Subcutaneous mastectomy (SCM) plays a major role in female-to-male (FtM) gender affirming surgery, and obtaining a flattering chest contour remains a challenge to the surgeon. We present an operative method using a dermal nipple-areola-complex (NAC) flap with the aim to create a naturally masculine appearance, while reducing the risk of NAC complications by maintaining sufficient neurovascularization.
Through a horizontal incision, a superior thoracic full skin flap was elevated at the dissection plane for mastectomy. The mastectomy was continued inferiorly, creating an inferior flap including the NAC. The surface of the inferior flap was deepithelialized, secluding the NAC, which allowed the inferior dermal flap to be inserted posterior to the superior flap. A circular defect was created in the superior flap, into which the NAC was sutured.
The surgery delivered satisfactory results with an aesthetically pleasing masculine appearance and a high level of patient satisfaction. We were able to place the horizontal scars inferiorly along the pectoral muscles, which enabled some camouflage. Additionally, the inferior flap provided a uniform filling effect to the chest, further contributing to the male aesthetic. There were no NAC complications.
The dermal NAC flap method could be applied as an excellent alternative to the traditionally performed free nipple graft technique in FtM gender confirming surgery. The method is simple, provides an aesthetically appealing outcome, and poses a low risk of NAC complications. Intraoperatively, it allows for good exposure and a uniform removal of breast tissue, as well as repositioning and/or reduction of the NAC where required.