Color Doppler Sonography Assisted Subcutaneous Mastectomy with Inferior Pedicled Nipple-Areola Complex in Female-to-Male Transsexuals: A Retrospective Cohort Analysis

We read with great interest the article titled ‘‘Color Doppler Sonography Assisted Subcutaneous Mastectomy with Inferior Pedicled Nipple-Areola Complex in Female-to-Male Transsexuals: A Retrospective Cohort Analysis’’ by C. Caro et al.1 We appreciated the Author’s efforts in performing masculinization of the thoracic wall in female-to-male transsexuals (FMT) while preserving, at the same time, nipple–areola complex (NAC) sensitivity, but we have some elements to discuss. Maintaining an inferior neuro-vascular pedicle unavoidably requires preserving part of the inferior pole of the breast which could represent a real limit in FMT thoracic reshaping as the inferior pedicle inevitably causes inferior bulging, strongly recalling a female appearance.2,3,4 Since FMT gender-affirming mastectomy is quite similar to gynecomastia patients’ post-operative expectations, creating a masculine thoracic appearance represents the main objective in this type of surgery.5,6,7 Therefore, residual adipo-glandular tissue in the inferior quadrants could represent a real limit in patient self-perception and, thus, an element of disclaim. Although NAC preservation could represent without a doubt an advantage, however, this item could be considered of secondary importance as opposed to accurate masculine thoracic reshaping. The Author’s study included 23 FMTs where most patients were overweight (average BMI 28 kg/m2) and presented large ptotic breasts. Although free nipple graft is characterized by obvious disadvantages, including loss of sensitivity and risk of nipple necrosis, in overweight patients with very large and ptotic breasts, according to Wolter et al. algorithm, subcutaneous mastectomy with free nipple graft in FMTs should be considered to obtain a high level of patient satisfaction and avoid post-operative disclaims. As reported in the article, following subcutaneous mastectomy and multi-layer skin suture, the new nipple position was planned at the intersection of the breast halving line and the lateral margin of the pectoral muscle. Do the Authors believe that a pedicled NAC limits the distance as to where the new nipple may be repositioned? Did the Authors investigate the importance of maintaining NAC sensitivity rather than thoracic reshaping? How did the Author’s investigate this essential item? Did the patients have a final voice in the decision-making process? A high degree of NAC sensitivity was maintained, according to a subjective evaluation of the FMTs included in this study. Why was objective testing of NAC sensitivity not performed?