A Novel Technique for Nipple-Areola Reconstruction in Gender-Affirming Mastectomies With Nipple Punch Grafts and...

Free nipple-areola grafting (FNAG) is the most common approach for nipple-areola complex (NAC) reconstruction in transgender patients and is often performed in conjunction with double-incision mastectomy for chest masculinization. Unwanted consequences of FNAG include graft failure, hypopigmentation, and circular scarring around the areola.

We developed a novel technique for NAC reconstruction with nipple punch grafts in conjunction with 3-dimensional (3D) areola tattooing (NPAT). Patient demographics and postoperative complications were reviewed. To compare aesthetic outcomes of NPAT with FNAG, postoperative images of both groups were distributed among public raters on the crowdsourcing platform Amazon MTurk. Raters were asked to rank the aesthetic appearance of each NAC on a 1 to 7 Likert scale.

Eighteen patients (mean age 30 ± 10.74, mean BMI 27 ± 7.36) underwent double-incision mastectomy together with NPAT for NAC reconstruction. Mean follow-up was 100 days after surgery. Postoperative complications such as graft loss, partial graft necrosis, and hypertrophic or distended scarring were not observed. One patient demonstrated a loss of graft projection, and 1 patient developed partial graft depigmentation. Across the full sample of 895 public raters, NPAT received significantly higher aesthetic ratings than FNAG (NPAT 5.0 ± 1.5 vs FNAG 4.5 ± 1.8, P < .001), a pattern that persisted across different genders and age groups.

The NPAT technique is a simple and effective approach to NAC reconstruction in transgender patients, combining the advantages of traditional FNAG and 3D tattooing. Our findings suggest that NPAT may provide an aesthetically superior NAC and potentially reduce complications associated with traditional FNAG.

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