Nerve-Preserving Superomedial Pedicle Breast Reduction Approach for Chest Wall Masculinization: A Case Report

Introduction

In recent years, gender affirmation surgeries (GAS) have been increasingly performed as a treatment for transgender and gender diverse individuals who suffer from gender dysphoria [1]. These surgeries present a wide array of chest, genital, and facial feminizing and masculinizing procedures [1].

Gender affirming chest surgeries have similarities to breast augmentation and mastectomy surgeries common to plastic surgeons, but differ in the contour, nipple-areolar position, presence or absence of an inframammary fold, and quality of the breast skin if affected by breast binding [2, 3, 4]. Double incision mastectomy with free nipple grafting is the most common chest masculinization technique and is frequently utilized for Fischer grade 2B to 4 patients [3, 4, 5, 6].

However, this technique sacrifices the nerves to the nipple-areolar complex (NAC). While multiple nipple pedicles have been described in cisgender reduction mammoplasty, only an inferior pedicled mammaplasty approach has been described for chest wall masculinization for Fischer grade 2B to 4 patients [3, 7, 8].

We describe a superomedial pedicled NAC technique of chest masculinization for transgender patients with larger breasts that preserves the anterior branch of the intercostal nerves to leave NAC sensation intact.

Case Presentation

All institutional and governmental regulations for ethical human subject research were followed. Written consent was obtained from the patient for publication of this case report and any accompanying images.

Discussion

Masculinizing chest surgery improves gender dysphoria, health related quality of life, self-esteem and body image, and may be lifesaving [9, 10, 11]. The described superomedial pedicle chest wall masculinization technique of larger breasts helps in the preservation of the innervation and sensation of the NAC. This report provides an alternative method to the previously described inferior pedicle mammoplasty [3, 7, 8]. Wright, et al. reported in 2018 that over 70% of patients retained nipple sensation and erectile function [8], specific outcome measures of sensation have not been reported for the chest wall masculinization flap technique [3, 7]. The several subjective and objective measures of clinically meaningful preservation of sensation are therefore a strength of the present report. The described technique may provide superior preservation of sensation when a thin pedicle is needed.

NAC innervation, although variable and incompletely understood, arises via nerve branches of the 3rd, 4th, and 5th intercostal nerves [12]. Intercostal nerves divide into lateral and anterior cutaneous branches (LCB and ACB, respectively) that exit the deep fascia at the midaxillary line and parasternal line, respectively. The ACB sends a lateral branch inferolaterally to the NAC [12]. The LCB divides into posterior and anterior branches, and off of the anterior branch are superficial and deep branches that course to the NAC (Figure 2) [12]. A subdermal plexus that innervates the NAC has been described [13, 14, 15, 16]. Although not always found and debatable whether truly present Farina, et al. [17, 18, 19] is suggested by NAC sensation remaining intact despite simultaneous nerve block of multiple intercostal nerves [20]. Because the nerves to the nipple course from lateral and medial directions, we propose the possibility of increased sensory preservation from more axial-plane oriented flaps, such as the superomedial flap, than craniocaudally oriented flaps.

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Despite being erogenous, the areola and the nipple are physiologically less sensitive than other chest areas [21] which explains why our measured findings were less in the areola than in the inferior sternum. Our outcomes were assessed at 4-months, a time-frame sufficient for any iatrogenically disrupted myelin to recover [22]. Suggesting

normal physiologic asymmetry contributing to the slight difference in sensation between the left and right areolas or considerations related to flap dimensions. This case report is limited by a lack of preoperative assessments, so additional larger studies with outcome assessments are needed.

Conclusion

For patients requesting NAC sensation preservation, a thin, superomedial pedicled NAC with rigorous dissection to preserve intercostal nerve branches to the NAC may be considered.

Established Facts

Masculinizing mastectomy for female-to-male transitioning individuals is a potentially life-saving and quality-of-life improving surgical procedure.

Fischer grade 2B-4 individuals undergoing masculinizing mastectomy are most often offered free-nipple-grafts that leave the nipple-areolar complex insensate, or an inferior pedicle approach which may preserve some sensation to the nipple-areolar complex.

Novel Insights

A superomedial pedicle allows preservation of a nerve innervating the nipple-areolar complex and may be the preferred technique for Fischer grade 2B-4 individuals desiring a masculinizing mastectomy.

At 4-months post-surgery, subjective sensation, 2-point discrimination, and Semmes-Weinstein monofilament testing were preserved to the areola.

Statement of Ethics

All institutional and governmental regulations for ethical human subject research were followed. This report describes a single case outcome and does not quality for human subjects research requirements for ethical board approval.

Written Informed Consent for Publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Ethical Review Board

This report describes a single case outcome and does not quality for human subjects research requirements for ethical board approval.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Statement

No funding was involved in this report.

Author Contributions Statement

Clinical and operative tasks were performed by Salam Al Kassis and Patrick E. Assi; Data collection was by Adam G. Evans and Benjamin C. Park; Primary manuscript writing was by Adam G. Evans, Benjamin C. Park and Mariam Saad; with revisions and critical concept development by Patrick E. Assi and Salam Al Kassis; Figure drawing was by Benjamin C. Park with revisions by Patrick E. Assi and Adam G. Evans.

Data Statement

All data generated or analysed during this study are included in this article. Further inquiries may be directed to the corresponding author.