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Rahmani B, Park JB, Adebagbo OD, Foppiani JA, Nickman S, Lee D, Lin SJ, Tobias AM, Cauley RP. Understanding Public Perceptions of Nipple and Scar Characteristics After Chest Wall Masculinization Surgery. Aesthetic Plast Surg 2024:10.1007/s00266-024-04172-1. [PMID: 38951227 DOI: 10.1007/s00266-024-04172-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/30/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Surgical chest masculinization procedures, especially gender-affirming top surgery (GATS), are becoming increasingly prevalent in the USA. While a variety of surgical techniques have been established as both safe and effective, there is limited research examining ideal aesthetic nipple appearance and incision scar pattern. This study employs patient images to understand the public's perception on top surgery outcomes when adjusting for BMI ranges and Fitzpatrick skin types. METHODS Images from RealSelf modified via Adobe Photoshop depicted various scar types and nipple-areolar complex (NAC) sizes/positions. A Qualtrics survey was distributed utilizing Amazon Mechanical Turk. Statistical analysis was performed through JMP Pro 17 for ordinal and categorical values, with a p value less than or equal to 0.05 statistically significant. RESULTS A moderately sized and laterally placed NAC was preferred. A transverse scar that resembles the pectoral border between the level of the inframammary fold and pectoral insertion was deemed most masculine and aesthetic. Majority of results demonstrated that this is unaffected by Fitzpatrick skin types. Increased BMI images impacted public preferences, as a nipple placed farther from the transverse incision (p = 0.04) and a transverse scar position closer to the IMF was preferred in higher BMI patients. CONCLUSIONS An understanding of the most popular NAC and scar choices, as well as how these factors may differ when considering a Fitzpatrick skin type or BMI categorization was attained. This validates the importance of patient-centered approach when employing surgical techniques in GATS. Future studies intend to obtain reports from actual patients considering GATS. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable.
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Affiliation(s)
- Benjamin Rahmani
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - John B Park
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - Oluwaseun D Adebagbo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - Jose A Foppiani
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - Sasha Nickman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - Daniela Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - Adam M Tobias
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA
| | - Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 5A, Boston, MA, 02215, USA.
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Adidharma L, Adidharma W, Latack KR, Moog D, Morrison SD, Wilkins EG. Quantifying Nipple-Areolar Complex Shape and Location After Transmasculine Top Surgery: A Study of Postoperative Photographs Posted on Social Media and Surgeons' Professional Websites. Transgend Health 2024; 9:83-91. [PMID: 38312453 PMCID: PMC10835154 DOI: 10.1089/trgh.2021.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions. Methods In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed. Results We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012). Conclusion Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.
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Affiliation(s)
- Lingga Adidharma
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Widya Adidharma
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Kyle R Latack
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Dominic Moog
- School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Shane D Morrison
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Edwin G Wilkins
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Ramasamy K, Shet SM, Patil P, Tripathee S, Dhevi N, Alagarasan AR. Anthropometric Measurements and Analysis for Objective Assessment of Gynecomastia Surgery Results. Aesthet Surg J Open Forum 2023; 5:ojad073. [PMID: 37638341 PMCID: PMC10456205 DOI: 10.1093/asjof/ojad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Background Gynecomastia surgery is one of the most common aesthetic procedures in males. There is a lack of objective analytical parameters to judge outcomes. In this study, the authors aim to introduce novel anthropometric measurements and analysis techniques for the objective assessment of surgical outcomes based on specific aesthetic targets. Objectives To introduce quantification of gynecomastia surgery outcomes and compare the results among the different grades of gynecomastia. Methods A total of 192 patients with gynecomastia were included. The patient cases were grouped according to grades and a set of anthropometric measurements were taken both before the operation and 6 months postoperatively. Liposuction and glandular excision were done through minimal incisions in all grades of gynecomastia, with the addition of ultrasound and nipple areola complex (NAC) lifting plaster in selected Grade 3 and all Grade 4 cases. Results A statistically significant improvement in the perimeter of the triangular relationship of sternal notch and nipples, the elevation of the NAC, the reduction of the area of the NAC, and the correction of asymmetry of the chest were seen in all grades of gynecomastia, with increased differences in higher grades. Conclusions A systematic objective analysis of the specific aesthetic targets helps to reliably compare results in a standard way and for carrying out improvisation of surgeons' techniques. Meanwhile, this approach helps identifying the need for customization, eventually providing symmetric and aesthetically pleasing surgical results. Level of Evidence 3
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Affiliation(s)
- Karthik Ramasamy
- Corresponding Author: Dr Karthik Ramasamy, New No 12, Old 10, Mc Nichols Rd, 4th Lane, Chetpet, Chennai, Tamil Nadu 600031, India. E-mail: ; Instagram: @ramdrkarthik, @chennai_plastic_surgery
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Burhamah W, Alshawaf SM, Alwazzan S, AlYouha S, Al-Sabah S. The Utilization of Three-Dimensional Printing in Creating a Surgical Instrument: An Areola Cookie Cutter. Aesthet Surg J Open Forum 2022; 4:ojac055. [PMID: 35903516 PMCID: PMC9317162 DOI: 10.1093/asjof/ojac055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Three-dimensional (3D) printing is a rapidly evolving technology with many applications in the medical field. It involves printing solid objects from a digital file. In this paper, we describe our experience with the use of 3D printing in creating an areola cookie cutter that is compatible with sterilization. The objective of this study is to explore accurate and cost-effective methods of producing patient-specific areola cookie cutters. Auto computer-aided design (CAD) 3D software was used to design a digital model that was subsequently converted to a standard tessellation language (STL) file. The models were printed with the Formlabs Form 3+ SLA printer (Somerville, MA) using a resin material. Washing and curing were then performed followed by autoclave sterilization of the models. A total of 3 areola cookie cutters were created, each with different sizes (33, 38, and 42 mm) using resin material (Formlabs BioMed Clear Resin; Somerville, MA). All 3 models were able to withstand autoclave sterilization. The use of 3D printing has proven to be a valuable tool in Plastic surgery. We describe our experience of designing and producing an areola cookie cutter using a 3D printer; our model is compatible with the process of sterilization. We emphasize the advantages of a quick production time and accuracy in design.
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Affiliation(s)
- Waleed Burhamah
- Division of Plastic & Reconstructive Surgery, Jaber Al Ahmad Al Sabah Hospital, Kuwait City, Kuwait
| | - Solaiman M Alshawaf
- Division of Plastic & Reconstructive Surgery, Jaber Al Ahmad Al Sabah Hospital, Kuwait City, Kuwait
| | - Sabika Alwazzan
- Department of General Surgery, Jaber Al Ahmad Al Sabah Hospital, Kuwait City, Kuwait
| | - Sarah AlYouha
- Corresponding Author: Dr Sarah AlYouha, Health Sciences Centre, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait. E-mail: ; Instagram: @drSarahalyouha
| | - Salman Al-Sabah
- Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
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Timmermans FW, Elfering L, Smit JM, van de Grift TC, Bouman MB, Mullender MG. Long-Term Changes in Free Nipple Graft Morphology and Patient-Reported Outcomes in Gender-Affirming Mastectomies. Aesthetic Plast Surg 2022; 46:2174-2180. [PMID: 34988634 DOI: 10.1007/s00266-021-02666-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/30/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND After gender-affirming mastectomies with free nipple grafts, satisfaction with nipples tends to fall short behind chest outcomes. This might be related to changes in nipple areolar complex (NAC) dimensions over time. Therefore, the aim of this study is to establish the long-term changes in NAC morphology and compare these to cisgender male NAC outcomes. MATERIALS An observational, cross-sectional study was performed. Data from two prospective cohorts were collected: (1) transgender men after a mastectomy with free nipple grafts and (2) cisgender men (reference sample). Demographics and 3-D images were collected for both groups. NAC measurements were performed on the 3-D images at 4 time points (7-, 30-, 90- and 365-days postoperative) in transgender men and once in cisgender men. Furthermore, the BODY-Q (nipple module) was administered postoperatively at 30-, 90- and 365-days in transgender men. RESULTS In total, 67 transgender and 150 cisgender men were included. NAC width and height in trans men changed from 21.5 mm (±2.7) to 23.8 mm (±3.9, p<0.001) and 16.2 mm (±2.5) to 14.7 mm (±3.0, p=0.01) within a year, respectively. On average, the NACs increasingly rotated 21 degrees in the latero-caudal direction (p<0.001). The mean NAC width and height in cisgender men were 28.1 mm (±5) and 20.7 mm (±4), being significantly larger than in transgender men. Satisfaction for size, shape and flatness decreased significantly after postoperative day 30 (p=<0.05) in transgender men. CONCLUSIONS Morphology of and satisfaction with the NACs in transgender men significantly changed over time. Understanding and incorporating these differences into pre-operative counseling and surgical planning might help increase patient satisfaction. LEVEL OF EVIDENCE IV 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 .
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Savas SA. The Effect of Suction-Assisted Liposuction on Reduction of Diameter of Nipple-Areola Complex Among Patients with Simon Grade IIb and III Gynecomastia. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03276-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Moorefield AK, Stock A, Rose-Reneau Z, Singh PK, Azari Z, Wright BW, Singhal V. Analysis of Nipple-Areola Complex Localization Using Male Cadavers: Considerations for Gender-Affirming Surgery. Aesthet Surg J Open Forum 2021; 3:ojab032. [PMID: 34611624 PMCID: PMC8486918 DOI: 10.1093/asjof/ojab032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Masculinizing chest reconstruction is the most common gender-affirming surgery in transgender males. Despite the current literature's acknowledgment of the vital role that proper placement of the nipple-areola complex (NAC) plays in a masculine chest contour, there is still much debate regarding the best anatomical landmarks to achieve the desired result. Objectives The primary aim of this study is to determine which landmarks for NAC placement can be applied across diverse body types and aid surgeons in creating a masculine chest. Methods Twenty-five formaldehyde-embalmed male cadavers were analyzed by conducting various measurements of the NAC, nipple, and surrounding bony and muscular landmarks to identify the most consistent landmarks for proper NAC placement. Linear regression analyses were run to determine how the distance between nipple to respective landmarks varied based on antemortem body mass index (BMI), height, weight, and age. Results The measurements for the inferior and lateral borders of the pectoralis major muscle (PMM) displayed the least amount of variance of all the anatomical landmarks studied. Additionally, there was no significant change in these pectoral measurements with varying BMI, height, weight, or age, indicating that these measurements are reliable landmarks for NAC placement across various body types. The average NAC placement in relation to the inferior and lateral borders of PMM was around 2.5 and 2.0 cm, respectively. Conclusions Our cadaveric analysis indicates that aesthetically pleasing masculine chest results can be produced consistently across varying body types when adhering to a simple pectoral approach in NAC placement.
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Affiliation(s)
- Amanda K Moorefield
- Anatomy Department Chair, Division of Clinical Anatomy, Kansas City University, Kansas City, MO, USA
| | - Anna Stock
- Anatomy Department Chair, Division of Clinical Anatomy, Kansas City University, Kansas City, MO, USA
| | - Zak Rose-Reneau
- Anatomy Department Chair, Division of Clinical Anatomy, Kansas City University, Kansas City, MO, USA
| | - Pratima K Singh
- Anatomy Department Chair, Division of Clinical Anatomy, Kansas City University, Kansas City, MO, USA
| | - Zubeen Azari
- Anatomy Department Chair, Division of Clinical Anatomy, Kansas City University, Kansas City, MO, USA
| | - Barth W Wright
- Anatomy Department Chair, Division of Clinical Anatomy, Kansas City University, Kansas City, MO, USA
| | - Virender Singhal
- Anatomy Department Chair, Division of Clinical Anatomy, Kansas City University, Kansas City, MO, USA
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Technical Refinement in Three-Dimensional Nipple-Areola Complex Tattooing of the Reconstructed Breast. Plast Reconstr Surg 2021; 148:737-746. [PMID: 34550927 DOI: 10.1097/prs.0000000000008390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
SUMMARY Three-dimensional nipple-areola complex tattooing has previously been described as an alternative to surgical reconstruction using local flaps and grafts. This technique offers patients an option that can achieve aesthetically pleasing results without a donor site, changes in projection over time, or additional scarring. Plastic surgeons may be limited in their ability to create a realistic-appearing nipple-areola complex because of limited experience with basic tattooing techniques and unfamiliarity with the artistic principles of light and shadow required to create depth on a two-dimensional surface. Consistent results can be achieved with attention to the technical pearls discussed in this article.
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Bustos SS, Kuruoglu D, Yan M, Bustos VP, Forte AJ, Ciudad P, Kim EA, Del Corral GA, Manrique OJ. Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:612. [PMID: 33987310 DOI: 10.21037/atm-20-4522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.
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Affiliation(s)
- Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA.,Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Doga Kuruoglu
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Maria Yan
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Valeria P Bustos
- Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Antonio J Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Esther A Kim
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, CA, USA
| | - Gabriel A Del Corral
- Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA.,Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
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Ding N, Yu N, Dong R, Kong L, Xue H, Long X, Li Y, Wang Y, Huang X, Jin Z. Blood supply of the male breast nipple-areola complex evaluated by CTA. J Plast Reconstr Aesthet Surg 2021; 74:2588-2595. [PMID: 33879411 DOI: 10.1016/j.bjps.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/12/2021] [Accepted: 02/26/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE In addition to women, men also undergo breast surgeries, and early studies on the blood supply of breasts are nearly all conducted in female subjects. The vasculature of the male breast is seldom studied. Understanding the male-specific blood supply of the breast is important for pre-operative planning and reducing complications. The purpose of this retrospective study is to fill the gap in the literature by describing the main blood supply and its orientation in the male breast. METHODS We retrospectively evaluated thoracic computed tomographic angiography (CTA) data from January 1, 2017 to July 30, 2019. Single or multiple dominant arteries and their origins were traced, and the artery route and orientation related to the nipple-areola complex (NAC) were revealed through data analysis of the images. RESULTS Totally, 284 breasts were included. Most breasts were supplied by a single dominant artery (196, 69%), among which the lateral thoracic artery (LTA; 119, 41.9%; type I) and internal thoracic artery (ITA; 63, 22.2%; type II) were the most common arteries. A minority of breasts were supplied by vascular anastomoses formed by dual arteries (17, 6.0%; type III), and in 25.0% of breasts, no specific dominant artery was found (type IV). The predominant artery distribution was evaluated. CONCLUSION This study cohort of male thoracic CTA provided and analysed the elaborate vascular anatomy of the NAC region. Our results favour inferior periareolar incision in regard to diminished vascular-related complications in male surgeries without pre-operative vascular evaluation. This study also suggests that super-lateral or lower-lateral-based pedicles can reserve more vasculature.
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Affiliation(s)
- Ning Ding
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuai Fu Yuan 1#, Dongcheng Dist., Beijing 100730, China
| | - Nanze Yu
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruijia Dong
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Lingyan Kong
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuai Fu Yuan 1#, Dongcheng Dist., Beijing 100730, China.
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuai Fu Yuan 1#, Dongcheng Dist., Beijing 100730, China
| | - Xiao Long
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yumei Li
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuai Fu Yuan 1#, Dongcheng Dist., Beijing 100730, China
| | - Yun Wang
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuai Fu Yuan 1#, Dongcheng Dist., Beijing 100730, China
| | - Xin Huang
- Department of Breast Surgery, Peking Union Medical College Hospital Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhengyu Jin
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuai Fu Yuan 1#, Dongcheng Dist., Beijing 100730, China.
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The Ideal Male Nipple-Areola Complex: A Critical Review of the Literature and Discussion of Surgical Techniques for Female-to-Male Gender-Confirming Surgery. Ann Plast Surg 2021; 84:334-340. [PMID: 31633544 DOI: 10.1097/sap.0000000000002018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Top surgery (mastectomy and masculinization of the chest) is a key gender affirming operation for many female-to-male transgender patients. Positioning of the nipple-areola complex (NAC) is a crucial part of this procedure. To date, there are no standards as to where to place the new NAC based on the patient's anatomy, to achieve the most aesthetically pleasing result. OBJECTIVE The objectives of this study were to review the literature and analyze the anatomical averages for NAC shape, width, and height as well as vertical and horizontal placement and to compile the recommendations and proposed equations of NAC placement based on chest wall measurements, chest wall landmarks, and body habitus. METHODS A systematic review of the literature was conducted in the spring of 2018. Eleven articles met the inclusion criteria, with objective measurements of, and guidelines for, positioning the male NAC in men that had not been preselected for being aesthetically perfect. RESULTS The average diameter for a round NAC was 25.9 mm (SD, 2.5 mm), and the width and height of the oval-shaped NAC were found to be 25.3 mm (SD, 2.6 mm) and 20.1 mm (SD, 0.75 mm), respectively. The average sternal notch to nipple distance was found to be 19.3 cm (SD, 1.7 cm). The average internipple distance was 22.3 cm (SD, 1.6 cm). CONCLUSIONS The data are inconclusive about the effects of anatomical measurements on NAC vertical and horizontal position, but areola diameter is reasonably consistent. There are a wide variety of guidelines and algorithms offered for determining these measurements.
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Timmermans FW, Jansen BAM, Mokken SE, de Heer MH, Veen KM, Bouman MB, Mullender M, van de Grift TC. The ideal location of the male nipple-areolar complex: A pinpointing algorithm. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2021; 22:403-411. [PMID: 37818394 PMCID: PMC10561627 DOI: 10.1080/26895269.2021.1884926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Background In the treatment of gender dysphoria, appropriate nipple-areola complex (NAC) positioning is essential for achieving a natural appearing male chest after subcutaneous mastectomy. An accurate predictive model for the ideal personalized position of the NAC is still lacking. The aim of this study is to determine the anthropometry of the male chest to create individualized guidelines for appropriate NAC positioning in the preoperative setting. Materials and methods Cisgender male participants were recruited. Multiple chest measurements were manually recorded. Best subset regression using linear models was used to select predictors for the horizontal coordinate (nipple-nipple distance; NN) and vertical coordinate (sternal notch-nipple distance; SNN) of the NAC. Internal validation was assessed using bootstrapping. Furthermore, a cohort of transgender men who had received a mastectomy with replantation of nipples according to current practice was identified. Comparison testing between the algorithm and standard practice was performed to test the limitations of standard practice. Results One hundred and fifty cis male participants were included (median age: 26, IQR: 22-34 years). Four predictors were found to predict NN (age, weight, chest circumference (CC), anterior-axillar fold to anterior-axillar fold (AUX-AUX)) and reads as follows: NN = 4.11 + 0.035*age + 0.041*weight + 0.093*CC + 0.140*AUX-AUX Two predictors were found to predict SNN (NN and weight), and reads as follows: SNN = 7.248 + 0.303*NN + 0.072*weight. Both models performed well (Bootstrapped R2: 0.63 (NN), 0.50 (SNN)) and outperformed previous models predicting NAC position. Ninety-six transgender men were eligible for evaluation of current practice and showed an average placement error of -0.9 cm for NN and +2.2 cm for SNN. Conclusion The non-standardized approach of NAC repositioning results in a significant error of nipple placement. We suggest that the two predictive models for NN and SNN can be used to optimize NAC positioning on the masculinized chest wall. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1884926.
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Affiliation(s)
- F. W. Timmermans
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands
| | - B. A. M. Jansen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - S. E. Mokken
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - M. H. de Heer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - K. M. Veen
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M. B. Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - M. Mullender
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - T. C. van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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Bustos SS, Forte AJ, Ciudad P, Manrique OJ. The Nipple Split Sharing vs. Conventional Nipple Graft Technique in Chest Wall Masculinization Surgery: Can We Improve Patient Satisfaction and Aesthetic Outcomes? Aesthetic Plast Surg 2020; 44:1478-1486. [PMID: 32500321 DOI: 10.1007/s00266-020-01803-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/23/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Double incision mastectomy with free nipple grafts (DIFNG) offers more flexible nipple-areola complex (NAC) resizing and repositioning in transmale and gender non-conforming individuals. The cis-male NAC has a smaller diameter, oval shape and lateral position. If nipple grafts are performed without having these considerations, aesthetics can be dissatisfying. We aim to describe the nipple split sharing technique during chest wall masculinization surgery comparing surgical, patient-reported outcomes (PRO) and aesthetic results with the conventional technique. METHODS This was a retrospective review of transmale patients who underwent DIFNG from January 2017 to January 2019. The cohort was divided into two groups: conventional and the splitting technique. Demographics, intraoperative and postoperative outcomes were recorded. In addition, PRO using Body-Q scale and aesthetic results using a Likert-based scale were analyzed. RESULTS Thirty-four patients (68 breasts) underwent DIFNG. A total of 32 breasts underwent the split nipple reconstruction approach, whereas 36 underwent conventional technique. Median patient age and BMI in the nipple sharing and conventional technique groups were 27 years and 35.4 kg/m2, and 24 years and 32.2 kg/m2, respectively. Differences on postoperative complications were not statistically significant. Patient satisfaction on nipples' module was 90.7% vs. 58.1% in the nipple sharing vs. conventional technique, respectively (p < 0.05). The nipple's masculine aspect, size, contour, position and scars were aesthetically superior to the split approach (p < 0.05). CONCLUSION Double incision mastectomy with nipple split sharing technique has good aesthetic outcomes, a low complication rate and high patient satisfaction. It is a great surgical alternative to improve aesthetics in chest wall masculinization surgery. LEVEL OF EVIDENCE III 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 . Breast Surgery.
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Affiliation(s)
- Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Antonio J Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA.
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14
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Kaoutzanis C, Schneeberger SJ, Wormer B, Song H, Ye F, Al Kassis S, Winocour J, Higdon K, Perdikis G. Current Perceptions of the Aesthetically Ideal Position and Size of the Male Nipple-Areola Complex. Aesthet Surg J 2020; 40:NP228-NP237. [PMID: 31606742 DOI: 10.1093/asj/sjz276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The dimensions of the nipple-areola complex (NAC) and its location on the chest wall are important aesthetic factors in male breast surgery. OBJECTIVES This study examines the perceptions of aesthetic surgeons and the general population for the aesthetically ideal position and size of male NAC. METHODS An online survey was distributed to the American Society for Aesthetic Plastic Surgery (ASAPS) members and to the general population. Parameters queried included demographics for all participants and academic details for ASAPS members. Both surveys included a male model picture with 16 separate choices for the NAC position from a frontal view, 5 choices for the NAC position from a lateral view, and 6 choices for the NAC dimensions. For all 3 sets of images, the participants were asked to rank the top 3 images they considered most "aesthetically pleasing" in descending order. A weighted scoring rule was created to quantitatively evaluate image choices. Standard statistical methods were employed for analysis. RESULTS The survey was completed by 272 ASAPS members and 4909 participants from the general population. The top 3 choices for NAC location on frontal view were the same for ASAPS members and the general population. The most popular NAC location on lateral view was the same for both groups, but the preferred locations differed between the 2 groups for the second and third choices. The most popular dimensions of the NAC were 2 cm (vertical) × 3 cm (horizontal) followed by 2 cm × 2 cm for both groups. Comparison of the 3 top image choices scores between different ethnic groups and individuals with different gender or sexual orientation demonstrated similar trends. CONCLUSIONS This survey identified the preferred position and dimensions of the NAC on the male breast for plastic surgeons and the general population. These parameters should be considered when counseling males undergoing breast surgery.
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Affiliation(s)
- Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Steven J Schneeberger
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Blair Wormer
- Plastic Surgery Service, Novant Health, Charlotte, NC
| | - Haocan Song
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Salam Al Kassis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Julian Winocour
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kent Higdon
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
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15
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Analysis of Chest Masculinization Surgery Results in Female-to-Male Transgender Patients: Demonstrating High Satisfaction beyond Aesthetic Outcomes Using Advanced Linguistic Analyzer Technology and Social Media. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2356. [PMID: 32095382 PMCID: PMC7015616 DOI: 10.1097/gox.0000000000002356] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/04/2019] [Indexed: 11/26/2022]
Abstract
Background: Satisfaction rates are reported as high after subcutaneous mastectomy for chest masculinization. We examined patient satisfaction based on linguistic analysis of social media posts showing postoperative results and compared them to aesthetic quality ratings from plastic surgeons. Methods: Fifty publicly available images of subcutaneous mastectomy postoperative results of female-to-male gender transition patients were selected from Instagram. The photograph’s corresponding post and comments were then analyzed for sentiment through the IBM Watson tone analyzer, which rated the presence of joy on a continuous scale from 0 to 1. Three plastic surgeons rated aesthetic quality on an ordinal scale of 1 to 10. Results of both analyses were then compared. Results: Joy was rated as a mean value of 0.74 (±0.13) in posts and 0.81 (±0.13) in comments. The mean ratings of results were found to be chest contour 6.1 of 10 (±1.7), scar position 5.3 of 10 (±1.8), scar quality 4.8 of 10 (±1.9), nipple position 5.2 of 10 (±1.9), and nipple quality 5.1 of 10 (±2.0). A positive relationship was found between post joy and nipple quality (r = 0.33, P = 0.0169). There were no other associations detected between level of joy and the ratings of results by plastic surgeons (P > 0.05). Conclusions: Despite wide variety in surgical appearance, there is a high level of satisfaction and community support. This is in contrast to the low-quality ratings by plastic surgeons. The results demonstrate the strong psychological and functional underpinnings chest masculinization has for patients. However, surgical results can be improved through a variety of techniques such that patients have both excellent surgical results and high satisfaction.
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Kagaya Y, Shiokawa I, Karasawa H, Ono K, Momosawa A. Nipple-Areolar Complex Position in Female-to-Male Transsexuals After Non-skin-excisional Mastectomy: A Case-Control Study in Japan. Aesthetic Plast Surg 2019; 43:1195-1203. [PMID: 31144007 DOI: 10.1007/s00266-019-01409-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mastectomy is performed in female-to-male transsexual (FTM TS) patients as a surgical treatment to make a female thorax resemble a male thorax; however, no studies have examined the nipple-areolar complex (NAC) position in FTM TS patients after mastectomy. PATIENTS AND METHODS The NAC position in 41 FTM TS patients before and after non-skin-excisional mastectomy was examined and compared with that in 50 age- and BMI-matched biologically male subjects as controls. The factors affecting the NAC position after the operation were also examined and verified by multiple regression analysis. RESULTS AND CONCLUSIONS After non-skin-excisional mastectomy, the NAC in the FTM TS patients was positioned significantly more medially (horizontal NAC position ratio {('internipple distance'/'width of thorax') × 100} [HNPR]: preoperatively, 70.07% ± 4.19%; postoperatively, 63.28% ± 3.79%) and cranially (vertical NAC position ratio {('distance from sternal notch to nipple height'/'distance from sternal notch to umbilicus') × 100} [VNPR]: preoperatively, 43.87% ± 3.68%; postoperatively, 41.37% ± 3.15%). Postoperatively, the NAC in the FTM TS patients was located significantly more medially than that in the control subjects (HNPR: 63.28% ± 3.79% to 66.79% ± 4.82%), although the height of the NAC was the same. Multiple regression analysis revealed that the NAC position on breasts characterized by ptosis, a high projection, and lateral leaning (low skin elasticity and a substantial amount of skin between the nipples) tended to be positioned more medially after non-skin-excisional mastectomy. Laterally deviated eccentric circular type mastectomy may be a good option for FTM TS patients who have moderately sized breasts with such features. LEVEL OF EVIDENCE IV 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 .
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Affiliation(s)
- Yu Kagaya
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Ichiro Shiokawa
- Department of Plastic and Reconstructive Surgery, Yamanashi University Hospital, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3863, Japan
| | - Hiroki Karasawa
- Keiseikai Clinic, 1-7-30 Higashi-shinsaibashi, Chuo-ku, Osaka-shi, Osaka, Japan
| | - Kentaro Ono
- Skin Clinic Fujieda, 1-3-1 Maejima, Fujieda-shi, Shizuoka, Japan
| | - Akira Momosawa
- Department of Plastic and Reconstructive Surgery, Yamanashi University Hospital, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3863, Japan.
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