Male chest reconstruction
In men with female 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.
While technically this procedure is the same as reduction mamoplasty, due to differences in the male and female breasts, extra steps are needed to obtain desired results, most notably in nipple placement and dealing with excess skin. The surgery is also very similar to mastectomy although the nipples are often retained for sensation and aesthetic reasons.
Important: after surgery, there is still the chance of developing breast cancer. While the risk is similar to cismen, self exams are recommended.
Procedures at a glance
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.
"Double incision" is used for guys with bigger chests, C cup or higher but is also recommended for some guys around a B cup. In this method, large incisions are made horizontally across each breast, usually below the nipple. The skin is then peeled back so that the mammary glands and fatty tissue can be removed with a scalpel. The muscles of the chest are not touched. Certain areas of harder-to-reach fatty tissue may also be removed via liposuction (such as areas near the armpits). Once the breast tissue has been removed, the excess chest skin is trimmed and the incisions closed, leaving two seams/scars just below the line of the pectoral muscles.
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.
"Keyhole" incision techniques are effective for individuals with small amounts of breast tissue (cup size A or smaller is ideal; sometimes recommended by certain surgeons for cup size B). They (this and Peri-areolar) are both done via incisions around the areola, though the techniques differ slightly.
In the keyhole method, a small incision is made along the border of the areola (usually along the bottom), and the breast tissue is removed via a liposuction needle through the incision. The nipple is left attached to the body via a pedicle (a stalk of tissue) in order to maintain sensation. Once the breast tissue has been removed, the incision is closed. The nipple is usually not resized or repositioned.
The keyhole incision (think skeleton key) augments the periareolar incision further by making a vertical closure underneath (lollipop like, with stitching directly under the areola), which results after the unwanted skin is pulled in from side to side and the excess is removed.
In the peri-areolar method, an incision is made along the entire circumference of the areola. The nipple is usually left attached to the body via a pedicle in order to maintain sensation. Breast tissue is then "scooped out" by scalpel, or with a combination of scalpel and liposuction. The areola may be trimmed somewhat to reduce its size. Excess skin on the chest may also be trimmed away along the circumference of the incision.
The skin is then pulled taut toward the center of the opening and the nipple is reattached to cover the opening-- much like pulling a drawstring bag closed. 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.
This procedure is also sometimes referred to as the drawstring or "purse string" technique. The nipple/areola may be repositioned slightly, depending on original chest size and the available skin.
The placement of the nipples varies from doctor to doctor. Usually the nipples are completely removed, trimmed to a smaller size and then grafted back on in a more aesthetically-male location. However, as with any graft there is a chance of poor circulation and tissue death.
There are many techniques to reconstruct a nipple as well as tattoo the areolar area should that be necessary.
Another technique is the "pedicle" technique, wherein the nipples are left partially attached to the body via a stalk of tissue. They are then repositioned in a more aesthetically-male location, while their connection to the body via the pedicle stalk remains intact. They may or may not be trimmed to a smaller size. The pedicle option is sometimes chosen in an attempt to maintain sensation in the nipples.
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 trans men desire.
- Ettner, Randi (2007). Principles of Transgender Medicine and Surgery. ISBN 0789032686. OCLC 85484977.
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