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Complementing the buttonhole technique with targeted liposuction: an approach to maximize masculinization during gender-affirming mastectomy

Keeley Newsom, BS, Christopher Ingersol, MD, Ivan Hadad, MD
Indiana University School of Medicine
2021-01-31

Presenter: Keeley Newsom, BS

Affidavit:
I certify that the material proposed for presentation in this abstract has not been published in any scientific journal or previously presented at a major meeting.

Director Name: William Wooden

Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: Breast (Aesthetic and Recon.)

Background: Chest wall masculinization via mastectomy, or "top surgery," is a crucial gender affirming surgery for transmasculine and non-binary patients, but aesthetic revisions remain common. The "buttonhole" technique, as opposed to free nipple grafting, maintains sensation to the nipple-areolar complex (NAC). We describe our experience using the buttonhole technique coupled with targeted chest-wall liposuction to maximize masculinization of the chest wall and minimize need for revision.

Technique: We present our approach in a 67-year-old transmasculine patient undergoing double-incision mastectomy using the buttonhole technique. Briefly, the NAC is maintained on a thin inferior dermal pedicle. The new nipple location is then marked on the superior mastectomy flap and the nipple inset similar to a no vertical scar breast reduction. For further masculinization of the chest wall, excisional lipectomy is performed medially and power assisted liposuction used through the tail of Spence, in a diamond pattern overlying the sternum, and laterally around the end of the incision. Finally, quilting sutures are used for drainless recovery.

Results: This technique successfully achieves a masculinized chest appearance. Our patient had no complications, including wound healing problems following surgery. No aesthetic revisions were necessary. The patient reports a high level of satisfaction and maintains bilateral nipple-areolar sensation and projection.

Conclusions: The buttonhole technique is a reliable method for masculinizing the chest wall of transmasculine and non-binary patients with medium-large breast tissue and a short lower pole height. Coupling the buttonhole technique with targeted liposuction and lipectomy may reduce the need for aesthetic revisions.

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