Position Of Nipple-areola Complex Research Articles

Abstract PO2-22-08: Nipple areolar complex changes after breast-conserving surgical therapy and periareolar mastopexy: a three-dimensional Surface Analysis

Abstract Objectives: The position and configuration of the nipple-areolar complex (NAC) have a high impact on satisfaction (objective and subjective) after breast-conserving therapy (BCT). The aim of this study is to objectively measure the changes in the NAC after breast conservation surgery by the use of the 3D whole body scanner and compare its results with the outcome reported by the patients. This will support further patients and help physicians to tailor their technique prior to breast-conserving surgery. Methods: In a unicentric pilot project 6 months after BET with periareolar mastopexy and adjuvant radiation between 2019 and 2022, 38 women were studied. The mean age was 56.3 ±11.6 and BMI was 24.6 ± 4.5 kg/m². Objective 3D parameters were collected using the Vectra Whole Body Surface Imaging System (WB360) based on breast and NAC dimensions. In addition, the patients received the BCT module and the mastopexy module items about satisfaction with the NAC from the BREAST Q questionnaire. Results: In a group of 38 women, BCT with periareolar mastopexy and irradiation showed a small but significant change in NAC position and shape (see Table 1). This small change is matched by the high satisfaction with the nipple and areola surveyed in the BREAST-Q questionnaire. More than 66% of the women were rather satisfied or very satisfied. The BREAST-Q results from the Items about satisfaction with the nipple and areola are shown in Table 2. However, 34% of participants reported being somewhat dissatisfied to very dissatisfied with the symmetry of placement. This could be due to a significant cumulative small change in nipple-sternal notch distance and nipple-midline distance. No significant difference was found when measuring the nipple-inframammary fold distance (p=0.649). The absolute difference was of 0.13 ± 1.22 mm. The change in breast diameter was of 0.55 ± 1.54 mm (relative 2,75 ± 7.95%). There was also no significance (p=0.042). This indicates that after BCT, the nipple-inframammary fold distance and breast diameter did not change significantly. Breast volume decreases insignificantly by 49.2 ± 136.1 cc (relative 12,96 ± 33.51) on the operated side (p=0.009). In particular, a difference in vertical diameter of the NAC of -4,79 mm (14,27%) was observed between the non-operated and the operated breast (p=0.005 by Wilcoxon-test). The BREAST-Q BCT Module consists of 8 domains. The higher the score, the higher the satisfaction with the questioned item. In our sample of 38 women, satisfaction with the surgeon(s) was highest (BREAST-Q score of 83,97 ± 19,12). The mean Q score for satisfaction with "psychosocial well-being" is 67,47 ± 22,03. For the item "sexual well-being", only 35 women answered sufficient questions and the mean Q score was 54,42 ± 16,43. “Satisfaction with breast” had a Q-score of 61,03 ± 19,36. The questions about "physical well-being" had a mean of 70,11 ± 16,69. The Q-score for “satisfaction with medical team”, “with office staff”, and “with information” can be seen in Table 3. Conclusions: In a nutshell, the conclusion of this study is that the Vectra XT 3D-Imaging is a useful tool to assess the cosmetic outcome in terms of NAC position and shape. Hence, it is a helpful tool to support the planning of the surgery and may have a positive impact on the outcome. Postoperatively, there was only a slight change in the NAC dimension and position compared with intraoperative planning. The 3D Surface Analysis is most useful in assessing the quality of reconstruction after BCT and additionally the NAC is therefore an important factor for patient satisfaction. Results of a multicenter study are pending. Table 1: Descriptive statistic and Wilcoxon-test Results from the measures from the Breast and from NAC Dimension and Position (n=38) The 3D Measures from the Breast and from NAC Dimension and Position Table 2: Results from the BREAST-Q mastopexy modul about satisfaction with the nipples (n=38) Satisfaction with the nipples Table 3: Results from the BREAST-Q BCT Modul after BCT and periareolar mastopexy und adjuvant radiation (n=38) BREAST-Q Scores Citation Format: Therese Peter, Konstantin Koban, Denis Ehrl, Pamina Geiger, Nadia Harbeck, Steffen Kahlert, Carolin Luczak, Johannes Schmid, Rachel Wuerstlein, Friederike Hagemann. Nipple areolar complex changes after breast-conserving surgical therapy and periareolar mastopexy: a three-dimensional Surface Analysis [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-22-08.

Marking the nipple-areola complex in mastopexy and reduction mammoplasty: a geometrical method.

Mastopexy and reduction mammoplasty are well-established procedures used to address ptotic and hypertrophic breasts. A variety of methods have been described in the literature for managing the three main aspects of these procedures: skin excess, parenchyma, and the nipple-areola complex (NAC). Among these techniques, several have specifically addressed the markings of the NAC in procedures involving a preoperatively established NAC position. While many of these have proven effective over time, the literature lacks standardized and reproducible methods. In this paper, we introduce, step-by-step, a novel approach based on geometrical principles to address this limitation. This method involves the simple process of drawing two hemi circumferences on the vertical limbs of the skin resection pattern, which are commonly marked using the Bisemberg maneuver or similar techniques. The method we introduce is adaptable to virtually all NAC pedicles. Furthermore, as exemplified in the accompanying video, it can be incorporated to most skin resection patterns with a preoperatively defined NAC position. The clinical application, as evidenced in the case reported, appears to be promising. Although it has some limitations, this procedure shows the potential to reduce inaccuracy by minimizing variability factors. As a result, even inexperienced surgeons can achieve precise markings.

Nipple-Preserving Inferior Ellipse Mastectomy: A New Technique for Gender-Affirming Top Surgery.

The two most common techniques for gender affirming mastectomy are the double incision free nipple graft and peri areolar. There are however patients that are not well suited for either technique. When the nipples are high and on the pectoralis muscle yet there is marked breast tissue and skin redundancy, a double incision free nipple graft would land the incision above the pec shadow but a peri-areolar approach would not adequately remove the excess skin. In these patients, a nipple-preserving inferior ellipse incision allows for appropriate chest contouring leaving the nipple position unchanged and placing the incision in the pectoralis muscle shadow. Retrospective review identified all consecutive patients undergoing nipple-preserving inferior ellipse mastectomy by the senior author. Indications were patients with moderate glandular tissue, skin excess and a high nipple areolar complex (NAC) above the inferior border of the pectoralis major. Sixteen patients underwent inferior ellipse mastectomy and were included. Mean follow-up was 203 days. Two patients (14%) required revision of the NAC. There was no partial or complete NAC loss. One patient (7%) developed postoperative seroma which resolved with aspiration. In summary, for patients with moderate glandular tissue, excess skin in the inferior pole and NAC position above the inferior border of the pectoralis major, the nipple-preserving inferior ellipse mastectomy technique achieves excellent chest contour.

Addressing the Gray Zone in Affirmative Mastectomy: An Analysis of Fischer 2 Patients.

Surgical decision making in gender-affirming mastectomy (GAM) is based on a patient's classification using the Fischer scale. Fischer 1 patients are excellent candidates for periareolar (PA) approach and Fischer 3 patients almost exclusively undergo double incision with free nipple grafting (DIFNG). Fischer 2 patients are in a gray zone in which decision making is more challenging. In this patient population, periareolar approaches can lead to increased complication and revision rates but free grafting procedures seem excessive. We have created a treatment algorithm to address Fischer 2 patients and additionally developed a novel technique, the batwing, to provide patients with more options. A retrospective chart review was undertaken to analyze the Fischer classification of all patients undergoing top surgery by a single surgeon at an academic institution from 2014 to 2021. The choice of surgical technique used as well as the outcomes of GAM among Fischer 2 patients was analyzed. Four hundred four patients underwent GAM, and 51 (11%) had Fischer 2 classification. The surgical techniques used were PA (27%), batwing (39%), nipple-sparing double incision (NSDI, 24%), and DIFNG (10%). Of those, 10% had major complications and 20% requested revision for contour irregularities. Major complication rates for PA, batwing, NSDI, and DIFNG were as follows: 2 of 14 patients (14%), 1 of 20 patients (5%), 1 of 12 patients (8%), and 1 of 5 patients (20%), respectively. The revision rate by technique was PA (36%), batwing (15%), NSDI (17%), and DIFNG (0%). For Fischer 2 patients, batwing and NSDI techniques avoid the need for free nipple graft while providing better exposure, improved control of nipple-areolar complex position, and decreased rate of revision as compared with the PA technique. The complication rate was not significantly different. We present an algorithm accounting for Fischer grade, unique patient characteristics, and patient desires.

Optimizing aesthetic results in autologous breast reconstruction.

Advances in breast cancer management have provided most patients with the hope for cure or avoidance of cancer altogether. Such advances have made quality of life much more important after treatment and have led to equally incredible advances in breast reconstruction, to the point where reconstructive goals have altered the way mastectomies are now performed. As experience and expertise in microsurgery has grown, the surgical feat of successfully transferring tissue to restore breast volume is no longer considered an adequate endpoint for aesthetic breast reconstruction. A shift towards patient-centered care has motivated plastic surgeons to adapt their approaches to reconstruction integrating aesthetic principles to the process of recreating a breast mound in order to provide patients with a long-term, natural, and optimal result. Vital to restoring a shapely breast is a thorough preoperative assessment and the understanding of the breast footprint, breast conus, skin envelope and nipple-areolar complex (NAC) position. These aesthetic goals should also extend to the donor site, where adequate contour improvement is sought to offset the price of the donor site scar and the morbidity is minimized. By utilizing strategies for optimizing the NAC position, incorporating novel techniques to ensure core projection, and paying attention to the donor site, the skilled microsurgeon can elevate breast reconstruction to the level of true aesthetic surgery where the reconstructed appearance is superior to the presurgical one.

The NIU (Nipple-Inframammary Fold-Upper Breast Border) Principle: Preoperative Marking of the Ideal Nipple Position in Augmentation Mastopexy.

Although the beauty of the breast depends on aesthetic proportions, the position of the nipple-areola complex (NAC) on the breast mound and in relation to the implant during breast augmentation or mastopexy augmentation is critical. In fact, lack of nipple position determination in relation to the breast footprint is a deficiency of most currently applied measurements and evaluation tools. The authors hereby present a simple formula that allows accurate and proper prediction of the ideal NAC positioning for every patient depending on the chosen implant in case of mastopexy augmentation, or revision mastopexy with exchange of implants. A prospective level IV analysis of all consecutive patients undergoing primary mastopexy augmentation or revision mastopexy with exchange of implants was performed between January of 2021 and January of 2022. Forty-eight consecutive patients were included in the study. The nipple-inframammary fold-upper breast border (NIU) principle was applied to all patients to determine the ideal position of the NAC. Patients were photographed preoperatively and postoperatively in a standardized manner. The main endpoint was to determine whether the NAC is located at the most projected point of the breast on follow-up. The NIU principle was applied to 48 patients between January of 2021 and January of 2022. Of those patients, 27 underwent primary augmentation mastopexy, and 21 underwent revision augmentation mastopexy with exchange of implants. The mean follow-up duration was 9.2 months (range, 6 to 18 months). All patients demonstrated proper NAC positioning on follow-up. The NIU principle is a simple and reliable method to determine the ideal NAC position during mastopexy augmentation or mastopexy with implant exchange. Therapeutic, IV.

How Useful Is the SSN–Nipple Distance? An Analytical Questionnaire Survey on Anthropometric Measurements for the Aesthetically Ideal Positioning of the Nipple–Areolar Complex

Several studies have attempted to identify the optimal anthropometric measurement for the aesthetically ideal positioning of the nipple-areolar complex. However, no standardised solutions and measurements for planning surgical procedures have been reached. The aim of this study is to identify the optimal anthropometric measurement between the suprasternal notch (SSN)-nipple distance and mid-clavicle (MC)-nipple distance for the aesthetic position of the nipple-areola complex (NAC) on the breast. A detailed online survey was sent to 300 board-certified plastic surgeons and residents of plastic surgery departments of hospitals in German, Austrian, and Swiss. A similar survey was also provided to 100 patients who had planned or had already undergone breast surgery. All participants were asked to rank the attractiveness of a series of women's breasts in images with different NAC position measurements. The images showed breasts from two different measurements and distances: all the breasts had equal dimensions and proportions and the same areola size. Complete datasets were obtained from 203 of the 300 board-certified plastic surgeons and residents of plastic surgery departments in German-speaking countries (recall 68%) and from 100 patients. The majority of doctors and patients find a symmetrical breast with a mirrored position of the nipple-areola complex more attractive than a non-symmetrical breast. In cases with minor measurement differences, such as 0.5 cm (SSN vs. MC), there is no relevant difference in the breast symmetry. However, at larger distances, the MC-to-nipple distance is superior for achieving aesthetically appealing symmetry compared with the SSN-to-nipple distance. Using the MC-to-nipple distance seems to be superior for correct nipple positioning than the SSN-to-nipple distance and is a valuable preoperative measurement option for breast symmetry with correct nipple height. Further studies on this topic involving a more general population should be conducted to confirm the improvements in perception with the preoperative measurements using the anatomical landmarks.

Complications following Breast Augmentation in Transgender Female: A Systemic Review and Meta-analysis

PURPOSE: Gender confirming surgery (GCS) improves quality of life and alleviates psychological distress in transgender and gender diverse individuals[1]. For a transgender female, breast augmentation with implants is a frequently sought-after procedure, as breast growth from hormone therapy alone is often inadequate[2]. Peri-operative complications such as infection, implant malposition, hematoma, and capsular contracture are well-described in the literature in treatment of hypomastia for cis-gender females, however their description in the transgender female community has been less elucidated and limited to case series. In this study, we performed a meta-analysis of the published literature to evaluate peri-operative complications following breast augmentation in transgender females to evaluate its safety and efficacy in relative to the similar procedure in cis-gender females. METHOD: PubMed and the Cochrane Library and other resources were queried for studies published up to Jan 2022. The following keywords were used: ‘transgender’, ‘transfeminine’, ‘implant’, ‘augmentation’, ‘breast’, and ‘chest’. Primary outcomes of interest were complications (i.e. capsular contracture, hematoma or seroma, infection, implant asymmetry/malposition, hemorrhage, skin or systemic complications), patient satisfaction, and reoperation rates. Quantitative analyses were performed with STATA 16 statistical software (STATA Corp., College Station, TX, USA). Rates were pooled with the -metaprop function and reported in 95% confidence intervals. Breast implant surgery complications were compared between cis-gender and trans-gender patients. A chi-square test was performed to analyze the incidence of complications between cis-gender vs trans-gender female breast augmentation. RESULTS: A total 1864 patients from 14 studies were included for analysis in the transgender female group. Studies were conducted in various regions including the USA, Netherlands, Switzerland, and France. In the transgender female group, pooled rate of capsular contracture from 7 studies was 3.62% ((95% CI, 0.0038-0.0908); hematoma/seroma from nine studies was 0.63% ((95% CI: 0.0014-0.0134); infection incidence from eight studies was 0.08% (95% CI, 0.0000-0.0054); pooled rates of implant asymmetry/malposition from five studies was 4.51% (95% CI, 0.0089-0.1010. A comparison between cis-gender vs trans-gender females was performed via chi-square test by comparison of our pooled data with previously published data from cis-gender breast augmentation meta-analyses[3,4]. There was no statistical difference between rates of capsular contracture (p=0.41) and infection (p=0.71) between the two groups, while there were higher rates of hematoma/seroma (p=0.0095) and implant asymmetry/malposition (p=0.004) in the transgender female group. CONCLUSION: Breast augmentation surgery has similar published rates of post-operative infection and capsular contracture between cisgender and transgender females but has higher rates of hematoma/seroma and malposition in the transgender group. This could be explained by contributing factors such as patient’s chest size, differences in musculature and soft tissue envelope, and native nipple-areola complex position. Relative to the published literature on cis-gender breast augmentation, there is a relative paucity, smaller sample size and inconsistent reporting in the transgender female group, which is a limitation of the study. Lack of reporting of complications relative to surgical approach (i.e subglandular vs submuscular implant positioning) is another limitation of the published literature in the transgender female group and an area of further study. REFERENCES: 1. White Hughto JM, Reisner SL. A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals. Transgend Health. Jan 2016;1(1):21-31. doi:10.1089/trgh.2015.0008 2. Surgeons ASoP. 2020 Plastic Surgery Statistics Report. 2020:26. 3. Li S, Mu D, Liu C, et al. Complications Following Subpectoral Versus Prepectoral Breast Augmentation: A Meta-analysis. Aesthetic Plast Surg. Aug 2019;43(4):890-898. doi:10.1007/s00266-019-01404-7 4. Shen Z, Chen X, Sun J, et al. A comparative assessment of three planes of implant placement in breast augmentation: A Bayesian analysis. J Plast Reconstr Aesthet Surg. Dec 2019;72(12):1986-1995. doi:10.1016/j.bjps.2019.09.010

Clinical Evaluation of Safety and Efficacy of Radiofrequency-Assisted Lipolysis on Breast Envelope and Nipple-Areola Complex Position.

Breast ptosis as a result of pregnancy and/or breastfeeding, age, genetics, and weight loss is a common complaint among women visiting a plastic surgeon. This study sought to evaluate the utility, efficacy, and safety of radiofrequency-assisted lipolysis on the breast and nipple-areola complex position in women with breast ptosis. This was a single-center (i.e., Maxwell Aesthetics) study of women desiring tightening of the breast envelope and elevation of the nipple-areola complex. Each patient underwent one treatment with radiofrequency-assisted lipolysis in the operating room. Radiofrequency-assisted lipolysis was applied to each breast with a BodyTite Pro handpiece. Patients were evaluated preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 12 months by means of manual and three-dimensional computer-generated measurements (i.e., Vectra). Ten female patients were enrolled. Ages ranged from 23 to 54 years. Follow-up was 12 months. Data were captured for seven measurements from the nipple longitudinally at five time points. The sternal notch-to-nipple distance, the nipple-to-inframammary fold distance, and the nipple-to-nipple distance improved statistically at 6-week follow-up, which persisted through the 12-month follow-up ( p < 0.05). Patient questionnaires revealed moderate to excellent satisfaction. Radiofrequency-assisted lipolysis with a bipolar device to deliver radiofrequency energy to the breast is an effective modality to moderately improve breast ptosis. This study demonstrates that this treatment improves breast measurements across time, regardless of measurement type (manual versus Vectra). This modality affords a minimally invasive, effective method to improve mild to moderate breast ptosis with minimal scarring and high patient satisfaction. Therapeutic, IV.

Revising Prepectoral Breast Reconstruction.

Prepectoral prosthetic breast reconstruction continues to gain popularity, largely due to its decreased postoperative pain, animation deformity, and operative time as compared to subpectoral reconstruction. Widespread use has led to opportunities for surgical revisions. While some techniques for submuscular reconstruction revisions, such as implant exchange and fat grafting, also apply to prepectoral revisions, others require modification for the prepectoral space. The prosthesis' unique reliance on the mastectomy flaps and acellular dermal matrix for support leads to a progressive alteration of the breast footprint, conus, envelope, and nipple-areola complex position. To date, revisions of prepectoral reconstructions have not been addressed in the literature. This article presents the senior author's (N.P.B.) techniques for (1) revising prepectoral breast reconstructions, including staged and direct-to-implant reconstructions, with a special focus on nipple-sparing reconstruction, and (2) minimizing undesirable outcomes of prepectoral reconstruction.

Breast Splint for Prevention of Nipple-areolar Complex Malposition after Direct-to-implant Breast Reconstruction.

Summary:Breast reconstruction with immediate placement of breast implants (direct-to-implant methods) following nipple-sparing mastectomy has increased because of the low burden on the patient and good aesthetic results. However, nipple–areolar complex (NAC) malposition after this surgery remains a common complication that has yet to be entirely resolved. Here, we introduce an approach using Duoactive CGF to prevent postoperative NAC malposition. Immediate postoperative fixation of Duoactive CGF cranially to the NAC of the operated breast was applied for 2–4 weeks. This is referred to as a breast splint. In the study, nine patients who received breast splints and 15 patients who did not were enrolled. The NAC position on the splint-treated breast was compared with that on the healthy side within 6 months after surgery. A case with little visual malposition was defined as having a good outcome, based on the deviation in the cranial direction not exceeding the position of the contralateral NAC. Our preliminary data demonstrated that the rate of good outcomes was significantly higher (P = 0.028) in cases in which a breast splint was used, compared with those that were not treated with a breast splint (7/9, 78.8% versus 4/15, 26.7%). Postoperative application of a breast splint using Duoactive CGF is a simple and useful method to prevent NAC malposition after breast reconstruction, using a direct-to-implant method.

Should the ‘normal’ and ‘ideal’ nipple position in a male influence the surgeon when planning severe gynaecomastia correction?

BackgroundThe ideal nipple areolar complex (NAC) position of the male chest following gynaecomastia surgery is well documented; however, with increased development of the chest muscles, the NAC placement can change, leading to the medial displacement of the nipple giving a poor aesthetic outcome. Therefore, we believe that these measurements need to be applied to the patients’ build and take into consideration the future fitness goals of the patients. MethodWe have analysed the photographs of three groups of men: super athletes, athletes and individuals with severe gynaecomastia. We have assessed the proportions of the chest in relation to the NAC, degree of ptosis and TAP index. ResultsThere was a wide variation between the athlete and the super athlete group, with minor variations within each group. The range of measurement in the severe gynaecomastia group was significantly larger than those in the other groups. We feel that based on this research study, surgeons should however be somewhat circumspect in their choice of nipple position as there is a wide variation in what can be considered as normal, and positioning of the NAC too early in the recovery process may lead to an abnormal aesthetic appearance following muscle development. ConclusionDespite the multitude of techniques available in the literature to determine the position of nipple, there is a lack of understanding on how the NAC position changes with muscle development. Adopting a dogmatic approach may result in a very aesthetically displeasing outcome, which can be very difficult to correct in men.

REDUCTION MAMMOPLASTY FOR BENIGN PHYLLODES TUMOUR IN AN ADOLESCENT FEMALE

Phyllodes tumours are rare neoplasm of female breast especially among adolescent women. We present a case of 17 year old female patient present with large benign phyllodes tumour. The patient was treated with one stage excision with reduction mammoplasty. Symmetry of the breast contour and nipple areola complex position could be restored. Standard plastic surgery techniques like reduction mammoplasty might be applied in treating large benign tumours not compromising the aesthetic aspect of the breast.

An Intraoperative Measurement Method of Breast Symmetry Using Three-Dimensional Scanning Technique in Reduction Mammaplasty.

Intraoperative symmetrical assessment plays a decisive role in the aesthetic results of reduction mammaplasty, but it depends mostly on the surgeons'experience that may be biased by individual subjective factors. This study was intended to propose an objective method based on a hand-held three-dimensional (3D) scanner to assist intraoperative symmetrical assessment, aiming to achieve better aesthetic results in reduction mammaplasty. Sixty patients were enrolled in the study from April 2018 to January 2020. Intraoperative 3D scanning was routinely performed on 29 patients (study group) to assist symmetrical adjustments during breast shaping. 3D surface scanning data of both groups were obtained at 3 months postoperatively to objectively assess breast symmetry. Postoperative symmetry scores in five aspects, including nipple-areolar complex position, inframammary-fold height, breast size, shape, and footprint, were rated by six independent observers based on anonymized photographs to subjectively evaluate pre- and postoperative breast symmetry of the two groups. The bilateral breast volume difference of the study group was significantly smaller than the control group (39.1 vs. 113.3cm3, p = 0.001), as well as the difference in nipple to inframammary-fold distance (2.79 vs. 7.43mm, p = 0.01). The observer-reported results showed that breast reduction significantly improved postoperative symmetry in all five aspects compared with preoperative symmetry in the study group (P<0.001). Furthermore, postoperative symmetrical ratings of all five aspects in the study group were statistically better than the control group (P<0.05). Intraoperative 3D scanning provided a reliable method to assist symmetry adjustments and ensure better postoperative breast symmetry in reduction mammaplasty. 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 .

The ideal location of the male nipple-areolar complex: A pinpointing algorithm

Background In the treatment of gender dysphoria, appropriate nipple-areola complex (NAC) positioning is essential for achieving a natural appearing male chest after subcutaneous mastectomy. An accurate predictive model for the ideal personalized position of the NAC is still lacking. The aim of this study is to determine the anthropometry of the male chest to create individualized guidelines for appropriate NAC positioning in the preoperative setting. Materials and methods Cisgender male participants were recruited. Multiple chest measurements were manually recorded. Best subset regression using linear models was used to select predictors for the horizontal coordinate (nipple-nipple distance; NN) and vertical coordinate (sternal notch-nipple distance; SNN) of the NAC. Internal validation was assessed using bootstrapping. Furthermore, a cohort of transgender men who had received a mastectomy with replantation of nipples according to current practice was identified. Comparison testing between the algorithm and standard practice was performed to test the limitations of standard practice. Results One hundred and fifty cis male participants were included (median age: 26, IQR: 22-34 years). Four predictors were found to predict NN (age, weight, chest circumference (CC), anterior-axillar fold to anterior-axillar fold (AUX-AUX)) and reads as follows: NN = 4.11 + 0.035*age + 0.041*weight + 0.093*CC + 0.140*AUX-AUX Two predictors were found to predict SNN (NN and weight), and reads as follows: SNN = 7.248 + 0.303*NN + 0.072*weight. Both models performed well (Bootstrapped R2: 0.63 (NN), 0.50 (SNN)) and outperformed previous models predicting NAC position. Ninety-six transgender men were eligible for evaluation of current practice and showed an average placement error of −0.9 cm for NN and +2.2 cm for SNN. Conclusion The non-standardized approach of NAC repositioning results in a significant error of nipple placement. We suggest that the two predictive models for NN and SNN can be used to optimize NAC positioning on the masculinized chest wall. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1884926.

Optimizing Aesthetic Outcomes in Breast Reconstruction After Nipple-Sparing Mastectomy.

Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.

Crowdsourcing the Ideal Nipple-Areolar Complex Position for Chest Masculinization Surgery.

Background:Chest masculinization surgery is increasing in prevalence. However, the ideal location of the nipple-areolar complex (NAC) is unknown. Our purpose was to determine the most aesthetically favorable male NAC position for use in chest masculinization through crowdsourcing.Methods:Using Adobe Photoshop CC 2017, 8 locations for the NAC were created based on previous literature descriptions. Amazon Mechanical Turk was utilized as a crowdsourcing interface—respondents were asked to rank the top 3 most favorable and least favorable images. Analysis of variance with subsequent Tukey HSD was used for a statistical comparison of favorability scores for different NAC localizations. Values were considered significant with P < 0.05.Results:Eight hundred nineteen respondents participated in the survey. NAC positions of Images C (mean score = 1.9222) and A (mean score = 1.7365) received higher favorability scores than those of Images D, E, F, G, and H (all P < 0.05). There were no significant differences between Images C and A (C versus A: P = 0.6412). NAC localizations from Images G (mean score = −2.0353) and H (mean score = −1.6908) received lower favorability scores than Images A, B, C, D, E, and F (all P < 0.05). There were no significant differences between Images G and H (P = 0.2279).Conclusions:Most respondents preferred Images C and A, and few favored Images G and H, suggesting that lateral NAC placement is favored over more medial localizations. Additionally, both Images C and A utilize relatively inferior NAC placements. Therefore, we recommend a location inferior and lateral to the NAC. Ultimately, NAC localization during chest masculinization will be the result of shared decision-making between the patient and the surgeon to fulfill each patient’s aesthetic goals.

A Three-Step Technique for Optimal Nipple Position in Transgender Chest Masculinization.

The ideal position of the nipple-areola complex (NAC) in the transgender population can be a challenge to determine. The authors sought to determine the best location and aesthetics of the female to male NAC. Patients who underwent female to male mastectomy with free nipple grafting were included. NAC position is confirmed utilizing a vertical coordinate at the level of the 4th rib near the border of the pectoralis muscle and a horizontal coordinate determined by dividing each unilateral chest into vertical thirds from midline to anterior axillary line laterally. The NAC position is confirmed at the junction of the middle and lateral third. Symmetry is ensured bilaterally by creating a triangle and transposing it side to side; the base lies from sternal notch to inframammary fold in the midline and the apex is adjusted to the NAC. A 24-question survey utilizing a 5-point Likert scale was distributed postoperatively to assess the patient's thoughts about their chest, nipples, scar, and overall experience with the gender affirmation process. Thirty-one patients were included in this study. Eighteen patients responded to the postmastectomy survey, all of whom were highly satisfied with the aesthetic result postoperatively. All patients felt comfortable with their exposed chest. Nipple location was particularly highly received with 100% satisfaction rate (mean Likert score, 4.72). Nipple size and shape received a mean Likert score of 4.17 and 3.89, respectively. The triple confirmation technique is an easy, reproducible method to guide the surgeon in relocation of the NAC.

Oncoplastic Procedures in Preparation for Nipple-Sparing Mastectomy and Autologous Breast Reconstruction: Controlling the Breast Envelope.

Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, such as breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine whether a staged approach would expand the indications for nipple-areolar complex preservation and permit greater control over nipple-areolar complex position and skin envelope following autologous reconstruction. A retrospective analysis was conducted of female patients with a diagnosis of breast cancer or BRCA mutation with grade 2 or 3 ptosis and/or macromastia who underwent bilateral (oncoplastic) reduction/mastopexy (stage 1) followed by bilateral nipple-sparing mastectomy with immediate reconstruction with free abdominal flaps (stage 2). The authors were specifically interested in the incidence of mastectomy skin necrosis and nipple-areolar complex necrosis and malposition following stage 2. Sixty-one patients with a mean age of 45.1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m (range, 23.4 to 49.0 kg/m) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-areolar complex necrosis (n = 5, 8.2 percent), complete nipple-areolar complex necrosis (n = 4, 6.6 percent), nipple-areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series. Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented. Therapeutic, IV.

Dermal Triangular Flaps to Prevent Pseudoptosis in Mastopexy Surgery: The Hammock Technique.

This paper describes a new mastopexy technique developed for moderate to severe ptosis/pseudoptosis associated with upper pole deflation. Considering some of the commonest risk factors generally considered predictive of worse outcomes (massive weight loss, multiple pregnancies, skin quality, smoking, age), we aimed to assess whether this technique could be beneficial in the support of the desired breast shape over time. Twelve patients, all featuring 1 or more of the abovementioned preoperative risk factors, were operated on by the same senior surgeon with the hammock mastopexy technique using dermal flaps as a support for the glandular reshaping (6 bilateral mastopexies and 6 unilateral mastopexies for contralateral symmetrization after breast reconstruction). Patients' characteristics, such as smoking, weight loss, or multiparity with consequent inelastic skin, age, and lengthy nipple-areola complex lift, were considered as independent risk factors for ptosis recurrence and bottoming out. Patients were divided into 3 subgroups according to the number of their risk factors. Aesthetic results were assessed at 12 months postoperatively. Changes in postoperative were assessed for each patient by breast measurements and a superposition of the standardized breast photographs. Long-term outcomes were compared with a control group of 6 patients who benefited from mastopexy without "hammock technique." Satisfactory maintenance of shape and stable nipple-areola complex position was seen at 12 months regardless of the number of risk factors. However, a statistically significant difference was found in lower pole lengthening between patients with more than 3 risk factors compared to other groups. Aesthetic measurement results were consistent between the patient and surgeon reporting a satisfying cosmetic result, regardless of the number of risk factors. In the control group, we found a significant increase in breast lower pole measurements at 12 months when compared with the hammock group. This mastopexy technique improves projection and reinforces the lower pole support with lateral and medial dermal flaps. The technique is safe and reliable and provides easily reproducible results for patients with risk factors for postoperative pseudoptosis.