Male chest reconstruction

A transverse inframammary incision with free nipple areolar grafts may be one approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T).

The areola is trimmed to a pre-agreed-upon diameter and the nipple sectioned with a pie-shaped excision and reconstituted. There may be varying sensory loss because of nerve disruption.

One of the most common male chest reconstructive procedures, double incision involves an incision above and below the breast mass, the removal of the fatty and glandular tissue, and the closure of the skin. This method leaves scars under the pectoral muscles, stretching from the underarms to the medial pectoral.

Double incision is usually accompanied by free nipple grafts to make male-looking nipples. The areola and nipple is removed from the breast tissue, cutting away along the circumference and removing the top layer of flesh from the rest of the tissue. After the chest has been reconstructed, the nipples are grafted on in the appropriate male position. The areolae are often sized down as well as the nipples themselves, as female areolae are often larger in circumference and the nipples protrude farther.

Nipple grafts are generally associated with double incision style chest reconstruction, but may be used in any reconstruction procedure if necessary. With nipple grafts comes the possibility of rejection. In such cases, the nipple is often tattooed back on cosmetically or further surgical procedures may be applied.

Some sensation will usually return to the grafted nipples over time. However, the procedure severs the nerves that go into the nipple-areola and there is a substantial likelihood for loss of sensation. [5]

To remove the glandular and fatty tissue which comprise the breast mass and the added skin that drapes the mass, there are three basic approaches.

For petite breasts, such as an A or a small B, a peri-areolar incision can be done. That is a circular incision around the areola, combined with an inner circular incision to remove some of the excess areola. Drawing the skin into the center will result in some puckering, but this often smooths out with time. There will be significant tension on the scar line, and to prevent spreading of the scar, a permanent fixation suture is needed. Leaving outer dermis (raw skin) underneath the marginalized areola helps in its survival.

The keyhole incision (think skeleton key) augments the periareolar incision further by making a vertical closure underneath (lollipop), which results after the unwanted skin is pulled in from side to side and the excess is removed.[6]

An anchor incision adds to that a transverse incision usually in the infra mammary fold to further remove excessive skin. Draping or blousing is not desirable. This is reserved for much larger breasts or topographically a larger surface area as seen in women with postpartum breast atrophy.

The nipple areolar complex may be supported by a pedicle which has the advantage of leaving some sensation and blood supply intact, but can have the disadvantage when the pedicle has sufficient bulk not to provide the flat look most FTM patients desire.

Occasionally the side limbs may be quite long, and the expression doctors use is "chasing a dog ear" into the axilla (or underarm). A dog ear is an unpleasant ruffle of skin in the corner of an incision when there is too much gathering usually at an angle greater than 30 degrees.[7] Using a curved incision can reduce the chances of dog ears developing because it requires less gathering of skin to be done, but some patients dislike the appearance of the curved scar as it can mimic the appearance of breasts.

Not uncommonly the surgeon will revise the incision lines after 3 or more months of settling shows some residual problem areas.