What complications is a transgender individual at risk for after undergoing mastectomy?

Complications After Mastectomy in Transgender Individuals

Transgender individuals who undergo mastectomy are at risk for several complications including hematoma formation, infection, sensory disturbances, persistent pain, and need for revision surgery, though the overall complication rate is relatively low compared to cisgender mastectomy patients.

Common Post-Mastectomy Complications

Physical Complications

• Hematoma: Occurs in approximately 3.6-7.8% of patients 1, 2
• Infection: Affects 2.9-7.8% of patients, potentially requiring antibiotic treatment 1, 2
• Areola/nipple necrosis: Seen in about 4.4% of cases 1
• Seroma formation: Reported in approximately 0.7% of patients 2
• Hypertrophic scarring: Requiring steroid injection in about 2.9% of cases 2
• Sensory disturbances: Affect up to 47.5% of patients 1
• Persistent pain: Experienced by approximately 27.4% of patients, though most (60.9%) categorize it as mild and manageable without opioids 1

Need for Revision Surgery

• Overall revision rate: Approximately 10.9-38% of patients require some form of revision 2, 3
• Common revisions include:
  • Chest wall recontouring (due to inadequate tissue removal)
  • Scar revision (9%)
  • Dog ear corrections (20%)
  • Nipple corrections (6%)
  • Contour corrections (6%) 3, 4

Risk Factors and Considerations

Surgical Technique Impact

• Smaller incision techniques (areolar incisions) have higher secondary correction rates (48%) compared to larger incision techniques (sub-mammary incisions) at 21% 3
• Technique selection should be based on:
  • Breast size
  • Degree of ptosis
  • Skin elasticity 3

Medication and Hormone Considerations

• Testosterone therapy may increase risks of:
  • Obstructive sleep apnea
  • Hypertension
  • High body weight
  • Erythrocytosis and theoretical increased blood viscosity 5

Special Perioperative Considerations

• Chest binders: Should be removed during surgery if ventilation is required, especially in prone position, but can be reapplied as soon as safely possible postoperatively to minimize dysphoria 5
• Pain management: Evidence suggests transgender patients may be prescribed more opioids than needed, increasing risk of misuse; multimodal pain management should be employed 5
• Substance use: Higher rates of substance use in transgender populations may complicate perioperative management 5

Long-Term Considerations

Regret and Psychological Outcomes

• Regret rate is extremely low: Only about 0.95% of patients express regret after mastectomy, with no reversal surgeries reported in follow-up periods of 3-7 years 2

Cancer Screening

• For patients who have undergone total mastectomy, routine breast cancer screening is generally not indicated according to the American College of Radiology 5
• For patients who have undergone partial tissue removal or reduction rather than complete mastectomy, some residual breast tissue remains and may require monitoring 5

Clinical Implications

• The overall complication profile for transgender mastectomy is similar to or better than that seen in cisgender patients undergoing mastectomy for other indications 6
• BMI has been identified as a significant predictor of all-cause and wound complications 6
• Despite previous concerns, mastectomy is safe even in transgender men with a history of prior breast reduction surgery 4
• Careful technique selection based on individual breast characteristics is essential to minimize revision rates 3

Transgender patients undergoing mastectomy should be counseled about these potential complications while being reassured that the procedure is generally safe with manageable complications and high satisfaction rates.