Hockey stick incision: a modified technique for chest wall masculinization

Abstract

Background: Chest wall masculinization is often performed for transgender men in order to address gender dysphoria. Peri-areolar and double-incision mastectomy with free nipple grafts, are the most common techniques employed in chest masculinization surgery, but are limited by their relative inconsistency and inefficiency in reconstructing a natural anterior contour that comprehensively resembles that of a cismasculine chest. The purpose of this study is two-fold. The first is to describe the "hockey stick" approach, which expands on the widely performed double-incision mastectomy to the axilla, with an additional step of revising lateral chest wall folds of tissue excess. This technique is scalable to the degree of pre-operative excess tissue on the anterior and lateral chest wall. The second is to compare the "hockey stick" incision to existing reconstructive options, with respect to clinical outcomes and patient satisfaction.Methods: Patients who received chest masculinization surgery at Yale-New Haven Hospital were included.A retrospective chart review, comprising demographic variables, procedural details, and post-operative events, was conducted. Selected modules from a validated survey instrument, the BODY-Q, were measured.Patients were classified by body mass index and incision, which included peri-areolar, inframammary fold, and "hockey stick" incision by date.Results: Twenty-seven of 73 (37.0%) participants completed the full survey and were included in the analysis. The "hockey stick" incision had comparable patient satisfaction and post-operative outcomes, compared to peri-areolar and double-incision mastectomy with free nipple graft techniques. Greater BMI patients had a higher incidence of wound dehiscence, compared to other weight classifications. Conclusions:The "hockey stick" incision is a readily performed, effective surgical technique for building a cis-masculine appearing chest in transgender men with efficient and predictable outcomes. While performed in patients with higher BMI, the "hockey stick" confers equivalent patient satisfaction and clinical outcomes to peri-areolar and double-incision mastectomy.

Body Contouring as Gender-Affirming Surgery in Transgender Patients: A Systematic Review of the Current Literature

“…Most chest-wall contouring studies were case series ranging from 11 to 464 patients. Nine articles compared outcomes from different mastectomy incisions in trans male patients, as well as aesthetic and patient-reported outcomes (PROs) [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ], while two focused only on the latter [ 12 , 23 ].…”

“…For patients needing more than 1 kg to be resected, the inframammary resection, the Hockey Stick (HS) [ 14 ], the inframammary skin resection with full-thickness free nipple graft (ISFNG) [ 16 ], and the complete mastectomy with free NAC graft (CMFNG) [ 20 ] were suitable. The periareolar and semicircular techniques reported more bleeding, as did obese patients who underwent a DIFNG [ 16 , 17 , 18 ].…”

“…Nipple necrosis was reported as 0 in most studies; however, there were 7 cases in double incision patients, of which 4 were partial [ 15 , 19 ], 7 cases in periareolar, and 7 in inframammary incisions [ 18 ]. Dehiscence was more common in Class II (BMI 35–39.9) obese patients who had a double-incision mastectomy [ 17 ] and the first cohort of HS incisions [ 14 ]. As for the return to the operating room, the DINTP had the most patients, 31 (39.2%) [ 19 ], followed by periareolar incisions with a superiorly based NAC flap (PNAC), spindle-shaped simple mastectomy with an inferiorly based NAC flap [ 20 ] and periareolar techniques in Makkonen and Kamali’s study [ 21 , 22 ] ( Table 4 ).…”

“…Only one study evaluated the sensitivity return in patients who underwent DINTP [ 19 ]. Two studies reported aesthetic scores [ 15 , 20 ], and six studies reported PROs using the BODY Q scale [ 12 , 14 , 15 , 17 , 22 , 23 ] ( Table 6 ).…”

“…As for aesthetic scores, the spindle-shape simple mastectomy and the complete mastectomy with free NAC had the best scores compared to the conventional DINS and conventional DIFNG [ 15 , 20 ]. In general, patients with double incision techniques reported better BODY Q scores than normal-weight patients [ 14 , 15 , 22 ].…”