The authors should be complimented for what (definitely) is the largest study to date examining aspects of the normal parameters for the male nipple-areola complex (NAC), with recommendations about the ideal position to place the NAC on the chest wall.1 For this study a total of 158 patients were recruited from different ethnic backgrounds, of different ages and with various BMIs. In contrast to the anatomy of the female breast where an abundance of articles is available in the literature, there are no universally established and well accepted criteria for nipple-areola placement in male patients. This article meets the need for many plastic surgeons who nowadays quite often are confronted with a growing interest in male breast aesthetics among their patients. The information provided in this article is not really meant for patients with mild malpositioning of the NAC. For patients requesting only minor aesthetic correction, it rather provides guidelines on where to place the nipple-areola complex after surgery. This article addresses major malposition or absence following trauma or burns, and probably most frequently of all, in female-to-male transgender patients requesting a subcutaneous mastectomy as their (usually first) gender confirming operation. The number of patients consulting a plastic surgeon for this specific indication has substantially increased over the past years.2 An exact placement of the nipple-areola complex is essential to obtain a good result in female-to-male transgender patients with larger breasts in whom the male chest contouring surgery requires an oblique resection of a substantial excess of skin and breast tissue with replacement of the nipple-areola complex as a full thickness skin graft.3 However, the recommendations provided in this article can also be useful for other techniques of subcutaneous mastectomy such as the inferior pedicle technique, which also involves a (usually smaller) skin and glandular tissue resection with a reconstruction of the NAC based on a thin, inferiorly pedicled, dermo-glandular flap.4 Information about the exact placement of the NAC can even be useful in transgender patients with smaller breasts in whom the so-called concentric circular technique is used. This is where an asymmetrical desepidermization around the NAC can provide a minor but important correction of the diameter and the position of the NAC.3 It is surprising to notice that the results in this large series of patients seem to confirm the NAC dimensions already published in previous, mostly small, studies. The average sternal notch to nipple distance (SNND) in this report is 204.2 mm, while in previous articles it varied between 18.4 and 21 cm. The inter nipple distance (IND) reported in previous publications was between 20.6 and 22 cm, while in this article the reported average IND is 249.4 mm. This confirms that the ideal placement of the NAC might be more lateral as was already suggested by Beckenstein in 1996.5 Despite a rather wide variance of individual dimensions within this large group of patients, there was no statistical difference in the IND/AFD ratio, the SNND or NAC parameters comparing different ethnic groups. The recommendations provided in this article about where to best place the NAC on the chest wall are simple and easy to measure. The authors advise to start at the sternal notch and draw an arc over the pectoral region with a radius of 20 to 22 centimeters depending on the BMI and the age. The anterior axillary fold distance (AFD) can be easily measured using the palpable lateral edge of the pectoralis major as a landmark and the multiplier of 0.65 to the AFD should be applied to obtain the IND, which is then symmetrically superposed on the arc to exactly locate the NAC. In contrast to some previous methods used for calculating NAC position, the authors here did not use patient height. But they do not provide a clear reason why this measurement is not so important. Neither is mention made on how, in male-to-female transgenders, the exact ‘male’ NAC dimensions can simply be applied on a ‘female’ thorax. All measurements in this study were made with the patient standing upright, which might be somewhat different from the patient on the operating table although in most cases the patient is brought in a more sitting position at the time of the nipple placement. Most people agree that the final decision for size and position of the nipple-areola complex should always rest with the surgeon (eventually, after discussion with the patient). So one could question to what point the 100% exact dimensions and the very precise location of the NAC (up to 1/10 of a mm) are important and have a real influence in decision-making for the plastic surgeon interested in this kind of surgery. Still, there is no doubt that the information provided in this article will be helpful for many surgeons, and especially for the less experienced surgeons, that perform a subcutaneous mastectomy for gender confirming surgery where placing the nipple-areola complex in the perfect position on the chest wall is essential to ensure a satisfactory outcome. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Yue D , Cooper LRL , Kerstein R , Charman SC , Kang NV . Defining normal parameters for the male nipple-areola complex: a prospective observational study and recommendations for placement on the chest wall . Aesthet Surg J . 2018 . doi: 10.1093/asj/sjx245 . 2. Colebunders B , De Cuypere G , Monstrey S . New criteria for sex reassignment surgery: WPATH standards of care, Version 7, Revisited . Int J Transgender . 2015 ; 16 ( 4 ): 222 - 233 . Google Scholar CrossRef Search ADS 3. Monstrey S , Selvaggi G , Ceulemans P et al. Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm . Plast Reconstr Surg . 2008 ; 121 ( 3 ): 849 - 859 . Google Scholar CrossRef Search ADS PubMed 4. Wolter A , Diedrichson J , Scholz T , Arens-Landwehr A , Liebau J . Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy . J Plast Reconstr Aesthet Surg . 2015 ; 68 ( 2 ): 184 - 191 . Google Scholar CrossRef Search ADS PubMed 5. Beckenstein MS , Windle BH , Stroup RT Jr . Anatomical parameters for nipple position and areolar diameter in males . Ann Plast Surg . 1996 ; 36 ( 1 ): 33 - 36 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: email@example.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Aesthetic Surgery Journal – Oxford University Press
Published: Mar 12, 2018
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