Aesth Plast Surg https://doi.org/10.1007/s00266-018-1131-0
ORIGINAL ARTICLE
BREAST SURGERY
Shape, Position and Dimension of the Nipple Areola Complex in the Ideal Male Chest: A Quick and Simple Operating Room Technique Sara Tanini1 • Giulia Lo Russo1
Received: 11 December 2017 / Accepted: 31 March 2018 Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2018
Abstract Introduction The anatomical features of the chest identify an individual as male or female and even the smallest details of these features determine the appropriate appearance for each gender. In female-to-male patients, the creation of an aesthetically pleasing male chest is the most important step. Incorrect positioning of the nipple areola complex (NAC) on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation. Patients and Methods We have analyzed the anatomical chest features of 26 water polo players, to verify our hypothesis of the relationship between the pectoralis major muscle and NAC and to create a method for repositioning the NAC that is applicable in the operating room, is easy, practical and reproducible without the use of formulas and based on an easily identifiable landmark. Results In our reference group, the NAC has a constant relationship with the pectoralis major muscle, positioned on average 3 cm medial to the lateral border of the pectoralis muscle and 2.5 cm above the inferior pectoralis major insertion. This supports our hypothesis and our surgical technique. We use the index finger to find a vertical axis and a line 2.5 cm above the inferior pectoralis shadow to find the horizontal axis. We also introduce a modification to the receiving site to recreate an oval areola more similar to that of an ideal male chest. Conclusions Our anatomical study and statistical analysis support a consistent relationship between the position and & Giulia Lo Russo
[email protected] 1
Department Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
shape of the NAC and the borders of the pectoral muscle. We have used this relationship to develop our ‘‘trick,’’ which is easily applicable in the operating room to find the NAC position without using formulas and numbers. This method allowed us to place the NAC in a position very close to that of a typical male subject, and it permitted us to reduce the surgery time. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords FTM top surgery Ideal male chest Chest wall contouring Female-to-male transsexuals Nipple areola complex NAC graft
Introduction The anatomical features of the chest are represented by shape, contour, inframammary fold, position and dimensions of the nipple–areola. These identify an individual as a male or female, and even the smallest detail contributes in determining the appropriate appearance for each gender. The ideal male chest is not flat, but there is instead a defined contour and a natural fold. This fold is predominately horizontal and follows the contour of the pectoralis major muscle. The nipple is prominent and small, while the areola has a typical ‘‘male’’ position, dimension and orientation [1, 2]. After massive weight loss, in high-grade gynecomastia and in transsexual patients, reconstruction of the male body and its gender specific contour is required [1]. In female-tomale (FTM) patients who are in transition to a male
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identity, the most important and often the only step in sexual reassignment surgery is the creation of an aesthetically pleasing male chest. In these patients, the breast represents the stigma of feminine identity, and it is important to remove them, creating a male chest with an accurate repositioning of the nipple areola complex [2, 3]. In the past, surgeons have tried to define the position of the male NAC on the biological male chest measuring young, healthy men. Due to differences in height and weight, the position must be adapted to the whole appearance. Therefore, several formulas in relation to anatomical landmarks have been developed [1, 2]. In the context of female-to-male chest reconstruction, these formulas are difficult to apply, due to limited exposure of anatomical landmarks and the difficulty in predicting the final shape of the chest during preoperative planning [2]. This prompted us to analyze the anatomical characteristics of water polo players’ chests, to verify our hypothesis of the relationship between the pectoralis major muscle and the NAC, while creating a method to reposition the nipple areola complex that is applicable in the operating room, easy, practical, reproducible without the use of formulas and based on a simple identifiable landmark.
Measurements were performed in a warm room to prevent cold-induced nipple areola contraction, and photographs of all participants were taken in an upright position with arms by their sides. The same investigator did all measurements and data collection. A ruler was adhered to each individual’s chest to be used as a measuring reference. The pectoral outline measurement, the length of the lateral border of the pectoralis major muscle and the inferior pectoralis shadow were analyzed. The measurements we took were: (1) the horizontal distance from the lateral pectoralis border and nipple, (2) the vertical distance from the pectoralis shadow to the nipple, (3) the vertical height of the areola, (4) the horizontal width of the areola and (5) the diameter of the nipple. Additional measurements were made such as: height of the patient, height of the nipple, distance between nipples, chest circumference, distance from sternal notch to nipple and distance from the umbilicus to suprasternal notch. These were made to compare our method with a variety of measurements and formulas described in existing literature. Statistical analysis of the measurements including means and standard deviations was performed.
Results Methods
Demographics
Twenty-six male water polo players were recruited to evaluate the NAC position. Thirteen of these were grown, professional, A-league, male players with a well-developed lean body mass and a three-dimensional hypertrophic pectoralis major muscle. The others were teenage water polo players in youth championships with a defined lean body mass and non-hypertrophic pectoralis major muscle (Fig. 1). Our idea was to analyze some ‘‘aesthetically’’ well-defined chest contours to demonstrate a real correlation between the position of the nipple areola complex and the pectoralis major muscle. We have chosen a cohort with normal BMIs because it is harder to identify the pectoralis surface anatomy in heavier patients, whereas we have chosen water polo players because they have a defined chest contour and it is easier to identify our landmark. We analyzed two different cohorts to evaluate not only the relationship between the pectoral border and the nipple areola complex but also the relationship between this complex and hypertrophy of pectoral muscles. The exclusion criteria were: previous history of chest trauma or surgery, preexisting chest wall pathologies, previous hormonal therapy and previous diagnosis of gynecomastia or other mammary pathologies.
Measurements were obtained for 52 NACs in the 26 male water polo players. We used two different groups: Group 1: 13 grown men, professional water polo players mean age 25 years (range 23–34 years), mean height 187 cm (range 180–195 cm), mean weight 85 kg (range 60–102 kg), mean BMI 24 (range 18–25). Group 2: 13 younger water polo players, mean age 15 years (range 14–16 years), mean height 176 cm (range 165–186 cm), mean weight 66 kg (range 54–83 kg), mean BMI 22 (range 18–25) (Table 1).
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Nipple Areola Shape and Dimensions Group 1: in this group 93% of the areolas were oval in an elongated oblique direction, only one man had a round areola. The areolar major axis ranged from 1.8 to 4.5 cm with an average of 2.8 cm [standard deviation (SD) 0.71]. The areolar minor axis ranged from 1.2 to 3 cm with an average of 2 cm (SD 0.55). Average nipple diameter was 0.5 cm range from 0.3 to 0.6 cm; nipple height was 0.2 cm range from 0.1 to 0.4 cm. Group 2: even in this group 93% of the areolas were oval in an elongated oblique direction, and only one man had a round areola. The areolar major axis ranged from 1.8 to 3.5 cm with an average of 2.5 cm (standard deviation
Aesth Plast Surg Fig. 1 Above male chest of two professional water polo players; this group has well-developed body muscle and a threedimensional hypertrophic pectoralis major muscle. Below male chest of two teenage water polo players in youth championships; this group has an easily identifiable pectoralis major muscle
Table 1 Patient demographics Demographic data (n 26)
Range
Average
The average nipple diameter was 0.6 cm ranging from 0.4 to 0.7 cm; average nipple height was 0.2 cm ranging from 0.1 to 0.4 cm.
Group 1 (n 13) Age
25
23–34
Height (cm)
187
180–195
Weight (kg)
85
60–102
BMI
24
18–25
Group 2 (n 13) Age
15
14–16
Height (cm)
176
165–186
Weight (kg)
66
54–83
BMI
22
18–25
(SD) 0.46). The areolar minor axis ranged from 1.4 to 2.8 cm with an average of 1.9 cm (SD 0.40).
NAC Position Relative to Pectoralis Major While measuring the position of the NAC on the chest wall, in group 1, we found the average center nipple position was 3 cm medial to the lateral border of the pectoral muscle (range 1.8–4.5 cm, SD 0.38), instead in group 2 the average center of nipple position was 3 cm medial to the lateral border of the pectoral muscle (range 2.5–4 cm, SD 0.50). In group 1, the distance above the inferior pectoralis insertion average was 6 cm (range 4.5–8 cm, SD 0.97); in group 2, the average was 2.5 cm (range 1.5–4.5 cm, SD 0.60). We have also measured the lengths of the lateral and inferior borders of the pectoralis major muscle. In group 1,
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the average length of the lateral border was 14 cm (range 9.1–17 cm, SD 2.09) and the average length of the inferior pectoralis shadow was 15 cm (range 11–20 cm, SD 2.2). In group 2, the average length of the lateral border was 10 cm (range 9.3–11 cm, SD 0.60) and the average length of the inferior pectoralis shadow was 8.7 cm (range 7.6–9.5 cm, SD 0.74) (Table 2). Operative Approach In our technique we position the NAC after the mastectomy has been completed and after the final incisions have been adjusted with the patient in an upright position. Usually, we position the incisions along the inframammary fold, with a horizontal orientation in the middle part and an oblique orientation in the lateral part, to camouflage the scar in the pectoralis shadow [3]. With the patient in a semi-upright sitting position, using partially closed sutures, we can identify and palpate the lateral margin of the pectoralis major muscle with the index finger. From this position, the index finger is moved medially to a vertical position using the ‘‘corner’’ of the pectoralis major muscle, as the pivot point, and its projection is marked on the skin. This line represents the vertical axis and the lateral part of the NAC. In accordance with our results and data found in literature [4, 5], the horizontal axis where the nipple is positioned is generally 2.5 cm above the inferior pectoralis shadow. Upon closure, the areola will be positioned at approximately 1 cm distance from the suture. Both sides are calculated using this technique, and the final symmetry is verified using a ruler. This method
allowed us to place the NAC in a position very close to that of a typical male subject, and it has permitted us to reduce surgery time, because, compared to formulas using numeric calculations to determine the NAC position, the pectoralis major muscle is easily and rapidly identifiable during chest masculinization surgery. Once the ideal NAC position is identified, we proceed with the repositioning of the NAC using forms, dimensions and orientations as similar as possible to the male chest. According to the data in the literature, our results showed that most male areolas were oval in an oblique elongated direction (perpendicular to the pectoralis major fibers) [6]. In the case of free nipple grafting, the nipple shape is primarily determined by the dimensions of the recipient site. Once the position of the new NAC is chosen and marked, to recreate an oval areola more similar to that of an ideal male chest, we modify the receiving site. We have found that modification of the de-epithelialized recipient site to an oblique oval shape at the time of grafting has been an effective method for creating a final oval shape. We have orientated the areola with a larger axis that goes from bottom to top and lateral to medial, approximately perpendicular to the pectoral fibers. The difference between the two axes is lower, 2.5 cm for the main axis and 2 cm
Table 2 NAC shape, dimensions and position measurements in centimeters NAC measurements
Averages
SD
Range
Areolar major axis
2.8
0.71
1.8–4.5
Areolar minor axis
2
0.55
1.2–3
Nipple diameter
0.5
0.30
0.3–0.6
Group 1 (n 13)
Nipple height
0.2
0.22
0.1–0.4
Vertical position
6
0.97
4.5–8
Horizontal position Group 2 (n 13)
3
0.38
1.8–4.5
2.5
0.46
1.8–3.5
Areolar major axis Areolar minor axis
2
0.40
1.4–2.8
Nipple diameter
0.6
0.22
0.4–0.7
Nipple height
0.2
0.20
0.1–0.4
Vertical position
2.5
0.60
1.5–4.5
Horizontal position
3
0.50
2.5–4
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Fig. 2 One of the water polo players. The ‘‘ideal’’ chest: easy to identify the pectoralis major muscle with the oblique and horizontal borders and an oval areola. In the left part of the photo, we have calculated the position of the NAC using some formulas and numbers described in literature. In blue, the prepared position of NAC using the Shulman et al. ratio; in red, using Atiyeh’s formulas, in yellow, using the Beer et al. measurements and in green the position using our results. In the right part of the photo, a schematic drawing represents our ‘‘trick’’ technique applicable in the operating room to find the NAC position easily without using formulas and numbers
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for the smallest. After de-epithelializing the recipient sites for the reception of the harvested full-thickness areolar grafts, they are fixed with continuous sutures. The nipple is made separately from the areola with a small portion of the original one (about 5 mm diameter) to recreate a small nipple with masculine characteristics [3], placed centrally in the areola and fixed with multiple fine sutures. A tie over dressing is applied on the NAC graft, and it is secured circumferentially with a 3–0 silk suture to maintain the graft in place.
Discussion Numerous studies have been performed to outline the ideal male chest and the ideal configuration and localization of the NAC in males using a variety of measurements and formulas [3, 6–12].
In our clinical practice, we realized that we needed a method for repositioning of the nipple areola complex that can be applied directly in the operating room, is easy, practical, reproducible and based on easily identifiable landmarks. In the pectoralis major muscle, we have identified the landmark which can be used for chest masculinization surgery, which is present in each individual regardless of gender or body type. Using the anatomical features of the objectively ideal male chest of water polo players, we have demonstrated a relationship between the position of the nipple areolar complex and the pectoralis major muscle, developing an easy and immediate technique to find the perfect position of the NAC in the operating room when the pectoralis major is visible and palpable. We have analyzed two different groups; in the first, the pectoralis major muscle had a three-dimensional form (where it was possible to identify length, width and
Fig. 3 Clinical case: a 19-yearold patient preoperatively (a, b) and three months postoperatively (c, d) after the double incision method with free NAC grafts in small and not pendulous breasts
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Aesth Plast Surg Fig. 4 Clinical case: a 23-yearold patient preoperatively (a, b) and three months postoperatively (c, d) after the double incision method with free NAC grafts in pendulous breasts
thickness). The distance between the NAC and the pectoralis shadow was greater because of the hypertrophy of the muscle even if the optic effect showed the NAC to be very close to the pectoralis shadow. This can be particularly useful in repositioning of the NAC in a high grade of gynecomastia and athletic physique. In the second group, the pectoralis major muscle was visible, without hypertrophy with a two-dimensional shape. This is the most similar to our clinical case, and it is our reference group. Many authors have proposed their method to determinate the NAC position; in early cases the positioning of size and shape of the nipple and areola was decided by ‘‘intuition’’ and ‘‘eye-balling’’ [3]. Seckel et al. used two ratios to determinate the nipple level; the first ratio between the sternal notch to the nipple level and the suprasternal notch to the pubis and the second ratio between inter-nipple distance and chest circumference [7]. Vogt et al. [1] determined the NAC position using the Mohrenheim point (infraclavicular groove) and a 4-4,5 horizontal line above the sub-mammary fold.
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Atiyeh has created formulas to position the NACs utilizing the golden number pi (0.618) and two measurable distances, umbilicus–anterior axillary fold apex and umbilicus–suprasternal notch [9]. Shulman et al. [10] determined the NAC position using ratios between the height of the patient and the height of the nipple, the distance between nipples and chest circumference and the ratio between the sternal notch to nipple distance and height of the patient. Beer has used the circumference of the thorax and length of the sternum to establish a formula for NAC positioning [6]. McGregor’s novel method employs sutures inserted into the sternal notch, midclavicular and midsternal lines at a point midway between the elbow crease and axillary crease [13, 14]. Monstrey et al. [4] state that ‘‘absolute measurements can be misleading’’. We also have proposed the use of three landmarks to design the new NAC position: one-third lateral of the clavicle length, the lower and larger cross on the midline axis of the sternum (approximately at the junction of the fifth to six rib) and the suprasternal notch [3]. In the context of female-to male chest reconstruction, we found these formulas difficult to apply, and in the field
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of surgery with our experience we concluded that the use of precise numbers and formulas is unmanageable. The use of landmarks such as the sternal notch, midclavicular and midsternal lines or the intercostal space can be useful, but these reference points can be difficult to identify in overweight patients and in the operating room where the patient’s position is horizontal and not ideal. In our clinical practice on chest wall contouring surgery, we have found that positioning the NAC close to the borders of the pectoralis major muscle was most useful, quick and adaptable to the anatomical characteristics of the individual (Fig. 2).
Conclusions Our anatomical study on the ideal male chest and our statistical analysis support a consistent relationship between the position and shape of the NAC and the borders of the pectoralis major muscle. We have used this relationship to develop our ‘‘trick’’ technique to find the NAC position, which is easily applicable in the operating room without using formulas and numbers. This ‘‘trick’’ can be applied by identifying an accessible landmark such as the pectoralis major muscle, present in each individual regardless of gender or body type. Once the new NAC position is identified, we recreate the physical masculine NAC characteristics modifying the receiving site of the NAC graft. To do this, we draw an ellipse with the major axis oriented perpendicular to the fibers of the pectoralis major muscle and graft only a small fragment of the nipple. The combination of this quick and simple operating room technique and of these small details in the re-creation of the NAC has allowed us to create aesthetically pleasing results in NAC creation and placement during chest masculinization surgery (Figs. 3, 4). Compliance with Ethical Standards Conflict of interest The authors declare that they have no conflict of interest to disclose.
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