Flap Technique Prevents Nipple Dyspigmentation in Male MWL Patients of Color

A study describes surgical experience with a modified elliptical excision and NAC transfer to prevent nipple dyspigmentation in male MWL patients undergoing breast reduction.

Although men who have breast reduction surgery after significant weight loss are able to achieve good chest flattening results, they can also experience unwanted outcomes, including nipple discoloration, report authors of a recent study.

The paper called, “Alternative Treatment of Pseudogynecomastia in Male Patients After Massive Weight Loss,” describes an approach that addresses the challenges associated with free nipple areola complex (NAC) grafting.

According to the authors, “There continues to be drawbacks to the current treatment of pseudogynecomastia.” They note that while the bulkiness of the pedicled technique can result in male chest feminization, it can be avoided with free NAC grafting. However, free NAC grafting comes with its own unwanted outcomes, including nipple dyspigmentation and a “deflated” appearance.

The authors’ reported technique employs a modified elliptical excision and NAC transfer on an inferior dermal pedicle.

“The method, we propose, provides many benefits to conventional mastopexy. The dermal pedicle described allows for preservation of the vascularity of the NAC and minimal bulk to the anterior chest. This is particularly relevant in darker skin types where free nipple grafts may result in dyspigmentation,” the authors write.

For the study, the authors conducted a retrospective chart review and identified 14 male patients who underwent the described approach to treat pseudogynecomastia between January 2011 and January 2019.

Jeffrey Kenkel, M.D., chair of the plastic surgery department at UT Southwestern, performed the first of 14 of the proposed flap procedures in 2011, according to a release from UT SouthWestern. He is the surgeon who performed all of the flap procedures in this study.

Patients were an average of 40.5 years of age (range, 31 to 58), and average weight loss was 79.72 kg (range, 25.0 kg to 186.0 kg). A total of three patients were former smokers and none had previous breast surgery.

According to the authors, the key to preventing nipple dyspigmentation is preserving blood supply, and this is made possible by maintaining a wide dermal pedicle with approximately 5 mm to 10 mm of subdermal fat.

“Preserving a wide dermal pedicle keeps the base of the random flap wide helping to maintain an appropriate blood supply, with main contributions from the internal mammary and lateral thoracic arteries,” they write.

The authors note that their technique employs a random, inferior dermal pedicle, which they carefully thin to help avoid excess breast projection. They also perform aggressive resection of remaining chest tissue and suggest liposuction as an adjunct.

The study reports few complications. One patient experienced partial nipple necrosis, which resolved on its own, and one patient developed a seroma. There was no dysesthesia reported, which, the authors point out, suggests a well-preserved NAC neurovascular supply.

The authors list small sample size and single-surgeon experience as study limitations.

They also note that there is a tradeoff in terms of chest scarring for reducing the risk of nipple discoloration.

“These are operations that allow people – we like to say – to look as good as they feel,” Dr. Kenkel says in the UT SouthWestern release. “There are tradeoffs, you have to trade a scar for shape, but in most patients, this is very acceptable.”

“This is a nice alternative to the standard nipple grafting techniques we have used for years. It allows us to preserve the shape of the nipple and in many cases the color in patients of color,” he says.

Reference:

Krista L Hardy, MD, Ran Stark, MD, Kevin H Small, MD, Jeffrey M Kenkel, MD, FACS, An Alternative Treatment of Pseudogynecomastia in Male Patients After Massive Weight Loss, Aesthetic Surgery Journal Open Forum, Volume 2, Issue 2, June 2020, ojaa013, https://doi.org/10.1093/asjof/ojaa013