Invited Discussion on: The Nipple Split Sharing Versus Conventional Nipple Graft Technique in Chest Wall Masculinization
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EDITOR’S INVITED COMMENTARY
Invited Discussion on: The Nipple Split Sharing Versus Conventional Nipple Graft Technique in Chest Wall Masculinization Surgery: Can We Improve Patient Satisfaction and Aesthetic Outcomes? Peter D. Scott1
Received: 3 June 2020 / Accepted: 3 June 2020 Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Level of evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. The authors of this paper are to be complimented on the thoroughness of their research and clear presentation of their conclusions. This paper adds to our armamentarium on chest surgery in male-to-female transgender patients. Let us assume that all of these patients are assessed and treated via a transgender clinic with a team approach including plastic surgeons, endocrinologists and psychologists and this is certainly our approach to these patients. The ideal chest reconstruction for female-to-male patients would involve minimal scarring, a masculinized chest, corrected nipple positioning and nipple areola morphology appropriate to a male patient. The authors have given a comprehensive literature review and discuss in their paper the preference of a simple mastectomy with free nipple graft as being the best form of treatment. Techniques which involve the use of a pedicle with a nipple attached often lead to a bulky reconstruction especially in patients with a higher BMI. In addition, a Wise pattern may be required leading to a lot of extra scarring. This technique is well described by Knox et al. [1].
& Peter D. Scott [email protected] 1
Johannesburg, South Africa
The position of the male nipple areola complex (NAC) has been dealt with in several articles, and the recommended position would be 2 cm above and 2 cm medial to the lateral border of pectoralis major. Agarwal et al. [2] have summarized the literature on this and have done measurements on volunteers to determine the best position. In addition, their recommendations are a 2.2 diameter NAC and the graft recipient site should be oval in the horizontal axis 2.5 cm by 1.5 cm to avoid a vertically oval areola as the mastectomy flaps settle. This brings us to the current paper where Bustos et al. have looked at the most aesthetic appearance of the free nipple graft converting from a female NAC, which is a wider diameter areola and a larger and more projecting nipple. Traditional techniques have taken an appropriate diameter areola and thinned out the nipple to flatten it and if necessary to remove small wedges. This paper compares that technique to splitting the NAC in half and rotating each half to a new NAC. This allows for a smaller projection of the nipple and a more masculine appearance. In addition, they explain the surgical technique and dressing in great detail to avoid seroma formation. Con
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