Free Nipple Graft Research Articles

Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes.

Chest reconstruction ('top surgery') is an important component of transition in the transmasculine population that can substantially improve gender incongruence. The aim of this study was to evaluate the demographic characteristics, surgical technique, and postoperative outcomes following transmasculine chest surgery. Using ICD codes, we identified all cases of gender-affirming transmasculine chest surgery from the ACS NSQIP database (2010-2017). CPT codes were used to categorize patients by reconstructive modality: reduction versus mastectomy (± free nipple grafting [FNG]). Univariate analysis was conducted to assess for differences in demographics, comorbidities, and postoperative complications. Multivariable regression analysis was used to control for confounders. A total of 755 cases were identified, of whom 591 (78.3%) were mastectomies and 164 (21.7%) were reductions. No significant differences were noted in terms of age or BMI. Mastectomies had shorter operative times, but similar length of stay compared to reductions. Rates of postoperative complications were low, with 4.7% (n = 28) of mastectomies and 3.7% (n = 6) of reductions experiencing at least one all-cause complications. Postoperative complication rates were not statistically different between mastectomy with (3.4%) and without (5.6%) FNG. After controlling for confounders, there was no difference in terms of risk of all-cause complications between reduction and mastectomy, with or without FNG. Mastectomy and reduction mammaplasty are both safe procedures for chest reconstruction in the transmasculine population. These results may be used to encourage shared decision making between patient and surgeon such that the reconstructive modality of choice best aligns with the desired aesthetic outcome. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes

BACKGROUND: Reconstruction of the chest is an important component of transition in the transmasculine population that can substantially improve gender incongruence. Recent improvements in social stigma and changes to insurance legislation have led to a sharp rise in gender affirmation surgeries across the country, the most common of which being chest reconstruction. However, there is still debate regarding the optimal technique for transmasculine chest contouring and few studies have explored complication rates between the various approaches. The aim of this study was to evaluate the demographic characteristics, surgical technique, and postoperative outcomes following transmasculine chest contouring. METHODS: Using International Classification of Diseases codes, we isolated all cases of gender affirmation surgery from the American College of Surgeons National Surgical Quality Improvement Program database (2010–2017). Current Procedural Terminology codes were used to categorize patients by reconstructive modality: reduction versus mastectomy (± free nipple grafting [FNG]). Univariate analysis was conducted to assess for differences in demographics, comorbidities, and postoperative complications. The 2-sided unpaired t test was used to assess the difference in means of continuous variables, whereas categorical data were compared using the chi-square test. Multivariable regression analysis was used to control for confounders. RESULTS: A total of 755 cases were isolated, of which 591 (78.3%) were mastectomies and 164 (21.7%) were reductions. Compared with mastectomies, a higher rate of obesity was noted in the reduction cohort (34.4% versus 43.5%; P = 0.031). No significant differences were noted in terms of age or other comorbidities. Mastectomies had shorter operative times but similar length of stay when compared to reductions. Plastic surgeons performed the majority of procedures overall (87.2%). General surgeons performed nearly 10 times as many mastectomies as they did reductions (P < 0.001). Rates of postoperative complications were low, with 4.7% (n = 28) of mastectomies and 3.7% (n = 6) of reductions experiencing ≥1 all-cause complications. Postoperative complication rates were not statistically different between mastectomy with FNG (3.4%) and skin-sparing mastectomies (5.6%). After controlling for confounders, there was no difference in terms of risk of all-cause complications between mastectomy and reduction or between FNG and skin-sparing mastectomy. CONCLUSION: Mastectomy and reduction mammaplasty are both safe procedures for chest reconstruction in the transmasculine population. Furthermore, mastectomy techniques involving FNG had comparable postoperative complication profiles when compared to techniques that did not involve FNG. Overall, these results may be used to encourage shared decision-making between patient and surgeon such that the reconstructive modality of choice best aligns with the desired esthetic outcome.

Free Nipple Grafting as A Simple Technique in Severe Forms of Post-Bariatric Male Pseudogynecomastia

Free Nipple Grafting as A Simple Technique in Severe Forms of Post-Bariatric Male Pseudogynecomastia

A Drain-free Technique for Female-to-Male Gender Affirmation Chest Surgery Decreases Morbidity: Outcomes From 306 Consecutive Masculoplasties.

One of the most common surgical procedures for gender affirmation surgery of the chest is mastectomy. The aims of this article are to review the outcomes of a single surgeon's experience with a drainless technique, which we named "masculoplasty" and compare morbidity in this group to previously published outcomes where drains were used. A retrospective chart review was undertaken of all patients presenting to a single surgeon for gender-affirming chest surgery. A literature review was completed, compiling data from previously published studies of mastectomy with free nipple graft for the transgender patient. Outcomes of this drain-free group were compared with historical data, where drains were known to have been used. One hundred fifty-three patients underwent 306 masculoplasties in a university teaching hospital. The mean age of patients was 30 years (17-66 years). Sixty-five (42%) had 1 or more chronic medical comorbidities with 17 diabetic patients (11%). The mean body mass index was 32 kg/m (18-57 kg/m), and 83 (54%) were obese. Forty-two (27%) of the patients had a history of smoking. Mean operative time was 136 minutes (74-266 minutes).Hematoma occurred in 1 patient (0.3%). Infections occurred in 7 masculoplasties (2%) with wound dehiscence in 3 (1%). Two masculoplasties (0.7%) had partial nipple necrosis. Two patients (0.7%) developed a symptomatic pneumothorax. There were 0 seromas, and no procedures were performed to drain fluid. Eight masculoplasties (3%) underwent secondary corrections. Median follow-up was 9 months.Outcomes from this drain-free technique were compared with previously published outcomes of mastectomy where drains were known to be used. When compared with previously published series (n = 1334), the drain-free group had statistically significantly lower rates of hematoma (1/306 vs 39/1334, P = 0.0036) and acute reoperation (1/306 vs 42/1334, P = 0.0024). There was a shorter length of hospital stay in the drain-free group with a statistically significantly lower revision rate (8/306 vs 116/1334, P = 0.0001). Gender affirmation chest surgery can be safely offered using a drain-free or "masculoplasty" technique. Compared with historical data, the use of progressive tension sutures decreases the incidence of hematoma, the need for acute reoperation, and other complications.

Atypical ductal hyperplasia in men with gynecomastia: what is their breast cancer risk?

Atypical ductal hyperplasia (ADH) significantly increases the risk of breast cancer in women. However, little is known about the implications of ADH in men. Review of 932 males with breast pathology was performed to identify cases of ADH. Patients were excluded if ADH was upgraded to cancer on excision, or if they had contralateral breast cancer. Cases were reviewed to determine whether any male with ADH developed breast cancer. Nineteen males were diagnosed with ADH from June 2003 to September 2018. All had gynecomastia. Surgical procedure was mastectomy in 8 patients and excision/reduction in 11. One patient had their nipple areola complex removed, and 1 required a free nipple graft. Median patient age at ADH diagnosis was 25years (range 18-72years). Of the 14 patients with bilateral gynecomastia, 10 had bilateral ADH and 4 had unilateral. Five cases of ADH were described as severe, bordering on ductal carcinoma in situ. No patient reported a family history of breast cancer. No patient took tamoxifen. At a mean follow-up of 75months (range 4-185months), no patient developed breast cancer. Our study is the first to provide follow-up information for males with ADH. With 6years of mean follow-up, no male in our series has developed breast cancer. This suggests that either ADH in men does not pose the same risk as ADH in women or that surgical excision of symptomatic gynecomastia in men effectively reduces the risk of breast cancer.

Abstract: Prediction of Resection Weight in Reduction Mammaplasty: Validation of the Galveston Scale

INTRODUCTION: Reduction mammaplasty (RM) is one of the most commonly performed plastic surgery procedures. Prediction of resection weight is important both for the patients and the surgeons. Current literature suggests that symptomatic relief does not correlate with resection weight, however, insurance carriers are still using resection weight as one of the most important criteria to determine medical necessity. A number of prediction scales have been proposed, none of which are validated and widely accepted. The purpose of our study was to assess the validity of current scales in our patient population and propose a more accurate tool for prediction of resection weight. METHODS: A retrospective chart review of patient that underwent reduction mammaplasty at the University of Texas Medical Branch from 2012–2017 was performed. Multiple regression analyses were applied to all patients operated by the senior author (L.G.P.) to identify independent predictive factors for breast resection weight. A new prediction scale was created. Established prediction scales and the new Galveston scale were then applied to patients operated by different surgeons, excluding the patients that were operated by the senior author, and compared for accuracy of prediction of resection weight. Results were analyzed through linear regression analysis and p-values <0.05 were considered statistically significant. RESULTS: A total of 184 patients were used for the initial single-surgeon analysis. The new Galveston scale included BMI, breast measurements and age as independent predictive values. 130 patients were included in the multiple-surgeon group for validation of the new scale. There was no overlap in patients between the single- and multiple-surgeon groups. The mean age was 39.2 years, mean BMI 34.5 and the average resection weight was 907 grams. 62.3% of the patients underwent inferior pedicle wise pattern reduction, 26.9% medial or superiomedial pedicle and 10.8% amputation style with free nipple grafting. Galveston scale demonstrated the best predictive value (R2 = 0.71). Appel and Descamps performed worse with R2=0.69 and R2=0.68 respectively. Schnur scale demonstrated the poorest prediction value with R2=0.28. CONCLUSION: Prediction of resection weight in RM remains important for patient counseling and as an adjunct tool for the plastic surgeon preoperatively and intraoperatively, as a guide to estimate the amount of tissue to be resected. We recommend a patient-specific and surgeon-specific approach, instead of the “one-scale-fits-all” paradigm. We propose the Galveston scale for older patients with higher BMI and breasts requiring large resections. Symptomatic relief does not correlate with amount of tissue removed and medical necessity should be based on patient symptoms, physical examination and the physician’s clinical judgment.

A Single Surgeon's Experience With Transgender Female-to-Male Chest Surgery.

Chest wall recontouring is a common surgical treatment of gender dysphoria in transmen and nonbinary individuals assigned female at birth. This study reviews more than 20 years of cases to identify risk factors for postoperative complications and likelihood of preservation of nipple sensation. One hundred thirty-seven cases of female-to-male chest wall recontouring by a single surgeon from 1994 to 2016 were reviewed, 99 of which were included for final analysis. Double-incision free nipple graft and double incision with nipple transposition on a pedicle were the most common techniques used. Complication rates between these 2 techniques were compared, and multivariate analysis was used to identify possible predictors of major complications, and minor complications. No significant risk factors for major complications were identified. With regard to minor complications, advanced patient age (odds ratio [OR], 1.67; P = 0.03) and early surgical experience (OR, 5.08; P = 0.001) were found to be associated with increased risk. Preoperative hormonal treatment was found to trend toward a protective effect (OR, 0.13; P = 0.07). Any of the reviewed techniques are safe in practice; however, there is a learning curve associated with their use, and longer follow-up will allow for the identification of late complications. The double incision with nipple transposition on a pedicle technique can be considered for patients for whom depigmentation of the nipple-areola complex is a significant concern, especially if they are willing to tolerate a potentially suboptimal chest contour.

Modified Treatment Algorithm for Pseudogynecomastia After Massive Weight Loss.

Pseudogynecomastia is the increased aggregation of fatty tissue in the area of the male breast with resultant female appearance. Two forms can appear: pseudogynecomastia after massive weight loss (pseudogynecomastia obese [PO]) and pseudogynecomastia, which is caused only by adipose tissue (pseudogynecomastia fat). For PO, only the Gusenoff classification with corresponding operative treatment options exists. However, this classification is limited by the fact that it underestimates the extensive variability of residual fat tissue and skin excess, both crucial factors for operative planning. For this reason, we propose a modification of the treatment algorithm for the Gusenoff classification based on our results to achieve more masculine results. A total of 43 male patients with PO were included in this retrospective study (grade 1a, n = 1; grade 1b, n = 1; grade 2, n = 17; grade 3, n = 24). Forty-two mastectomies with a free nipple-areola complex (NAC) transposition (grades 2 and 3) and 1 with a subcutaneous mastectomy (grade 1a) with periareolar lifting were performed. A retrospective chart review was performed to obtain data regarding age, body mass index, body mass index loss, weight loss, reason for weight loss, comorbidities, nicotine, and additional procedures, postoperative sensitive on the NAC transplants and complications. None of the free-nipple grafts were lost. Forty (95%) of 42 patients with mastectomy had a resensitivity on the NAC. For pseudogynecomastia, the treatment algorithm of the Gusenoff classification should be modified and adapted according to our recommendations to achieve more optimal masculine results.

Supero-medial reduction mammaplasty: a safe and reliable technique in gigantomastia and severe breast ptosis.

Reduction mammaplasty in huge breasts poses a great challenge for plastic surgeons. The classic technique is free nipple and areola grafting after breast amputation. This paper is a short technical report of reduction mammoplasty on 40 patients with severe breast ptosis (suprasternal notch to nipple >35 cm) and giganticomastia (anticipated resection of more than 1 kg per breast) were operated upon using superomedial pedicle technique for reduction mammaplasty. All patients were satisfied with their results aesthetically, and showed relief in their neck pain. There were no cases of total nipple-areola loss. In one breast, the nipple-areolar complex (NAC) was congested intra-operatively and free nipple grafting was done. The NAC sensation was preserved in 36 cases, and all other complications were minimal and self-limiting. The superomedial pedicle technique has proven to be a safe and reliable method for reduction mammaplasty in huge breasts. Compared to the classic free nipple and areola technique, this method showed promising results in preserving the nipple sensation and giving more pleasant natural projecting breasts.

Why Choose the Septum-Supero-Medial (SSM)-Based Mammaplasty in Patients with Severe Breast Ptosis: An Anatomical Point of View.

Nipple-areola complex (NAC) loss is one of the most devastating complications of mastopexy or breast reduction, and it requires revisional procedures with poor aesthetic outcome. In high-risk patients, a free nipple graft could be a choice, but it is associated with the same aesthetic concerns for both patients and surgeons. We report our experience with the septum-supero-medial-based mammaplasty to treat 22 patients with severe breast ptosis (nipple-to-sternal-notch distance > 40cm). No NAC loss was observed. The study highlights surgical technical details and discusses anatomical considerations to justify the successful result. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes.

Chest wall masculinization by means of mastectomy is an important gender affirming surgery for transmasculine and non-binary patients. Limited data exist comparing commonly used techniques in masculinizing top surgery, and most are single institution studies. A systematic review was performed on primary literature dedicated specifically to the technical aspects and outcomes of mastectomy for masculinizing top surgery. For each study, patient demographics and surgical outcomes were compared. Eight studies met inclusion criteria. There were 2138 breasts with an average patient age of 28.6 years and the average breast weight was 353 g. The most commonly reported techniques are those without skin resection (8.0%), those with periareolar skin resection (34.1%), inferior pedicle mammoplasty (15.7%), and inframammary fold skin excision with free nipple grafting (FNG, 42.2%). In total, 6.0% of all breasts required acute reoperation for hematoma and 26.5% required secondary operations. Acute reoperation occurred significantly less often in the FNG cohort (4.8%) compared with both the inferior pedicle mammaplasty cohort (8.9%, P < 0.05) and techniques without skin resection cohort (10.3%, P < 0.05). Secondary operations occurred significantly more often in the periareolar skin resection cohort (37.5%) than techniques without skin resection cohort (19.0%, P < 0.01), inferior pedicle mammaplasty cohort (27.9%, P < 0.01), and FNG cohort (20.3%, P < 0.05). In addition, secondary operations occurred significantly more often in inferior pedicle mammaplasty cohort (27.9%) compared with FNG cohort (20.3%, P < 0.01). This analysis notes several significant differences with regard to percentage requiring acute reoperation and percentage requiring secondary revision based on technique. Candidates for masculinizing top surgery should be educated on these differences.

Does Previous Breast Reduction Affect the Outcome of Gender-Affirming Subcutaneous Mastectomy?

Despite the rising popularity of subcutaneous mastectomy (top surgery) in patients born female and identifying as male or nonbinary, there are limited studies on how prior breast surgeries affect subcutaneous mastectomy. This study evaluates if previous breast reduction affected subcutaneous mastectomy in this patient population. The case series consists of 5 patients who, having had prior breast reductions, elected to have subcutaneous mastectomy. The data were collected retrospectively for mastectomy conducted from 2015 to 2016. Demographic data collected included age at surgery, body mass index, smoking status, medical comorbidity, and use of hormone medication. Outcome data included postoperative complications and need for operative revision. Postoperative follow-up was at 1 week and at 1, 3, 6, and 12 months. Patients' ages were between 29 and 46 years with body mass index from 24 to 33 kg/m. They underwent breast reduction approximately 9 to 26 months prior to subcutaneous mastectomy. All 5 patients successfully underwent subcutaneous mastectomy via double incision and free nipple grafts. Blood loss was estimated to be approximately 42 mL. All patients were discharged on the same day of surgery. The last follow-up averaged at 13 months after surgery and no major complication was reported. However, 1 patient required revision of the nipple graft and chest scars. This small case series suggests that subcutaneous mastectomy could be safely performed in transmasculine or nonbinary patients who had previous breast reduction.

Preoperative CT angiography to facilitate pedicle selection for high-risk breast reduction patients

Introduction: Large volume breasts, and also breasts with a long distance between the sternal notch and the nipple, have a higher risk of postoperative nipple necrosis after breast reduction surgery. This is due to vascular insufficiency. For these high-risk cases, free nipple grafts are sometimes performed. Free nipple grafts are not an ideal technique due to reduced sensation, duct disruption, variable take and common result of an under-projecting nipple and poor aesthetic outcome. In order to avoid both necrosis of the nipples and the use of free nipple grafts, we have investigated the use of angiographic computerized tomography (CTA) in the selection of the dominant blood supply in breast reduction pedicle selection. The first aim of this study was to investigate the dominant vascular supply to the nipple areolar complex (NAC) using CTA. The second aim was to investigate whether the preoperative CTA could change surgical planning and also reduce the incidence of nipple necrosis after breast reductions for patients considered to be at a high risk of nipple loss. Methods: Phase 1: All female CT thoraces performed at a single centre between January and May 2013 were reviewed by a single cardiothoracic radiologist to find arterial sources, which intercostal space that was perforated, glandular/subcutaneous course and vessel entry point into the NAC of each breast. Phase 2: Preoperative planning CTA’s performed for the 28 cases of high-risk breast reductions of the 392 breast reductions between 2008 and 2014. Results: Phase 1: The analysis was performed on CTAs of 69 patient cases, involving 132 breasts. The dominant blood supply was the internal mammary artery (IMA) in 96 breasts, with long thoracic artery (LTA) in 21 breasts. Phase 2: A dominant vascular supply was identified in all cases. In 27 of the 28 cases, preoperative planning was undertaken as guided by the CTA. Of the 28 cases, there was one case of unilateral infection, one hematoma, and a single case of partial thickness areolar necrosis. No free nipple grafts were required. Conclusion: Preoperative CTA for large-volume breast reduction may be a useful surgical planning tool for high-risk patients. With the insight gleaned from a CTA, pedicle design can be tailored to the specific patient’s blood supply in order to reduce the incidence of necrosis to the nipple areolar complex and to avoid the need for free nipple grafts.

Preoperative CT angiography to facilitate pedicle selection for high-risk breast reduction patients

Introduction: This study aimed to investigate the dominant vascular supply to the nipple areolar complex (NAC) using CTA and whether the preoperative CTA could change surgical planning and reduce the incidence of nipple necrosis after breast reductions for patients considered to be at a high risk of nipple loss.Methods: All female CT thoraces performed at a single centre between January and May 2013 were reviewed by a single cardiothoracic radiologist to find arterial sources, which intercostal space that was perforated, glandular/subcutaneous course and vessel entry point into the NAC of each breast. Preoperative planning CTA’s performed for the 28 cases of high-risk breast reductions of the 392 breast reductions between 2008 and 2014.Results: Analysis was performed on CTAs of 69 patient cases, involving 132 breasts. The dominant blood supply was the internal mammary artery (IMA) in 96 breasts, with long thoracic artery (LTA) in 21 breasts. A dominant vascular supply was identified in all cases. In 27 of the 28 cases, preoperative planning was undertaken as guided by the CTA. Of the 28 cases, there was one case of unilateral infection, one hematoma, and a single case of partial thickness areolar necrosis. No free nipple grafts were required.Conclusion: Preoperative CTA for large-volume breast reduction may be a useful surgical planning tool for high-risk patients. With CTA, pedicle design can be tailored to the specific patient’s blood supply in order to reduce the incidence of necrosis and avoid the need for free nipple grafts.

Combining Breast Reduction Techniques to Treat Gigantomastia in Ghana

Summary:In this presentation of 2 consecutive cases of symptomatic juvenile breast hypertrophy in Ghana, we review the patient presentation, workup, and discuss outcomes following a combined technique of inferior pedicle stump with free nipple graft reduction mammoplasty. Surgical goals for treatment of gigantomastia were 2-fold: to resect adequate tissue to obtain symptomatic relief with improved quality of life, while avoiding a flat, boxy-appearing breast shape.

Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a Population With BRCA Mutations

Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance; however, its role among patients with BRCA mutations remains controversial. To report on the oncologic safety of NSM and provide evidence-based data to patients and health care professionals regarding preservation of the nipple-areolar complex during a risk-reducing mastectomy in a population with BRCA mutations. We retrospectively reviewed the outcomes of 9 institutions' experience with prophylactic NSM from 1968 to 2013 in a cohort of patients with BRCA mutations. Patients with breast cancer were included if they underwent contralateral risk-reducing mastectomy; however, only the prophylactic side was considered in the analysis. Patients found to have an occult primary breast cancer at the time of risk-reducing mastectomy, those having variant(s) of unknown significance, and those undergoing free nipple grafts were excluded. The primary outcome measure was development of a new breast cancer after risk-reducing NSM. Three reference data sources were used to model the expected number of events, and this was compared with our observed number of events. A total of 548 risk-reducing NSMs in 346 patients were performed at 9 institutions. The median age at NSM was 41 years (interquartile range, 34.5-47.5 years). Bilateral prophylactic NSMs were performed in 202 patients (58.4%), and 144 patients (41.6%) underwent a unilateral risk-reducing NSM secondary to cancer in the contralateral breast. Overall, 201 patients with BRCA1 mutations and 145 with BRCA2 mutations were included. With median and mean follow-up of 34 and 56 months, respectively, no ipsilateral breast cancers occurred after prophylactic NSM. Breast cancer did not develop in any patients undergoing bilateral risk-reducing NSMs. Using risk models for BRCA1/2 mutation carriers, approximately 22 new primary breast cancers were expected without prophylactic NSM. Prophylactic NSM resulted in a significant reduction in breast cancer events (test of observed vs expected events, P < .001). Nipple-sparing mastectomies are highly preventive against breast cancer in a BRCA population. Although the follow-up remains relatively short, NSM should be offered as a breast cancer risk-reducing strategy to appropriate patients with BRCA mutations.

Female-to-Male Chest Reconstruction: A Review of Technique and Outcomes.

Female-to-male transgender individuals frequently seek out chest wall masculinization as part of their gender transition and to aid with treating gender dysphoria. Critical evaluation of techniques, complications, and outcomes is important particularly as the surgery becomes more commonly performed. A retrospective review was performed of all patients undergoing female-to-male chest wall reconstruction by the senior author from 2008 to 2015. Charts were reviewed to evaluate patient demographics, intraoperative details, and postoperative outcomes. Complications were stratified into major and minor complications based on the need to return to the operating room. Inframammary fold techniques and periareolar techniques cohorts were compared for major complications, minor complications, and need for revision surgeries. Over 8 years, 130 patients were identified. One hundred ten patients underwent inframammary fold techniques, and 20 patients underwent periareolar incisions. Early postoperative complications occurred in 25% of patients. Hematoma was the most common complications, occurring in 14% of patients. Major complications occurred in 8% of patients. Minor complications occurred in 16% of patients, with respiratory problems found to be a significant risk factor. On long-term follow up, 9% of patients had a revision procedure performed. Patients with prior breast surgery were more likely to require revisions (P = 0.009). Of patients requiring revision, 38% had a periareolar incision, compared with only 13% of patients who did not (P = 0.03). For unplanned revisions, there was no difference in periareolar and inframammary techniques. Our patient cohort demonstrates that female-to-male patients who undergo chest wall contouring through a transverse inframammary fold incision with either composite or standard free nipple grafting have decreased rates of revision surgery and trend toward having lower complication rates as compared with periareolar and limited scar techniques. To best manage expectations, patients undergoing a periareolar or other limited incision technique are counseled regarding an increased risk of hematoma and an increased likelihood of revisions.

Surgical Indications and Outcomes of Mastectomy in Transmen: A Prospective Study of Technical and Self-Reported Measures.

Background:Although transgender surgery constitutes a growing field within plastic surgery, prospective studies on masculinizing mastectomies are lacking. The objectives of the present study were to prospectively follow a cohort of transmen undergoing mastectomy to assess technical and self-reported outcomes and to evaluate surgical decision-making.Methods:Fifty-four transmen were recruited during a 10-month period at the Department of Plastic Surgery of the Centre of Expertise on Gender Dysphoria. Preoperative assessment included standardized chest examination. Six months postoperatively, participants rated their satisfaction with surgery, and 12-month postoperative surgical outcomes were reviewed independently. Surgical decision-making was evaluated by comparing indications and outcomes per technique, and assessing the clinical validity of the most-used decision aid (using the Cohen's kappa statistic).Results:One periareolar mastectomy, 26 concentric circular mastectomies, and 22 inframammary skin resections with free nipple graft were performed in the authors’ cohort. Five participants were still to be operated on. Concentric circular mastectomy was performed in smaller or medium-size breasts with low ptosis grade and good elasticity, whereas the inframammary skin resection group showed a wider range of physical characteristics. Despite being performed in better quality breasts, concentric circular mastectomy was associated with more secondary corrections (38.5 percent), dehiscence, seroma, and lower postoperative satisfaction compared with inframammary skin resections. Clinical decision-making was generally in line with the published decision aid.Conclusions:Compared with inframammary skin resections, concentric circular mastectomy—despite being performed in favorable breast types—appears to produce poorer technical and self-reported outcomes. Surgical indications and preoperative counseling regarding secondary corrections may therefore be subject to improvement.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

Die Ribeiro-Technik bei Gigantomastie – Review von 294 Reduktionsplastiken in 8 Jahren

Reduction mammaplasty in patients with gigantomastia is challenging even to very experienced plastic surgeons. Extremely elongated pedicles impair the vascular supply of the nipple-areola complex. Breast shaping and effective reduction are difficult due to the severely stretched skin envelope. The Ribeiro technique is the standard technique for reduction mammaplasty in our clinic. The aim of this study is to review our approach in patients with gigantomastia in comparison to the current literature. From 01/2009 to 12/2016, we performed 1247 reduction mammaplasties in 760 patients. In 294 reduction mammoplasties (23.6 %), resection weight was more than 1000 g per breast corresponding to the definition of gigantomastia. The Ribeiro technique with a superomedial pedicle and inferior dermoglandular flap for autologous augmentation of the upper pole was implemented as standard procedure. In cases with a sternal notch-nipple distance > 40 cm, free nipple grafting was performed. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and surgical revision rate were obtained and retrospectively analysed. In 174 patients, 294 reduction mammaplasties were performed with a resection weight of more than 1000 g per breast. Average resection weight was 1389.6 g (range, 1000-4580 g). Average age was 43.5 years (range, 18-76 years), average body mass index (BMI) was 29.2 kg/m2 (range, 19-40 kg/m2), average sternal notch-nipple distance was 34.8 cm (range, 27-52 cm), average operation time was 117 minutes (range, 72-213 minutes). A free nipple graft was necessary in 30 breasts. Overall complication rate was 7.8 %; secondary surgical revision rate was 16 %. 93 % of the patients were "very satisfied" and "satisfied" with the aesthetic result. Nipple sensitivity was rated "very good" and "good" in 88 %. The Ribeiro technique is a well established, versatile standard technique for reduction mammaplasty, which helps to create high-quality reproducible results with longterm formstable shape. In gigantomastia, this procedure is also very effective to achieve volume reduction and aesthetically pleasing results with a low complication rate.

Mastopexie nach massivem Gewichtsverlust – Erweiterte Ribeiro-Technik und Einsatz der lateralen Interkostalarterien-Perforatorlappenplastik (LICAP-Flap) zur Autoaugmentation

Mastopexy in massive weight loss patients is challenging. The breast mound is often unstable and deflated, with a loose inelastic skin envelope. It has become apparent that mammaplasty techniques in these cases should rely more on glandular recontouring rather than on the skin envelope for shaping. Published methods include plication, suspension and autoaugmentation. The residual local tissue (glandular breast tissue, fat tissue, dermoglandular fat flap) is utilised to its full extent in order to reshape a form-stable breast with full upper pole projection. The evolution of a technique is presented. In this study we retrospectively analysed 68 massive weight loss patients who underwent an extended Ribeiro technique with a superomedial pedicle mastopexy and suspension by an inferior dermoglandular flap. The current procedure involves incorporating the lateral intercostal artery perforator flap (LICAP flap) and medial breast pillar additionally to the inferior dermoglandular Ribeiro flap. This essentially autoaugments the upper pole by creating an "autoprosthesis", narrows the widened breast, and redefines the inframammary fold. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility and surgical revision rate were obtained. From 01/2011 to 12/2016, we performed 136 autoaugmentation mastopexies. The average age was 41.2 years, average body mass index (BMI) was 27,1 kg/m2, average weight loss was 54.3 kg, average sternal notch-NAC distance was 32.3 cm, average operation time was 109 minutes. In 12 breasts, a free-nipple graft was necessary. The complication rate was 5.1 %, surgical revision rate was 17.6 %. 95 % of the patients were "very satisfied" or "satisfied" with the aesthetic result. Nipple sensibility was rated as "very good" or "good" by 85 % of patients. Modification of the Ribeiro technique by using the medial and lateral breast pillar (LICAP flap) allows autoaugmentation of the upper pole. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, with the aim of reducing the incidence of recurrent ptosis. The presented technique is a reproducible and reliable method with a low complication rate.