While for very small breasts a peri-areolar skin excision can be performed, the problem of maintaining an adequate pedicle to support the nipple areolar complex without protrusion of the pedicle through the skin becomes challenging. Bringing skin into the borders of a contracted areola will cause puckering which hopefully with time will smooth out. A permanent fixation suture is often required to prevent tension on the suture line from causing a slowly expanding scar.
The areola is trimmed to a pre-agreed-upon diameter and the nipple sectioned with a pie-shaped excision and reconstituted. There may be varying sensory loss because of nerve disruption, though distal nerves are known to regenerate.
Some crusting of the grafts is not unusual and will usually shed by the 3 or 4th week. It is suggested to not lift or pick them off as the adherence of the graft may be very tenuous and its viability very fragile.
After tissue settling some revision surgery may be required. Breast sizes greater than a C, need to be done in hospital setting.
For petite breasts, like an A or a small B, a peri-areolar incision can be done. That is a circular incision around the areola, combined with an inner circular incision to remove some of the unneeded areola as well. Drawing the skin into the center will result in some puckering, but this often smooths out with time. There will be significant tension on the scar line, and to prevent spreading of the scar, a permanent fixation suture is needed. Leaving outer dermis (raw skin) underneath the marginalized areola helps in its survival.
The keyhole incision (think skeleton key) augments the periareolar incision further by making a vertical closure underneath (lollypop), which results after the unwanted skin is pulled in from side to side and the excess is removed.
An anchor incision adds to that a transverse incision usually in the infra mammary fold to further remove excessive skin. Draping or blousing is not desirable. This is reserved for much larger breasts or topographically a larger surface area as seen in women with postpartum breast atrophy.
Not uncommonly the surgeon may wish to revise the incision lines after 3 or more months of settling shows some residual problem areas.
The nipple areolar complex may be supported by a pedicle which has the advantage of leaving some sensation and blood supply intact, but can have the disadvantage when the pedicle has sufficient bulk not to provide the flat look most FTM patients desire.
Soaking the dressing with normal saline every 3 hours round the clock for 5 days prevents the tissues from drying out before sufficient capillary ingrowth has occurred. There are many techniques to reconstruct a nipple as well as tattoo the areolar area should that be necessary.