Buttonhole Approach | Top Surgery Center of Connecticut

Female To Male (FTM) & Female To Nonbinary (FTN) Reconstruction Chest Surgery

FTM & FTN Buttonhole Surgery

Buttonhole Pre Surgery

Photo By: John Doe
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Buttonhole Pre Surgery

Photo By: John Doe
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The buttonhole approach and inverted-T approach are similar in that their purpose is to provide some hope of retaining erotic nipple sensation after surgery. Both procedures avoid free nipple grafting by keeping the nipple areola attached to some underlying breast tissue, thus the result is a chest wall that is not as flat compared to the Double Incision technique. Patients who require less skin excision can avoid the vertical incision that comes with the inverted-T.

How the Procedure is Performed

First, the nipple is preserved on what is called the “pedicle” which is a small mound of breast tissue that lies beneath and inferior to the nipple areola. This pedicle is carefully preserved underneath the skin to provide some nerve supply and blood supply to the nipple areola. Then an elliptical skin excision pattern is developed similar to the Double Incision technique, with the only difference being that the lower incision needs to lie at the inferior chest fold, so there is less customizability regarding scar shape after surgery. Breast tissue is removed through those incisions on either side and above the pedicle to the nipple areola. Blood supply to the nipple areola is continuously monitored throughout the case, and any concerns may result in less tissue being excised or the nipples being converted to free nipple grafts. The skin incisions are then closed together to result in an inferior horizontal chest wall scar and the nipple areola complex is brought out through a separate oval or circular incision within the chest wall skin.

Indications for the Buttonhole Approach

Desire for a chance at retaining erotic nipple sensation
Ok with the lack of complete flatness of the chest wall
Moderate skin excess

Downsides to the Buttonhole Approach

The obvious major downside to this approach is the lack of complete chest wall flatness as compared to the Double Incision approach. This lack of flatness may also make it difficult to see visible muscle definition beneath the skin. Other downsides include lack of control over nipple areola position and lack of control over the shape of the inferior chest scar. In addition, this approach only provides a chance at retaining erotic nipple sensation, not a guarantee. Because nerves take a long time to recover after surgery, it may not be known for months whether nipple hypersensitivity has been preserved.

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