Prepared by Alan H. Appelbaum, MB, BCh, BAO from the
Department of Radiology, University of Tennessee, Memphis,
Bilateral mammography with standard and pushback views revealed
bilateral wedge-shaped densities radiating from the nipples,
slightly larger on the left (figure 1A). The densities blended
gradually into surrounding lucent adipose tissue and had
strand-like extensions. A 6-mm focal asymmetric density was visible
in the outer left breast in the standard and pushback craniocaudal
views. This resolved on a craniocaudal magnification compression
view consistent with mammary stroma (figure 1B). Implants were
visible bilaterally. The pectoral muscles could be seen deep to the
Scintigraphy of the breasts with Tc-99m sestamibi revealed
activity at the surface of the breasts where skin and subcutaneous
tissues were viewed tangentially with mild diffuse increases at the
sites of gynecomastia in the retroareolar areas (figure 2). There
were photopenic defects deep to the foci of gynecomastia
corresponding to the breast implants.
A 46-year-old male-to-female transsexual with bilateral breast
augmentations on hormone therapy presented for evaluation of left
breast tenderness. No breast masses or other focal abnormalities
could be identified on physical examination.
Breasts of a male-to-female transsexual
Transsexualism is defined as "the desire to live and be accepted
as a member of the opposite sex, usually accompanied by the wish to
make his or her body as congruent as possible with the preferred
sex through surgery and hormone therapy."
Breast development may result if male-to-female transsexuals
undergo hormone re-placement therapy or sex reassignment surgery.
Breast augmentation is frequently performed in these patients.
Although transsexualism is a well-known entity, I can find no
previously published reports of the mammographic or
scintimammographic appearance of the breasts of male-to-female
Hormone therapy and surgical castration in male-to-female
transsexuals result in hypertrophy of vestigial breast tissue, ie,
The wedged-shape, retroareolar location, bilaterality, lack of a
discrete edge, and strand-like extensions seen in the mammogram in
this case are typical of gynecomastia.
Subpectoral implants have a greater risk of cranial and lateral
migration in male-to-female transsexuals than in women.
Subglandular implants are, therefore, preferred.
Identification of the pectoral muscles deep to the implants
demonstrates the subglandular location of the implants. Hence, the
mammographic appearance of the breasts seen in this case is what
would be expected in a transsexual; gynecomastia directly overlying
Incidence of transsexualism is estimated at 1 in 11,900 males
and 1 in 30,400 females. Not all patients with gender identity
disorders are candidates for sex reassignment surgery. Selection of
patients for surgery is a lengthy process involving careful
diagnostic assessment followed by a real-life experience in the
desired gender role and hormone therapy. Psychotherapy is now
optional, since it is usually ineffective for this condition.
Breast augmentation may be performed if breast enlargement is not
sufficient for comfort in the social gender role after 18 months of
Approximately two-thirds to three-fourths of male-to-female
transsexuals request augmentation.
Augmentation mammoplasty may be performed preceding, simultaneously
with, or subsequent to genital surgery. Some believe that it is
safer to perform augmentation mammoplasty first as it is reversible
and the effects on the patient's adjustment can be observed before
performing irreversible penovaginal surgery and castration.
This case demonstrates the mammographic and scintimammographic
appearance of the breasts of a male-to-female transsexual with
subglandular implants (the most common type of augmentation
mammoplasty in transsexuals). As expected, the mammogram has the
same appearance of gynecomastia as seen in other genetic males,
but with an implant directly beneath it. The increased activity in
the retroareolar areas and the photopenic defects below them on
scintimammography correspond to the mammographic findings.