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Non-Binary Nipple and Areola Options

This article gives an overview of the variety of nipple and areola options that are available to all top surgery patients–whether they are getting a chest reconstruction or breast reduction–and have been of particular interest to our non-binary, gender fluid and gender non-conforming patients. We discuss the difference between free nipple grafting and pedicle preservation for patients whose greatest priority is maintaining a heightened level of nipple sensation. Then, we go over the different options for altering the nipple-areola complex’s size, position and projection. We conclude by reviewing the possibility of having no nipples and how patients who opt to remove them can get hyper realistic nipples tattooed onto their chest by a trusted provider.

In plastic surgery terms, the areolas are the wide (usually circular) pigmented area that also contains the nipple. The nipple is the only part that projects outward from the chest and is usually somewhat cylinder shaped.

Nerve reconstruction for top surgery

For some patients, having heightened, erotic sensation in their nipples can be a cause of gender dysphoria. For this reason, they are eager to remove their nipples or have their nipple sensitivity reduced with a free nipple graft. On the other hand, maintaining heightened levels of sensation in their nipples after surgery is a priority for other patients. The double incision (DI) top surgery procedure performed with a free nipple graft (FNG) often comes at the cost of reducing nipple sensitivity to a tactile level of sensation. However, the GCC now offers a neurotization or sensation preservation technique so that DI FNG patients can retain heightened sensitivity in their nipple areola complex post-op. For more information about nerve preservation or nerve grafting in top surgery, click here.

Nipple Grafting vs. Pedicle Preservation: Sensation Preservation

Top surgery patients seeking chest reconstruction or a breast reduction have the option of (1) undergoing a free nipple graft or (2) a pedicle preservation; both of these procedures can be used for chest reconstruction or breast reductions. A free nipple graft allows a surgeon to have greater control over the resizing and repositioning of the nipples and areolas. On the other hand, a pedicle preservation leaves a hope for heightened nipple sensation to be maintained by keeping the areola and nipple alive in its original form–as opposed to turning it into a skin graft. Concretely, this means that a surgeon must leave a certain amount of tissue behind to preserve the nipple’s original blood and nerve supply. As a result, the trade-off of a pedicle preservation is that complete chest flatness cannot be achieved. It is also important to note that with this procedure there is no 100% guarantee of nipple sensation conservation. A patient would have to wait up to two months after the procedure to know how much sensation will return to the nipples. The pedicle preservation is most commonly conducted as a part of an inverted-T or a buttonhole incision procedure.

Conversely, the advantage of a nipple graft is that it allows for the surgeon to take out all mammary tissue, leaving the patient with as much flatness as they desire. In the case of a breast reduction, a nipple graft allows the surgeon to have more precise control over the repositioning and resizing of the nipples; for instance, nipple grafting ensures that the nipple will be repositioned onto the most projecting point of the new, much smaller breasts. That said, even if you do not opt for free nipple grafts, you can still have your areolas resized (i.e., making your areola smaller).

For more information on ways that non-binary patients typically ask for their nipples to be resized and repositioned during top surgery, read the sections below. If you would like to read more about top surgery techniques that leave behind a degree of fullness to the chest or breasts, click here.

Aesthetic Factors: Features of “Binary, Male-Appearing” Nipples and Areolas

During a top surgery procedure, the areolas are usually resized to the diameter of 22 mm (about the size of a nickel) and are most commonly made to be circular. 22 mm is the average areola size of a cisgender male with minimal chest fat:

Smaller areolas (about 22 mm diameter) may be ideal for patients who desire a more conventionally masculine result to their top surgery procedure

• Projection: For double Incision top surgery, the degree of projection of the nipples is dramatically reduced. This is a necessary step as part of the nipple grafting procedure. However, in other procedures such as keyhole or periareolar top surgery, the nipple is not typically reduced though the areolas are typically reduced.
• Size: Most who wish to have a more conventionally masculine appearing chest usually opt for considerably smaller areola (22 mm in diameter) and a considerably less projected nipple.
• Location: A typical location of a conventionally masculine areola would be approximately 3 cm inside and also superior to the pectoralis major muscle border. Though there are a number of calculations that try to define the optimal location, ultimately it is the surgeon’s sense of aesthetics and the patient’s preferences which primarily determines the best location for the nipple at the time of the procedure.

Aesthetic Factors: Features of Androgynous Appearing Nipples and Areolas

Most often, if a non-binary individual wants to have a more androgynous appearing areola, they may choose a size that is slightly larger in diameter (usually 25 to 26 mm). This slightly larger areola option is about the size of an American quarter or a European One Euro coin.

• Projection: Some non-binary patients have also wished to maintain more projection of the nipples. Nipple projection can be controlled to some degree with the composite nipple grafting procedure. 
• Size: For those wanting to have larger diameter areolas, it’s important to note that beyond about 30 mm in diameter the areola can begin to become more conventionally feminine in appearance.

Larger areolas (about 30 mm diameter) reflect a more conventionally “feminine” appearance and may appeal to non-binary or gender expansive patients who wish to customize the results of their top surgery procedure

Medium-sized areolas (about 25-26 mm diameter) example

• Location: Non-binary folks may wish to have a location of the nipple areola more complex, so that is either slightly more narrow than usual or higher than usual that of someone wanting to obtain a conventionally male-appearing result. Our surgeons find that when patients choose a wider areola, a slightly higher placement seems to be overall aesthetically most pleasing.

Upward nipple location example

Inward nipple location example

• No Nipples: It’s very important to mention that some individuals may not want to have any nipples at all as a part of their procedure. This would require the procedure to be a double incision procedure but one in which we would avoid using the free nipple grafts altogether. Some individuals wish to never have any nipples on their chest, and other individuals will tattoo nipples and areolas on their chest later in life instead of opting for a nipple graft. It is interesting to note that there are some outstandingly well designed temporary stick-on areolas made of silicone which can be attached to the chest temporarily when desired–although options with a variety of skin tones are limited.

No nipples, diagonal incision, example

No nipples, curved incision, example

How can I take care of my nipple grafts after top surgery?

In the following clip, Dr. Facque (he/him) explains how you can take care of your nipple grafts after surgery:

What should my nipple grafts look like through the recovery process?

In the following informational video, Dr. Mosser (he/him) describes the healing process of a nipple skin graft:

In Conclusion

If you’re interested in customizing a top surgery procedure so the end result feels or appears more affirming to you, please read this additional content on non-binary incision and chest contouring options.