Novel Top Surgery in Small-Breasted Individuals with Gender Dysphoria: Periareolar Interlocking Suture and Waterjet-Assisted Liposuction

Abstract

Background:

In small-breasted individuals with gender dysphoria (GD), the concentric periareolar approach is typically the preferred method for mastectomy. However, this method carries a notable risk of hypertrophic scars and changes in areolar dimensions. In this article, the authors introduce the periareolar interlocking suture (PIS) as a new scar-minimizing procedure with a low complication rate and high level of patient satisfaction.

Methods:

The corresponding author (A.W.) performed a concentric periareolar mastectomy combined with PIS and waterjet-assisted liposuction in patients with small breasts (A to B cup) and good skin quality and elasticity. Outcome measures included complication rates, patient satisfaction (based on the BODY-Q Chest and Nipples scales and scar appearance), nipple sensitivity, and rate of surgical corrections.

Results:

Between April of 2017 and December of 2023, the corresponding author (A.W.) conducted 2312 mastectomies in 1156 individuals with GD, with 410 breasts treated using concentric periareolar mastectomy combined with PIS and waterjet-assisted liposuction. The mean patient age was 23 years; the mean hospital stay was 4 days; and the mean operative time was 96.1 minutes. The overall complication rate was 7.8%, with acute hematomas occurring in 4.6% of cases. Secondary revisions were necessary in 2.2% of cases. Patient satisfaction, measured using the BODY-Q scale, was statistically significant and very high.

Conclusions:

Individuals with GD are well informed and increasingly demand aesthetically pleasing outcomes. Whenever feasible, procedures with minimal scarring are preferred. The technique presented here resulted in a high level of patient satisfaction, preserved nipple sensitivity, and a low rate of complications and secondary aesthetic corrections in a carefully selected cohort of patients with small breasts.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.

Chest reconstruction (ie, top surgery), often the initial gender-affirming procedure for individuals with gender dysphoria (GD), requires careful consideration of surgical techniques by skilled plastic surgeons who recognize the anatomic variations within this patient population. For any gender-affirming procedure, the World Professional Association for Transgender Health standard of care criteria should be met.¹ The criteria mandate that patients must be capable of providing full consent for treatment. Many individuals pursuing gender-affirming procedures have already undergone hormone therapy (eg, testosterone), but this is not always required, particularly for nonbinary individuals.

Several surgical algorithms exist for mastectomy techniques in patients with GD, considering factors such as breast size and volume, grade of breast ptosis, skin quality and elasticity, the relationship between the nipple-areola complex (NAC) and inframammary fold (IMF), and the amount of skin redundancy.^2–5 For individuals with a small cup size (A to B cup), ptosis grade 0 or 1,⁶ good skin quality and elasticity, and a NAC position above the IMF, we usually prefer a scar-sparing concentric periareolar mastectomy (CPM). In such cases, the purse-string suture and Benelli round-block technique⁷ traditionally have been used, similar to the approach for grade 2b gynecomastia.^8–10 However, the purse-string technique often results in a hypertrophic-dehiscent and aesthetically unsatisfying scar around the areola.

The interlocking suture, first described by Hammond and colleagues,^11,12 originally represented a periareolar mastopexy technique for cisgender women. The classic Benelli technique uses the purse-string suture, resembling a tobacco pouch suture, only on the outer edge of the areola; however, the interlocking suture is stitched like a wagon wheel, with longer segments on the outside and shorter segments on the inside (Figs. 1 and 2), thus reducing overall tension on the suture. This notably improved tension distribution by use of the wagon wheel–shaped suturing method compared with the Benelli technique was demonstrated in a study by Righi and Robotti.¹³

Fig. 1.

Illustration of chest-wall contouring. (Right side) Illustration of periareolar interlocking suture and release of IMF (hashed area). (Left side) Status after concentric periareolar interlocking suture, with reduction of NAC diameter, slight craniolateral elevation of NAC position, and release of IMF, emphasizing the contour of the pectoralis major muscle. (Below) Reduction of the nipple projection and volume is achievable through a wedge excision and Prolene 6-0 single knots.

Fig. 2.

Demonstration of the periareolar interlocking suture. (Above, left) Marking was performed with a surgical pen at the points of the outer circle at 12, 3, 6, and 9 o’clock, as well as at 02:30, 04:30, 07:30, and 10:30. The inner NAC was quartered by a vertical cross (at 12, 3, 6, and 9 o’clock), corresponding to the equivalent points on the outer circle (above, right). (Below) An incision for mastectomy was made laterally under the preservation of a superomedial NAC-bearing pedicle. The position of the NAC can potentially be modified in the appropriate direction by an oval craniolateral deepithelialization figure, ideally projected onto the edge of the pectoralis muscle. The beginning of the periareolar interlocking suture should be initiated with the polytetrafluoroethylene thread (white) from deep to superficial as it passes through the deepithelialized dermal edge and then ends by passing from superficial to deep. In this fashion, the knot can be buried deeply under the dermal edge to avoid any chance of postoperative exposure. Note the release of the IMF from the inner chest cavity to eliminate the breast footprint (above, right; hashed area).

We adapted this technique as a combined support of a periareolar interlocking suture (PIS) and waterjet-assisted liposuction (WAL) for subcutaneous and epipectoral hydrodissection of the breast gland, aimed at scar-sparing CPMs in a small-breasted cohort of patients with GD. Based on our collective experience, we observed a very low incidence of hypertrophic-dehiscent periareolar scars, as well as high patient satisfaction and a very low complication rate. This study presents our surgical technique, along with a retrospective evaluation of our results compared with the current literature.

PATIENTS AND METHODS

According to the algorithmic approach described in 2015,² the ideal mastectomy technique is selected on the basis of breast size, mastoptosis grade,⁶ amount of skin envelope, skin quality and elasticity, NAC to IMF relation, and NAC diameter. All patients were operated on and followed up by a single surgeon (A.W.). In patients with small breasts (A to B cup), mastoptosis grade 0 or 1, and moderate to poor skin elasticity, we adopted the CPM approach. The collected data included demographics (Table 1) (eg, age, body mass index [BMI], smoking status), duration of hormone therapy, breast measurements including NAC areolar diameter (preoperatively and postoperatively), glandular resection weight, length of hospital stay, duration of surgery, and outcome measures (Table 2), such as complications and surgical correction rates. We analyzed patient satisfaction using the BODY-Q Chest and Nipples scales,¹⁴ as well as subjective assessment of nipple sensation (1, very sensitive; 2, sensitive; 3, less sensitive; 4, not sensitive). The NAC diameter was measured preoperatively and postoperatively in a horizontal orientation (A.W.).

Table 1.

Demographic Characteristics^a

Characteristics	Value
Total no. of patients/mastectomies	1156/2312
Concentric periareolar procedure (combined with PIS/WAL)	205/410 (17.7)
Transgender male	194 (94.6)
Nonbinary	11 (5.4)
Smoker	44 (21.5)
Compression binders use	190 (93)
Active testosterone therapy	190 (94.6)
Pubertal suppression	4 (2)
Follow-up time, mo	15.14 ± 8.2 (12–63)
Duration of hormone therapy, mo	15.6 ± 19.1 (1–96)
Age	23 ± 4.9 (18–40)
18–25 years	149 (72.7)
25–30 years	36 (17.6)
30–35 years	12 (5.8)
35–40 years	8 (3.9)
BMI, kg/m2	21.1 ± 2.4 (16.3–30.8)
Underweight (<18.5)	31 (15.1)
Normal (18.5–24.9)	162 (79)
Overweight (25–29.9)	10 (4.9)
Obese (>30)	2 (1)
Right distance between sternal notch and NAC, cm	18.1 ± 1.4 (15–22)
Left distance between sternal notch and NAC, cm	18.2 ± 1.4 (15–22)
Right distance from NAC to IMF, cm	5.4 ± 0.8 (2.9–8.7)
Left distance from NAC to IMF, cm	5.4 ± 0.9 (2.8–8.5)
Right breast width, cm	13.6 ± 1.4 (10.5–19.2)
Left breast width, cm	13.6 ± 1.4 (10.4–19.3)
Right NAC diameter before surgery, mm	34.12 ± 6.49 (25–61)
Right NAC diameter after surgery, mm	26.12 ± 2.88b (20–39)
Left NAC diameter before surgery, mm	34.38 ± 6.65 (24–62)
Left NAC diameter after surgery, mm	26.15 ± 2.72b (19–38)
Underbust circumference, cm	74.43 ± 5.3 (63–89)
Right breast resection weight, g	105.79 ± 44.0 (10–289)
Left breast resection weight, g	106.02 ± 43.3 (10–292)
Right lipoaspirate volume, mL	37.9 ± 27.9 (10–250)
Left lipoaspirate volume, mL	37.8 ± 27.8 (10–250)
Operative time, min	96.1 ± 21.5 (57–172)
Hospital stay, days	4 ± 1.1 (1–11)
Breast skin elasticity
Good	352/410 (85.8)
Intermediate	51/410 (12.4)
Poor	8/410 (1.8)
Ptosis (Regnault grade6)
0	398/410 (97.1)
1	12/410 (2.9)
2	0
3	0

^aData are presented as no. (%) or mean ± SD (range).

^bP < 0.001 (paired t test for continuous variables; chi-square or Fisher exact test for categorical variables).

Table 2.

Outcome Measures^a

Outcome Measures	No. (%) or Mean ± SD
Overall complications	32 (7.8)
Minor	12 (2.9)
Partial NAC necrosis	4 (1)
Seroma needle aspiration	4 (1)
Wound dehiscence healed by secondary intention	4 (1)
Major	20 (4.9)
Full NAC necrosis	0
Acute hematoma with surgical evacuation	19 (4.6)
Wound dehiscence with surgical repair	1 (0.2)
Secondary revisions or corrections	9 (2.2)
NAC revisions (retightening or areola reshaping)	7 (1.7)
Contour revision by lipofilling	1 (0.2)
Conversion to double-incision with free NAC graft	1 (0.2)
Nipple sensitivity
Very sensitive	221/378 (58.5)
Sensitive	115/378 (30.4)
Less sensitive	35/378 (9.3)
Not sensitive	7/378 (1.8)
BODY-Q scores
Nipples
Before surgery	32.8 ± 19.02
After surgery	94.3 ± 9.23 (P < 0.001b)
Chest
Before surgery	15.6 ± 12.01
After surgery	94.78 ± 7.78 (P < 0.001b)
Satisfaction with appearance of the scars
Very satisfied	131/189 (69.3)
Somewhat satisfied	57/189 (30.2)
Somewhat dissatisfied	1/189 (0.5)
Very dissatisfied	0/189 (0)

^aBased on 205 patients, 410 breasts/mastectomies. Data are expressed as no. (%) or mean ± SD.

^bP < 0.001 (paired t test for continuous variables; chi-square or Fisher exact test for categorical variables).

We obtained permission to use the German BODY-Q Chest module from the copyright holders. Translation to German and linguistic validation have been performed previously.¹⁵ The sum scores were converted into an equivalent transformed Rasch score that ranged from 0 (worst) to 100 (best). BODY-Q Chest and Nipples scales were used to evaluate satisfaction with postmastectomy scars on a 4-point scale ranging from “very dissatisfied” to “very satisfied.” These questionnaires were administered during the written informed consent process preoperatively and 12 months postoperatively during clinical consultation or telephone interviews. In addition, all patients underwent preoperative psychologic evaluation to confirm the indication for mastectomy.

Photographs of all patients were obtained preoperatively and postoperatively from standard perspectives. Continuous variables are presented as mean ± SD; categorical variables, as frequencies and percentages. For continuous variables, a paired t test was used to analyze preoperative and postoperative data. For categorical variables, appropriate tests, such as the chi-square or Fisher exact test, were applied where applicable. A significance level of P < 0.05 was considered statistically significant. Means, SDs, and t tests were calculated using Microsoft Excel for Macintosh version 16.7 (Microsoft Corporation) and SPSS Statistics version 29.0.0.0 (IBM Statistics).

Ethical Considerations

This retrospective study complied with the current version of the Declaration of Helsinki guidelines and the International Committee of Medical Journals Editors. Research ethics review board approval and consent were obtained from the Ethics Board Committee of the Faculty of Health, University of Witten/Herdecke, Witten, Germany (file decision no. S-001-/2024). Data for this study were anonymized and analyzed retrospectively.

Surgical Technique

The corresponding author (A.W.) conducted both preoperative and postoperative breast examinations, markings, and surgical procedures. With moderate pinching, the PIS figure was marked, along with the IMF, in standing patients (Figs. 1 through 3). (See Video 1 [online], which demonstrates a 22-year-old patient preoperatively in standard perspective, with ptosis grade 0; sternal notch to NAC, 19 cm on both sides; NAC to IMF, 5.5 cm on both sides; breast width, 14 cm on both sides; NAC diameter, 4.5 cm on both sides; underbust circumference, 80 cm; and BMI, 21.6 kg/m². Preoperative markings, WAL, glandular extirpation by CPM, IMF release, and glandular specimen presentation are shown. See Video 2 [online], which demonstrates intraoperative markings, surgical technique with 2-0 polytetrafluoroethylene SurgiGlide suture for PIS, intracutaneous suturing, wound dressing, and results from before to 16 months after surgery.) The inner circular figure (future NAC) was set to approximately 2.0 to 3.0 cm. The size of the outer periareolar circular figure was determined on the basis of the amount of excess skin, ensuring that it was not too large to prevent the formation of hypertrophic-dehiscent radial scars. To achieve optimal chest placement for low-positioned and enlarged NACs, a craniolateral oval excision was performed (see patient example, Fig. 3). All patients received a single dose of antibiotics and 1 g tranexamic acid perioperatively. The chronology of the surgical steps was as follows:

Fig. 3.

(Left) A 22-year-old patient before surgery with preoperative markings; ptosis grade 0; sternal notch to NAC, 19 cm on both sides; NAC to IMF, 5.5 cm on both sides; breast width, 14 cm on both sides; NAC diameter, 4.5 cm on both sides; underbust circumference, 80 cm; and BMI, 21.6 kg/m². (Right) Sixteen months after surgery, resection weight was 120 g on the right side and 100 g on the left side, with 25 mL of lipoaspirate on each side. Note the craniolateral elevation of the NAC position, highlighted by the green lines placed on anatomically identical regions (this patient is also shown in Videos 1 and 2 [online]).

1. WAL for hydrodissection of the glandular tissue and equalization of contouring

2. CPM, including excision of the complete glandular tissue from the lateral side while preserving a superomedial pedicle and releasing the IMF from the internal wound cavity

3. PIS for tension-free skin closure around the areola

Video 1. This video demonstrates a 22-year-old patient preoperatively in standard perspective, with ptosis grade 0; sternal notch to NAC, 19 cm on both sides; NAC to IMF, 5.5 cm on both sides; breast width, 14 cm on both sides; NAC diameter, 4.5 cm on both sides; underbust circumference, 80 cm; and BMI, 21.6 kg/m². Preoperative markings, WAL, glandular extirpation by CPM, IMF release, and glandular specimen presentation are shown.

Download video file ^{(167.3MB, mp4)}

Video 2. This video demonstrates intraoperative markings, surgical technique with 2-0 polytetrafluoroethylene SurgiGlide suture for PIS, intracutaneous suturing, wound dressing, and results from before to 16 months after surgery.

Download video file ^{(167.7MB, mp4)}

For hydrodissecting liposuction of the breast gland, we used the WAL procedure (body-jet system; Human Med AG) (see Video 1 [online]). For tumescence, 1000 mL of Ringer’s solution with 1 mL of 1:1000 diluted adrenaline was used. In all cases, liposuction was performed as a method for hydrodissection subcutaneously and epipectorally before the actual mastectomy. The WAL method, with the addition of adrenaline, facilitated the mastectomy through its vasoconstrictive effect, and could be used as a contouring procedure at the margins of the glandular tissue. The diameter of the liposuction cannula ranged from 3.5 to 4.2 mm.

Next, the CPM was prepared. This involved deepithelialization of the excess skin mantle circumferentially at the outer edge of the NAC (Figs. 1 and 2 and Video 2 [online]). The access for the mastectomy was performed through a lateroareolar incision, because the superomedial pedicle of the NAC can be most effectively preserved neurovascularly at this location. The use of a headlight is strongly recommended.

The mammary gland was then gradually released subcutaneously and epifascially by releasing the Cooper ligaments. A pedicle thickness of 1.5 to 2 cm was always maintained to ensure adequate blood supply to the NAC and to prevent indentations or dimpling to the pectoralis fascia. Close attention must be paid to the elimination of the IMF, because the internal fascial band structures must be released. All glandular breast specimens were submitted for histologic examination. Before skin closure, blood pressure was increased to 140 mm Hg systolic (according to previously published preventive measures¹⁶). The breast cavity was then irrigated with saline solution, and 1 g of tranexamic acid was administered locally. Drains were placed in all patients through previously placed stab incisions for liposuction.

At that point, preparation for the PIS was performed. Marking was performed using a surgical pen, as shown in Figures 1 and 2 and Video 2 (online). The PIS was performed using a 2-0 polytetrafluoroethylene nonabsorbable monofilament suture (SurgiGlide; SurgiGlide LLC) in a Keith needle, constricted to the desired areolar diameter (20 to 30 mm). The knot was buried underneath the edge of the periareolar incision to minimize the risk of postoperative exposure. The areola was then sutured intracutaneously using 4-0 Monocryl. In isolated cases, additional nipple reduction was performed by wedge excision and suturing with 6-0 Prolene single knots (Fig. 1).

The wounds were covered with fatty gauze and compresses. Patients were given a compression bandage for 24 hours after surgery, followed by a recommended 6-week use of a compression vest. They were also advised to undergo manual lymphatic drainage of the chest for 6 weeks, starting 2 weeks after surgery. They were instructed to avoid excessive upper-body training for 6 months to prevent tension and scar complications.

RESULTS

From April of 2017 to December of 2023, we performed 2312 mastectomies in 1156 adults with GD. A total of 410 breasts (18%) of 205 individuals were treated by CPM combined with PIS and WAL. A total of 194 patients (94.6%) were transgender men and 11 (5.4%) were nonbinary. A chart review of the patient group revealed that this was the first transition-related surgery for all included patients.

All patients had undergone mental health counseling related to GD before surgery, confirming the necessity for mastectomy with written consent. A total of 52% of the patients had a psychiatric diagnosis at the time of surgery, most commonly anxiety or depression; 44 were active smokers (21.5%); 190 (93%) used compression binders before surgery; 194 (94.6%) received testosterone, with a mean duration of hormone therapy of 15.6 ± 19.1 months before surgery; and 4 (2%) received pubertal suppression before surgery.

Demographic characteristics are summarized in Table 1. The mean age of this study population was 23 ± 4.9 years. A total of 72.7% of participants (149 of 205) were age 18 to 25 years, 17.6% (36 of 205) were age 25 to 30 years, 5.8% (12 of 205) were age 30 to 35 years, and 3.9% (8 of 205) were age 35 to 40 years. The mean BMI was 21.1 ± 2.4 kg/m². Subgroup analysis of BMI showed that 31 patients (5.1%) were underweight, 162 (79%) had normal weight, 10 (4.9%) were overweight, and 2 (1%) were obese.

Of the 410 breasts that received CPM combined with PIS and WAL, elasticity was good in 352 (85.8%), intermediate in 51 (12.4%) and poor in 8 (1.8%). The ptosis grade was 0 in 398 breasts (97.1%), 1 in 12 breasts (2.9%), and 2 or 3 in 0 breasts. The mean distance between the sternal notch and NAC was 18.12 ± 1.4 cm on the right side and 18.2 ± 1.4 cm on the left side, mean distance from NAC to IMF was 5.4 ± 0.8 cm on the right side and 5.39 ± 0.9 cm on the left side, mean breast width was 13.6 ± 1.4 cm on the right side and 13.61 ± 1.4 cm on the left side, mean NAC diameter was 34.12 ± 6.49 mm on the right side and 34.38 ± 6.65 mm on the left side, and the mean underbust circumference was 74.43 ± 5.3 cm.

The mean operative time was 96.1 ± 21.5 minutes. The average weight of the resected breast tissue was 105.79 ± 44 g on the right side and 106.02 ± 43.3 g on the left side, and the mean volume of lipoaspirate was 37.9 ± 27.9 mL on the right side and 37.8 ± 27.8 ml on the left side. The mean length of hospital stay was 4 ± 1.1 days.

Complications were assessed as minor, which could be managed conservatively (12 mastectomies [2.92%]), or major, in which surgical revision was necessary (20 mastectomies [4.9%]; Table 2). Minor complications included seroma treated by needle aspiration (4 mastectomies [1%]), partial NAC necrosis (4 mastectomies [1%]), and wound dehiscence healed by secondary intention (4 mastectomies [1%]). Complete NAC necrosis was not observed. The most frequent major complication was acute hematoma requiring surgical evacuation, which occurred in 19 breasts (4.6%); 1 wound dehiscence (0.2%) had to be surgically repaired.

Secondary surgical corrections for aesthetic improvement were necessary in 9 mastectomies (2.2%). These were grouped as NAC revisions, including concentric skin retightening and areola reshaping in 7 breasts (1.7%) and chest contour corrections by lipofilling in 1 breast (0.2%). One patient (0.2%) underwent a conversion to an inframammary double-incision mastectomy and free NAC grafting due to poor skin quality, high residual skin redundancy, and low elasticity. Tertiary correction was not necessary.

All patients were scheduled for follow-up examination 12 months after surgery to increase the comparability of results. Several individuals also presented for later checkups, up to 63 months postoperatively. Mean follow-up time after initial surgery was 15.14 ± 8.2 months, with a median of 12 months. Of all patients, 189 (92.2%) completed the preoperative surveys and could be interviewed during the 12-month follow-up appointment or by telephone survey.

Satisfaction with the periareolar and stab incision and drain scars was high. For appearance of the scars, 69.3% of patients (131 of 189) reported being very satisfied, 30.2% (57 of 189) somewhat satisfied, and 0.5% (1 of 189) somewhat dissatisfied; no patient reported being very dissatisfied. Nipple sensitivity was rated subjectively by 189 participants (378 NACs); 221 NACs were reported to be very sensitive (58.5%), 115 sensitive (30.4%), 35 less sensitive (9.3%), and 7 not sensitive (1.8%).

Comparison of the NAC diameter preoperatively and postoperatively demonstrated a highly significant reduction in areolar diameter. The NAC diameter on the right side decreased from 34.12 ± 6.49 mm preoperatively to 26.12 ± 2.88 mm postoperatively (P < 0.001). The NAC diameter on the left side decreased from 34.38 ± 6.65 mm preoperatively to 26.15 ± 2.72 mm postoperatively (P < 0.001).

The patient survey revealed a high satisfaction rate with the aesthetic result. Comparison of the preoperative and 12-month postoperative BODY-Q results demonstrated a highly significant improvement in the Rasch sum score for the Chest and Nipples scales. For the Nipples scale, the score increased from 32.8 ± 19 preoperatively to 94.3 ± 9.23 postoperatively (P < 0.001). For the Chest scale, the score improved from 15.6 ± 12 preoperatively to 94.78 ± 7.78 postoperatively (P < 0.001) (Table 2 and Fig. 4). Histopathologic analysis did not reveal any malignant or pathologic findings.

Fig. 4.

Comparison of the preoperative and 12-month postoperative BODY-Q results demonstrated statistically significant improvement in the Rasch sum score for Chest and Nipples scales (nipples, 32.8 ± 19 preoperatively versus 94.3 ± 9.23 postoperatively [**P < 0.001]; chest, 15.6 ± 12 preoperatively versus 94.78 ± 7.78 postoperatively [**P < 0.001]).

DISCUSSION

In recent years, the field of gender-affirming surgery has seen significant advancements, particularly in mastectomy techniques for people with GD. Patients usually aim for a flat chest contour with scars that are as invisible as possible and to preserve the NAC sensation as much as possible. One technique that has garnered attention, particularly in individuals with small breasts, is CPM. This study provides a comprehensive comparison of our CPM technique with other current approaches in the recent literature.

CPM is usually used in patients with small breasts (A to B cup), good skin quality and elasticity, and NAC above the IMF, according to previously published algorithmic approaches.^{2–5,17–23} CPM involves removing breast tissue through a semicircular areolar incision, thereby preserving nipple sensation and minimizing scarring compared with traditional mastectomy approaches with usually large IMF scars, such as double-incision mastectomy with free or pedicled NAC transposition. However, the small amount of surgical access provided by CPM may limit the surgeon’s ability to thoroughly remove all breast tissue, especially in individuals with larger breast volume. Incomplete tissue removal can result in suboptimal aesthetic outcomes and may necessitate revision surgery to achieve the desired chest contour. Furthermore, an outer skin resection diameter planned too ambitiously may distort the NAC during tissue manipulation and closure. Nipple flattening, puckering, enlargement, or irregular areolar shape may occur, compromising the natural masculine flat appearance of the chest and necessitating secondary corrective procedures. An inadequately addressed and unresolved IMF leads to the persistence of a feminine appearance, as the original footprint of the breast remains unchanged. In addition, a higher incidence of acute hematoma requiring surgical intervention can be found in the literature associated with CPM, most likely caused by the limited surgical access. While CPM aims to preserve the NAC, repositioning the NAC to achieve optimal chest aesthetics can also be challenging.^24,25 If the NAC is originally positioned too low and too medially, our approach involves performing a slightly craniolateral oval excision around the new NAC to achieve ideal positioning on the edge of the pectoralis muscle (Figs. 1 and 2). Therefore, performing CPM demands a high level of surgical skill and precision, given the confined operative field and aesthetic needs of the patient cohort.

The interlocking suture, originally designed by Hammond and colleagues¹¹ for periareolar mastopexy in cisgender women, has a significant advantage in periareolar force distribution compared with purse-string sutures, as demonstrated by Righi and Robotti.¹³ In our study, satisfaction with the periareolar scars was high, with 69.3% of patients (131 of 189) being very satisfied and 30.2% (57 of 189) somewhat satisfied (Table 2). This aspect must be highlighted, because the propensity for poor scarring with radial scar extensions and distorted NACs in CPMs is high using traditional purse-string techniques.

In a CPM procedure, it is not uncommon to encounter an overly large NAC diameter in the long-term follow-up, along with potential residual excess skin requiring secondary surgical correction.²² The widest preoperative areolar diameter measured 62 mm. In some cases (eg, Figs. 3 and 5) with significant ptosis and a large amount of excess skin, excision beyond the areola skin diameter is necessary to achieve an adequate tightening effect.

Fig. 5.

(Left) A 24-year-old patient before surgery in standard perspective, with ptosis grade 1; sternal notch to NAC, 20 cm on the right side, 19 cm on the left side; NAC to IMF, 5 cm on the right side, 4 cm on the left side; breast width, 14 cm on both sides; NAC diameter, 5 cm on the right side, 4 cm on the left side; underbust circumference, 78 cm; and BMI, 20.8 kg/m². (Right) At 12 months postoperatively, resection weight was 80 g on the right side and 40 g on the left side, with 25 mL of lipoaspirate on each side; additional nipple reduction was performed by wedge excision.

In our cohort, the overall correction rate, including NAC revision, contour revision, or conversion to double incision with free NAC graft, was low (2.2%). Another key procedure in our approach involves blunting the contour of the IMF, allowing the thoracic skin to lie flat against the chest wall (Figs. 6 through 8). Especially in the long-term follow-up, the presented technique demonstrated consistently favorable results (see also Fig. 8). (See Figure, Supplemental Digital Content 1, which shows [above] a 20-year-old patient before surgery in standard perspective, with ptosis grade 0; sternal notch to NAC, 19 cm on both sides; NAC to IMF, 4.5 cm on both sides; breast width, 13 cm on both sides; NAC diameter, 3 cm on the right and 3.2 cm on the left; underbust circumference, 73 cm; and BMI, 19.5 kg/m². [Below] At 37 months postoperatively, resection weight was 120 g on the right side and 130 g on the left side, with 25 mL of lipoaspirate each side, http://links.lww.com/PRS/H711. See Figure, Supplemental Digital Content 2, which shows [above] a 32-year-old patient after surgery in standard perspective, with ptosis grade 0; sternal notch to NAC, 21 cm on the right side and 22 cm on the left side; NAC to IMF, 5 cm on both sides; breast width, 15 cm on both sides; NAC diameter, 4 cm on the right and 4.1 cm on the left; underbust circumference, 83 cm; and BMI, 23.4 kg/m². [Below] At 42 months postoperatively, resection weight was 66 g on the right side and 94 g on the left side, with 25 mL of lipoaspirate each side, http://links.lww.com/PRS/H712.)

Fig. 6.

(Left) A 19-year-old patient before surgery in standard perspective, with ptosis grade 0; sternal notch to NAC, 19 cm on both sides; NAC to IMF, 6 cm on both sides; breast width, 16 cm on both sides; NAC diameter, 4.5 cm on both sides; underbust circumference, 73 cm; and BMI, 20 kg/m². (Right) At 12 months postoperatively, resection weight was 230 g on the right side and 240 g on the left side, with 50 mL of lipoaspirate on each side.

Fig. 8.

(Left) A 23-year-old patient before surgery in standard perspective, with ptosis grade 0; sternal notch to NAC, 18 cm on the right side, 18 cm on the left side; NAC to IMF, 5 cm on both sides; breast width, 15 cm on both sides; NAC diameter, 4.9 cm on both sides; underbust circumference, 81 cm; and BMI, 23.6 kg/m². (Right) At 61 months postoperatively, resection weight was 160 g on the right side and 170 g on the left side, with 100 mL of lipoaspirate each side.

Fig. 7.

(Left) A 30-year-old patient before surgery in standard perspective, with ptosis grade 0; sternal notch to NAC, 21 cm on both sides; NAC to IMF, 6 cm on both sides; breast width, 15 cm on both sides; NAC diameter, 4 cm on both sides; underbust circumference, 81 cm; and BMI, 20.9 kg/m². (Right) At 12 months postoperatively, resection weight was 240 g on the right side and 220 g on the left side, with 25 mL of lipoaspirate each side; additional nipple reduction was performed by wedge excision.

An analysis based on uniformly internationally validated and accepted patient-reported outcomes measures—in our study, the BODY-Q Chest and Nipples modules,¹⁴ satisfaction with scar appearance, and subjectively rated nipple sensitivity—is rare in the current literature.^26–29 The importance and validity of the BODY-Q Chest and Nipples scales for evaluating chest masculinization surgery in patients with GD have been demonstrated by Klassen et al.^14,26 In accordance with other studies, we were able to ascertain a high level of patient satisfaction (Table 2 and Fig. 4). In addition, we noted excellent preservation of NAC sensation, with 88.9% of participants rating their sensitivity level as very sensitive or sensitive.

We also recorded a low overall complication rate of 7.8%, with only 4.6% of participants experiencing acute postoperative bleeding, and no case of complete NAC necrosis. Overall chest-contouring complications have been reported in the literature at rates ranging from 10% to 35%.^4,17 The reported average rate of the most common complication, acute hematoma, is highest in CPM groups, ranging from approximately 6% to 33%, with an average of 15% according to the literature.^4,17,20,30 Donato et al.²¹ attribute this difference to the limited visibility of the operative field. Therefore, we strongly recommend using a headlight during surgery, along with implementing preventive measures, as previously detailed.¹⁶

The WAL procedure facilitates removal of the breast gland by hydrodissection and potentially reduces bleeding during dissection by adrenaline solution irrigation. Another unique aspect of our approach is the lateral access with superomedial pedicled nipple (Figs. 1 and 2). Traditionally, the access is usually chosen infra-areolarly. However, our access route offers the advantage of improved physiognomic preparation as well as high neurovascular reliability of the superomedial pedicle. This is also reflected in the low neurovascular complication rate.

A major strength of this study is the high degree of homogeneity within a large subgroup of 205 patients, corresponding to 410 CPM mastectomies (Table 1), from a large patient cohort (1156 patients, 2312 mastectomies). In addition, all surgical procedures and follow-ups were performed by a single surgeon (A.W.) to ensure uniformity in the surgical technique and clinical evaluation. The survey achieved a remarkably high response rate, with 189 of 205 patients participating (92.2%).

The relatively long average hospital stay of 4 days has several underlying causes. In Germany, GD procedures are generally billed under a day case or case lump sum system.

Limitations of our study include the relative lack of diversity (the participants were predominantly White) and the potential for selection bias among those motivated to respond to the surveys. At the time of surgery, 94.6% of the participants were receiving testosterone, with an average duration of hormone therapy of 15.6 months. The effects of long-term testosterone hormone therapy on body image, chest hair growth, and muscle development were only marginally explored in our study. This study elucidated a dramatic improvement in body image and quality of life after gender-affirming top surgery. In the future, it will be essential to implement transgender-specific surveys—such as the GENDER-Q developed by Klassen et al.²⁶—to enable more nuanced and patient-centered evaluations of individuals with GD.

CONCLUSIONS

This new CPM technique, combining WAL and PIS, presents a promising option for gender-affirming mastectomy in people with GD with small breasts (A to B cup), offering advantages such as aesthetic outcomes and preservation of nipple sensation. When deciding on surgery, it is crucial to consider its limitations and potential complications, along with individual patient factors. Further research is warranted to better understand the long-term outcomes and patient satisfaction of this technique compared with other mastectomy approaches.

DISCLOSURE

Dr. Hammond is the owner of SurgiGlide, LLC, the company that distributes SurgiGlide, the suture used in this study, and represents the inventor of the original interlocking suture technique. The other authors have no commercial interests to report with regard to this study, and received no financial or material support. None of the authors received any financial support from Dr. Hammond.

PATIENT CONSENT

Patients provided written informed consent for the use of their images.