Nipple Grafts

Many patients worry about nipple skin graft survival. It can be  helpful to understand how skin grafts work and to know what you can do to maximize nipple graft survival. In our practice, nipple grafts 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 our practice it is extremely rare to lose a considerable portion of a skin graft for any reason, and we have 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, but in a much more controlled manner. The skin graft is then placed on the ‘open’ area.

Immediately after placement, the body is developing new blood vessels that will grow into the graft. 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 with sutures. When the surgeon removes the outer bolster dressing about 1 week after surgery, the grafts are a little bit delicate, but already have a new 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 should be fully healed  and usually have the strength of non-grafted tissue.

Nipple Graft Healing Process 

It can take up to a year or more until the final healing of nipple grafts is complete and the redness around the areolas has disappeared. When nipples heal it is normal for them to look worse before they look better, especially around 14-21 days after surgery. Our surgeons have created a visual breakdown of what most nipples look like from 7 days after top surgery all the way up to 3 months.  For a printable version of the nipple healing process pictured below, click here.

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 cannot grow through a collection of blood into the graft. Surgeons do everything they can to control for this issue, including injecting a solution with epinephrine (to constrict the blood vessels) to the area as part of site preparation.
  • Infection. This is also controlled by the surgeon as well as possible during surgery by using IV antibiotics and maintaining a sterile operating room
  • Smoking. Smoking can cause issues with blood flow, and so we encourage patients to stop using anything containing nicotine in advance of surgery to ensure your body is able to adequately heal and establish blood flow to the new nipple grafts. Medical conditions, such as uncontrolled diabetes, can cause issues with healing. Your primary care provider can work with you and your surgeon to ensure any conditions you have are well-controlled and will not adversely impact your surgery. 
  • Shear Force. This is one factor patients 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.

In our 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 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.

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