Delivery of a truly patient-centred service for chest reconstruction in trans gender persons

Persons diagnosed with gender dysphoria generally experience distress due to the dissonance between their birth-assigned and experienced gender. The goal of medical and surgical interventions is to align the physical... [ view full abstract ]

Persons diagnosed with gender dysphoria generally experience distress due to the dissonance between their birth-assigned and experienced gender. The goal of medical and surgical interventions is to align the physical characteristics with the experienced gender. The World Professional Association for Transgender Health (WPATH) recommend that medical transition be managed in an interdisciplinary setting.
North Manchester General Hospital has a dedicated chest reconstruction service for Trans gender persons, receiving approximately 70 referrals for surgery each year. The service has been developed over the last 10 years and is delivered by two Consultant Oncoplastic Breast Surgeons, at team of clinical nurse specialists, and a clinical psychologist.

To represent our service for Trans gender persons undergoing chest reconstruction, we describe the pertinent features of the care that we deliver for Trans male persons referred for chest contouring surgery. A service which we... [ view full abstract ]

To represent our service for Trans gender persons undergoing chest reconstruction, we describe the pertinent features of the care that we deliver for Trans male persons referred for chest contouring surgery. A service which we believe to be a unique in the UK. It is a truly patient-centred and individualised model of care.

The full process of care for Trans male persons having chest reconstruction at North Manchester General Hospital is presented, with particular reference to selection of surgical technique. At our institution, five different... [ view full abstract ]

The full process of care for Trans male persons having chest reconstruction at North Manchester General Hospital is presented, with particular reference to selection of surgical technique.
At our institution, five different mastectomy techniques for chest reconstruction in Trans male persons are available:
1. Liposuction: Suitable for small, predominantly fatty breasts with very little glandular tissue. This technique retains full nipple sensation
2. Techniques which maintain the nipples’ own blood supply and retain sensation in >70% of cases:
I. Periareolar incision and Gortex closure: Suitable for small breasts where only a small amount of tissue and skin need be excised. A Gortex suture is utilised to prevent stretching of the scars
II. Inferior dermal flap: Suitable for the majority of patients with medium to large breasts (approximately 200 to 600g excision)
III. Bipedicled flap: Suitable for medium-sized breasts with naturally high-sitting nipples where it is not possible to place the double incision scars low. This technique results in nipples within horizontal scars
3. Free full thickness nipple graft: Suitable for large breasts or patients with medical conditions which preclude a longer anaesthetic-time or use of flap techniques

To present what we believe to be a reliable, thorough and reproducible model of patient-care which adheres to and exceeds the WPATH standards. [ view full abstract ]

To present what we believe to be a reliable, thorough and reproducible model of patient-care which adheres to and exceeds the WPATH standards.

Prior to referral for surgery, all patients have been fully assessed by a Gender Identity clinic and have made a social gender role transition. At initial consultation for chest reconstruction surgery, a thorough history and... [ view full abstract ]

Prior to referral for surgery, all patients have been fully assessed by a Gender Identity clinic and have made a social gender role transition. At initial consultation for chest reconstruction surgery, a thorough history and chest examination is performed, taking in to account the shape of chest wall, and the amount of tissue and skin to be removed. The patients’ goals for surgery with respect to the importance of nipple-sensation and regarding scar placement are explored.
Multidisciplinary care is provided. There is assessment by a clinical psychologist, who assesses all patients who have healthy tissue removed, to ensure psychological robustness to deal with major surgery and its potential complications. Clinical nurse specialists are involved in exploring and informing the patient’s understanding of the procedure with use of counselling and viewing the unit’s bank of pre and post-operative photographs. Medical photography is employed to document and reference with the patient the chest-appearance at each stage. All patients over forty years have mammographic assessment.
To ensure high quality and respectful delivery of care, the unit delivers education and training sessions for clinic, ward, theatre and medical staff.
To safeguard best practice, the unit has an active programme of audit, governance and research.

Patient-involvement in the surgical decision-making process is central to our model of care. We have a range of reconstruction techniques which may be employed, each with its own strengths and weaknesses. The success of each... [ view full abstract ]

Patient-involvement in the surgical decision-making process is central to our model of care. We have a range of reconstruction techniques which may be employed, each with its own strengths and weaknesses. The success of each technique is hinged upon a both detailed and holistic understanding of the patients’ goals, and their baseline physical and emotional health.