Invited Commentary

Innocenti and Andreoli¹ comment that in cases of severe gynecomastia, a pedicled flap containing the nipple/areola complex (NAC) can cause a parenchymal bulge, compromising the result. In this situation, these Italian surgeons recommend a radical mastectomy to obtain a “suitable male chest.” Of course, the authors mean a simple mastectomy and grafting of the NAC. The authors are correct in observing that persistent chest fullness is a drawback of a vertical mammaplasty with preservation of the NAC on a pedicle.²

However, the consequences of nipple grafting should not be underestimated.^2,3 After grafting, the NAC is so debilitated it is not really a nipple anymore. Nipple “grafting” is a euphemism. The projection is lost because this 3-dimensional structure is now 2-dimensional. Erectility is lost because the smooth muscle does not survive the transfer. The NAC must rely on plasmatic imbibition to survive. Some surgeons believe that 100% of NAC grafts have complications,⁴ which may be true if one includes epidermolysis and hypopigmentation. Normal sensation is lost along with erotic sensation.^2,3

Most surgeons performing gynecomastia surgery rarely (<4%) offer NAC grafting as an option.² This is not true for gender-affirming mastectomy (>80%).² In transgender and nonbinary patients, mastectomy and nipple grafting are routinely performed.² The reason for this disparity is unclear.

Over a century ago, Thorek⁵ was the first surgeon to report nipple grafting as part of his breast reduction procedure. However, his contemporaries were aware of the importance of this unique anatomic structure, and designed reductions that preserved the NAC on a pedicle.² Nipple transposition is the basis for modern breast reductions.

All of us are aware of the disconcerting feeling of numbness after a dental procedure. We would not welcome the news that such numbness is permanent. The nerve supply to the nipple is surprisingly strong. Erotic sensation is important in both women (80%) and men (50%).² Alarmingly, Shaffrey et al⁶ recently reported that almost half (42.7%) of patients undergoing gender-affirming mastectomy developed intraoperative bradycardia. Five operations in their series needed to be halted. Two patients required chest compressions for asystole. The 2 factors associated with this risk were nipple grafting and fluoxetine, an antidepressant.

Chronic neuropathic chest pain is an underrecognized problem associated with transection of the nerve supply to the NAC. Remy et al⁷ reported that chest pain persisted in 22.9% of patients 9 months after mastectomies and nipple grafts. The proportion of these patients with neuropathic chest pain was 71.4%. A subject of great interest today is neurotization of the grafted NAC.^7–11 Of course, such a procedure requires microsurgical expertise and may require nerve grafting with allografts. These methods add expense, operating time (an additional 50 minutes),¹¹ and are unlikely to achieve sensory results comparable to a pedicled NAC.²

Plastic surgeons need to be careful not to overoperate. If the surgeon maintains the NAC on a pedicle, there is no need to reinnervate it. An analogy is to be found in surgery for capsular contracture. The trend is to remove the capsule and then replace it with allografts or xenografts (acellular dermal matrix), in a lengthy, arduous, and expensive operation.¹²

A medial pedicle is optimal because it preserves the dominant medial superficial innervation provided by the medial anterior cutaneous branches of the 3rd, 4th, and 5th lateral intercostal nerves (Fig. 1).¹⁴ Schlenz et al¹⁵ showed that nipple sensation is not well maintained on a superior pedicle. Courtiss and Goldwyn¹⁶ reported that 35% of women experience persistent nipple numbness 2 years after an inverted-T, inferior pedicle breast reduction.

FIGURE 1.

The dominant superficial nipple innervation is provided by the medially based 3rd, 4th, and 5th anterior cutaneous branches. A deep branch of the lateral cutaneous branch of the 4th intercostal nerve consistently provides deep innervation to the nipple. Reprinted from Swanson.¹³

Innocenti and Andreoli¹ emphasize the importance of correct shape and anatomic location of the NAC on the chest wall. When performing a mastectomy (commonly called a double incision free nipple graft, or DIFNG), it is often difficult to keep the resulting skin closure low enough,² resulting in a scar that is too high on the chest. The NAC is positioned high on the chest to keep it above the horizontal repair. To avoid this problem in top surgery patients, Robinson et al¹⁷ recommend an upper incision coursing below the NAC rather than above it in patients with high NACs, preserving the NAC on the superior skin flap. Measurements to local landmarks such as the sternal notch can be unreliable. A malpositioned NAC creates an unnatural appearance, especially when combined with an artificial-looking grafted NAC. Patients may be reluctant to go without a shirt after surgery.²

The problem of correct NAC siting is largely avoided when preserving the NAC on its pedicle.² In gynecomastia patients, a smaller-than-usual diameter (2.5 cm) is used for the circumareolar incision. The nipple is sited after the reduction. The wound is closed and a circular pattern of skin is excised at the new NAC site, which is located slightly below the apex of the breast mound. This method avoids having to predict the location of the NAC before the reduction (no mosque-dome incisions).^13,18

Innocenti and Andreoli¹ recognize that patient satisfaction is the most important measure of success. The single most relevant question to ask gynecomastia patients is whether they are comfortable in public with their shirt off. Patients will tolerate some degree of persistent chest fullness, which of course is natural and even preferred in some nonbinary patients.² Reassuringly, 75% of the gynecomastia survey respondents in my study reported being comfortable without a shirt after surgery, compared with only 8% before surgery. The vertical scar, which is only present in patients who require skin resections, is well tolerated. The only published prospective randomized study finds that breast reduction patients prefer the aesthetic result of a vertical mammaplasty over an inferior pedicle, inverted-T reduction,¹⁹ with its long horizontal (“anchor”) scar.

Innocenti and Andreoli¹ believe that when performing a mastectomy, the horizontal scar may be concealed along the pectoralis border. The authors reference 3 publications by the senior author.^20–22 However, none of the referenced articles contains patient photographs depicting this obliquely oriented scar. Because a large horizontal ellipse of skin is removed, the scar is very long,² the geometric consequence of repairing any elliptical defect. The scar is not concealed in the inframammary fold. It extends medially almost to the midline and laterally to the midaxillary line.² Revision of dog ears is common (56% in 1 series),²³ and repairing (“chasing”) them extends the scar farther. It may be necessary to connect the incisions in the midline.² The medial and lateral portions of the scar are now conspicuous. Scars that extend onto the chest are more prone to hypertrophy.²

By contrast, a vertical mammaplasty orients the ellipse vertically instead of horizontally.^13,18 A common misconception is that “vertical” refers mainly to the scar.¹³ “Vertical” refers to the orientation of both the skin and parenchymal resection. When the edges are brought together, the NAC pedicle is pushed superiorly. The NAC requires very little transposition because 80% of the elevation is provided by this geometric effect.¹⁸ A vertical mammaplasty does produce dog ears at the top and at the bottom. The dog ear at the top is largely removed by creating the new circular opening for the NAC. The dog ear at the bottom is managed by making a horizontal elliptical incision in the inframammary fold. This modification is not comparable to the horizontal mastectomy incision. It is much more limited, just enough to remove the redundant skin at the bottom of the vertical incision.^2,13,18 Importantly, this horizontal scar does not tend to ride up onto the breast because there is no up-and-down wound tension. The wound tension is side-to-side.²

Innocenti et al²⁰ have previously published a technique of banking the NAC in the groin crease and then returning 3 months later to graft it to the chest. Obviously, staged nipple grafting requires a major concession on the part of the patient. This method has not been widely adopted.

When treating mild and moderate cases of gynecomastia using a semicircular incision along the lower NAC border, my preference is to perform liposuction before the tissue excision. This approach, starting with infusion of a wetting solution of 0.05% lidocaine and 1:500,000 epinephrine (double the usual epinephrine concentration), followed by liposuction and then the subcutaneous mastectomy, maximizes vasoconstriction and reduces the amount of tissue resection. Tissue dissection is performed with scissors rather than electrodissection to minimize thermal injury and reduce the risk of seromas.²

When performing a vertical mammaplasty, hemostasis is easier to achieve because the wound is open (also true for a “double incision” mastectomy). In fact, one reason many surgeons prefer an open mastectomy, as opposed to a subcutaneous mastectomy, is because hemostasis is easier.²

When performing a subcutaneous mastectomy, Innocenti and Andreoli¹ recommend internal quilting sutures in an effort to reduce the risk of a hematoma. Murugesan and Karidis²⁴ prefer external quilting sutures, believing that a small periareolar access wound would not permit internal quilting sutures. Regardless, quilting sutures require additional operating time and, unsurprisingly, produce a quilted appearance, at least temporarily. Whether this method is truly effective is unclear; a controlled study has not been published. An alternative use of this operating time would be a meticulous clockwise inspection of each pocket, with loupe magnification and headlight illumination, frequent saline irrigation, and insertion of a closed suction drain (removed in 3 days) through the inframammary liposuction access incision.²

Innocenti and Andreoli¹ mention the use of interlocking sutures to limit areolar scarring and widening. However, their reference²⁵ includes no description of this method. In another reference,²⁰ Innocenti et al reported using Gore-Tex (Gore Medical, Newark, DE.) 3-0 purse-string sutures. The periareolar tissue is quite thin and fragile. Such large nondissolving sutures frequently require removal at some point postoperatively. There is no reliable evidence regarding their efficacy in improving periareolar scar quality.¹³ Few surgeons use them. Fortunately, periareolar scar problems are infrequent (none in my series) among gynecomastia patients when NAC grafting is avoided.²

My approach differs from previous guidelines by making NAC preservation mandatory.² Informed patients are unlikely to choose no nipples or nipple grafts. It is concerning to see some patients choosing no nipples, not even grafted nipples, in a recent publication.²⁶ Patients with limited financial resources may wish to make the surgery more affordable. However, this is a choice that cannot be remedied later (nipple reconstruction being another euphemism) and which patients may come to regret.² Ethically, there should be no discount for no nipples.

The argument that a successful outcome is compromised if the chest is not flattened is not supported by surveyed patients.² Only 1 surveyed gynecomastia patient (8%) reported that his postoperative chest contour was too full. Indeed, plastic surgeons may be more insistent on a flat chest than our patients. Innocenti and Andreoli¹ mention the importance of recognizing different patient groups and their needs. In overweight patients, a flattened chest can produce an unflattering negative synergy with a protuberant abdomen.² Unlike a lean, athletic patient, some breast fullness gives a more balanced and natural appearance to the overweight patient. In response to the authors' question,¹ there is no significant difference in mean pain scores comparing gynecomastia surgery with top surgery (4.9/10 vs 4.0/10 on a scale of 0–10).

Revisions are common after traditional mastectomies and nipple grafting, often to treat dog ears or revise the NACs.² Patients with NAC hypopigmentation are often referred for tattooing.² In my series, there were no cases of NAC loss or hypopigmentation; no patients required NAC revisions. None of the gynecomastia patients needed a dog ear revision. Although this approach leaves open the possibility of a second liposuction procedure for additional chest volume reduction in patients undergoing vertical mammaplasties, other types of revisions are common when a mastectomy and NAC grafting are performed.² A second procedure for additional liposuction is not onerous for patients. The surgery is not painful and little recovery time is needed. It is also relatively inexpensive, less than half the price of the original surgery.

Despite practicing plastic surgery for 36 years, I have never grafted an NAC. Barring some very unusual circumstance, all breast reductions, gynecomastia surgery, and gender-affirming surgery may be done with nipple preservation (ie, not grafted nipples).² The advantages of this new approach are clear. The NAC is never sacrificed. Scars are minimized. Chest volume is reduced. A second liposuction procedure is available for patients desiring a flatter chest.²

Eric Swanson, MD
Swanson Center Leawood, KS