Axillary Approach Mastectomy Without Endoscopic Assistance in Chest Masculinization Surgery

BACKGROUND: For gender-affirming mastectomy in patients with gender dysphoria and small/nonptotic breasts, traditional periareolar techniques carry risks of visible scar complications. A scar-minimizing alternative is needed. OBJECTIVES: The aim of the study was to evaluate the outcomes of a novel nonendoscopic axillary approach mastectomy, aiming to eliminate areolar scars or diminish circumareolar incision while assessing safety and patient satisfaction. METHODS: This study included patients classified with Fisher 1, 2A, and a portion of 2B patients. Mastectomy was performed through an axillary incision without endoscopic assistance. Outcomes were evaluated through complication rates and patient-reported outcomes using the BODY-Q questionnaire (score 0-100). RESULTS: From December 2020 to August 2024, 48 patients (average age 33.65) underwent the procedure. The average operative time was 167.1 min. The overall complication rate was 45.8% (22/48), predominantly minor, reversible nipple-areola superficial skin necrosis (20.8%). Severe complications were rare: total NAC necrosis 2.0% (1/48) and acute hematoma 2.0% (1/48). Patient satisfaction on the BODY-Q scale was statistically very high. CONCLUSIONS: This axillary approach for mastectomy successfully prioritizes minimal scarring, a key aesthetic concern particularly for East Asian patients. In a carefully selected cohort, it achieves high patient satisfaction with a low rate of severe complications, offering a valuable surgical alternative. LEVEL OF EVIDENCE: 4 (THERAPEUTIC): For image description, please refer to the figure legend and surrounding text.