Nipple graft

A nipple graft is a nipple and areola that have been removed completely, trimmed smaller and stitched back onto the chest in a new position with no blood or nerve supply of their own. It is the standard way nipples are handled in double incision top surgery.

A nipple graft, also called a free nipple graft, is a nipple and areola cut fully away from the chest and reattached as a patch of skin. The opposite is a pedicled nipple, the surgeon's term for one that stays on a stalk of tissue. Peri-areolar, keyhole, inverted-T and the buttonhole variant of double incision all keep the nipple pedicled. A nipple graft does not, and that one difference explains everything below.

Where does a nipple graft come up?

A nipple graft is the default in double incision, so on anything bigger than a small chest it is almost certainly what a surgeon means by "we'll keep your nipples". Quotes list it as "bilateral mastectomy with free nipple grafts".

How is a nipple graft done?

The surgeon cuts the nipple and areola away as a disc of skin, trims it to roughly the size of a coin, thins it from behind, and stitches it into a matching patch of skin removed at the new position. A bolster, a pad of dressing sewn over the top, holds the graft still, because a graft that shifts in the first days will not take.

How does a nipple graft heal?

A nipple graft heals by "take": it survives on fluid seeping up from the tissue underneath for the first couple of days, then new blood vessels grow into it. That is why it looks dark, then crusts and peels, before pink skin shows through. The bolster comes off at about a week with the drains, and the scabs lift over the following two or three weeks.

What happens to sensation?

Most people lose erotic nipple sensation permanently with a nipple graft, and many have little or no touch sensation either, because cutting the graft free cuts every nerve to it. Some light touch returns over one to two years as nerves grow in from the edges, but I would plan on it not coming back. If sensation matters most to you, the pedicled techniques above are the conversation to have, on a chest that qualifies.

How often does a nipple graft fail?

Complete loss of a nipple graft is uncommon; published series mostly put it in the low single figures per hundred, lower still with experienced surgeons and no nicotine. Partial loss, where an edge or the nipple tip does not take and heals by scarring, is considerably more common. Colour change is common too: grafted areolas often heal paler or patchier than they started, sometimes darker, and nipple projection is usually reduced. That is the nature of a graft rather than a failure of technique.

What is done when a nipple graft struggles?

Dead tissue is trimmed and the wound left to close from underneath, which takes weeks. A patch that stays black and hard past the first couple of weeks is usually dead. A fully failed nipple graft leaves a flat patch of scar, and the usual fix later is a 3D nipple tattoo. Uneven size, position or colour are the common reasons for a revision at a year, nearly all of it minor work under local anaesthetic.

What should I ask the surgeon?

Ask what proportion of their nipple grafts fail, in part or in full, and what they do when one does. Ask to see healed nipple grafts at a year, straight on. And ask directly whether you are a candidate for a pedicled technique instead, so the choice between sensation and scars is one you have made rather than one made for you.

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