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Page 6 of 14 Bonapace-Potvin et al. Plast Aesthet Res. 2025;12:34 https://dx.doi.org/10.20517/2347-9264.2025.65

One of the technical challenges in performing keyhole surgery can be complete excision of breast tissue
through a very small incision, limited to a hemi-areola. Often there is more glandular tissue than initially
appreciated, particularly in the lateral and inferior aspects of the breast. We prefer to use a combination of
both liposuction and an arthroscopic shaver to aid in flap contouring as this allows a more precise excision
of the most lateral and inferior portions of the breast tissue where direct visualization is difficult
[Supplementary Video 1]. Very wide undermining of the skin flaps is important, well beyond the natural
anatomic breast borders, to obliterate all natural breast landmarks and allow for optimal skin re-draping
[21]
and retraction .
Buttonhole technique
The buttonhole technique consists of a radical breast reduction with resection of all tissue of the lateral,
superior and medial breast, while maintaining an inferior-based dermoglandular pedicle to the NAC [18,22,23] .
This technique is typically indicated in patients who do not desire a breast mound or more feminine chest
shape, but wish to maintain nipple vascularity and sensation to avoid a free nipple graft, and/or do not want
a chest that is completely flat. It works best in two patient cohorts: (1) those with broad chests, who are
overweight and do not have an excessively long nipple-inframammary fold (IMF) distance and wish to have
a chest “proportionally flat” to their body [Figures 3 and 4] and (2) slim athletic patients with minimal
glandular tissue volume, moderate skin excess and a short nipple-IMF distance where the pedicle is short
and can therefore be thinned extensively to be mostly dermal [Figures 5 and 6].

The buttonhole technique will result in fullness in the lower pole of the chest to maintain perfusion and
sensation to the nipple. In slim patients, even a small amount of glandular tissue can compromise a
completely flat chest contour, so counseling in this regard is important. It is our preference to secure the
dermoglandular pedicle along the lateral border of the pectoralis major with 2-0 Vicryl sutures to flatten the
volume of the pedicle as much as possible and orient the volume of the pedicle along the line of the
pectoralis [Figure 6]. This camouflages the tissue and at times, augments the appearance of the pectoral
muscle. Although it is possible to support the NAC on a dermal pedicle alone to minimize any lower pole
fullness, this can increase the risk of NAC loss and significantly reduce nipple sensation. Therefore, in more
slender patients who want a fully flat chest contour and to maintain nipple sensation, it is our preference to
perform a double incision mastectomy with free nipple grafts and TNR. Patients in larger bodies with a
naturally occurring lateral bra roll can have a smooth and cohesive appearance to the chest following
buttonhole top surgery, as the tissue of the lower pole pedicle blends smoothly into the lateral chest wall
adipose tissue and bra roll [Figure 3]. The final result can be a chest that is “proportionally flat” relative to
the patient’s body habitus [Figure 4].

TNR
Achieving desired levels of nipple sensation has emerged as a critical factor for many individuals
undergoing top surgery. While certain techniques (i.e., the buttonhole technique) preserve a pedicle to the
nipple-areola complex, they may result in post-operative chest fullness due to retained glandular tissue. In
order to obtain a flat contour, the majority of gender-affirming mastectomy techniques will involve the use
of free nipple grafts. However, this approach often results in the loss of nipple sensation. The innovative
technique of nipple neurotization or TNR was first introduced in 2020 by Rochlin et al. and has grown in
[24]
popularity in recent years with increased patient awareness of this as a surgical option. The procedure
involves preserving lateral cutaneous branches of the 3rd-5th intercostal nerves allowing for direct
neurotization of the nipple, elongating them with nerve grafts if needed [Figure 7]. Current data support a
minimum of two intercostal nerve transfers per side, with direct neurotization being performed when
[9]
possible or the use of an autologous nerve graft . The most recent sensory data with TNR show promising