approaches a mean of 6 years in the NHS with a similar situation observed in other public health systems. There are limited units that offer these procedures and a rather small number of surgeons willing to offer the procedure within public practice.

There are currently no data related to the number of surgeons or operations that are performed each year at national level, although recently, a live database has been set up to provide the Gender Dysphoria National Referral Support Service (GDNRSS) commissioning unit with this information moving forward. This is an important advancement in the development and provision of transgender healthcare in the UK in accordance with national healthcare standards.

The situation varies around the world. As an example, the situation in the USA appears to be complicated, inconsistent and dictated mainly by insurance companies.

Considerations for male to female (MtF) top surgery

MtF top surgery is not regularly funded in the NHS. This is because hormonal treatment will result in the development of some glandular tissue; however the surgeon must be aware of certain anatomic differences between the female and male chest to obtain an acceptable outcome. These differences notably include difference in the width between the female and male chest, difference in size of the areolae and, overall, a smaller degree of ptosis even after extended hormonal therapy. The principles of augmentation remain the same for cis and transwomen. Due to the smaller degree of ptosis in transwomen one should consider lowering the inframammary fold (IMF) and releasing the medial attachments of the pectoralis major muscle to increase the pocket to accommodate the implant, which can be placed either in the subglandular or subpectoral (more common) plane. Due to the small areola size the most common incision used is an inframammary one. Surgeons should be aware that most transwomen tend to request larger implants as a means of underlining their femininity and because of their chest width.