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Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze?

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  • Gender Affirmation Surgery
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Abstract

Background

Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity.

Methods

Transgender and cisgender participants were enrolled and shown images of surgery naïve chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image.

Results

Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naïve: 802 vs. 395 ms; p = 0.02, masculinized: 940 vs. 692 ms, p = 0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391 ms; p = 0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847 ms; p = 0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59 ms; p = 0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p < 0.05).

Conclusions

This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

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References

  1. van Boerum MS, Salibian AA, Bluebond-langner R, Agarwal C (2019) Chest and facial surgery for the transgender patient. Transl Androl Urol 8:219–227

    Article  Google Scholar 

  2. Morrison SD, Wilson SC, Mosser SW (2018) Breast and body contouring for transgender and gender nonconforming individuals. Clin Plast Surg 45:333–342. https://doi.org/10.1016/j.cps.2018.03.015

    Article  PubMed  Google Scholar 

  3. Miller TJ, Wilson SC, Massie JP et al (2019) Breast augmentation in male-to-female transgender patients: technical considerations and outcomes. JPRAS Open 21:63–74. https://doi.org/10.1016/j.jpra.2019.03.003

    Article  PubMed  PubMed Central  Google Scholar 

  4. Hughes SM, Gallup GG (2003) Sex differences in morphological predictors of sexual behavior. Evol Hum Behav 24:173–178. https://doi.org/10.1016/S1090-5138(02)00149-6

    Article  Google Scholar 

  5. Fan J, Dai W, Liu F, Wu J (2005) Visual perception of male body attractiveness. Proc Biol Sci 272:219–226. https://doi.org/10.1098/rspb.2004.2922

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Walzer NK, Rivera A, Wright L, Agarwal CA (2017) Female-to-male chest reconstruction. Ann Plast Surg 79:259–263. https://doi.org/10.1097/SAP.0000000000001099

    Article  CAS  PubMed  Google Scholar 

  7. Salim AM, Deschamps-braly JC (2019) Current concepts in feminizing gender surgery. Plast Reconstr Surg. https://doi.org/10.1097/PRS.0000000000005595

    Article  PubMed  Google Scholar 

  8. Lane M, Ives GC, Sluiter EC et al (2015) Trends in gender-affirming surgery in insured patients in the United States. Plast Reconstr Surg Glob Open. https://doi.org/10.1097/GOX.0000000000001738

    Article  Google Scholar 

  9. Sutcliffe PA, Dixon S, Akehurst RL et al (2009) Evaluation of surgical procedures for sex reassignment: a systematic review. Br J Plast Surg 62:294–306. https://doi.org/10.1016/j.bjps.2007.12.009

    Article  CAS  Google Scholar 

  10. Frison E, Sessiecq Q, Al MK (2012) Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plast Reconstr Surg. https://doi.org/10.1097/01.prs.0000434415.70711.49

    Article  PubMed  Google Scholar 

  11. Klassen AF, McEvenue G, Wang Y et al (2020) The BODY-Q chest module: further validation in a Canadian chest masculinization surgery sample. Aesthet Surg J. https://doi.org/10.1093/asj/sjaa224

    Article  Google Scholar 

  12. Klassen AF, Kaur M, Poulsen L et al (2018) Development of the BODY-Q chest module evaluating outcomes following chest contouring surgery. Plast Reconstr Surg 142:1600–1608. https://doi.org/10.1097/PRS.0000000000004978

    Article  CAS  PubMed  Google Scholar 

  13. Nolan IT, Hazen A, Morrison SD (2018) On the gender identity of breast patients. JAMA Surg 153:1164. https://doi.org/10.1001/jamasurg.2018.3227

    Article  PubMed  Google Scholar 

  14. Olson-Kennedy J, Warus J, Okonta V et al (2018) Chest Reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr 172:431–436. https://doi.org/10.1001/jamapediatrics.2017.5440

    Article  PubMed  PubMed Central  Google Scholar 

  15. Klassen AF, Kaur M, Johnson N et al (2018) International phase I study protocol to develop a patient-reported outcome measure for adolescents and adults receiving gender-affirming treatments (the GENDER-Q). BMJ Open 8:e025435. https://doi.org/10.1136/bmjopen-2018-025435

    Article  PubMed  PubMed Central  Google Scholar 

  16. Morrison SD, Massie JP, Crowe CS, Smith JR (2018) Patient-reported outcomes needed for chest masculinization. Ann Plast Surg 80:90–91. https://doi.org/10.1097/SAP.0000000000001130

    Article  CAS  PubMed  Google Scholar 

  17. Cai LZ, Paro JAM, Lee GK, Nazerali RS (2018) Where do we look? assessing gaze patterns in breast reconstructive surgery with eye-tracking technology. Plast Reconstr Surg 141:331e–340e. https://doi.org/10.1097/PRS.0000000000004106

    Article  CAS  PubMed  Google Scholar 

  18. Cai L, Kwong J, Azad A et al (2019) Where do we look? assessing gaze patterns in cosmetic face-lift surgery with eye tracking technology. Plast Reconstr Surg 144:63–70. https://doi.org/10.1097/PRS.0000000000005700

    Article  CAS  PubMed  Google Scholar 

  19. Peterson MF, Eckstein MP (2013) Individual differences in eye movements during face identification reflect observer-specific optimal points of fixation. Psychol Sci 24:1216–1225. https://doi.org/10.1177/0956797612471684

    Article  PubMed  Google Scholar 

  20. American Society of Plastic Surgeon (2021) Before & after photos. https://www.plasticsurgery.org/photo-gallery. Accessed Jan 2021

  21. Olsen A (2012) The Tobii I-VT fixation filter. www.tobiipro.com. Accessed Oct 2020

  22. Boardman JP, Fletcher-Watson S (2017) What can eye-tracking tell us? Arch Dis Child 102:301–302. https://doi.org/10.1136/archdischild-2016-311693

    Article  PubMed  Google Scholar 

  23. Dindaroğlu F, Doğan S, Amado S, Doğan E (2017) Visual perception of faces with unilateral and bilateral cleft lip and palate: an eye-tracking study. Orthod Craniofac Res 20:44–54. https://doi.org/10.1111/ocr.12140

    Article  PubMed  Google Scholar 

  24. Adetayo AM, James O, Adeyemo WL et al (2018) Unilateral cleft lip repair: a comparison of treatment outcome with two surgical techniques using quantitative (anthropometry) assessment. J Korean Assoc Oral Maxillofac Surg 44:3. https://doi.org/10.5125/jkaoms.2018.44.1.3

    Article  PubMed  PubMed Central  Google Scholar 

  25. Mallucci P, Branford OA (2012) Concepts in aesthetic breast dimensions: analysis of the ideal breast. J Plast Reconstr Aesthet Surg 65:8–16. https://doi.org/10.1016/j.bjps.2011.08.006

    Article  CAS  PubMed  Google Scholar 

  26. Lewin R, Amoroso M, Plate N et al (2020) The aesthetically ideal position of the nipple-areola complex on the breast. Aesthet Plast Surg 44:1130–1138. https://doi.org/10.1007/s00266-020-01814-y

    Article  Google Scholar 

  27. Ayyala HS, Mukherjee TJ, Le T-M et al (2020) A three-step technique for optimal nipple position in transgender chest masculinization. Aesthet Surg J. https://doi.org/10.1093/asj/sjaa150

    Article  PubMed  Google Scholar 

  28. Top H, Balta S (2017) Transsexual mastectomy: selection of appropriate technique according to breast characteristics. Balkan Med J 34:147–155. https://doi.org/10.4274/balkanmedj.2016.0093

    Article  PubMed  PubMed Central  Google Scholar 

  29. Maas M, Howell AC, Gould DJ, Ray EC (2020) The ideal male nipple-areola complex: a critical review of the literature and discussion of surgical techniques for female-to-male gender-confirming surgery. Ann Plast Surg 84:334–340. https://doi.org/10.1097/SAP.0000000000002018

    Article  CAS  PubMed  Google Scholar 

  30. Wilson SC, Morrison SD, Anzai L et al (2018) Masculinizing top surgery: a systematic review of techniques and outcomes. Ann Plast Surg 80:679–683. https://doi.org/10.1097/SAP.0000000000001354

    Article  CAS  PubMed  Google Scholar 

  31. Tanini S, Calabrese S, Lo Russo G (2020) The importance of nipple-areola complex position in chest masculinization surgery. Aesthet Plast Surg. https://doi.org/10.1007/s00266-020-01707-0

    Article  Google Scholar 

  32. Sun J, Mu D, Liu C et al (2019) The comparison of scars in breast implantation surgery with inframammary fold incision versus axillary incision: a prospective cohort study in Chinese patients. Aesthet Plast Surg 43:328–335. https://doi.org/10.1007/s00266-018-1299-3

    Article  Google Scholar 

  33. Randquist C, Por YC, Yeow V et al (2018) Breast augmentation surgery using an inframammary fold incision in Southeast Asian women: patient-reported outcomes. Arch Plast Surg 45:367–374. https://doi.org/10.5999/aps.2018.00045

    Article  PubMed  PubMed Central  Google Scholar 

  34. Bekeny JC, Zolper EG, Fan KL, Del Corral G (2020) Breast augmentation for transfeminine patients: methods, complications, and outcomes. Gland Surg 9:788–796

    Article  Google Scholar 

  35. McEvenue G, Xu FZ, Cai R, McLean H (2018) Female-to-male gender affirming top surgery: a single surgeon’s 15-year retrospective review and treatment algorithm. Aesthet Surg J 38:49–57. https://doi.org/10.1093/asj/sjx116

    Article  Google Scholar 

  36. Broussard KA, Warner RH (2019) Gender nonconformity is perceived differently for cisgender and transgender targets. Sex Roles 80:409–428. https://doi.org/10.1007/s11199-018-0947-z

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA

    Shanique A. Martin

  2. Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA

    Viren Patel

  3. Section of Plastic Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA

    Shane D. Morrison

  4. Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA

    David Kahn & Rahim Nazerali

  5. Align Surgical Associates, San Francisco, CA, USA

    Thomas Satterwhite

  6. Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA

    Shane D. Morrison

Authors
  1. Shanique A. Martin
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  2. Viren Patel
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  3. Shane D. Morrison
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  4. David Kahn
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  5. Thomas Satterwhite
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  6. Rahim Nazerali
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Corresponding author

Correspondence to Shane D. Morrison.

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Institutional review board approval was obtained for the study.

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All patients provided informed consent.

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US Professional Association for Transgender Health 2019, Washington D.C. and California Society of Plastic Surgeons Annual Meeting 2020, Virtual Meeting.

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Martin, S.A., Patel, V., Morrison, S.D. et al. Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze?. Aesth Plast Surg 45, 1860–1868 (2021). https://doi.org/10.1007/s00266-021-02378-1

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  • DOI: https://doi.org/10.1007/s00266-021-02378-1

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