Top Surgery

Mastectomy top surgery—Periareola incision with liposuction and free nipple grafts

This was a 23-year old patient requesting top surgery. He had very good skin elasticity and desired solely an incision around the areola; he refused to have an incision extend along the bottom and outside of the pecs.

As you can see in the “After” photo, his overall contour is achieved in a satisfactory manner. However, as I explained to him before surgery, the risk of having only an incision around the areola is that the scar will widen, and the size and diameter of the areola will also widen over time. This is because the excess skin has to be removed by making a large circular incision several inches away from the areola. When this is closed, it pulls the areola to make it wider. While this can provide an excellent result for the correct patient, a minor revision surgery may be required approximately 6-12 months later, to restore a more appropriate size to the areola.

Mastectomy top surgery—Pectoralis crease incision with liposuction and free nipple grafts.

This was a 31-year old patient requesting top-surgery. He had only mild to moderate skin elasticity, and required a larger incision along the crease underneath the pecs. This larger incision is needed to remove the excess skin once the breast tissue is removed. He chose to undergo free-nipple grafts.

In my opinion, free nipple grafts will frequently provide a more natural appearance of the male nipple/areola, because it allows thinning of the tissue so that it does not appear as thick.

Mastectomy top- surgery—Periareola incision with liposuction (No free nipple grafts)

This was a 25-year old patient requesting top-surgery. He had excellent elasticity of the skin, along with a small to moderate size of glandular tissue.

He desired to keep the nipple/areola complex connected to its blood and nerve supply, in hopes of maintaining sensation (even if this is done, there is a 20-30% chance of sensation loss). When the blood supply is kept intact, the surgeon is not able to reduce the nipple size at the time of surgery (doing so will destroy the blood supply). Therefore, revision surgery will be required to correct the nipple size once healing has occurred.

In the “After” photo, you can see that he achieved an excellent result. The top-right photo shows what appears at first to be a residual crease beneath the pec. However, this patient had quite prominent ribs, with a recessed sternum; it is his rib prominence along the inferior left pec border that makes it look as if there is a crease. These subtle changes, due to the underlying ribs and sternum, are again hard to predict, but they will never cause a “bad” result.

Lastly, I felt this patient’s nipple size was too wide, and the areolas had widened, becoming more circular-shaped as opposed to the intended “oval” shape. Again, this is because of the tension that is placed on the areola during a periareola-only incision. So, these patients will often need a minor revision surgery to reduce the nipple size, and correct the areola size and shape.

Mastectomy top surgery—Pectoralis crease incision with liposuction (no free nipple graft)

This was a 29-year old patient requesting top surgery. He explained that he quit smoking about 18 months prior (when he started hormonal therapy).

His skin elasticity was poor, and he required a pectoralis crease skin incision. He desired the nipple/areola complex remain connected to its blood and nerve supply. Postoperatively, the patient experienced incisional breakdown. He admitted to using a vaporizer containing nicotine starting two-weeks after surgery. Upon stopping, he healed completely but was left with widened and darkened scars along the incisions as well as the areolas. The scars were ultimately excised, and he ended up with the expected fine-lined incisional scars.