Buttonhole Top Surgery

More sensitivity with a masculine chest shape for trans* men

Medically reviewed by: Dr. med. Timo Spanholtz
Specialist in Plastic and Aesthetic Surgery | Medical Director

The Buttonhole Top Surgery is a surgical technique for gender-affirming chest reconstruction (Top Surgery for trans* men) that aims to create a flat, masculine chest while preserving as much sensitivity as possible. This method combines features of the classic double-incision technique with the preservation of the nerve connections to the nipple, by using a "buttonhole" approach, through which the nipple-areola complex is not completely detached from the surrounding tissue. This provides a greater chance that sensation in the chest area is preserved.

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What does "Buttonhole" mean in Top Surgery?

The term Buttonhole comes from English and describes a technique in which the nipple is not removed and repositioned as a free graft (as in a classic double incision). Instead, the nipple-areola complex remains connected via a skin and nerve pedicle, while the surrounding breast tissue is removed. In this way – if the anatomy allows it – part of the natural nerve connections can be preserved.

Advantages of the Buttonhole Technique

Preservation of sensitivity

Because the nipple-areola complex is preserved with its tissue pedicle, there is a good chance that sensation and sensitivity are largely retained or regenerate faster than with methods involving free transplantation.

Masculine chest shape

Despite the preservation of sensitivity (for small breasts), the Buttonhole technique makes it possible to achieve a clear, masculine chest contour, which for many people is a central goal of Top Surgery.

Who is the Buttonhole technique suitable for?

The Buttonhole Top Surgery is particularly suitable if:

you want to preserve sensation and sensitivity of the nipple
you are aiming for a flat, masculine result
your anatomy has a sufficient tissue column (pedicle) for the nipple-areola complex
a classic double-incision transplantation is less attractive for you

If there is a large excess of skin or higher complexity in the tissue, another technique – possibly combined with nerve preservation/neurotization – may be the more suitable solution during the consultation.

Risks & Limits of the Buttonhole Technique

As with all surgical procedures, the following can occur here as well:

temporary or permanent changes in sensitivity, wound healing problems or scarring, asymmetrical results.

In addition, this technique is not suitable for every anatomical starting point – especially with significant excess skin or large breast volumes, it can be limited. The personal consultation provides clarity here.

Buttonhole vs. other sensitivity-preserving procedures

Many patients wonder how Buttonhole compares to other techniques:

Technique	Sensitivity preservation	Masculine contour	Scar appearance
Buttonhole	★★☆☆☆ (high)	★★★★☆	horizontal scars
Neurotization (nerve preservation)	★★★★☆ (very high)	★★★★☆	variable
Double Incision (free transplantation)	★☆☆☆☆	★★★★★	horizontal scars
Periareolar/Keyhole	★★★☆☆	★★★☆☆	small scars

Note: Rating stars serve as orientation – the actual sensation and aesthetics vary individually.

Procedure of the Buttonhole Operation

Consultation & Planning:
Beforehand, a detailed discussion takes place in which chest shape, sensitivity goals and anatomical conditions are taken into account.

Incision & Pedicle formation:
The double incision is made, while the nipple-areola complex remains connected via a defined tissue pedicle.

Tissue removal:
Breast gland tissue and excess skin are removed through the incisions, while the areola complex is preserved in its position or via the pedicle.

Contouring & Completion:
The upper body is anatomically re-contoured, the skin is closed and drained if necessary.

Sensation after the operation

Since the nipple-areola complex remains connected via a tissue pedicle, many people report that they retain or regain more natural sensation and tactile feedback in the chest area faster. This can also have positive effects on physical well-being, intimacy and identity.

However, sensitivity can vary individually and depends, among other things, on healing, nerve regeneration and surgical planning.

Sensitivity & masculine shape combined

The Buttonhole Top Surgery is an excellent option for people who find both sensation and a masculine result important in chest reconstruction – and whose anatomy is suitable for this technique. The decision should be made together with your surgical team, based on your goals, your build and your expectations.

Frequently asked questions about Buttonhole Mastectomy

We are happy to answer your questions about the treatment here.

Does the Buttonhole technique leave scars behind?

Yes, since this technique involves removing excess skin, horizontal scars form beneath the chest muscles – just like with the classic Double Incision. Additionally, there is a fine scar around the repositioned nipple-areola. With good scar care, these lines usually fade very well over time.

Who is the buttonhole mastectomy best suited for?

This method is ideal for you if you have a medium to large chest, want a very flat, masculine result, but do not want your nipples to heal as a free graft. It is the perfect choice for people for whom preserving nipple sensitivity is particularly important.

Is the buttonhole technique possible with any breast size?

In principle yes, as long as there is enough tissue for the inner pedicle. With extremely large breasts or very deeply sagging tissue, your surgeon must individually assess during the consultation whether the tissue pedicle is long enough to bring the nipple to its new position without too much tension.

Can the chest become completely flat with the Buttonhole Mastectomy?

Yes, the goal of the Buttonhole Mastectomy is a flat, masculine profile. However, a small difference compared to the classic Double Incision is that a minimal amount of tissue must remain under the nipple to protect the blood supply and the nerves (the tissue pedicle). In most cases, this is not visually noticeable and even contributes to a natural contour.

What is the biggest advantage of the buttonhole method?

The decisive advantage is the preservation of sensitivity. Since the nipples remain connected to their original nerves and blood vessels throughout the entire operation, sensation (including erogenous sensitivity) is preserved in most cases. In addition, blood circulation remains more stable, which minimizes the risk of losing the nipples.

What is a buttonhole mastectomy?

The buttonhole technique is a variant of mastectomy with large horizontal incisions (similar to the Double Incision), but in which the nipples are not completely removed and re-transplanted. Instead, they remain connected to the body via a tissue bridge (the so-called pedicle) and are guided to the outside through a new opening in the skin – similar to a button through a buttonhole.

How does healing with the Buttonhole Mastectomy differ from other methods?

The healing phase of the large incisions in the Buttonhole Mastectomy is identical to the Double Incision. The major advantage lies in the healing of the nipples: Since they do not have to grow on as a graft, the critical phase in which one has to worry about the nipples "taking" is eliminated. They are supplied with blood immediately after the surgery and usually retain their natural color.

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