A Novel Technique for Nipple-Areola Reconstruction in Gender Affirming Mastectomies Using Nipple Punch Grafts and Areola Tattooing (NPAT) - A Pilot Study.

Abstract

Free nipple-areola grafting (FNAG) is the most common approach for nipple-areola complex (NAC) reconstruction in transgender patients and is often performed in conjunction with double incision mastectomy for chest masculinization. Unwanted consequences of FNAG include graft failure, hypopigmentation as well as circular scarring around the areola. We developed a novel technique for NAC reconstruction using nipple punch grafts in conjunction with 3D areola tattooing (NPAT). Patient demographics and postoperative complications were reviewed. To compare aesthetic outcomes of NPAT with FNAG, postoperative images of both groups were distributed among public raters using the crowdsourcing platform Amazon MTurk. Raters were asked to rank the aesthetic appearance of each NAC on a 1-7 Likert scale. Eighteen patients (mean age 30 ± 10.74, mean BMI 27 ± 7.36) underwent double incision mastectomy together with NPAT for NAC reconstruction. Mean follow-up was 100 days after surgery. Postoperative complications such as graft loss, partial graft necrosis, hypertrophic/distended scarring were not observed. One patient demonstrated a loss of graft projection, and one patient developed partial graft depigmentation. Across the full sample of 895 public raters, NPAT received significantly higher aesthetic ratings than FNAG (NPAT 5.0 ± 1.5 vs FNAG 4.5 ± 1.8, p < 0.001), a pattern that persisted across different genders and age groups. The NPAT technique is a simple and effective approach to NAC reconstruction in transgender patients, combining the advantages of traditional FNAG and 3D tattooing. Our findings suggest that NPAT may provide an aesthetically superior NAC and potentially reduce complications associated with traditional FNAG.