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, 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 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.
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 about 1 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.
It can take up to a year or more until the final healing of your nipples is complete and the redness around the areolas has disappeared. When nipples heal they can look worse before they look better, especially around 14-21 days after surgery. For this purpose, Dr. Mosser 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.
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:
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.
Bonus! Here’s a video to bring it all home and show again how this works: