Masculinizing Chest Surgery: Challenges and Improvements

Research output: PhD ThesisPhd-Thesis - Research and graduation internal


In the first part of this thesis, we aimed to further define and improve on the current practice of free nipple grafting, specifically for NAC positioning and morphology. Firstly, we addressed the challenges of appropriate NAC localization. In Chapter 2, we proposed a two- step algorithm for the most ideal positioning of the nipple-areolar complex based on a large cohort of cisgender men. This methodological approach had to be further validated in an external cohort. A collaboration with Ghent University Hospital, Belgium was established and the algorithm was validated in a Belgian validation cohort. These outcomes are presented in Chapter 3. Secondly, we addressed NAC morphology. In this study, we aimed to establish the morphology of the free grafted nipples during a year follow-up. The results of this study, including the clinical implications and considerations are discussed in Chapter 4. In the second part of this thesis, we focused on surgical and scar outcomes following gender- affirming surgery. In Chapter 5, we addressed the reported risk that prior breast reduction surgery has on mastectomy outcomes. In an effort to decrease postoperative complications, we performed a within-patient randomized controlled trial in transmasculine individuals. To establish a better understanding of the long-term effects that incisional negative pressure wound therapy (iNPWT) has on scarring, a systematic review was performed incorporating all currently known pre-clinical and clinical outcomes. This review is presented in Chapter 6. In Chapter 7, we tested the efficacy of this dressing technique in preventing complications. The secondary outcomes of the within-patient randomized trial were patient-reported outcome measures and scar quality. Patients were followed for up to a year, and the results of these outcomes are presented in Chapter 8. In the last chapter of this thesis, Chapter 9, an overview is presented on techniques using skin substitutes for scar management, as a potential future modality to further improve surgical outcomes.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Vrije Universiteit Amsterdam
  • Middelkoop, Esther, Supervisor
  • Mullender, Margriet, Supervisor
  • Bouman, Mark-Bram, Co-supervisor
  • van de Grift, Tim, Co-supervisor
Award date9 Mar 2023
Place of PublicationEnschede
Print ISBNs9789464197235
Publication statusPublished - 9 Mar 2023


  • Gender Surgery, Mastectomy, Masculinization, Nipple, Wound Healing, Scar Formation, Anatomy, Negative Pressure Wound Therapy, Reconstruction

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