A Novel Periareolar Approach to Chest Wall Reconstruction Using a Nipple-Areola Complex Transposition Flap.

A Novel Periareolar Approach to Chest Wall Reconstruction Using a Nipple-Areola Complex Transposition Flap C wall reconstruction for transgender men and gender nonbinary patients seeks to improve contour and nipple-areola complex position.1–3 The male nipple-areola complex is described as small, ovoid, and laterally positioned along the pectoralis major.1,2 Patients with small breasts, minimal ptosis, and good skin quality are suitable candidates for periareolar techniques; however, traditional approaches fail to reposition the nipple-areola complex to a more masculine-appearing position.4,5 We describe a novel periareolar technique using a lateral nipple transposition flap based on a superomedial neurovascular pedicle, which permits versatile mobility of a vascular and neurotized nipple-areola complex. An eccentric ellipse is marked around the nipple-areola complex with the nipple located in the medial pole and the ellipse extending inferolaterally to encompass the ideal nipple-areola position. Incisions are made to the level of the dermis around the native areola using a cookie cutter as well as around the previously marked ellipse. The skin intervening the two markings is de-epithelialized. Inferiorly, the dermis is incised and dissected to the chest wall. The breast gland is then dissected inferiorly and laterally off of the chest wall. A superomedial pedicle is marked and the dermis is incised were very close to the proposed 1-2-3 rule.4 This rule is effective, even in a population of smaller stature. There are also some points that surgeons should know before using the 1-2-3 rule. Distance in the anatomical studies, including that by Lee et al.4 and our own, was measured with a microcaliper, which resulted in a “displacement” and was not a “distance” that curved along costal cartilage (Fig. 1).4 This could be confusing for the surgeon intraoperatively, and a wrong method of measurement could lead to inferior precision for locating internal mammary vessels. Moreover, the studies were conducted using formalin-embalmed cadavers and not fresh cadavers.4 There is a potential that the tissue has shrunken and the distance could minimally deviate.5 Therefore, the proposed 5-mm deviation4 from the 1-2-3 rule should be kept in mind during dissection near the theoretical point. In conclusion, we confirm that the 1-2-3 rule is useful and could be generalized to a population of patients of smaller stature. DOI: 10.1097/PRS.0000000000005925