What is my best FTM top surgery approach? Peri-areolar or DI? (photo)

Hello and thank you for your photos for evaluation. The double incision mastectomy is the procedure of choice, since there is extra skin that needs to be removed as well as the fat and glandular components of the breasts. The advantage is a flat chest with a relocation of the areola and nipple complex to a masculine position. 

Excellent question and thank you for sharing your photos. 
The two major methods I use for FTM top surgery are double incision mastectomy with nipple grafting and keyhole. Double incision mastectomy procedure is ideal for medium to large chested transgender men. During this procedure, the skin on the chest is opened along two horizontal incisions, at the top and bottom of the pectoral muscle. (The muscle itself is not touched.) The skin is pulled back and the breast tissue is then removed. Keyhole (also known as peri-areolar) is ideal for small chested transgender men, up to a b-sized chest, with good skin elasticity. During this procedure, an incision is made all around the border of the areola. Additionally, a second, larger concentric circle incision is made and the resulting ring of skin removed. A "drawstring" technique is used to bring the skin together and connect it to the edges of the areola. 
In both techniques, additional liposuction may be performed to adjust the contour of the chest, and the nipples may be made smaller and more oval in shape, and positioned higher on the pec muscle, to achieve a more masculine looking chest. Which method we choose for your top surgery will depend on the size of your breasts. But, rest assured, no matter how much breast tissue there is to remove, there is a surgery for you. Our aim is to help you feel comfortable, happy, and confident in your own skin. 
The best way to assess and give true advice would be an in-person exam. Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery. best of luck!

Dr. Schwartz

Board Certified Plastic Surgeon

#RealSelf100Surgeon

#RealSelfCORESurgeon

Hello, Thanks for sharing your pics.  From your pics feel a circumareolar mastectomy would be adequate to get a good shape. The skin retraction after surgery cannot be predicted. You may requise a small touch up procedure to re position the nipple at a later date. Consult a board certified plastic surgeon for further assessment.

Hi Cael2,Thanks for the post and photos. You will need double incision with free nipple/areolar grafts for the following reasons:1. You have too much skin in the lower part of the breasts that will end up looking deflated after the mastectomy.2. Your nipple position is too low for a male chest.3. Your areolas are too wide.The double incision with free grafts will address all three areas and give you the best contour, best areolar size, and best nipple/areolar location in one surgery. Sincerely,Dr. Dadvand

Thanks for the question.  Based on these photos you would likely require a double incision in order to address the laxity of the skin and tissues.  Even though the scar is more prominent, most patients are more bothered by the contour issues.  A peri technique would likely leave you with some contour issues and an unattractive appearance to the chest wall in general.  Good Luck"The above answer has been given without seeing this patient and cannot be substituted for actual in-person examination and medical advice; it is only opinion. Seek in-person treatment with a trained medical professional for appropriate care."

Based on your pictures, I would recommend the double incision and nipple grafting.  In my opinion, I think the periareolar approach would leave too much skin laxity at the inferior portion of the chest and the nipple position would not be as controlled and, therefore, unpredictable. While the DI results in longer scars, the result should be better.  As I always tell patients, your best chance for a great result is to have the best operation from the start and make sure your surgeon is ABPS certified. Good luck!

By looking at your pictures, your pectoral muscles are higher on your chest and the reposition of your nipples will require removal of skin below the nipples. If you don't do this you will have sagging skin. The periareolar approach will not accomplish this, therefore the double incision is the right technique for you.

Hi There.  Thank you for your question which is an important one.  The goals of surgery should be to create as normal a male chest as possible at the same time as removing all of the breast tissue to avoid the need for breast cancer screening in the future.  From your photos - I would recommend the double incision approach over the periareola one as this will achieve a more predictable outcome.  Revision rates with the periareola approach are 30% or more.  You should have a full consultation with a plastic surgeon who is experienced in FtM Top surgery.  Hope that this is helpful.