Mastectomy Reconstruction Techniques for Gender Diverse Breast Cancer and High Risk Patients: A Case Series and Literature Overview

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,
Your work addresses a topic that is still underrepresented in the literature. I also appreciated the technical section, which is described with a good level of detail and can help the reader understand the surgical rationale behind the different choices.

Below are my comments:

You state that you included transgender or gender-diverse patients, but in Table 1, under Gender, patients 1 and 2 are classified as F. This wording is ambiguous for the reader. If F indicates cisgender women, it is unclear why they are included in a gender-affirming surgery series; if instead these patients are trans men or TGD individuals, then clarification is needed.

A second point concerns the title. The title includes and Review. Overall, this appears more like a narrative overview included in the introduction and discussion. I would therefore suggest choosing one of two options: either add a clear and reproducible methodology for a review, or remove the term Review from the title and replace it with a more accurate expression, such as literature overview or similar.

The sample is limited, but statements suggesting the absence of associations between complications or revisions and variables such as hormone therapy or surgical technique are not sustainable with such a small number, because the main issue is the lack of statistical power. I would suggest rephrasing these observations.

There is a complete lack of a structured assessment of satisfaction or patient-reported outcomes. I would suggest discussing this more thoroughly in the limitations.

From an oncologic perspective, some information appears incomplete or not uniform across cases. It would be better to explain the reason for this lack of data.

From an ethical perspective, it is not clear whether patients provided consent for the dissemination of their images.

 

Author Response

Reviewer 1

• You state that you included transgender or gender-diverse patients, but in Table 1, under Gender, patients 1 and 2 are classified as F. This wording is ambiguous for the reader. If F indicates cisgender women, it is unclear why they are included in a gender-affirming surgery series; if instead these patients are trans men or TGD individuals, then clarification is needed.
  1. Thank you for your through review of our manuscript. We apologize for the oversight and have corrected this typo in the table in our revised manuscript.
     
     
• A second point concerns the title. The title includes and Review. Overall, this appears more like a narrative overview included in the introduction and discussion. I would therefore suggest choosing one of two options: either add a clear and reproducible methodology for a review, or remove the term Review from the title and replace it with a more accurate expression, such as literature overview or similar.
  1. Thank you for your feedback, we have adjusted the title to read: Mastectomy Reconstruction Techniques for Gender Diverse Breast Cancer and High Risk Patients: A Case Series and Literature Overview to enhance the accuracy of our title.
     
     
• The sample is limited, but statements suggesting the absence of associations between complications or revisions and variables such as hormone therapy or surgical technique are not sustainable with such a small number, because the main issue is the lack of statistical power. I would suggest rephrasing these observations.
  1. We appreciate this important point and agree that our case series is not powered to assess associations between hormone therapy, surgical technique, and postoperative outcomes. We have revised the Discussion to clarify that observations regarding continued hormone therapy are descriptive only and should be interpreted cautiously given the small sample size. The revised language avoids implying statistical association and emphasizes the exploratory nature of these findings.
     
     
• There is a complete lack of a structured assessment of satisfaction or patient-reported outcomes. I would suggest discussing this more thoroughly in the limitations.
  1. Thank you for this comment, we agree that the absence of structured patient-reported outcome and satisfaction measures is an important limitation in exploring the outcomes of these various operative techniques. We have expanded the Limitations section to more explicitly acknowledge the lack of validated PROMs and to emphasize how this restricts interpretation of outcomes following OGAM, particularly in the TGD population. We have included PROM’s in our future directions section and hope to expand on our data in the future with a larger patient cohort.

 

• From an oncologic perspective, some information appears incomplete or not uniform across cases. It would be better to explain the reason for this lack of data.
  1. Thank you for bringing this to our attention. The empty columns were to indicate the specific row did not apply for a specific patient as they did not have a cancer diagnosis but were high-risk and underwent a prophylactic mastectomy. It is important to ensure clarity in the interpretation of our tables and thus we have added “ ---” in these areas to indicate that specific rows did not apply to certain patients.
     
     
• From an ethical perspective, it is not clear whether patients provided consent for the dissemination of their images.
  1. Thank you for pointing out this key point we appreciate your emphasis on patient protection and consent. Our patients did provide consent for use of their images. We have added a statement clarifying this in the methods section of the manuscript and in the backmatter.
     
     

Reviewer 2 Report

Comments and Suggestions for Authors

This article presents a single-center case series that systematically summarizes and illustrates the feasibility, safety, and multidisciplinary value of various individualized reconstructive strategies for transgender and gender-diverse (AFAB TGD) patients with breast cancer or at high oncologic risk undergoing oncologic gender-affirming mastectomy (OGAM).

1. The research topic has clear clinical relevance and real-world significance
This study focuses on OGAM and reconstructive strategies in AFAB transgender and gender-diverse patients with breast cancer or high-risk conditions, a population that has been markedly underrepresented in the existing literature. From a multidisciplinary perspective, the authors comprehensively summarize multiple technical approaches to OGAM and non-binary reconstruction, aligning well with contemporary principles of precision medicine and patient-centered care, and providing meaningful guidance for clinical practice.

2. Surgical techniques are described in detail with strong reproducibility
The manuscript provides structured and clear procedural descriptions of key techniques, including double-incision OGAM, Goldilocks reconstruction, nipple-sparing mastectomy with staged reconstruction, free nipple grafting, and fat grafting. These descriptions are supported by intraoperative and postoperative images, facilitating readers’ understanding of indications, technical nuances, and surgical planning aimed at balancing oncologic safety with gender-affirming goals.

3. Results are presented objectively, with appropriately cautious conclusions
Despite the limited sample size, the authors report postoperative complications, revision rates, and oncologic outcomes in a measured manner without overgeneralizing their findings. The inherent limitations of a case series design are explicitly acknowledged in the “Limitations and Future Directions” section, reflecting sound academic rigor and transparency.

4. Recommendation to include additional key references to strengthen the literature context
The authors are encouraged to cite the following relevant studies in the Discussion section to further enhance the completeness of the literature review and the discussion on balancing nipple-sparing mastectomy with oncologic and reconstructive considerations:
DOI: 10.21037/gs-22-499 and DOI: 10.1016/j.tranon.2024.102012.
These publications are highly relevant to the topic and would improve the systematic depth and international comparability of the manuscript.

5. Overall structure is clear and well suited to the journal’s readership
The manuscript is well organized, written in a professional academic style, and supported by figures and tables that are well integrated with the text. Overall, the quality of the work meets the standards of journals at the interface of clinical medicine and reconstructive surgery. Future expansion to multicenter cohorts and inclusion of patient-reported outcome measures would further enhance its evidentiary impact.

Author Response

Reviewer 2

• The research topic has clear clinical relevance and real-world significance. This study focuses on OGAM and reconstructive strategies in AFAB transgender and gender-diverse patients with breast cancer or high-risk conditions, a population that has been markedly underrepresented in the existing literature. From a multidisciplinary perspective, the authors comprehensively summarize multiple technical approaches to OGAM and non-binary reconstruction, aligning well with contemporary principles of precision medicine and patient-centered care, and providing meaningful guidance for clinical practice.
  1. Thank you for your comment and support in highlighting reconstructive options/techniques for TGD patients.
     
     
• Surgical techniques are described in detail with strong reproducibility. The manuscript provides structured and clear procedural descriptions of key techniques, including double-incision OGAM, Goldilocks reconstruction, nipple-sparing mastectomy with staged reconstruction, free nipple grafting, and fat grafting. These descriptions are supported by intraoperative and postoperative images, facilitating readers’ understanding of indications, technical nuances, and surgical planning aimed at balancing oncologic safety with gender-affirming goals.
  1. Thank you for your through review and comment.
     
     
• Results are presented objectively, with appropriately cautious conclusions. Despite the limited sample size, the authors report postoperative complications, revision rates, and oncologic outcomes in a measured manner without overgeneralizing their findings. The inherent limitations of a case series design are explicitly acknowledged in the “Limitations and Future Directions” section, reflecting sound academic rigor and transparency.
  1. Thank you for your comment we have further updated this section to highlight the limited case series size and further clarify the descriptive nature of our manuscript.
     
     
• Recommendation to include additional key references to strengthen the literature context. The authors are encouraged to cite the following relevant studies in the Discussion section to further enhance the completeness of the literature review and the discussion on balancing nipple-sparing mastectomy with oncologic and reconstructive considerations: DOI: 10.21037/gs-22-499 and DOI: 10.1016/j.tranon.2024.102012. These publications are highly relevant to the topic and would improve the systematic depth and international comparability of the manuscript.
  1. Thank you for highlighting these important studies. We have added both references to the Discussion section (references 14 and 15) to strengthen the literature context and to better situate our findings within the broader oncologic and reconstructive surgery literature, particularly with respect to mastectomy technique selection and outcome considerations.
     
     
• Overall structure is clear and well suited to the journal’s readership. The manuscript is well organized, written in a professional academic style, and supported by figures and tables that are well integrated with the text. Overall, the quality of the work meets the standards of journals at the interface of clinical medicine and reconstructive surgery. Future expansion to multicenter cohorts and inclusion of patient-reported outcome measures would further enhance its evidentiary impact.
  1. Thank you for your comment. We agree that future expansion to multicenter cohorts and inclusion of patient-reported outcome measures would further enhance its evidentiary impact and hope to provide such data in the coming years.
     
     

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for submitting your manuscript entitled “Mastectomy Reconstruction Techniques for Gender Diverse Breast Cancer and High Risk Patients: A Case Series and Review” to the JCM

We have some comments

 

1. The title includes "...and Review." However, the Methodology section describes only a "retrospective chart review" of clinical cases. There is no description of a systematic literature review methodology (search terms, databases, inclusion criteria for literature).
2. The cohort consists of only 8 patients over 5 years. While valuable, the authors must ensure the language in the Conclusion does not overgeneralize the findings.
3. There is a mathematical inconsistency regarding the resection weights.
4. The abstract states "minimum one year follow up", yet the results section does not explicitly state the mean or median follow-up time for the cohort.
5. The description of the Goldilocks procedure is helpful8. However, the distinction between the "Goldilocks" used here and a standard inferior dermal flap for auto-augmentation needs to be very clear, particularly regarding the preservation of the inframammary fold (IMF).
6. The terms "cisgender" and "transgender" are adjectives, not verbs.
7. The report honestly notes a 50% revision rate. This is a high but realistic figure for this population. The authors should be commended for this transparency. It would be beneficial to explicitly state if these revisions were performed under local or general anesthesia.
8. Figure 1 Legend: The figure contains the text "Butym". Is this a patient name or a typo? If it is a patient identifier, it must be removed for anonymity. If it is a typo, it should be cropped out.

 

 

Author Response

Reviewer 3

• The title includes "...and Review." However, the Methodology section describes only a "retrospective chart review" of clinical cases. There is no description of a systematic literature review methodology (search terms, databases, inclusion criteria for literature).
  1. Thank you for your feedback, we agree this study is not a formal literature review, and we have adjusted the title to read: Mastectomy Reconstruction Techniques for Gender Diverse Breast Cancer and High Risk Patients: A Case Series and Literature Overview.
     
     
• The cohort consists of only 8 patients over 5 years. While valuable, the authors must ensure the language in the Conclusion does not overgeneralize the findings.
  1. We agree with this concern. We have modified our Limitations section to explicitly acknowledge the small sample and have revised the Conclusion section to further temper the language and emphasize the descriptive nature of this case series.
     
     
• There is a mathematical inconsistency regarding the resection weights.
  1. We thank the reviewer for identifying this discrepancy. The resection weight values for mean and SD have been recalculated and corrected in the revised manuscript.
     
     
• The abstract states "minimum one year follow up", yet the results section does not explicitly state the mean or median follow-up time for the cohort.
  1. We thank the reviewer for this comment and identifying the discrepancy between the abstract and manuscript. All patients had a minimum of 12 months of follow-up. We have revised the Results section of our manuscript to explicitly report follow-up duration, including median, mean, and range.
     
     
• The description of the Goldilocks procedure is helpful. However, the distinction between the "Goldilocks" used here and a standard inferior dermal flap for auto-augmentation needs to be very clear, particularly regarding the preservation of the inframammary fold (IMF).
  1. We thank this reviewer for this recommendation. We agree that it is paramount to highlight the technical differences between a cis-female Goldilocks and OGAM Goldilocks and have modified the language in the technique section to stress these differences, particularly the difference in preservation versus obliteration of the inframammary fold.
     
     
• The terms "cisgender" and "transgender" are adjectives, not verbs.
  1. We thank the reviewer for this clarification. We have revised the manuscript to ensure that cisgender and transgender are used consistently as adjectives rather than verbs, including removal of “-ed” constructions and correction of hyphenation.
     
     
• The report honestly notes a 50% revision rate. This is a high but realistic figure for this population. The authors should be commended for this transparency. It would be beneficial to explicitly state if these revisions were performed under local or general anesthesia.
  1. We thank the reviewer for their comment and suggestion. We acknowledge that revision rates in OGAM are high and stressed the difference in thickness of the mastectomy flap in OGAM versus superior flap in a traditional gender affirming mastectomy for oncologic safety. We have added clarification that these revisions were done under general anesthesia as liposuction and fat grafting was performed. In our technique section we did make an effort to highlight that certain revisions can be done in office under local such as nipple reduction.

 

• Figure 1 Legend: The figure contains the text "Butym". Is this a patient name or a typo? If it is a patient identifier, it must be removed for anonymity. If it is a typo, it should be cropped out.
  1. Thank you for pointing this out. Figure 1 has our patient with markings reading “bottom line” to highlight the lower placement of the incision; this is not a patient identifier.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I am satisfied with the authors’ responses to the reviewers’ comments. The revisions have adequately addressed the raised issues and have improved the quality and clarity of the manuscript. The paper can now be considered suitable for publication.

Author Response

• Thank you for your comment.

Reviewer 2 Report

Comments and Suggestions for Authors

Congratulations, author. You have done a great job. I agree with the publication of this manuscript.

Comments on the Quality of English Language

Good.

Author Response

• Thank you for your comment.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for submitting a revised manuscript to our journal ,

We have one comment

In the Results, you state the "mean resection weight was 1336.8 grams". Based on Table 2, this figure represents the total bilateral weight per patient, whereas the mean weight per breast is approximately 668g. Please revise the text to specify "mean total bilateral resection weight" to avoid clinical misinterpretation.

 

Author Response

• Thank you for pointing this out. We have updated the text to read “mean total bilateral resection weight.”