Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men

Purpose:

            A primary goal in chest wall reconstruction (‘top surgery’) for trans men is achieving a symmetrical, aesthetically pleasing position of the reconstructed male NAC. In the context of existing surgical techniques for top surgery, the ability to achieve this goal is limited.

Methods:

            The senior author’s experience with component NAC creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March 2015 to October 2016.

            In this technique, the native NAC is first excised and carefully thinned. Mastectomy is then performed using a double incision technique. The position of the new NAC is marked at the level of the fourth to fifth ribs along the inferolateral margin of the pectoralis using a 2 by 3 cm ovoid template. This marking represents the dimensions of the skate flap to be utilized for nipple reconstruction. A 5 mm central, superior pedicle is marked, the previously marked ovoid is incised, and the flap is elevated from inferior to superior in the mid-dermal plane. Similar medial and lateral elevation towards the central, superior pedicle forms the lateral wings of the flap, which are then wrapped upon themselves and sutured. The tip of the new nipple is often trimmed to avoid a pointed tip. Next, a 2 by 3 cm free areolar graft is crafted from the amputated, native NAC using the previously crafted template and pie-crusted. A larger, central perforation is placed in the graft to accommodate the reconstructed nipple, and the graft is then inset and dressed with a bolster

Results:

            Fifty trans men underwent top surgery with this technique. Average operative time was 2 hours and 59 minutes. Average right- and left-sided mastectomy specimen weights were 629.73 and 625.86 grams, respectively. Average overall mastectomy specimen weight was 627.80 grams. Average length of hospital stay was 0.96 days; 92% of patients spent 1 night in the hospital, 6% of patients spent 0 nights, and 2% of patients spent 2 nights in the hospital, respectively. Average follow-up was 19.02 months (Range: 12.47-32.07 months).

            Five patients (10%) experienced complications, most commonly seroma formation (4%; n = 2). One patient developed a hematoma (2%), requiring operative intervention while one patient (2%) developed cellulitis, successfully treated with oral antibiotics, and one patient experienced suture granuloma (2%). Twenty-eight patients (56%) underwent secondary revisions, including scar revision (56%), liposuction (10%), and fat grafting (2%). Overall, 10% of reconstructed NACs (n = 5) underwent revision to adjust size, projection, or symmetry.

Conclusions:

            The use of a modified nipple flap and free areolar graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male NAC, in a safe and effective manner.