The great challenge in reconstructing a
male-appearing chest from a female breast is the management of the overlying
breast skin. There is always a "skin excess" when the underlying
glandular and fatty breast tissue is surgically removed. One goal in gender
reassignment surgery is to manage this skin excess with a minimal amount of
scarring. Excess skin can easily be cut away but every incision in surgery
leaves a scar - the challenge for the surgeon is to remove this excess skin
and to "hide" the incisions in natural folds, previous scars, or
in the pigmented skin of the nipple-areolar complex
The most critical factor in determining the
appropriate procedure for each patient is the breast size. A very large
breast (C-cup or larger) always requires a more extensive incision or series
of incisions. Obviously, the larger the breast size, the more overlying skin
there will be left to manage after the underlying breast tissue is removed.
My preference for the large breast is to
place an incision in a horizontal direction with a gentle curve that follows
the curve and lower border of the pectoralis muscle. This scar, although it
is long, can heal very nicely and can be "hidden" in the fold that
is created by the well-developed pectoralis muscle. With a long incision,
there is no problem removing the skin that is in excess after the breast
tissue is removed and this procedure can be performed in one stage with only
a small percentage of patients requiring any surgical revisions.
Chest hair growth is also very beneficial
in helping to conceal the scarring. With this procedure, I often will
completely remove the nipple areolar complex, decrease it to the appropriate
size, and replace the nipples in their new elevated and more lateral
position as skin grafts. Liposuction also is an integral part of any breast
reconstruction surgery to help create a smooth contour and transition from
the breast to the surrounding chest wall.
The B-cup breast size has always created
controversy for the plastic surgeon. A patient could be evaluated by 10
different surgeons and receive 10 different opinions on how the procedure
should be performed and where the incisions should be placed. Common
incisions used are: 1) the inverted "T", 2) a horizontal incision
on either side of the nipple, 3) a vertical incision under the nipple which
curves outward near the fold of the pre-existing breast, and 4) the
peri-areolar incision.
My preferred incision for the B-cup breast
and smaller is the periareolar incision. The average male nipple-areolar
complex (NAC) size is about the size of a dime or slightly larger. The
average female NAC size is about the size of a half dollar, but it will be
much larger in larger breasts. An incision is always made around the entire
border of the NAC to reduce the size. This incision is called a periareolar
incision. Because this incision is placed at the junction where the normal
skin joins the pigmented or colored skin of the NAC, this incision can
"hide" nicely and can appear to be the border of the pigmented
skin. The excess skin is removed in a circular fashion around the NAC.
The challenge is then to close the large
skin circle to the dime-sized new NAC. The discrepancy in size of the outer
skin circle to the inner circle (NAC) creates a very pleated skin closure -
much like a drawstring purse. With normal healing, all skin will contract
and tighten. We are relying on the skin contraction properties (which are
different in each patient) to tighten the skin and to reduce the appearance
of the pleating. Almost every patient will require a minor surgical revision
to manage persistent pleating after the first stage procedure. If bothersome
pleating exists after the revision, then the patient and surgeon must decide
on creating another scar and in which direction.
Often this additional scar or scars will be
short and well-accepted by the patient because residual pleating rarely
extends for more than an inch from the border of the NAC. Obviously, if the
scar can be limited to the periareolar incision, this is the most desirable
situation as there would be no obvious scarring that the patient might have
to "explain" to someone when the chest was exposed.
In summary, the goals of female to male
breast reconstruction surgery are to remove the glandular and fatty breast
tissue with a smooth transition to the surrounding chest wall, to decrease
the NAC size, and to perform the surgery with acceptable and minimal
scarring.
Citation:
Originally published in 1998 True Spirit Conference book.
