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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

Lo Russo, Giulia, M.D.; Tanini, Sara, M.D.

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1309e–1310e
doi: 10.1097/PRS.0000000000005657

Depertment of Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence Italy

Correspondence to Dr. Lo Russo, Department Plastic and Reconstructive Microsurgery, Careggi University Hospital, Largo Palagi 1, Florence, Italy 50139,

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We read with great interest the article entitled ‘‘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’’ by Frey et al.1 The authors presented their nipple-areola complex creation in chest wall reconstruction for transgender men with a modified skate flap and free areolar graft in conjunction with double-incision mastectomy.1 Inspired by the authors, we would like to express our considerations on nipple reconstruction technique.

The anatomical features of the chest identify an individual as male or female, and even the smallest details of these features determine the appropriate appearance for each gender. In transgender men, the creation of an aesthetically pleasing male chest is the most important step. Incorrect positioning of the nipple-areola complex on the chest wall and suboptimal shaping and sizing of the nipple-areola complex are common pitfalls in male nipple-areola complex creation.2 In our clinical practice of chest wall contouring surgery, double-incision mastectomy with nipple-areola complex grafting is the preferred technique in patients with large breasts, but even in those with medium-sized and small breasts, for the excellent reposition and reshaping of the nipple-areola complex and the great aesthetic results.2,3

We believe that the first choice for nipple reconstruction for chest wall reconstruction in transgender men is a graft of a smaller portion of the native nipple. With this technique, the surgical principle of plastic surgery—replacing like tissue with like tissue—is respected and we can obtain perfect reposition and reshaping of the nipple. We have good graft healing, projection, pigmentation, and aesthetically male results (Fig. 1). To avoid the main disadvantages of free nipple grafting, such as graft loss, nipple flattening, and severe depigmentation, we have introduced some procedural precautions. We harvest a small, full-thickness graft from the native nipple that is 5 mm in diameter and 4 mm in height. We use only four peripheral stitches to fix the nipple grafts, a tie-over dressing for 7 days, and, during postoperative follow-up, a “no touch” technique (Fig. 2).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Since the introduction of these precautions, we have had no graft loss or flattening, and we have a small nipple with “natural” projection and pigmentation. Depigmentation occurred only in a case of partial graft lost. In our surgical practice of almost 100 cases (55 double-incision mastectomies with nipple-areola complex grafting), we have had only three cases of nipple graft loss and in only one patient have we used a local flap in the second-step revision.

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The authors have no financial interest to declare in relation to the content of this communication.

Giulia Lo Russo, M.D.

Sara Tanini, M.D.

Depertment of Plastic and Reconstructive Microsurgery

Careggi University Hospital

Florence Italy

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1. Frey JD, Yu JZ, Poudrier G, et al. 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. Plast Reconstr Surg. 2018;142:331–336.
2. Tanini S, Lo Russo G. Shape, position and dimension of the nipple areola complex in the ideal male chest: A quick and simple operating room technique. Aesthetic Plast Surg. 2018;42:951–957.
3. Lo Russo G, Tanini S, Innocenti M. Masculine chest-wall contouring in FtM transgender: A personal approach. Aesthetic Plast Surg. 2017;41:369–374.
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