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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

Frey, Jordan D., M.D.; Motosko, Catherine C., B.S.; Poudrier, Grace, B.A.; Saia, Whitney V., M.S.N., R.N., F.N.P.-C.; Wilson, Stelios C., M.D.; Yu, Jessie Z., M.D.; Hazen, Alexes, M.D.

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1310e–1311e
doi: 10.1097/PRS.0000000000005658

Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, N.Y.

Correspondence to Dr. Hazen, Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, 110 East 66th Street, New York, N.Y. 10065,

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We would like to thank Lo Russo and Tanini for their comments regarding our article, “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.”1 We agree with them that one of the most important goals of chest wall contouring in masculinizing top surgery is the repositioning and reshaping of the nipple-areola complex. This can also be one of the most difficult goals to achieve if it is not properly planned or executed technically.

The double-incision mastectomy technique allows for great range in terms of setting the new nipple-areola complex position at the margin of the pectoralis major at the level of the fourth to fifth ribs. After mastectomy, the surgeon is free to reconstruct the new nipple-areola complex at whichever position is best, either using free graft techniques, as described by Dr. Lo Russo, or with local nipple flaps, as in our techniques. This is in contrast to periareolar techniques, which traditionally have failed to reposition the native nipple-areola complex to a more masculine position.

Lo Russo and Tanini demonstrate fantastic results using their graft technique, in which separate areolar and nipple grafts are taken and secured to the chest wall after double-incision mastectomy. Particularly, the nipple graft is small and thin, so as to decrease the metabolic demand of the graft. They report low rates of depigmentation and graft loss. They also note the importance of postoperative care on the part of the surgeon and patient in minimizing risk of complications after graft techniques, which we could not agree with more. In our experience, depigmentation and loss of projection of the grafted nipple have been limitations of the technique, spurring the development of this modification. The authors should be commended for their success. We look forward to reading more about their techniques and are sincerely grateful for their comments. Through multi-institutional collaboration and technical evolution, we can continue to improve outcomes for the transgender community.

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

Jordan D. Frey, M.D.

Catherine C. Motosko, B.S.

Grace Poudrier, B.A.

Whitney V. Saia, M.S.N., R.N., F.N.P.-C.

Stelios C. Wilson, M.D.

Jessie Z. Yu, M.D.

Alexes Hazen, M.D.

Hansjörg Wyss Department of Plastic Surgery

New York University Langone Health

New York, N.Y.

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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.
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