Vertical and Horizontal Coordinates of the Nipple-Areola Complex Position in Males

"Post Bariatric Male Chest Re-shaping Using L-shaped Excision Technique"

BACKGROUND

Male chest deformity after massive weight loss is complex and challenging to treat because of differing grades of excessive parenchyma/fat ptosis, nipple malposition, over-stretched skin, ill-defined infra-mammary fold, and prominent axillary rolls. Patients are eager to restore balanced upper body dominance. Two fundamental techniques are used for large breasts with moderate to poor skin elasticity; (1) the inferior pedicle Wise skin pattern and (2) double incision with free nipple graft technique.The author presents his experience in treating such severe breast deformities, besides correcting the prominent axillary rolls using an L-shaped mastectomy excision.

MATERIALS AND METHODS

Between March 2017 and December 2020, 55 consecutive patients were treated surgically for male chest re-contouring using the L-shaped mastectomy technique. Ages ranged from 20 to 57 years (median, 31 years). The average body mass index (BMI) was 29. The average follow-up period was 17 months (13-44 months).

RESULTS

Fifty-one patients (92.8%) reported greater levels of postoperative satisfaction with their results owing to lack of any major complication and minimal minor complications (two cases of minor ischemia that healed spontaneously, two small hematomas, two small seromas, and four hypertrophic scars).

CONCLUSION

The L-shaped excision is a useful procedure for severe grade gynecomastia with an atypical presentation in the form of complex chest deformity and prominent axillary roll after massive weight loss patients. The technique is associated with minor complications that are treated in an office setting. The technique preserves normal pigmentation and sensitivity of the nipple-alveolar complex.

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 .

Determination of Appropriate Umbilicus Position during Abdominoplasty in Male Patients

Background

Abdominoplasty techniques are well documented. The ideal position of the umbilicus has, however, received limited attention. Unfortunately, umbilicus position is not universally agreed upon in male cosmetic abdominoplasty. This study was conducted to determine the ideal umbilicus anthropometric measurements in young men, and the relationships between umbilical position and anterior trunk and torso reference points that may be applicable to intraoperative positioning. It is aimed also at investigating whether umbilicus position would be more accurately determined by considering nipple position instead of the abdominal crease, as recently proposed.

Methods

Several anthropometric measurements of various anterior abdominal and thoracic landmarks were conducted on 60 young and middle-aged male volunteers and 30 cadavers at São Paulo city. All statistical analysis was completed using Stata software.

Results

Of all the measured reference points, a much stronger correlation (0.513) was demonstrated between umbilicus-anterior axillary fold (U-AX) and inter-nipple (N-N) distances with a constant golden number ratio relationship (N-N = U-AX × 0.618) compared with the weak correlation of 0.034 between umbilicus-xiphisternum and umbilicus-abdominal crease. In 75% of volunteers, the calculated U-AX was within ±3 cm of actual measurement, and in 33.33% within ±1 cm.

Conclusions

U-AX = 1.618 × N-N equation is more predictive of adequate umbilicus repositioning during abdominoplasty in male patients. Chest and abdomen of men are a single aesthetic unit. Proper positioning of the nipples and umbilicus, as well as harmonious abdominal and torso proportions are critical for an optimal final aesthetic outcome.

[Treatment of pseudogynecomastia in massive weight loss patients: Liposuction assisted and made-to-measure desepidermization technique]

BACKGROUND

After massive weight loss (MWL), the chest in men may show significant deformities. The surgical treatment of gynecomastia after MWL remains a difficult and partially misunderstood surgery due to 4 main factors: a complex excess of skin in height and width that sometimes continues in the axilla or dorsal region, a predominantly fatty rather than glandular component, the malposition of the nipple-areola complex (NAC) that is often enlarged and an inframammary fold (IMF) that is often marked. The techniques currently described are either insufficient or lead to frequent and/or significant complications. The authors describe a new approach that dissociates the treatment of the volume and the skin with a customized resection that is simple, reproducible and safe. Our goal is to improve patient satisfaction while reducing complication rates.

METHODS

Seventeen patients with adipomastia with excess skin after massive weight loss were operated on using liposuction and skin redraping technique. The authors describe the technique, indications and contraindications of the procedure and analyze the results.

RESULTS

The average age of the patients was 39 years. The average body mass index (BMI) before weight loss is 42,7kg/m², the average weight loss before body correction is 49kg, with an average delta of BMI loss of 15,34kg/m^2. The average stay in hospital is 1,3 nights. No patient had major complications (hematoma, hemorrhage, necrosis, thrombophlebitis, immediate surgical revision to treat complications). Minor complications including scar dehiscence, infection, steatonecrosis, and distant scar correction were reported in 2 patients, i.e. 11%.

CONCLUSION

Liposuction assisted and desepidermization torsoplasty is a new technique for correction of pseudogynecomastia in MWL patients. The results are reproductible and the complication rates are low. There is no dead space and therefore no drains are needed. There is little pain and a short hospital stay. This technique is simple, quick and easy to learn. However, it is only applicable in adipomastia. A different technique should be used in the presence of firm glandular tissue.

An external validation of a novel predictive algorithm for male nipple areolar positioning: an improvement to current practice through a multicenter endeavor

The correct positioning of nipple-areolar complexes (NAC) during gender-affirming mastectomies remains a particular challenge. Recently, a Dutch two-step algorithm was proposed predicting the most ideal NAC-position derived from a large cisgender male cohort. We aimed to externally validate this algorithm in a Belgian cohort. The Belgian validation cohort consisted of cisgender men. Based on patient-specific anthropometry, the algorithm predicts nipple-nipple distance (NN) and sternal-notch-to-nipple distance (SNN). Predictions were externally validated using the performance measures: R2-value, means squared error (MSE) and mean absolute percentage error (MAPE). Additionally, data were collected from a Belgian and Dutch cohort of transgender men having undergone mastectomy with free nipple grafts. The observed and predicted NN and SNN were compared and the inter-center variability was assessed. A total of 51 Belgian cisgender and 25 transgender men were included, as well as 150 Dutch cisgender and 96 transgender men. Respectively, the performance measures (R2-value, MSE and MAPE) for NN were 0.315, 2.35 (95%CI:0-6.9), 4.9% (95%CI:3.8-6.1) and 0.423, 1.51 (95%CI:0-4.02), 4.73%(95%CI:3.7-5.7) for SNN. When applying the algorithm to both transgender cohorts, the predicted SNN was larger in both Dutch (17.1measured(±1.7) vs. 18.7predicted(±1.4), p= <0.001) and Belgian (16.2measured(±1.8) vs. 18.4predicted(±1.5), p= <0.001) cohorts, whereas NN was too long in the Belgian (22.0measured(±2.6) vs. 21.2predicted(±1.6), p = 0.025) and too short in the Dutch cohort (19.8measured(±1.8) vs. 20.7predicted(±1.9), p = 0.001). Both models performed well in external validation. This indicates that this two-step algorithm provides a reproducible and accurate clinical tool in determining the most ideal patient-tailored NAC-position in transgender men seeking gender-affirming chest surgery.

Long-Term Changes in Free Nipple Graft Morphology and Patient-Reported Outcomes in Gender-Affirming Mastectomies

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 .

Should the 'normal' and 'ideal' nipple position in a male influence the surgeon when planning severe gynaecomastia correction?

BACKGROUND

The ideal nipple areolar complex (NAC) position of the male chest following gynaecomastia surgery is well documented; however, with increased development of the chest muscles, the NAC placement can change, leading to the medial displacement of the nipple giving a poor aesthetic outcome. Therefore, we believe that these measurements need to be applied to the patients' build and take into consideration the future fitness goals of the patients.

METHOD

We have analysed the photographs of three groups of men: super athletes, athletes and individuals with severe gynaecomastia. We have assessed the proportions of the chest in relation to the NAC, degree of ptosis and TAP index.

RESULTS

There was a wide variation between the athlete and the super athlete group, with minor variations within each group. The range of measurement in the severe gynaecomastia group was significantly larger than those in the other groups. We feel that based on this research study, surgeons should however be somewhat circumspect in their choice of nipple position as there is a wide variation in what can be considered as normal, and positioning of the NAC too early in the recovery process may lead to an abnormal aesthetic appearance following muscle development.

CONCLUSION

Despite the multitude of techniques available in the literature to determine the position of nipple, there is a lack of understanding on how the NAC position changes with muscle development. Adopting a dogmatic approach may result in a very aesthetically displeasing outcome, which can be very difficult to correct in men.

The Ideal Male Nipple-Areola Complex: A Critical Review of the Literature and Discussion of Surgical Techniques for Female-to-Male Gender-Confirming Surgery

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.

The ideal location of the male nipple-areolar complex: A pinpointing algorithm

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.

A Three-Step Technique for Optimal Nipple Position in Transgender Chest Masculinization

BACKGROUND

The ideal position of the nipple-areola complex (NAC) in the transgender population can be a challenge to determine.

OBJECTIVES

The authors sought to determine the best location and aesthetics of the female to male NAC.

METHODS

Patients who underwent female to male mastectomy with free nipple grafting were included. NAC position is confirmed utilizing a vertical coordinate at the level of the 4th rib near the border of the pectoralis muscle and a horizontal coordinate determined by dividing each unilateral chest into vertical thirds from midline to anterior axillary line laterally. The NAC position is confirmed at the junction of the middle and lateral third. Symmetry is ensured bilaterally by creating a triangle and transposing it side to side; the base lies from sternal notch to inframammary fold in the midline and the apex is adjusted to the NAC. A 24-question survey utilizing a 5-point Likert scale was distributed postoperatively to assess the patient's thoughts about their chest, nipples, scar, and overall experience with the gender affirmation process.

RESULTS

Thirty-one patients were included in this study. Eighteen patients responded to the postmastectomy survey, all of whom were highly satisfied with the aesthetic result postoperatively. All patients felt comfortable with their exposed chest. Nipple location was particularly highly received with 100% satisfaction rate (mean Likert score, 4.72). Nipple size and shape received a mean Likert score of 4.17 and 3.89, respectively.

CONCLUSIONS

The triple confirmation technique is an easy, reproducible method to guide the surgeon in relocation of the NAC.

LEVEL OF EVIDENCE: 4

The Nipple Split Sharing vs. Conventional Nipple Graft Technique in Chest Wall Masculinization Surgery: Can We Improve Patient Satisfaction and Aesthetic Outcomes?

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.

Crowdsourcing the Ideal Nipple-Areolar Complex Position for Chest Masculinization Surgery

Chest masculinization surgery is increasing in prevalence. However, the ideal location of the nipple-areolar complex (NAC) is unknown. Our purpose was to determine the most aesthetically favorable male NAC position for use in chest masculinization through crowdsourcing.

Current Perceptions of the Aesthetically Ideal Position and Size of the Male Nipple-Areola Complex

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.

Nipple-Areolar Complex Position in Female-to-Male Transsexuals After Non-skin-excisional Mastectomy: A Case-Control Study in Japan

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 .

Shape, Position and Dimension of the Nipple Areola Complex in the Ideal Male Chest: A Quick and Simple Operating Room Technique

INTRODUCTION

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 female-to-male patients, the creation of an aesthetically pleasing male chest is the most important step. Incorrect positioning of the nipple areola complex (NAC) on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation.

PATIENTS AND METHODS

We have analyzed the anatomical chest features of 26 water polo players, to verify our hypothesis of the relationship between the pectoralis major muscle and NAC and to create a method for repositioning the NAC that is applicable in the operating room, is easy, practical and reproducible without the use of formulas and based on an easily identifiable landmark.

RESULTS

In our reference group, the NAC has a constant relationship with the pectoralis major muscle, positioned on average 3 cm medial to the lateral border of the pectoralis muscle and 2.5 cm above the inferior pectoralis major insertion. This supports our hypothesis and our surgical technique. We use the index finger to find a vertical axis and a line 2.5 cm above the inferior pectoralis shadow to find the horizontal axis. We also introduce a modification to the receiving site to recreate an oval areola more similar to that of an ideal male chest.

CONCLUSIONS

Our anatomical study and statistical analysis support a consistent relationship between the position and shape of the NAC and the borders of the pectoral muscle. We have used this relationship to develop our "trick," which is easily applicable in the operating room to find the NAC position without using formulas and numbers. This method allowed us to place the NAC in a position very close to that of a typical male subject, and it permitted us to reduce the surgery time.

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 .

Defining Normal Parameters for the Male Nipple-Areola Complex: A Prospective Observational Study and Recommendations for Placement on the Chest Wall

BACKGROUND

The nipple-areola complex (NAC) is important aesthetically and functionally for both sexes. Methods for positioning the NAC in males are less well established in the literature compared to females but are just as important.

OBJECTIVES

This study aims to determine the normal parameters for the male NAC, to review literature, and to present a reliable method for preoperative placement.

METHODS

Normal male patients, with no prior chest wall conditions, were prospectively recruited to participate. General demographics and chest wall dimensions were recorded-sternal notch to nipple (SNND), internipple (IND), anterior axillary folds distances (AFD), NAC, and chest circumference were measured. Comparisons were made using t test and ANOVA.

RESULTS

One hundred and fifty-eight patients were recruited (age range, 18-90 years); mostly (86.7%) with normal or overweight BMI. The IND averaged 249.4 mm, the SNND averaged 204.2 mm, and the AFD averaged 383.8 mm. Areola diameter averaged 26.6 mm and for the nipple, 6.9 mm. The IND:AFD ratio was 0.65. There was no statistical difference in the IND:AFD ratio, SNND, or NAC parameters comparing different ethnic groups. The SNND increased with greater BMI (P ≤ 0.001). Using these data, we suggest ideal NAC dimensions and devised a simple method for positioning of the NAC on the male chest wall.

CONCLUSIONS

This is the largest study, with the widest range in age and BMI, to date on this topic. Although fewer men than women undergo surgery to the breast, there is a growing awareness for enhancing the appearance of the male chest wall.

LEVEL OF EVIDENCE 4

Creation of an Aesthetic Male Nipple Areolar Complex in Female-to-Male Transgender Chest Reconstruction

BACKGROUND

Female-to-male chest wall reconstruction is becoming more common, but while there is a growing body of the literature describing technique and algorithms, little detail is written on methods for creating a male appearing nipple areolar complex (NAC) from a female NAC utilizing free nipple graft techniques. Incorrect positioning of the NAC on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation.

METHODS

With this paper, we present techniques for nipple grafting to achieve improved male appearing NACs, as well as a simple, reproducible method for appropriate placement of the NAC relative to the borders of the pectoralis muscle. To validate our technique, we performed photographic analysis of 64 NACs in 32 volunteers with BMI of 25 or less.

RESULTS

The anatomic study determined the cis-male nipple to be positioned on average 2.5 cm medial to the lateral border of the pectoralis muscle and 2.4 cm above the inferior pectoralis insertion. This supports our surgical technique of positioning the NAC in relation to the pectoralis borders rather than previously advocated anatomic landmarks. We also present reliable techniques for creating a round or horizontally oval final NAC shape as well as a composite grafting technique for cases of large papillae.

CONCLUSIONS

Our anatomic study supports placement of the male NAC relative to lateral and inferior borders of the pectoralis muscle. Nipple grafting techniques presented allow for a simple and reproducible method of creating an aesthetic male NAC shape in female-to-male transgender chest reconstruction.

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 .

Optimal Positioning of the Nipple-Areola Complex in Men Using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line): An Intuitive Approach

INTRODUCTION

The reconstruction of the body shape after post-bariatric surgery or high-grade gynecomastia involves, besides skin tightening, the repositioning of anatomical, apparent landmarks. The surgeon usually defines these during the preoperative planning. In particular, the positions of the nipple-areola complexes (NAC) should contribute to the gender-appropriate appearance. While in the female breast numerous methods have been developed to determine the optimal position of the NACs, there are only a few, metric and often impractical algorithms for positioning the nipples and areoles in the male. With this study, we show the accuracy of the intuitive positioning of the nipple-areola complex in men.

MATERIAL AND METHODS

From a pre-examined and measured quantity of 10 young and healthy men, six subjects were selected, which corresponded, on the basis of their chest and trunk dimensions, to the average of known data from the literature. The photographed frontal views were retouched in two steps. Initially, only the NACs were removed and the chest contours were left. In a second step, all contours and the navel were blurred. These pictures were submitted to resident and consultant plastic surgeons, who were asked to draw the missing NACs without any tools. The original positions of the nipples were compared with the inscriptions. Furthermore, the results were compared between the contoured and completely retouched pictures and between the residents and consultants.

RESULTS

A total of 8 consultants and 7 residents were included. In the contoured and completely retouched images, a significant deviation of the marked positions of the missing features was found. The height of the NAC was determined somewhat more precisely than the vertical position. There was no significant difference between the contoured and completely retouched images, with a discretely more accurate tendency on the contoured images. In comparison with the professional experience, the consultants were tangentially more precise, but without a statistically significant impact.

DISCUSSION

The intuitive determination of the NACs is a challenge for the plastic surgeon. In this study, a statistically significant deviation was seen in almost all dimensions, although the clinical relevance cannot be conclusively assessed. We found a positional relationship of the NAC to the infraclavicular groove ("Mohrenheim pit") in the vertical and 4-4.5 cm above the submammary fold. The position of the NAC can be satisfactorily determined by a combination of plastic surgical intuition, patient wishes and practical metric methods using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line).

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Masculine Chest-Wall Contouring in FtM Transgender: a Personal Approach

BACKGROUND

Chest-wall contouring surgery is one of the first steps in sexual reassignment in female-to-male (FtM) transsexuals that contributes to strengthening of the self-image and facilitates living in the new gender role. The main goal is to masculinize the chest by removing the female contour. Chest contour, scar placement, scar shape, scar length, nipple-areola position, nipple size and the areola size are the key points.

METHODS

Between July 2013 and June 2016, 25 FtM transgender patients underwent surgical procedures to create a masculine chest-wall contour. In our study, we just considered 16 patients who have undergone chest surgery with the double incision method.

RESULTS

The patients' survey revealed a high satisfaction rate with the aesthetic result. In our group, no complications occurred, and two patients have undergone supplementary surgery for axillary dog-ear revision and nipple reconstruction.

CONCLUSION

The authors propose a new technical approach and indications for FtM transgender patients' surgery. A longer scar that emphasizes the pectoralis muscle, a smaller nipple and a resized and refaced areola are the key points of our technique to give a masculine appearance to the chest. The scars are permanent, but most of them will fade and the patients are enthusiastic with their new "male" chest appearance. The high level of satisfaction, the great aesthetic result and the low rate of complications suggest to us the use of this technique in medium- and large-size breasts.

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 .

An anatomic study of nipple position and areola size in Asian men

BACKGROUND

In planning gender-reassignment surgery for biological women and treating men with gynecomastia, surgeons must have a thorough understanding of anatomically correct nipple positions and appropriate areola sizes in men.

OBJECTIVES

The authors sought to determine whether body height or body mass index (BMI) affects nipple position or areola size in men.

METHODS

Anatomic measurements of the nipples and areolae of 50 Japanese men were obtained. A relative coordinate system was defined, where the medial-lateral and superior-inferior positions of the nipple were quantitatively indicated by distance ratios between anatomic landmarks. Nipple positions were evaluated for each patient by referring to this coordinate system, and the positions were compared between groups categorized by body height or BMI.

RESULTS

Nipple position was not significantly affected by body height. However, the nipple tended to be located more laterally in participants with higher BMI. The vertical nipple position differed between standing and supine positions. Tall men had larger areolae than short men; however, areola size did not differ with respect to BMI.

CONCLUSIONS

Nipple position and areola size vary by body shape. Consideration of the differences is recommended when performing procedures such as female-to-male gender-reassignment surgery or correction of gynecomastia.