The Bilateral Inferior Pedicled Anterior Intercostal Artery Perforator–Sparing Flap for Correcting Funnel Chest Deformity in Gender-affirming Masculinizing Chest Surgery

Summary: Pectus excavatum (PE) is the most common congenital anterior chest wall anomaly, often requiring surgical correction due to both functional and aesthetic concerns. Gender-affirming surgery has seen a significant increase in recent decades, with mastectomy being the primary procedure for transgender men. For transmasculine patients with PE seeking chest masculinization, the possibility of addressing both conditions in a single surgery has not been well explored. We report the first known case of a 33-year-old transgender patient with PE undergoing a combined procedure of masculinization top surgery and chest wall reconstruction. A novel bilateral inferiorly pedicled adipocutaneous flap, supplied by vessels of the anterior intercostal artery perforators, was used to correct the sternal depression while performing a mastectomy. This technique provided an immediate, well-perfused autologous reconstruction, eliminating the need for foreign implants or multiple procedures. The patient had an uneventful recovery and, at 1-year follow-up, demonstrated a satisfactory chest contour with complete correction of the funnel chest deformity and a masculinized thorax. This approach offers a viable, single-stage solution for transgender patients with PE, avoiding complications associated with implants or fat grafting. By using autologous tissue and preserving vascular integrity, this method expands the surgical options for chest wall reconstruction in gender-affirming care.