Reply: Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men.

Reply: Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men Sir: We would like to thank Lo Russo and Tanini for their comments regarding our article, “Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men.”1 We agree with them that one of the most important goals of chest wall contouring in masculinizing top surgery is the repositioning and reshaping of the nipple-areola complex. This can also be one of the most difficult goals to achieve if it is not properly planned or executed technically. The double-incision mastectomy technique allows for great range in terms of setting the new nipple-areola complex position at the margin of the pectoralis major at the level of the fourth to fifth ribs. After mastectomy, the surgeon is free to reconstruct the new nipple-areola complex at whichever position is best, either using free graft techniques, as described by Dr. Lo Russo, or with local nipple flaps, as in our techniques. This is in contrast to periareolar techniques, which traditionally have failed to reposition the native nipple-areola complex to a more masculine position. Lo Russo and Tanini demonstrate fantastic results using their graft technique, in which separate areolar and nipple grafts are taken and secured to the chest wall after double-incision mastectomy. Particularly, the nipple graft is small and thin, so as to decrease the metabolic demand of the graft. They report low rates of depigmentation and graft loss. They also note the importance of postoperative care on the part of the Fig. 2. Intraoperative images. On the patient’s right, a tie-over dressing that was removed after 7 days is shown. On the patient’s left is the new nipple-areola complex. The new areola was reconstructed with a 2.5cm, circular, full-thickness graft harvested in the context of native areola and fixed with a running suture. The new nipple was reconstructed with a small graft harvested from the native nipple and fixed with four peripheral stitches.