Nipple and areola reduction for gender-affirming mastectomy: a novel and reproducible surgical technique.

The placement and appearance of the nipple following female to male gender affirming mastectomy is a well-documented factor in patient satisfaction. However, very little discussion of surgical techniques for nipple reduction itself exists, which we believe to be a cosmetically important area to be addressed in gender affirming surgery. Many existing techniques focus on reduction in projection without modifying the whole complex, and very few describe nipple grafting as a strategy. This article addresses a significant gap in the surgical literature, as achieving masculine chest aesthetics requires attention to the diameter, projection, and proportions of the nipple-areola complex relative to chest wall dimensions. In this article we present a single surgeon's 10-year experience of a step by step and easily reproducible approach to a novel technique for nipple reduction for double incision mastectomy with nipple-areola complex grating. This approach presents one standardized technique offering strategies for reduction, optimizing projection, and optimizing placement of the nipple graft in a female to male gender affirming mastectomy. The technique presented in this article allows for simultaneous modification of nipple size and shape by integrating nipple reduction as a routine component of the double incision procedure rather than treating it as a secondary consideration, optimizing efficiency. Although the approach is simple, it provides a framework for achieving optimal cosmetic outcomes in female to male gender affirming mastectomies. The reproducibility of this standardized approach across diverse patient anatomies makes it a valuable addition to the arsenal of surgical techniques for gender affirming chest reconstruction.