FTM & FTN Nipple Grafts

Many patients worry about nipple skin graft survival. It’s helpful to understand how skin grafts work and to know what you can do to maximize nipple graft survival. In Dr. Mosser’s experience, they are completely successful about 98% of the time.

Skin grafts are rather miraculous things! We can take a piece of a person’s body, remove it from their body, and put it somewhere else on the body where it will stay and survive. It’s an amazingly reliable procedure. In Dr. Mosser’s practice it is extremely rare to lose a considerable portion of a skin graft for any reason, and Dr. Mosser has not had a patient completely lose any of the hundreds of skin grafts performed.

How Nipple Grafts Work

First, we gently remove the outer layer of skin from the location where the graft is being relocated.  Think of it as skinning your knee pretty deeply. The skin graft is then placed on the ‘open’ area.

A few days after placement, the graft survives on the dissolving nutrients coming from the deeper layers directly into the skin graft. It can live that way for about 3-4 days. During that time, the body develops new blood vessels that grow into the skin graft. If that process is unsuccessful, the skin graft will fail.  To make sure the graft has solid and continuous contact with the body during this process, the surgeon places a bulky ‘bolster’ dressing on the graft that is tied down to the skin.

When the surgeon removes the outer bolster dressing about1 week after surgery, the grafts are a little bit delicate, but already have a blood supply.  During days 7-21 after surgery, the graft gains a lot of strength, and is quite resilient after 21 days.  By 42 days (6 weeks) after surgery, the grafts are very strong and usually have the strength of non-grafted tissue.

Threats to Skin Graft Survival

Anything that impairs the ingrowth of blood vessels can impact the survival of a skin graft. As you read above, the arrival of new blood vessels within a tight time frame is an important component of skin graft survival. Here are the various issues that can cause a problem:

  • Bleeding during the procedure. If the area beneath the skin graft is filled with blood, the blood vessels could not grow through a collection of blood into the graft. Surgeons do everything they can to control for this issue.
  • InfectionThis is also controlled by the surgeon as well as possible during surgery.
  • Smoking. Patients who smoke may have problems growing blood vessels because the underlying tissues have become unhealthy on a molecular level and therefore blood vessels did not grow quickly or effectively to reach the graft in time.
  • Medical conditions, such as uncontrolled diabetes can impair healing on a cellular level.
  • Shear Force. This is one factorpatients can consistently have control over and you can read more about how below.

The “Shear Force” in Nipple Grafts

A “shear force” is a sideways force of one plane being pushed to slide along another plane. Imagine blood vessels slowly making their way into the skin graft. If, at any point, the skin graft is pushed to the side, it would interrupt the ingrowth of those vessels. This would potentially result in failure of the vessels to arrive on time, and therefore failure of the skin graft.

To protect the graft from shear force, during surgery we place a thick dressing on top that securely presses the graft down. This keeps fluid from collecting underneath the graft and protects it from shear forces from the side.  A compression garment is often used, since it helps to keep the graft from being bumped to the side – (either during sleep or daily activities).  We strongly advise patients to avoid pushing the garment to the side or brushing their chests inadvertently with an arm to avoid creating shear force.

Your chances of skin graft success are greatest if you’re healthy, if the skin graft is well prepared, and the thick bolster dressing is applied to prevent shear force. In Dr. Mosser’s experience, it’s a better than 98 % chance of having a successful full thickness nipple graft.

Here’s an infographic that helps spell out this process of FTM/N nipple graft survival.  A PDF image of this diagram can be downloaded here. You can also find a video of Dr. Mosser explaining the procedure below.

Double Incision Nipple Grafts

Steps of FTM/N Nipple Graft Survival

Bonus!  Here’s a video to bring it all home and show again how this works:

When Your ‘Free Nipple Graft’ or ‘Nipple Areolar Reconstruction’ Code Gets Denied

Currently we’ve only seen the denial of the Free Nipple Graft code with the insurance companies Aetna and United Health Care. We hope that other insurance companies don’t follow suit. At the Gender Confirmation Center we believe that the patient should have the choice of whether or not to retain their nipples and believe it should be covered by insurance if they choose to keep them.

If your Free Nipple Graft CPT billing code gets denied you should do the following if you’re able to:

  1. Appeal the claim. You have the opportunity to ‘fight’ the insurance company
  2. Call your insurance company and let them know how you feel

If your insurance continues to deny your appeal and it’s looking like you’ll need to pay for your Free Nipple Grafts out of pocket then please read the following.

What Do You Do When Your ‘Free Nipple Graft’ Billing Code Gets Denied?

Anytime a surgeon cuts into a patient there is a code and a fee for it. If your insurance denies your free nipple graft billing code than you will be responsible for paying for the nipples out of pocket (unless you opt for no nipples at all). If you opt for ‘no nipples’ but still want the appearance of nipples there are 3D nipple tattooing options. If you want to retain your nipples and have to pay out of pocket you’ll want to understand why paying for the Free Nipple Graft (nipple reconstruction) is expensive.

 

How Are Gender Affirming Top Surgeries Coded?

‘Traditionally’ a Breast Mastectomy is most often performed when a CIS gender woman or trans/non-binary identified person who was assigned female at birth develops breast cancer and the doctor mandates this surgical procedure should be done. There are no transgender billing codes at this time, so this is why an FTM/N top surgery is coded as a Breast Mastectomy. For gender affirming surgeries CPT codes are used to code your surgery. CPT code stands for ‘Current Procedure Terminology’.

  • Breast Mastectomy CPT billing code: 19303
  • Free Nipple Graft (nipple removal and relocation) CPT billing code: 15200 / 15201
  • Nipple Areolar Reconstruction CPT billing code: 19350

When A Transgender Surgery Billing Code Is Denied

Once your ‘claim’ is submitted the insurance companies will come back with either an ‘approval’ or a ‘denial’ of specific CPT billing codes. Meaning if your surgery has more than one CPT billing code (such as FTM/N top surgery) then they could approve one, but deny the other.

Recently with health insurance companies like Aetna and United Health Care they may approve the Breast Mastectomy CPT code of 19303 but deny the Free Nipple Graft CPT code of 15200 or the Nipple Areolar Reconstruction CPT billing code of 19350. Insurance companies see getting free nipple grafts procedure as ‘cosmetic’ and due to this unfortunate decision by certain insurance companies we would be forced to collect the fees pertaining to this portion of your surgery.

The Cost of Free Nipple Grafts When Paying Out of Pocket

When you think of the size of your chest compared to the size of your nipples you would think the billing code related to a ‘smaller’ part of your body would be less expensive. This logic may arise if you’re thinking ‘smaller’ means ‘less’ work. However, Nipple Reconstruction (Free Nipple Grafts) is a detailed process no matter what type of FTM/N top surgery you’re having.

FTM/N Top Surgery Procedures That Don’t Have a ‘Free Nipple Graft’ CPT Code

Unless you are opting for an FTM/N top surgery with no nipples there will always be a ‘nipple reconstruction fee’. This is because when performing any type of FTM/N top surgery the nipple is being ‘reconstructed’ in some way. This includes the following procedure types: