REVIEW PAPER

The Ideal Male Nipple-Areola Complex

A Critical Review of the Literature and Discussion of Surgical Techniques for
Female-to-Male Gender-Confirming Surgery
Marissa Maas, BS,* Anna C. Howell, MD,* Daniel J. Gould, MD, PhD,* and Edward C. Ray, MD*†

Nipple-areola complex (NAC) placement and chest wall aes-

Introduction: Top surgery (mastectomy and masculinization of the chest) is a
thetics are the most important component of top surgery.2 These ana-
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/10/2021

key gender affirming operation for many female-to-male transgender patients.

Positioning of the nipple-areola complex (NAC) is a crucial part of this proce-
dure. To date, there are no standards as to where to place the new NAC based
on the patient's anatomy, to achieve the most aesthetically pleasing result.
Objective: The objectives of this study were to review the literature and analyze
the anatomical averages for NAC shape, width, and height as well as vertical and
horizontal placement and to compile the recommendations and proposed equa-
tions of NAC placement based on chest wall measurements, chest wall land-
marks, and body habitus.
Methods: A systematic review of the literature was conducted in the spring of
2018. Eleven articles met the inclusion criteria, with objective measurements
of, and guidelines for, positioning the male NAC in men that had not been
preselected for being aesthetically perfect.
Results: The average diameter for a round NAC was 25.9 mm (SD, 2.5 mm),
and the width and height of the oval-shaped NAC were found to be 25.3 mm
(SD, 2.6 mm) and 20.1 mm (SD, 0.75 mm), respectively. The average sternal
notch to nipple distance was found to be 19.3 cm (SD, 1.7 cm). The average
internipple distance was 22.3 cm (SD, 1.6 cm).
Conclusions: The data are inconclusive about the effects of anatomical measure-
ments on NAC vertical and horizontal position, but areola diameter is reasonably
consistent. There are a wide variety of guidelines and algorithms offered for de-
termining these measurements.
Key Words: transgender, top surgery, nipple-areola complex, FTM
(Ann Plast Surg 2020;84: 334–340)
R ecent population surveys suggest the incidence of gender noncon-
formity, with the wrong sex at birth may be much higher than pre-
viously thought.1 It has been estimated that 0.5% to 1.3% of the male
population identify as female (male-to-female [MTF]) and 0.4% to
1.2% of females identify as male (female-to-male [FTM]).1 With
emerging surgical options and increasing insurance coverage, optimiza-
tion and development of standards for gender-affirming surgery are on
the rise. Mastectomy and masculinization of the chest wall, top surgery,
is an important part of the physical transition for some FTM patients. It
may be the first and only gender-affirming operation they will choose to
undergo.2 It has been shown that top surgery improves patients' sense of
well-being and satisfaction with body image.3 Studies have shown that,
although body image in FTM patients has improved significantly after
the introduction of top surgery,3 results vary, underscoring the need for
a higher standard for FTM top surgery.
Received February 20, 2019, and accepted for publication, after revision May 27,
2019.
From the *Keck School of Medicine, University of Southern California; and †Cedars
Sinai Medical Center, Los Angeles, CA.
Conflicts of interest and sources of funding: None of the authors have any financial
disclosures. The authors declare no conflict of interest.
Presented at: CSPS, June 1, 2019 in Sacramento, CA.
Reprints: Edward C. Ray, MD, Cedars Sinai Medical Center, 8635 West Third Street
Suite 770-W, Los Angeles, CA 90048. E-mail: Edward.Ray@cshs.org.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/20/8403–0334
DOI: 10.1097/SAP.0000000000002018
tomic characteristics of the male chest wall also have implications for
cis-gender men (CGM), men who identify as male, undergoing correc-
tive surgery for gynecomastia, male breast cancer, or burn and trauma
reconstruction. Currently, there are no guidelines on how to create the
most male-appearing chest. These important chest wall characteristics
are largely decided on an individual basis by the surgeon and the pa-
tient. As such, this lack of agreed-upon ideals in male chest wall aes-
thetics may create wide variability in the outcomes of FTM top surgery.
The goal of this literature review is 2-fold. First, the anatomical
averages of CGM NAC diameter and horizontal and vertical position
are calculated. In addition, the different algorithms that have been pro-
posed to help the surgeon decide on the placement of the new NAC on
the patients' reconstructed chest are presented.
METHODS
This literature view was conducted following the guidelines set
forth by the Cochrane Handbook for Systematic Reviews of Inter-
ventions, and the preferred reporting items for systemic reviews and
metanalyses checklist was used to assess the quality of this study.
Literature Search
A systematic review of the literature was performed in the citation
databases PubMed, Medline, Embase, and The Cochrane Library in
spring 2018. Search terms included were the following: “Transgender
Persons”[Mesh] AND Nipple, “Transgender Persons”[Mesh] AND
chest wall, male nipple areolar complex AND (Humans[Mesh]), “Top
surgery,” and male chest shaping AND (Humans[Mesh]). No limits
were implemented in the search query. After the literature search, the
bibliographies of each study were manually assessed for additional ar-
ticles to be included in the final analysis.
Study Selection
In spring 2018, 3 authors (M.M., D.J.G., and A.C.H.) indepen-
dently searched the literature. After this initial search, the authors set
forth inclusion and exclusion criteria for the articles based on their titles
and abstracts. Inclusion criteria included the following: (1) full text ar-
ticles, (2) English language, (3) objective assessment of NAC, and (4)
male sex. Exclusion criteria included the following: (1) case studies
and series; (2) studies studying men they deemed aesthetically perfect
for anatomical measurements, because of lack of standardization in aes-
thetic perfection and limitations in translating these values to men of
different body dimensions; and (3) studies that included commentary
without objective measurements. This study selection yielded 11 stud-
ies that were included in the final data analysis. We also conducted a
manual search of each study's bibliography for more articles fitting
the inclusion criteria.
Data Collection
Data collection was performed on all articles meeting the inclu-
sion criteria. Extracted data included the type of study, number of

334 www.annalsplasticsurgery.com Annals of Plastic Surgery • Volume 84, Number 3, March 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Annals of Plastic Surgery • Volume 84, Number 3, March 2020 Evaluating the Ideal Male NAC

patients in the study, ethnicity of participants, participants' age, partici-
pants' body mass index (BMI), the type of patients recruited (such as
CGM vs FTM patients), average shape of NAC if recorded (oval vs
round), average width of NAC, average length of NAC, and average
or proposed vertical and horizontal coordinates of the NAC based on
sternal notch and internipple distance.
Statistical Methods
All numerical data were evaluated based on statistical models
and calculated in Microsoft Excel (Redmond, WA) using the AVER-
AGE and STDEV tools to calculate averages and standard deviations.
RESULTS
The initial search identified 90 articles on Embase, 3 on the
Cochrane Library, and 97 on PubMed with 38 repeats for a total of
152 articles. After a thorough assessment of titles and abstracts, 8 arti-
cles remained and the full text of these articles was evaluated based on
inclusion and exclusion criteria. Only 4 of these articles met the inclu-
sion criteria. A manual assessment of the bibliographies of these articles
yielded an additional 7 articles, leading to 11 articles in the final analy-
sis (Table 1). A total of 180 subjects were pooled for meta-analysis. The
average age of study participants was 29.8 years (SD, 9.0 years), and
BMI was 23.9 kg/m2 (SD, 1.3 kg/m2) (Table 1). Three studies reported
patients' ethnicities; within these studies, 69.4% of the participants were
Caucasian, and 30.6% percent were of other ethnicities. Of note, 1 study
only included Asian male participants. There were 8 studies that exam-
ined quantitative measurements of nipple shape and nipple positioning
on the chest wall. Five studies examined qualitative relationships be-
tween NAC and the chest wall and body habitus. Lastly, 4 studies of-
fered equations to help the reconstructive surgeon position the NAC
on the chest wall.
Nipple Shape
The anatomical studies revealed that the NAC of CGM may be
categorized as either round or elliptical in shape. One study examined
the NAC shape of 100 Caucasian CGM and determined that the
majority of men had oval-shaped areolae.4 When pooling the data ob-
tained from all of the anatomical studies included in this review, the
average width of the oval-shaped NAC was found to be 25.3 mm
(SD, 2.6 mm), and the height of the average oval-shaped NAC was
found to be 20.1 mm (SD, 0.75 mm)4–6 (Table 2). The average diameter
for a round NAC was found to be 25.9 mm (SD, 2.5 mm)4,7,10 (Table 2).
One study found that NAC diameter remained consistent across differ-
ent age groups, BMI ranges, and ethnicities.7
One study analyzed measurements of NAC diameter based on
patient's height and found a statistically significant difference between
height and NAC diameter.11 In the short group, (height, 165.6 cm; SD,
3.7 cm), the areola diameter was 26.2 mm (SD, 3.3 mm), and in the
tall group, (height, 176.5 cm; SD, 2.4 cm), the diameter was 30.6 mm
(SD, 4.6 mm). This study found no correlation between BMI and
NAC diameter.11
NAC-Chest Wall Measurements
The studies included in the final analysis used sternal notch-
to-nipple distance (NN) to define the vertical position of the NAC.4,6–11
The average NN was found to be 19.3 cm (SD, 1.7 cm) (Table 2).
The horizontal position of the NAC was defined by internipple distance
(IND).4,6–11 The studies included in the final analysis found the average
IND to be 22.3 cm (SD, 1.6 cm) (Table 2).
Qualitative Chest Wall Landmarks
In addition to their anatomic measurements, some studies pro-
posed other qualitative anatomic relationships to better define the ideal
male NAC. Beer et al4 suggested that the new NAC could be approxi-
mated between the fourth and fifth intercostal space, as his population
revealed that 75% of CGM had nipples landing in the fourth intercostal
space and 23% in the fifth intercostal space. Wolter et al8 advocates for
keeping the new NAC in the same horizontal position as the old NAC
and adjusting its vertical coordinate by raising the new NAC to the in-
ferior border of the major pectoralis muscle. Similarly, Monstrey et al12
recommends placing the new NAC on the same horizontal plane raised
2 to 3 cm above the lower border of the pectoralis muscle. Through

TABLE 1. Study Demographics: A Summary of the Studies Included in the Final Analysis

Authors No. Patients Ethnicities Represented Average Age, y Average BMI Participants Study Type
13
McEvenue et al (2017) 679 No data 26.3 26.2 FTM patients undergoing Retrospective
surgery
Yue et al7 (2018) 158 112 White, 46 non-White 57 25.3 Anatomical measurements Observational, anatomic
taken from hospitalized
patients
Agarwal et al5 (2017) 32 24 White, 6 Asian, 2 26.3 22.9 Healthy volunteers Observational, anatomic
Hispanic
Lo Russo et al14 (2017) 16 No data 31 FTM patients undergoing Surgical recommendation
surgery
Beer et al4 (2001) 100 100 White 26.7 23.9 Healthy volunteers Observational, anatomic
Kasai et al11 (2015) 50 50 Asian 29.9 22.5 Healthy volunteers Observational, anatomic
Monstrey et al12 (2006) 92 No data 31 No data FTM patients undergoing Retrospective
surgery
Wolter et al8 (2015) 173 No data 28.6 23.9 FTM patients undergoing Retrospective
surgery
Atiyeh et al9 (2009) 30 No data 23.9 24.5 Healthy volunteers Observational, anatomic/
tested ratio
Beckenstein et al10 (1996) 100 No data 20.9 22.4* Healthy volunteers Observational, anatomic
Shulman et al6 (2001) 50 No data 27.9 23.3* Healthy volunteers Observational, anatomic
Study averages 126.8 ± 180.9 29.76 ± 9.049 23.88 ± 1.283
*Calculated from the average height and weight.

© 2019 Wolters Kluwer Health, Inc. All rights reserved. www.annalsplasticsurgery.com 335

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Maas et al Annals of Plastic Surgery • Volume 84, Number 3, March 2020

TABLE 2. Anatomical Averages: A Summary of the Articles That Included Quantitative Measurements of NAC Dimensions and NAC Po-
sition on the Chest Wall

Average Areolar Average Areolar Average Areolar Horizontal: Vertical:

Authors Shape Width, mm Height, mm Internipple Distance, cm Sternal Notch to Nipple, cm
Yue et al7 (2018) Round 26.6 26.6 24.9 20.2
Agarwal et al5 (2017) Oval 22.3 20.1
Beer et al4 (2001) Round 23.1 23.1 22.4 20.0
Oval 26.9 19.3
Wolter et al8 (2015) 20.8
Atiyeh et al9 (2009) 22.4 16.1
Beckenstein et al10 (1996) Round 28.0 28.0 21.3 20.1
Shulman et al6 (2001) Oval 26.7 20.8 20.6 18.4
Kasai et al11 (2015) Group† Group Avg* Group Avg* IND = avg  TW NN = avg  TL
Short Short 26.2 Short 26.2 Avg* Group Avg* Group
Tall Tall 30.6 Tall 30.6 .68 Short .37 Short
Lean Lean 26.7 Lean 26.7 .67 Tall .36 Tall
Overweight Overweight 28.6 Overweight 28.6 .65 Lean .37 Lean
.69 Overweight .37 Overweight
Study averages 25.9 ± 2.5 25.3 ± 2.6 20.1 ± 0.75 22.3 ± 1.6 19.3 ± 1.7
*Excluded from averages because no raw data were provided on how many patients were categorized to each category.
†The patients had elliptically shaped nipples, but the authors only provided the average of the width and height (average areola diameter) for the patients without raw
width and height values.
TW, thoracic width; TL, thoracic height; avg, average.

clinical experience, McEvanue et al13 reports that, when using the
double incision free nipple graft approach, the best vertical position
for the nipple graft is 5 mm above the horizontal incision scar resulting
from the mastectomy. Lo Russo et al14 approximates the new NAC po-
sition using the intersection of 3 lines: a vertical line from the 1/3 lateral
of the clavicle length, a horizontal line from the junction of the fifth to
sixth rib, and a diagonal line form the sternal notch to the inferior
lateral chest.
Qualitative NAC-Body Habitus Relationships
In addition, several studies discuss the relationship between the
NAC and body habitus. Yue et al7 suggests that, because the majority
of anatomical measurement studies have been performed on younger,
thinner males, older age, and larger BMIs should be taken into account
when reconstructing the NAC.7 Their study revealed a statistically signif-
icant correlation between increasing age and increasing IND, with men in
the 18 to 35 years age group having an average IND of 23.8 cm and men
in the 80 plus years age group having an average IND of 27.3 cm.7 They
recommend that, because the majority of men undergoing top surgery
are under 80 years old, reconstructive surgeons can use the average
IND of men under 80 years old (24.9 cm) for the majority of their pa-
tients.7 Yue et al7 also reported a statistically significant correlation
between BMI and increasing NN. Men in the normal BMI category
(18.5–25 kg/m2) had an average NN of 19.6 cm, men in the over-
weight group (25.1–30 kg/m2) had an average NN of 21.2 cm, and
men classified as overweight (>30 kg/m2) had an average NN of
21.6 cm.7 They developed a chart with the suggested NN for each
BMI group based on these measurements (BMI 18.5–25 kg/m2, NN
20; BMI 25.1–30 kg/m2, 21; BMI >30 kg/m2, NN 22).7
Another study performed a linear regression and found that pa-
tient age, weight, height, and BMI did not affect IND.4 However, in-
creasing thorax diameter predicted an increase in IND (r = 0.68).4
Increasing length of the sternum correlated to increase in the NAC's ver-
tical distance from the midsternal line (r = 0.50).4 Controlling for
change in sternal length, this study found no statistically significant
correlation between overall body height and vertical NAC position.4
Conversely, Shulman et al6 and Beckenstein et al10 found a correlation
between increasing vertical NAC placement and increasing height.4
Kasai et al11 found that there was no significant effect from body height
on vertical or horizontal nipple position but increasing BMI led to an
increased horizontal nipple position. They found an average modifier
(mod) of .65 for their lean group and .69 for their overweight group
for their equation where IND = mod  thoracic width.11 McEvenue
et al13 advocates for increasing the NN based on both increasing sternal
length and increasing thoracic circumference. The recommendations in
this study are based on a chart in which the smallest thoracic circumfer-
ence (less than 87 cm) and smallest sternal length (13–14 cm) leads to
the smallest NN of 13 cm, and this increases in the largest thoracic cir-
cumference (larger than 91 cm) and sternal length (19–20 cm) to a NN
of 15.13 For horizontal coordinates, an increasing thoracic circumfer-
ence leads to an increasing IND, ranging from a thoracic circumference
of less than 87 and an IND of 10 and thoracic circumference of greater
than 91 and an IND of 11 and 12.13 One important surgical implication
that has been made, too, is that the patient's body position may also
change the measured NN, with the standing position increasing the ver-
tical distance when compared with the supine position.11
Proposed Equations
Lastly, multiple studies proposed equations to assist the surgeon
quantify where the NAC should be placed on the chest wall. An abstract
guide to NAC position, proposed by Atiyeh et al,9 bases chest wall mea-
surements off of the golden number φ. After the golden number,
internipple distance and the distance from suprasternal notch should
be an average of 23 cm and 18.5 cm.9 The golden number φ is a fixed
number that does not take into account how body proportions can
change with obesity or age. The other suggested formulas are based
on linear regressions comparing different anatomical measurements to
NAC vertical and horizontal distances.6,10,11 Beer et al4 found that tho-
racic diameter was the greatest predictor of the horizontal positioning of
the NAC, whereas sternal length was the greatest predictor for vertical

336 www.annalsplasticsurgery.com © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Annals of Plastic Surgery • Volume 84, Number 3, March 2020
positioning and developed a formula for NAC placement based on these
measurements.4 For the distance from the midsternal line to the nipples,
Beer et al4 proposed 2.4 cm + (.09  circumference of thorax), and for
vertical distance, 1.2 cm + (.28  length of sternum) + (.1  circumfer-
ence of thorax).4 Shulman et al6 suggested IND = 2.192 + (.190  cir-
cumference of thorax) and NN = (.120  height) − 2.782. Beckenstein
et al10 developed the equations 7.9 + (.17  height in inches) for
midclavicular line to nipple and 11.1 + (.13  height) for NN.
DISCUSSION
Surgical and Anatomic Considerations
Different mastectomy and nipple grafting techniques are avail-
able based on the size of a patient's breasts and the preferences of both
surgeon and patient, taking into account risks related to nipple viability
and scarring. These procedures can be split into NAC-sparing versus
NAC grafting. For patients with larger breasts where skin removal is a
priority, a double incision (Fig. 1) or inverted-T may be used. On occa-
sion, when only a thin wedge of lower pole skin is removed, the double
incision is performed without removal of the NAC from its native loca-
tion but is transposed with the upper pole skin to a new position closer
to the inframammary fold (IMF) (Fig. 2). When breast size warrants, or
when patient preference allows for it, the nipple can be transposed leav-
ing it attached to a pedicle of dermis and/or parenchyma, as in the “but-
tonhole” technique. When this would leave too much chest wall bulk
and compromise the patient's goals, free nipple grafts are typically used.
In the inverted-T method, the same incisions are made with an addi-
tional incision around and projecting vertically down from the NAC.
This allows the NAC to be reduced and repositioned while keeping it
attached to the pedicle. The inverted-T is somewhat less popular among
both patients and surgeons owing to the amount of scars involved.
For patients with smaller breasts, the periareolar approach is
sometimes a good option. In this procedure, the surgeon excises a ring
of skin around the NAC (reducing it in the process if necessary) and
then creates a slightly larger circular incision around the NAC. The
nipple remains attached to the pedicle, and after excess breast tissue
is removed, the skin is cinched together around the new NAC. The
Benelli or “purse-string” suture, a consecutive circular suture around
the areola, can be used to help prevent enlarging of the scar and areola.
Circumareolar reductions, however, may result in more scarring and
skin “ruffling.” For patients with small breasts who desire minimal
FIGURE 1. A, Preoperative and (B) early postoperative photos of an FTM patient who underwent gender-affirming double incision
mastectomy with free nipple grafting, resulting in transient areolar hypopigmentation.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Evaluating the Ideal Male NAC
scarring, the keyhole approach, may be an option. In this procedure,
the surgeon removes breast tissue, either by direct excision or using li-
posuction via a small incision under the NAC. Typically, the NAC is not
resized in this surgery, and nipple sensation is usually preserved.
There are modifications of this procedure performed by the senior au-
thor (E.C.R.) where a crescent of skin is removed to both resize and lat-
eralize the areola (Fig. 3)
For the double incision and periareolar techniques, the surgeon
has the opportunity to resize and/or reposition the NAC because cis-
gender women, especially those with fuller breasts, typically have sig-
nificantly larger areolae than men. After the removal of breast tissue
in top surgery, the surgeon adjusts areolae position and shape. There
is debate as to whether the areola should be oval or round and what
the ideal diameter is. Because the initial location of the NAC will be al-
tered with tissue removal, the surgeon must also decide its vertical and
horizontal placement. This review summarizes the literature on the ideal
positioning of the NAC and conduct a meta-analysis on the dimensions
and coordinates proposed.
Discussion of Results
The NAC has been studied to a much greater extent in females
than males,7 leaving the reconstructive surgeon to position the male
NAC without a criterion standard. Beer et al4 discusses pitfalls of male
NAC reconstruction: surgeons may fail to appropriately minimize the
areola and may place the NAC either too high or too wide on the chest
such that the reconstructed chest does not resemble that of the average
CGM. This is of particular interest among transgender patients, a med-
ically underserved community with many barriers to care.15 Because of
how contributory top surgery is to patients' psychological well-being,
especially for FTM patients undergoing their first gender-affirming sur-
gery,3 it is crucial to set strategies for the appropriate shape and location
for the NAC.
There are no widely accepted guidelines to help the reconstruc-
tive surgeon in placing the male NAC in the most aesthetically pleasing
location on the chest wall. Different practices range from rough pattern-
ing based on musculoskeletal features of the chest wall to complex al-
gorithms with a variety of chest and body dimensions. This review
demonstrates that the greatest consistency across studies is areolar di-
ameter. The majority of studies find that oval is the most natural shape
for the male NAC4–6 with a height of approximately 26 mm and width
of approximately 20 mm. The height of the NAC is approximated as
landing between the fourth and fifth intercostal space6,8,14 and along
www.annalsplasticsurgery.com 337
Maas et al Annals of Plastic Surgery • Volume 84, Number 3, March 2020

FIGURE 2. A, Preoperative and (B) postoperative photos of an FTM patient who underwent a double incision mastectomy with NAC
preservation. The areolae sit somewhat lower than the ideal CGM areolar position in accordance with this patient's wishes to avoid
nipple grafting.

the inferior margin of the pectoralis muscle.5,8 The anatomical studies
find average NAC placement in the male population approximately
19 cm away from the sternal notch and approximately 22 cm away from
each other,4–7,9,10 but using averages alone does not allow for differ-
ences that occur because of BMI, height, or age.7,11 Perhaps most im-
portantly, FTM patients exhibit female body habituses, and thus,
using ideal male measurements fails to address differences in body di-
mensions as a function of sex assigned at birth. To overcome this, vari-
ous algorithms that produce the ideal NAC position based on thoracic
diameter, length of sternum, and patient height have been intro-
duced.4,6,10,13 To date, there is no rigorous investigation of whether or
not these algorithms lead to consistent and aesthetically pleasing results.
One flaw with the current body of literature is a lack of patient
diversity. Many studies only examined young, thin patients of European
ancestry, even going so far as to exclude obese patients from their data
sets.7 As such, there is a discrepancy between the demographics of the
men who are used for anatomical study and the typical male. There are
significant variations in NAC and chest wall dimensions with both BMI
and age.7 Furthermore, studies that only measure NAC position based
on gender-specific anatomical features, such as a male's pectoralis ma-
jor muscle, have limited value for gender-affirming top surgery.
The experience of the senior author (E.C.R.) in gender-affirming
FTM top surgery has generated some useful points for consideration.
First, when discussing surgical options with a patient, it is of paramount
importance to solicit the patient's opinion. As with any cosmetic or re-
constructive effort, it really does not matter how happy the surgeon is
with the final aesthetic result if the patient is disappointed. To avoid this
situation, it is always best to discuss areola placement, as well as the ex-
pected chest contour and location of scars. Using preoperative and post-
operative photos of patients with similar anatomy to demonstrate what
the surgeon considers ideal is invaluable. The patient may express his
opinion of a given photo (eg, that the areola is too far lateral or too
high), which should prompt a more in depth discussion of what ideal
is in the view of the patient and perhaps allow the surgeon to better de-
fine and meet expectations. From our experience, there is a subset of
gender-fluid and nonbinary gender patients that will pose varying

FIGURE 3. A, Preoperative and (B) early postoperative photos of an FTM patient who underwent a modified keyhole procedure,
including a lateralizing crescentic mastopexy. A resulting depressed scar will likely require revision.

338 www.annalsplasticsurgery.com © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Annals of Plastic Surgery • Volume 84, Number 3, March 2020
FIGURE 4. A, Preoperative and (B) early postoperative anterior and (C) oblique lateral views of an FTM patient with high BMI. He
underwent a double incision mastectomy with free nipple grafting. The patient's body habitus and preexisting breast asymmetry
posed significant challenges to achieving a symmetric chest contour and areolar positioning.
requests for NAC position based on their nonbinary gender identity. For
example, we have treated patients who requested to have no NAC at all
and others who requested to have all sensation removed.
Second, much of what we use to define ideal is based upon CGM
anatomy. As we know from bottom surgery, the shape and proportions
of the body are not the same for CGM and FTM patients. The origin and
shape of the pectoralis major muscle, for example, may differ signifi-
cantly between such groups of patients, and so using the border of the
pectoralis as a landmark for areola placement will possibly give a differ-
ent result than in a CGM. The dimensions (height, width, and circum-
ference) of a CGM chest are also different from an FTM chest. The
effects of hormone replacement on muscle bulk should be considered,
because most FTM patients undergoing chest surgery are on testoster-
one replacement. To that end, every patient should be counseled about
changes in perceived NAC position that could occur if his chest muscu-
lature continues to hypertrophy with exercise and his muscle-to-fat ratio
increases owing to the ongoing effects of exogenous androgens. In any
case, more studies are needed to define human sexual dimorphisms (in-
cluding the changes that occur with hormone replacement) and how
they affect the perception of aesthetic ideals.
Third, intraoperative measurements can vary significantly de-
pending on a patient's BMI and body position. We find it very helpful
to sit patients up at the time of areola placement to get an eyeball test
and then use measurements to refine symmetry. Higher BMI patients
typically have more dynamic chest walls with more skin and tissue mo-
bility. Establishing a normal chest is particularly challenging in these in-
dividuals, and average CGM measurements do not work well in our
experience (Fig. 4). Perhaps this is one reason why authors defining an-
atomic norms exclude overweight and obese patients.
The senior author approaches FTM chest surgery on a case-
by-case basis and has not adopted specific formulas or rigid protocols
for NAC positioning. Rough guidelines include (a) keeping the areolae
medial to the inferolateral border of the pectoralis major muscle and (b)
1 to 3 cm superior to the neo-IMF, which is positioned at or slightly be-
low the lower of the 2 native IMFs. Patient preferences, chosen tech-
nique, and intraoperative measurements (the latter done mostly to
ensure symmetry) may cause some movement of the NAC, although
rarely outside the aforementioned guidelines.
Limitations for this study included lack of patient diversity in the
literature reviewed as well as exclusion of articles not written in English.
The goals for moving forward in this field should be to examine NAC
shapes and positions in prospective trials to measure postoperative aes-
thetic result and patient satisfaction for FTM patients. Greater diversity
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Evaluating the Ideal Male NAC
should be introduced in study populations as well. A more diverse pa-
tient population would allow the reconstructive surgeon to customize
NAC position for patients of differing body shapes and backgrounds.
A potential area of expansion in this field is through
crowdsourcing. This is a tool used to poll a wide variety of people from
diverse backgrounds. The majority of studies on aesthetics in FTM
surgery have focused on emulating the anatomy of CGM and not on
discovering which approach creates the most aesthetically pleasing re-
sult. Understanding public perception of what is the most natural
appearing and aesthetically pleasing position and shape of the NAC
on the male chest could help further guide reconstructive surgeons
and develop standards and guidelines for top surgery. Crowdsourcing
would also help address the lack of age, ethnicity, and BMI diversity
in the current literature.
CONCLUSIONS
There is great need for evidence-based guidelines in NAC place-
ment in top surgery. Currently, the literature only offers anatomical av-
erages that do not account for diverse body shapes, single surgeons'
methods for eyeballing the ideal NAC based on chest wall features,
and algorithms based on patient height and thoracic circumference
without prospective studies validating their success. Objective guide-
lines would help improve aesthetic outcomes in NAC placement, which
could help in the surgical management of gender dysphoria.
REFERENCES
1. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of
society. Lancet. 2016;388:390–400.
2. Hage JJ, van Kesteren PJ. Chest-wall contouring in female-to-male transsexuals:
basic considerations and review of the literature. Plast Reconstr Surg. 1995;96:
386–391.
3. Agarwal CA, Scheefer MF, Wright LN, et al. Quality of life improvement after
chest wall masculinization in female-to-male transgender patients: a prospective
study using the BREAST-Q and Body Uneasiness Test. J Plast Reconstr Aesthet
Surg. 2018;71:651–657.
4. Beer GM, Budi S, Seifert B, et al. Configuration and localization of the nipple-are-
ola complex in men. Plast Reconstr Surg. 2001;108:1947–1952; discussion 1953.
5. Agarwal CA, Wall VT, Mehta ST, et al. Creation of an aesthetic male nipple are-
olar complex in female-to-male transgender chest reconstruction. Aesthetic Plast
Surg. 2017;41:1305–1310.
6. Shulman O, Badani E, Wolf Y, et al. Appropriate location of the nipple-areola
complex in males. Plast Reconstr Surg. 2001;108:348–351.
www.annalsplasticsurgery.com 339
Maas et al
7. Yue D, Cooper LRL, Kerstein R, et al. Defining normal parameters for the male
nipple-areola complex: a prospective observational study and recommendations
for placement on the chest wall. Aesthet Surg J. 2018;38:742–748.
8. Wolter A, Diedrichson J, Scholz T, et al. Sexual reassignment surgery in female-
to-male transsexuals: an algorithm for subcutaneous mastectomy. J Plast Reconstr
Aesthet Surg. 2015;68:184–191.
9. Atiyeh BS, Dibo SA, El Chafic AH. Vertical and horizontal coordinates of the
nipple-areola complex position in males. Ann Plast Surg. 2009;63:499–502.
10. Beckenstein MS, Windle BH, Stroup RT. Anatomical parameters for nipple posi-
tion and areolar diameter in males. Ann Plast Surg. 1996;36:33–36.
11. Kasai S, Shimizu Y, Nagasao T, et al. An anatomic study of nipple position and
areola size in Asian men. Aesthet Surg J. 2015;35:NP20–NP27.
340 www.annalsplasticsurgery.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 84, Number 3, March 2020
12. Monstrey S, Selvaggi G, Ceulemans P, et al. Chest-wall contouring surgery in
female-to-male transsexuals: a new algorithm. Plast Reconstr Surg. 2008;
121:849–859.
13. McEvenue G, Xu FZ, Cai R, et al. Female-to-male gender affirming top surgery: a
single surgeon's 15-year retrospective review and treatment algorithm. Aesthet
Surg J. 2017;38:49–57.
14. Lo Russo G, Tanini S, Innocenti M. Masculine chest-wall contouring in
FTM transgender: a personal approach. Aesthetic Plast Surg. 2017;41:
369–374.
15. Romanelli M, Hudson KD. Individual and systemic barriers to health care: perspec-
tives of lesbian, gay, bisexual, and transgender adults. Am J Orthopsychiatry. 2017;
87:714–728.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.