Male Chest Reconstruction
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In men with female breast growth, or transmen, a Male Chest Reconstruction is often done to give the chest a male appearance again. In transmen, this is part of the transformation of a female body into the appearance of a male body.
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[edit] Breast Augmentation
Male Chest Reconstruction usually precedes below the waist surgery for transmen patients as protruding breast contours are a sine qua non of the female presentation.
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.
[edit] 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, though distal nerves are known to regenerate.
[edit] Nipple Grafts
Nipple areolar grafts must be kept wet with saline soaked gauze re-moistened every 3 hours for at least 5 days to maintain tissue viability until capillary buds grow into the graft.
Some crusting of the grafts is not unusual and will usually shed by the 3 or 4th week. It is suggested to not lift or pick them off as the adherence of the graft may be very tenuous and its viability very fragile.
After tissue settling some revision surgery may be required. Breast sizes greater than a C, need to be done in hospital setting.
[edit] Keyhole Procedure
To remove the glandular and fatty tissue which comprise the breast mass and the added skin that drapes the mass, there are basically 3 approaches.
For petite breasts, like an A, maybe small B, a peri-areolar incision can be done. That is a circular incision around the areola, combinedwith an inner circular incision to remove some of the unneeded areola as well. The areola is the pigmented shield that surrounds the nipple. Of course drawing the skin in to 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 (Gortex works well). 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 (lollypop), 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.
[edit] "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.
[edit] Areola Graft
The use of a free and reduced nipple areola graft allows the masculine looking graft to be placed precisely where it should be, best seen by sitting the patient up on the table while under anesthesia. The disadvantage is perhaps at times some predisposition to a partial take or failure for the graft to take at all.
Soaking the dressing with normal saline every 3 hours round the clock for 5 days prevents the tissues from drying out before sufficient capillary ingrowth has occurred. There are many techniques to reconstruct a nipple as well as tattoo the areolar area should that be necessary.
