The Buttonhole procedure is identical to the “Inverted T” procedure in many ways, and so the nipple and areola do not need to be placed as a free nipple graft. And, because less skin needs to be removed than with the Inverted T, the Buttonhole approach does not require a vertical incision.
Buttonhole surgery is a good choice for patients with less breast tissue and so require less skin excision. Therefore, this procedure avoids the extra vertical incision and resulting scar that is part of the inverted T procedure. Like the inverted T, there is the hope of maintenance of sensation density in the nipples.
As with the inverted T procedure, a thin “pedicle” is created that maintains the sensation and blood supply to the nipple area. Use of the pedicle means that it’s possible that sensation density may be maintained. It takes several weeks to months after surgery to tell whether sensation has been maintained.
Like the Inverted T procedure, the buttonhole has the potential upside of a greater chance of sensation retention. But – also like the Inverted T, possible downsides include more tissue remaining in the chest area and the surgeon may not have the full control over the lateral positioning of the nipple, as they would with the double incision procedure. The amount of fullness left over is variable – based on how large the breasts were before surgery, and also based on the firmness of the breast tissue.
Finally, the surgeon still has the same challenge as with the inverted T in that they may not be able to customize the location of the incision quite as well as they could with a double incision procedure.
If you do not want free nipple grafts, or you hope to take a chance at maintaining sensation density of the nipples, the Buttonhole or Inverted T are procedures worth considering.
However, if your priority is a chest that is as flat and male as possible and if you want to have the best position of the areolas on the chest, the Double Incision procedure is the most powerful tool we have to achieve these goals. And if your long-term priority is to work out and to have as muscular of a chest as possible, this procedure is not for you because the leftover tissue could obscure a clean muscular border. Ultimately, the best approach is to have a full discussion with a board-certified plastic surgeon who is comfortable with all possible chest reconstruction procedures and then determine which procedure is likely to have the best outcomes for you.