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Achieving symmetric positioning of the nipple-areola complex is a central aesthetic objective in double incision mastectomy for gender dysphoria. Discrepancies are easily perceived and can negatively influence postoperative satisfaction. Conventional markings rely on anthropometric measurements and anatomical landmarks, which are subject to variabilities, such as thoracic asymmetry, soft tissue variability and patient positioning. To address these limitations, we adopted a laser level projection technique, previously validated in reduction mammoplasty, to support precise horizontal alignment of the nipple-areola complex in chest masculinization surgery.

A class 2 laser level projection device was incorporated into routine preoperative markings and intraoperative positioning for patients undergoing a double incision mastectomy with free nipple-areola complex grafting. Mounted on a standard tripod at a defined distance from the patient, the device projects a continuous horizontal reference line across the anterior thoracic wall in both the upright and supine position, enabling direct visual control of bilateral nipple height prior to skin incision and immediately before definitive graft fixation. The technique was applied in 10 consecutive patients and descriptively compared to a prior cohort of 10 patients treated with conventional measurements alone. Feasibility, workflow integration, and symmetry outcomes at 6 months follow-up were assessed.

The laser system integrated seamlessly into the operative workflow without appreciable impact on preparation or surgery time. The projected horizontal reference line provided intuitive visual guidance and facilitated fine adjustments of nipple height prior to graft inset, representing a practical and reliable tool to established marking and positioning techniques.

Laser level projection shows to be a simple, safe, and reproducible adjunct for nipple-areola complex positioning in gender dysphoria double incision mastectomy with free nipple grafting. By providing an objective horizontal reference, the technique supports precise bilateral alignment and can be easily integrated into daily clinical practice.