There are two main ways I do subtotal subcutaneous mastectomy. The method I will recommend will depend on how much excess skin is present. For individuals with a significant amount of excess skin, I recommend a double incision technique. Those who have a small amount of excess skin and good skin elasticity may be candidates for a limited incision technique.
This technique is appropriate for individuals who require the excision of a good amount of skin at the same time as their subtotal mastectomy. This is a good option for individuals with breasts with excess skin, either because of weight loss, breast deflation from testosterone, skin stretching from binding, or because of the way the breasts developed. With the double incision technique, there are two ways I reposition the nipple and areola (the pigmented skin around the nipple) – either leaving them attached to a portion of skin and breast tissue, or taking them off completely and reattaching them as a free nipple graft.
Nipple transposition on a pedicle
The nipple and areola are left attached to a thin flap of skin and fat, and repositioned on the chest wall via an incision at the appropriate location on the upper skin flap. This typically preserves the color and character of the nipple and areola, which can be especially important in individuals with darker skin pigmentation. There may be a small bulge under the skin where the flap carrying the nipple passes underneath. In some cases, if there is insufficient blood supply to the tissue, this technique may need to be converted to a free nipple graft technique.
Free nipple graft
The nipple and areola complex is completely detached from the chest wall. They are then reapplied in a different position and sewn back onto the skin, like a postage stamp or sticker. This eliminates the erectile function of the nipple and can lead to depigmentation if portions of the nipple and areola do not survive the grafting process. Depigmentation is most noticeable in individuals with darker skin pigmentation. There is also a risk of complete loss of this tissue. If that happens, other techniques can later be used to reconstruct the appearance of a nipple.
For individuals who are comfortable with the size of their areolae and who do not have a significant amount of excess skin, a limited incision technique can be used. The incision may be hidden within the areola, and the breast tissue is removed via that small incision. The likelihood of postoperative bleeding is higher with this technique since it is harder to see the anatomy via the small incision. Attempting this procedure in an individual who has an excess of skin can lead to need for a revision procedure to remove the excess skin.