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Maintaining Sensation and Volume: The Inverted-T Anchor Technique

Inverted T chest reconstruction

Why do patients choose to have the Inverted-T Incision?

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.

The inverted T would be a good choice for your chest reconstruction surgery if…

  • Maintaining hypersensitivity or an erotic level of nipple sensation is one of your top priorities in getting top surgery.
  • You are not interested in or do not care that much about achieving complete chest flatness. For instance, though not always the case, this procedure is often pursued by plus-sized, transmasculine patients who would like the volume of their chest to coincide with the size of their abdomen and the amount of fat present in the rest of their body.
  • You are ok with muscle definition not being as visible since the leftover pedicle tissue will slightly conceal the chest muscles below.
  • You are fine with not having complete control over the repositioning and resizing of your nipples. That said, areola resizing (i.e., making your areola smaller) can still be done with the hope of keeping the areola and nipple sensation completely alive like before.

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.

The inverted T would be a good choice for your breast reduction surgery if…

  • You are interested in having a drastic reduction in breast tissue volume that a traditional breast reduction could accomplish. In other words, you are interested in maintaining some elements of the teardrop shape, having minimal breast overhang, and are okay with a bit of movement of the chest (i.e. “bounce”) after surgery. This option is frequently pursued by patients who do not want to get rid of their breast tissue all together, but find that having large breasts is a cause for dysphoria and/or a safety concern.
  • Maintaining hypersensitivity or an erotic level of nipple sensation is one of your top priorities in getting top surgery.
  • You are fine with not having complete control over the repositioning and resizing of your nipples. That said, areola resizing (i.e., making your areola smaller) can still be done with the hope of keeping the areola and nipple sensation completely alive like before.

The inverted T with a free nipple graft would be a good choice for your breast reduction surgery if…

  • You are interested in having a drastic reduction in breast tissue volume that a traditional breast reduction could accomplish. In other words, you are interested in maintaining some elements of the teardrop shape, having minimal breast overhang, and are okay with a bit of movement of the chest (i.e. “bounce”) after surgery. This option is frequently pursued by patients who do not want to get rid of their breast tissue all together, but find that having large breasts is a cause for dysphoria and/or a safety concern.
  • You are interested in having drastically smaller breasts than those you started out with. Because of the large amount of breast tissue you have to start off with, an aggressive reduction to achieve an A or B cup might have to eliminate more than the pedicle (the nipple’s original blood and nerve supply) to reach your desired volume.
  • Maintaining hypersensitivity or an erotic level of nipple sensation is not as important to you as achieving a specific reduction in volume and/or having greater control over the repositioning and resizing of the nipples. Once fully healed, a nipple graft typically has the same level of sensation as the rest of the skin around it. That said, there is a small risk of complete or partial sensation loss. 
  • You want to have complete, precise control over the repositioning and resizing of your nipples. Areola resizing (i.e., making your areola smaller) can still be performed without having to do free nipple graft. For instance, nipple grafting will ensure that the nipple be repositioned onto the most projecting point of the new, much smaller breasts.

Technique: Inverted-T Incision vs. the Buttonhole Incision

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. 

The Inverted-T vs. The Buttonhole Incision

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.

The Inverted-T vs. The Double Incision

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.

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