Background/Objectives: Assigned female at birth (AFAB) individuals who identify as transgender or gender-diverse (TGD) with concurrent breast cancer or high-risk genetic mutations represent a unique population, requiring consideration of oncologic and aesthetic goals. These patients sought chest masculinization with oncologic gender-affirming mastectomy (OGAM) or non-binary reconstruction to alleviate gender dysphoria and treat their breast cancer. There is limited literature on surgical techniques in this patient population. Methods: A retrospective chart review of AFAB TGD adults (>18 years of age) who underwent OGAM or non-binary reconstruction at the University of Washington between 2019 and 2023 was conducted. All patients had a consultation with a plastic surgeon for reconstruction and a minimum of one year follow-up. Demographic data, oncologic status, post-operative complications, and revision surgical history were collected. Results: Eight AFAB TGD individuals met the inclusion criteria. The mean age at the time of mastectomy was 35.13 years (SD = 8.04), and the mean BMI was 29.88 (SD = 6.40). Indications for mastectomy included a breast cancer diagnosis (N = 4) or a strong family history of breast cancer or genetic predisposition (N = 4). Two (25%) patients underwent nipple-sparing mastectomies (NSM), two patients (25%) underwent skin-sparing mastectomy with Goldilocks reconstruction, and four patients (50%) underwent simple mastectomy (oncologic gender-affirming mastectomy), flat closure with free nipple graft (FNG). Two patients had staged nipple mastectomy with secondary nipple reduction and fat grafting. Six patients had immediate reconstruction, four (50%) patients underwent immediate double-incision OGAM with FNG, and two (25%) patients underwent Goldilocks procedures—one with and one without FNG. One patient (12.5%) experienced a surgical site infection, and three patients (37.5%) underwent revision surgery. No patients had positive margins following their mastectomy. Conclusions: This case series highlights the importance of a multidisciplinary and highly personalized approach for AFAB and TGD individuals undergoing oncologic gender-affirming mastectomy or non-binary reconstruction. We reviewed reconstructive options performed at our institution, demonstrating safe oncologic and reconstructive techniques that emphasized collaboration between breast and plastic surgeons.

Transgender and gender-diverse (TGD) patients face multifactorial barriers to accessing medically-necessary interventions, including gender-affirming chest surgery (GACS). Surgeons may exacerbate this inequity by imposing preoperative body mass index (BMI) requirements on their patients. Recent studies present conflicting evidence regarding the association between BMI and postoperative complications following GACS; however, no studies have assessed these outcomes in cases of extremely high BMI (>40 kg/m²). Assigned female at birth patients ≥ 18 years old undergoing GACS at three institutions were reviewed. Demographic and clinical characteristics were analyzed descriptively between patients with BMI ≤40 and >40 kg/m². A multivariable logistic model was used to determine the effect of BMI on complications. 647 patients were included, of these, 82 (12.7%) had BMI >40 kg/m². Among patients with BMI >40 kg/m², 21.9% had at least one complication. A significant association was observed between BMI and overall complications (p=0.0026). Adjusted analyses suggested that patients with BMI >40 kg/m2 were 2.34 times more likely to experience at least one complication (95% CI 1.153, 4.733). Overall complications, incisional dehiscence, and major complications (requiring unplanned readmission and/or reoperation) were significantly higher in patients with BMI >40 kg/m². This multi-institutional retrospective review demonstrates a higher frequency of adverse outcomes in patients with BMI >40 kg/m². GACS can be performed safely in patients with extreme BMI, however appropriate informed consent is necessary. These data will facilitate evidence-based counseling on the risks and benefits of GACS in this patient population.