The inverted-T or anchor incision for chest reconstruction or breast reduction, like the buttonhole incision, has the potential to preserve hypersensitive or erotic nipple sensation. This is accomplished through the creation and preservation of the pedicle: a portion of the tissue behind the areola that is estimated to contain enough of the original blood and nerve supply to keep the nipple and areola alive. That said, regaining full nipple and areola sensation is never a 100% guarantee through surgery. In other words, for patients whose greatest priority is preserving a hypersensitive or erotic sensation in their nipples, the only way to accomplish this through top surgery is by preserving the pedicle or the tissue behind the areola in order to keep it alive. On the other hand, for patients interested in having more precise control over the shape and position of the areolas and nipples after surgery, a free nipple graft can be performed with the inverted T or most other procedures. Below we explore why chest reconstruction and breast reduction candidates might pursue an inverted T incision with or without a free nipple graft.
If you are interested in achieving a complete level of flatness and having greater control over the size and position of your areolas through top surgery, you can read more below about how the inverted T incision compares to the double incision, as the latter might be a more suitable option for you.
During an inverted-T procedure, unless a nipple graft is performed, the tissue attached to the nipple and areola is maintained to keep its original blood supply. This tissue is called a “pedicle.” While we know nerves are also traveling within this pedicle, a patient will not know how much nipple sensation, if any, will be maintained until about two months after surgery.
After the creation of the pedicle, the rest of the skin is folded around it and the excess is removed. This procedure involves the creation of incisions (1) around the areola (which typically becomes invisible once healing is done), (2) horizontal incisions at the lower part of the chest and (3) vertical incisions that connect the areola to the lower, horizontal incision. As a result, the scar formation ends up looking like an anchor or an upside down, or inverted, letter “T,” which is where this procedure’s name comes from.
As previously mentioned, both the inverted-T and buttonhole procedures involve the preservation of the pedicle: allowing for an increased chance of sensation preservation at the cost of leaving some volume behind on the chest. The deciding factors to help a patient choose between these two procedures are (1) the amount of excess skin that needs to be removed and (2) the patient’s desired aesthetic goals. First, the inverted-T, as opposed to the buttonhole, is recommended in patients with greater amounts of breast tissue and/or excess skin to remove. The vertical incision made between the areola and the lower, horizontal incision is what allows for excess skin removal and is the only factor that differentiates this procedure from a buttonhole. Second, the inverted-T tends to result in more teardrop shaped results, whereas the buttonhole procedure leaves a more moundlike shape.
Using the inverted-T method means the nipple and areola do not need to be placed as a free nipple graft, as it does with double incision. As a result, inverted-T may result in a better chance of maintaining pre-surgery levels of nipple sensation, though this outcome is not certain. As a tradeoff, the double incision is ideal for patients who want flatter results.
Another factor to consider if deciding between these two procedures is the location of postoperative scars. The double incision sometimes leaves the possibility of scars that are less visible or more tucked away. The inverted-T leaves an extra, more visible, vertical scar between the areola and the inferior incision. Additionally, with regards to scar placement, the lower curvature of the incision is not as customizable by the surgeon because it has to be located in the lower chest fold. In other words, the surgeon cannot customize the horizontal location of the areola as much as they could with the double incision approach.