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Hybrid CV-flap with free areolar graft for nipple areolar complex reconstruction in female-to-male top surgery: a novel technique for male chest wall reconstruction following mastectomy
Jennifer Thomson, BS, Stelios C. Wilson, MD, John T. Stranix, MD, Freya R. Schnabel, MD, Alexes Hazen, MD.
NYU Langone Medical Center, New York, NY, USA.

Female-to-male (FTM) transgender patients who elect to undergo mastectomy (either prophylactically for cancer prevention or solely for gender dysphoria) with male chest reconstruction require specific consideration, especially with regards to reconstruction of the nipple-areolar complex (NAC). NAC sparing mastectomy flaps often leaves a feminine NAC that is too large, too round, and suboptimal placed for FTM patients, additionally the excess skin is not useful for this reconstruction. In the author's experience, attempting to circumferentially manipulate the NAC after mastectomy can lead to unacceptably high rates of NAC loss, as well as inferior fullness due to breast pedicle which is not attractive on a male chest. Thus, a novel approach is required.
Oncologic Technique
The plastic surgeon should design the markings with a horizontal ellipse of skin to include the entire NAC, with a margin of skin on all sides. If possible, the incisions should be planned in such a way that the resulting scar will lay at the inferior border or the pectoralis, usually corresponding to the 6th or 7th rib interspace. Ultimately, care is taken to remove enough skin to allow for taut closure of the chest wall without a resulting breast mound. The oncologic surgeon then develops mastectomy skin flaps and completes the mastectomy in the standard fashion.
Reconstructive Technique
After each mastectomy is complete, the skin flaps are redraped. Any remaining excess skin is removed medially and laterally and is closed in 3 layers. The incisions should not violate the mid-axillary line and should remain at least 4 cm lateral to the midline. If dog-ears exist medially or laterally it is preferable to excise at a second stage. A Jackson Pratt drain is sewn in place laterally. The NAC is carefully dissected off the breast specimens, thoroughly defatted, and the mid-portion of the nipple is amputated. A new nipple is designed on the mastectomy skin flaps using a modification of the well-described CV-flap. The new nipples should be planned in the interspace between the 4th and 5th ribs and 9 to 11 cm lateral to the sternum, and 2 cm above the incision for both blood supply and aesthetic concerns. The de-epithelialized and defatted areola graft is then placed around the CV flap and sewn into the deepithelialized chest wall using interrupted 5-0 nylon sutures. A bolster dressing is then placed and sewn into place using 3-0 nylon sutures.
Lessons learned
This hybrid technique allows for the creation of multi-textured, masculine-appearing NAC with proper location, and size with adequate nipple projection and with a low rate of nipple loss. In fact, the author report 100% NAC survival rate using this technique. Preoperative and intraoperative coordination between the reconstructive and oncologic surgeons is paramount for optimal results. Images of our team's most recent 5 cases will be shown with associated satisfaction questionnaire results.

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