Analysis of Chest Masculinization Surgery Results in Female-to-Male Transgender Patients: Demonstrating High Satisfaction beyond Aesthetic Outcomes Using Advanced Linguistic Analyzer Technology and Social Media.

Gender dysphoria, also known as gender identity disorder, transgender, or transsexuality, refers to a patient’s incongruence between their gender at birth and their gender identity.1 The incidence of self-reported transgender identity is 0.5% to 1.3% in the United States.2 Many patients with gender dysphoria turn to medical therapy to help them transition to the sex that is most congruent with how they feel. Examples include endocrine therapy or plastic surgery. Subcutaneous mastectomy, or chest masculinization, is an option of patients undergoing the female-to-male gender transition to further masculinize their physique. Medical necessity criteria are based upon Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, published by the World Professional Association for Transgender Health.3 Criteria for mastectomy and masculinization of the chest in female-to-male patients according to World Professional Association for Transgender Health include (1) persistent, well-documented gender dysphoria; (2) capacity to make a fully informed decision and to consent for treatment; (3) age of majority in a given country; and (4) if significant medical or mental health concerns are present, they must be reasonably well controlled. Hormone therapy is not a prerequisite. Patients should always be evaluated by a mental health professional before undergoing the procedure. The evaluation includes, at a minimum, assessment of the gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of societal stigma on psychosocial adjustment, and the patient’s available support system.3 The mental health professional is required to make reasonably sure that the gender dysphoria is not secondary to another mental health condition. The goals of the subcutaneous mastectomy procedure are removal of the female breast contour, obliteration of the inframammary fold, excess skin removal, and proper reduction and positioning of the nipple–areolar complex (NAC).4,5 The ideal surgical result is a masculinized chest with minimal scarring and proper nipple positioning. Satisfaction rates for subcutaneous mastectomy are currently reported to be approximately 88%.6 Significant improvements in body image, feelings of attractiveness, and self-confidence were also found in various studies.7–10 However, note that body image in transgender individuals does not only relate to sexual characteristics but also includes psychosocial and factors associated with stigmatization and discrimination in society.11 Patient-reported outcome measures specific to the transgender patient are sparse.12,13 In evaluating chest masculinization, studies have examined satisfaction with scar and nipple position, with little emphasis in the overall satisfaction and quality of life.14 These measures are vital in qualifying and quantifying surgical interventions in the trans patient and should be further explored. The emerging applications of social media represent an avenue to obtain such data.15 Previous studies have examined the utility of social media as a means of assessing patient satisfaction after rhinoplasty and other forms of aesthetic plastic surgery using rating websites.16,17 We propose another method of assessing satisfaction on social media—using computerized linguistic analysis to determine postoperative satisfaction within social media posts. There exist powerful analytic tools utilizing artificial intelligence can analyze sentiment such as joy contained within written human language.18 We hypothesize that chest masculinization in the female-to-male transgender population transcends the aesthetic appearance of sexual characteristics but strongly correlates with the psychosocial and psychological functioning of the patient. To qualify the aesthetic appearance, we surveyed plastic surgeons on the quality of operative outcomes. To best quantify the psychosocial and psychological functioning of the patient, we used a linguistic tone analyzer to rate the level of joy present in both the posts and subsequent comments made by their peers. The results of both analyses were then compared.