"Going Flat": Aesthetic Flat Closure as a Breast Reconstruction Option in Gender-nonconforming Patients

Patients who desire a flatter chest contour after mastectomy can opt for aesthetic flat closure (AFC) instead of traditional autologous and breast implant options that recreate the breast mound. AFC is an evolving area of reconstructive surgery in breast reconstruction, and there have been no nipple-sparing techniques demonstrated in the current literature to date. We thus present an AFC surgical technique by the senior author for the oncoplastic gender-nonconforming patient population. Technically, this approach uses an inferior adipodermal flap to preserve the nipple-areola complex, similar to an inferior pedicle-based reduction mammaplasty, while achieving a masculinized chest contour. Key surgical pearls include preoperative planning to align patient goals with chest wall aesthetics, careful intraoperative assessment to ensure adequate nipple perfusion, and intraoperative flexibility in nipple resizing, reshaping, and repositioning to align with the patient's wishes. The technique also allows for customization of chest contour, enabling the creation of a completely flat chest or a small breast mound based on individual patients' preferences. Patients requiring extensive tissue removal or contraindications for breast-conserving surgery should be excluded due to the risk of inadequate nipple perfusion. This is the first and only nipple-sparing AFC technique in the current literature, addressing a need in reconstructive breast surgery for gender-nonconforming populations.