Should targeted nipple reinnervation be routinely offered in gender-affirming chest surgery? A narrative review

Chest masculinization, or top surgery, is a commonly sought procedure for transgender men and gender-diverse individuals. This surgery typically involves the removal of breast tissue with reconstruction of the nipple-areola complex (NAC). However, sensory loss following surgery is common and may negatively impact postoperative satisfaction, intimacy, and sexual function. As a result, techniques for targeted nipple reinnervation (TNR) have gained increasing attention.

To provide coverage of the current literature on TNR in gender-affirming chest surgery, including surgical approaches, sensory outcomes, and implications for access and patient satisfaction.

This narrative review summarizes the current literature on techniques, outcomes, and considerations regarding TNR in gender-affirming chest surgery. PubMed and Embase were queried using keywords. Studies were included if they discussed operative approach in the context of gender-affirming mastectomy. Articles were also reviewed for sensory outcomes, including return of erogenous function.

Various techniques for TNR have been explored, aiming to restore sensation and improve esthetic outcomes. These techniques involve direct coaptation, autografting, or allografting to enhance sensory recovery. Studies revealed mixed outcomes, with some patients reporting sensory return and others experiencing delayed or partial recovery. Although TNR has demonstrated potential benefits, including improved nipple and areola sensation, its results remain inconsistent, and it requires additional operative time, leading to increased costs. This may present financial barriers, especially when insurance coverage is limited.

Targeted nipple reinnervation is a promising adjunct to gender-affirming chest surgery, offering potential benefits in sensation and patient satisfaction. However, evidence remains limited and inconsistent. Until more robust standardized data are available, TNR should be offered as an optional component of care to informed patients who are aware of the risks and uncertainties, but it should not yet be considered a standard component of gender-affirming chest surgery.