When we talk about gender surgery we refer to a set of procedures whose objective is to accommodate the anatomy of the patient’s body to match that of his or her actual sex. Within these procedures, there are two groups that stand out among the rest:
- Breast surgery
- Genital surgery; the change of sex in the strict sense.
Both surgeries differ from each other if the patient is male or female, but in both cases they have a greater specific weight within gender surgery.
In breast surgery the approach is diametrically opposed depending on whether we want to masculinize or when we want to feminize. When considering breast or thoracic masculinization surgery, it is important to consider the differences between the male and female thorax. In the case of men, the thorax lacks a breast, a mammary gland; although it is true that men have a certain amount of mammary tissue, but they do not have a breast as such.
In addition, the male thorax differs from the female thorax in the position and size of the areola, the definition of the muscular reliefs of the chest and, of course, there are differences in the overall structure of the thoracic cage, which is much more muscular, square and wide. When a specialist plans a thoracic masculinization surgery, he must consider all these aspects in order to achieve a result as close as possible to what the patient is looking for.
However, it should be noted that some aspects are difficult to shape and others will also respond to hormonal treatment.
What aspects should be paid attention to before indicating the surgical procedure for thoracic masculinization?
The intervention to be performed is a mastectomy. Although part of the surgery is a reconstructive procedure, when it is an intervention to masculinize the thorax, the purpose is to readapt the female thorax to a male thorax.
Before the intervention, Dr. Triviño reminds us that it is very important to analyze the patient, since there are as many surgeries as there are patients and therefore the intervention must be properly planned according to the patient’s characteristics and conditions.
After the general analysis of the patient, the specialist proceeds to an analysis of the characteristics of the thorax, such as: size and complexion of the thorax, muscular structure, quality and characteristics of the skin, size of the breasts and position of the areolas, among others. It is essential to evaluate all these parameters and to determine the best strategy to obtain a male thorax with as few stigmata as possible.
Chest masculinization surgery seeks to achieve a flat, uniform thorax, with thoracic reliefs characteristic of the male sex.
Another element to consider is the size of the breast. Fortunately, nowadays, gender dysphoria is much more contextualized and socially understood. This makes it much more common for patients to be young and, in many cases, to have begun a process of hormonal treatment at an early age, which can slow down hormonal stimulation and pubertal development.
But this is not always the case and the possible scenarios are as follows:
- The ideal scenario corresponds to that of the young person who, in the pubertal stage, has taken some actions to prevent the breast from developing.
- The most common scenario is a young patient who has developed a breast of intermediate size.
- Patients who have had full breast development.
When the patient’s breast has little development, the areola has moved very little (it is still quite eccentric) and the skin has not given way excessively, the intervention is much simpler, since the glandular tissue can be managed.
In cases of patients with small breast tissue, there is an overextension of the breast tissue, so it is difficult to achieve an ideal skin accommodation by managing the skin through the areola. This forces the specialist to make an incision in use, peripheral to the areola, leaving the areola in the middle of this use, respecting a certain amount of subareolar breast tissue. For this reason, in these cases, efforts are made to minimize or control the medial scarring, which is potentially the most visible, trying to reduce it as much as possible, but it is inevitable that it will occur on both sides of the areola.
Finally, in the case of patients with moderate and large breasts, Dr. Triviño advises resorting to a somewhat more aggressive procedure, but one that allows a scar to be located in a lower plane, away from the natural location of the areola and, therefore, less visible.
The thoracic reliefs that allow us to adjust the position of the scar in a location more consistent with the anatomical reliefs, that makes it more aesthetic even if it is longer.
In conclusion, we have several procedures that respond to various scar options:
- Procedure with inferior areolar scar: very few, in which with a simple periareolar scar we can perform a glandular resection without having to reduce the areolar diameter.
- Procedure with periareolar scar: we will resect the gland and reduce the areolar diameter through a circumferential scar to the areola.
- Enlarged periareolar procedure: a periareolar incision that is enlarged on either side of the areola in order to remove some additional skin. Indicated in cases in which the breast is not large enough to make a larger scar, but in which it does not allow us, because of its size, to perform a procedure exclusively periareolar to leave a uniform and aesthetic thorax.
- Procedure with inferior scar and areolar graft: it would be, nowadays, the most common for those patients who have a more developed breast tissue, with soft and somewhat more punished skin and, therefore, will require a much wider resection. This will require a larger scar, but aesthetically much more concealable as it can be placed in a more anatomical position.