Male chest reconstruction
In men with breast growth, caused either by gynecomastia or by status as a trans man, a male chest reconstruction is often done to give the chest a more masculine appearance. In transgender and transsexual people, this surgery may be performed as part of the transition of a female body into a male/masculine body.
Breast Augmentation
Male chest reconstruction usually precedes genital surgery for trans men, as protruding breast contours are a secondary female sexual characteristic.
While for very small breasts a peri-areolar skin excision can be performed, the problem of maintaining an adequate pedicle to support the nipple areolar complex without protrusion of the pedicle through the skin becomes challenging. Bringing skin into the borders of a contracted areola will cause puckering which hopefully with time will smooth out. A permanent fixation suture is often required to prevent tension on the suture line from causing a slowly expanding scar.
Inverted "T" Procedure
A transverse inframammary incision with free nipple areolar grafts may be one approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T).
The areola is trimmed to a pre-agreed-upon diameter and the nipple sectioned with a pie-shaped excision and reconstituted. There may be varying sensory loss because of nerve disruption.
Double Incision Procedure
One of the most common male chest reconstructive procedures, double incision involves an incision above and below the breast mass, the removal of the fatty and glandular tissue, and the closure of the skin once again. This method leaves scars under the pectoral muscles, stretching from the underarms to the medial pectoral. Double incision is usually accompanied by nipple grafts, often provided free along with the procedure by surgeons.
Nipple Grafts
In this procedure, the goal is to make male-looking nipples using the nipples and areolas originally provided during surgery. The areola and nipple is removed from the breast tissue, cutting away along the circumference and removing the top layer of flesh from the rest of the tissue. After the chest has been reconstructed, the nipples are grafted onto a place that gives the most masculine appearance (best seen when the patient is sitting up under anesthesia). The areolas are often sized down as well as the nipples themselves, as female areolas are often larger in circumference and the nipples protrude farther. Nipple grafts are generally associated with double incision style chest reconstruction, but may be used in any reconstruction procedure if necessary. With nipple grafts comes the possibility of rejection. In such cases, the nipple is often tattooed back on cosmetically or further surgical procedures may be applied. Sensation will usually return to the grafted nipples over time, but erotic sensation is often lost completely, unlike in the keyhole procedure.[1]
Keyhole Procedure
To remove the glandular and fatty tissue which comprise the breast mass and the added skin that drapes the mass, there are three basic approaches.
For petite breasts, like an A or a small B, a peri-areolar incision can be done. That is a circular incision around the areola, combined with an inner circular incision to remove some of the unneeded areola as well. Drawing the skin into the center will result in some puckering, but this often smooths out with time. There will be significant tension on the scar line, and to prevent spreading of the scar, a permanent fixation suture is needed. Leaving outer dermis (raw skin) underneath the marginalized areola helps in its survival.
The keyhole incision (think skeleton key) augments the periareolar incision further by making a vertical closure underneath (lollipop), which results after the unwanted skin is pulled in from side to side and the excess is removed.
An anchor incision adds to that a transverse incision usually in the infra mammary fold to further remove excessive skin. Draping or blousing is not desirable. This is reserved for much larger breasts or topographically a larger surface area as seen in women with postpartum breast atrophy.
"Dog Ear"
Occasionally the side limbs may be quite long, and the expression doctors use is "chasing a dog ear" into the axilla (or underarm). A dog ear is an unpleasant ruffle of skin in the corner of an incision when there is too much gathering usually at an angle greater than 30 degrees.
Not uncommonly the surgeon may wish to revise the incision lines after 3 or more months of settling shows some residual problem areas.
The nipple areolar complex may be supported by a pedicle which has the advantage of leaving some sensation and blood supply intact, but can have the disadvantage when the pedicle has sufficient bulk not to provide the flat look most FTM patients desire.
See also
References
- ↑ Erickson-Schroth, Laura (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford University Press.