Fig. 32.1
Mastectomy with free nipple-areola complex grafting: (a, b) preoperative view; (c, d) postoperative view
Fig. 32.2
NAC position and mammary tissue distribution changes with different positions of the upper limbs
To achieve an aesthetically pleasing result, the scar is more important than the survival of the grafted NAC. The scar should be positioned on the border between two aesthetic units of the male chest, on the lower border of the pectoralis major muscle, and it should follow its profile also laterally, where it will go obliquely towards the anterior pillar of the axilla.
In patients with high BMI and breasts with a large base, the markings should extend laterally to avoid the creation of lateral dog-ears. Even with careful preoperative planning, they can still occur, but they are easy to correct in a secondary outpatient procedure. In these patients, care must be taken to avoid the joining of the median portion of the resulting scars, as this will make them even more visible. Even if small dog-ears arise intraoperatively, they can be left in place as they will usually disappear in the following months with a good morphologic result.
The tension between the two adipocutaneous flaps is evaluated with the patient’s forearms positioned horizontally on his head by trying to join the upper and lower markings. If the tension is excessive, the upper limit of the excised skin must be lowered until it is reduced or almost eliminated.
The operation starts with the incision and elevation of the planned NAC grafts that are placed in saline-soaked gauzes. The next step is the surgical incision of the lower preoperative marking. Both incisions can be oblique to preserve as much derma as possible and reduce the tension on the skin. The dissection continues caudally until the plane between the pectoralis major fascia and the mammary gland is reached, which is followed upwards to the upper pole of the mammary gland. The mastectomy is then completed with the upper incision, which should get to the same plane as the lower one. The axillary tail of the breast is a part of the gland that should not be left in place. That would be wrong from an oncological point of view, and it will cause a very visible, aesthetically unappealing result. After the mastectomy, the correct new position of the NAC can be double-checked, as the underlying structures are clearly visible, even in patients with higher BMI and less developed muscles.
The flaps on both sides are undermined to allow a tension-free closure. In some patients, the mammary fold has to be released without removing the overlying skin to position the scar and the NAC in the correct anatomic position [5]. After an accurate haemostasis, a drain is placed and the flaps are sutured. If the preoperative markings were correct, the suture should be on the lower border of the pectoralis major muscle. The NAC is defatted, as a thinner graft has a better chance of taking. The receiving bed is deepithelialized and the NAC positioned and secured in place with a tie-over suture over a paraffin gauze, which will stay in place for 5 days to allow the process of graft taking to complete. An elastic bandage is applied at the end of the operation that should be kept continuously by the patient for at least a month [5].
The drains are removed as soon as the amount of drainage is 30 cc or lower in 24 h. The sutures (usually intradermal) are removed 14 days postoperatively.
32.3.2 Semicircular Technique
The semicircular mastectomy technique (Fig. 32.3) was first described by Webster [14] for gynecomastia and is the best choice in small to medium breasts with good elasticity and without excessive ptosis. A well-distributed medium-sized mammary has a NAC that is central to the breast mound and thus just 2–3 cm from the male position. The skin elasticity will allow the surgeon to create a male-looking chest without additional scars on the skin.
Fig. 32.3
Semicircular technique: (a, b) preoperative view; (c, d) postoperative view
In this surgical technique, the only incision is done on the lower border of the areola between the skin and the areola. In very small areolas, the incision can be extended laterally to form an inverted omega.
With this access, it is possible to get to the inframammary fold and severe the breast gland insertions inferiorly. After doing so, the avascular plane of lax areolar tissue between the fascia of the pectoralis major muscle and the mammary gland should be found. By following this plane, the whole mammary gland can be raised from the underlying structures without significant bleeding. The mastectomy is then completed by dissection on the superficial plane between the gland and the overlying adipose tissue.
Due to the small surgical access, care must be taken to avoid traumas to the perforators of the mammary artery on the sternal side of the mastectomy, as they will be very difficult to locate and coagulate or ligate.
Lighted retractor blades are very useful in this procedure and should be used, if available, both during and after the mastectomy to double check the haemostasis. This is very important to avoid excessive postoperative bleeding that can potentially cause haematomas. To reduce the visibility of the final scar, we usually remove about 1 mm of skin and areola along the incision, as it has been traumatized during the surgical procedure. The skin is closed with simple interrupted sutures that will be removed 2 weeks later. An elastic bandage is applied at the end of the procedure, but there is less compression, compared to mastectomy with free NAC grafting. To avoid excessive pressure that could lead to partial or total necrosis, no additional gauzes are positioned on the NAC.
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