Nipple Necrosis

By Nick Peplow·Gender-affirming surgery coordinator

Last reviewed 27 September 2026· How this site is researched

Nipple necrosis means part or all of a nipple and areola dying after top surgery because it didn't get enough blood. It is the complication people fear most, and the one most often mistaken for something else, because a graft that is healing well looks alarming at the first dressing change.

How a graft takes

In double incision, the nipple is usually cut away completely, trimmed to about the size of a coin, and stitched onto the chest as a free nipple graft. For the first few days it has no blood supply of its own and lives on fluid seeping up from the tissue underneath. Over the next week or so, new vessels grow into it. That only works if the graft stays still and flat against its bed, which is what the bolster, the pad of dressing stitched over it, is for. Blood or fluid collecting underneath, infection, pressure and nicotine all get between the graft and the tissue it's feeding from.

How often it happens

Partial loss, where an edge or the tip doesn't take, is the common form. Complete loss is rarer. In Vico and Salmon's 2024 series of 155 double incisions, 6.5% had partial necrosis of the nipple-areola and another 5.2% lost pigment without losing tissue; no complete losses were reported. Rifkin and colleagues (2022), with 390 double incisions and 96 peri-areolar cases from one surgeon, recorded no nipple necrosis at all. A 2025 review of seven studies by Pollack and colleagues found tranexamic acid, the clotting drug that reduces hematoma, made no measurable difference to necrosis.

So the published range runs from none to about one in fifteen, almost all of it partial. The gap probably reflects surgeon and patient mix, which is why your own surgeon's figure is the one to ask for.

What normal looks like

When the bolster comes off, at around a week, a healthy graft commonly looks:

• dark purple, brown or close to black on the surface
• crusted, scabbed or peeling at the edges
• flat, with little or no projection
• pale pink or white in patches where the crust has lifted
• occasionally weeping a little clear or yellowish fluid

The dark layer is the top skin of the graft shedding, and what's underneath is usually alive. Over the second to fourth week the crust lifts away and leaves pink, shiny, fragile skin. Colour comes back over months, often lighter or patchier than before, and grafts often heal a little larger or more oval than drawn. They keep changing for a year.

I've lost count of the photos I've been sent at the one-week mark by someone certain a graft had died. Most of them showed exactly the dark, crusted graft described above, and most of those grafts went on to heal. Even surgeons often can't say at a week how much of a graft will take. Time settles it, and the judgement is theirs.

Signs a graft is in trouble

• It looks dry, hard, leathery and shrunken, rather than crusted over something soft
• It is turning solid black all the way across, rather than mottled
• The edges are lifting away from the chest
• Pus, a bad smell, or redness spreading out from it, which points to infection
• When the crust comes away there's a crater or yellow-grey tissue rather than pink skin
• A firm, swollen side under the graft, which can be a hematoma lifting it off its bed

Pedicled nipples

Peri-areolar, keyhole, inverted-T and the buttonhole version of double incision keep the nipple attached to a stalk of tissue with its own blood supply. Necrosis is less common, and Rifkin's peri-areolar group had none. When it does happen it's because the stalk isn't delivering enough blood, which is more of a risk the further the nipple is moved and the longer the stalk. The warning comes earlier than with a graft. An areola that turns dusky blue or grey, or goes pale and cold, in the first day or two is a same-day call, because a surgeon can sometimes relieve the pressure on a struggling stalk if they see it early.

When to call your surgeon

Call the same day if:

• a bolster has come off or shifted before you were told to remove it
• a graft has been knocked, rubbed or pressed on (a binder, sleeping face down, a pet, a hug)
• there's increasing redness, heat, pus or smell around a graft
• you have a temperature
• one side has swollen, tightened or become more painful than the other
• a pedicled nipple has gone dusky, blue-grey or pale

A high fever with a racing heart, shaking or confusion, or redness spreading fast across the chest, means an emergency department; the complications page lists the other emergency signs.

Most surgeons will look at a photo, and it's the fastest way to an answer. Take it in daylight, straight on, both sides in the frame. Don't peel crusts, don't put anything on a graft that wasn't given to you for it, and don't wear a binder over healing grafts; the compression page explains why a surgical vest is different.

What raises the risk

Nicotine in any form is the big one, because it narrows the small vessels a graft depends on in its first week. The others are diabetes, larger chests where grafts sit on a longer, thinner flap, previous chest surgery, a hematoma or seroma under the graft, infection, and anything that moves or presses on the graft in the first ten days or so. You control the nicotine and the pressure. The rest is the surgeon's to plan around, which may mean recommending grafts over a long stalk, or the other way round.

If part or all of it is lost

Partial loss is usually handled without surgery. Dead tissue is left to separate or trimmed in clinic, the area is dressed and kept moist, and it heals in from the edges over a few weeks. The result is often a smaller or irregular areola that looks better once pigment returns than it did at six weeks. In Vico and Salmon's series, partial losses were managed this way and then touched up, by reconstruction or tattoo under local anaesthetic, from about three months after full healing. Grafts that had only lost colour were tattooed from about six months.

Complete loss heals into a flat, pale patch of scar. Once your surgeon says the area has settled, the options are:

• Tattooing. A 3D nipple tattoo by an experienced artist can be convincing at normal distance, and is the most common route.
• Reconstruction. A small flap of local skin is shaped into a nipple with some projection, usually tattooed afterwards, as a minor revision.
• Nothing. Some people choose no nipples from the start, and some find after a loss that they're content without one.

At the consultation, I would ask what proportion of their grafts fail in part or in full, what they do when one does, and whether touch-up tattooing or reconstruction is included. Ask to see healed grafts at a year, including one that was partly lost.

Getting through the wait

The weeks between the first dressing change and knowing for sure are hard, and checking the grafts twice a day doesn't move anything along. Send the photos to your surgical team rather than a forum. The mental health page has more on the uncertain stretch of recovery.

This page is information, not medical advice. Whether a graft has taken is your surgeon's call.