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First published online April 26, 2020

Free Nipple Grafts: What to Expect During the Healing Process


A variety of surgical techniques for masculinizing chest wall reconstruction has been described. One well-described approach is the double incision subcutaneous mastectomy with free nipple grafts. There is little documentation available that clearly describes the healing process of free nipple grafts for patients and their caregivers. The nipple-areolar complex is harvested as a full-thickness skin graft. It is resized and repositioned to conform to a more masculine aesthetic. A bolster of nonadherent dressing is tied over the graft and left in position for 7 days as adherence, imbibition, and inosculation occur. The superficial layer of epidermis of the graft initially exfoliates as it is replaced by upwardly migrating cells of follicular epithelium. This is observed as a sloughing which can be disturbing to the patient although it is an expected progression of the healing process. Viable pink dermis will be seen underneath. Pigmentation of the nipple graft can take 3-9 months. Free nipple grafts are useful in cosmetic and reconstructive surgery of the breast. Additional documentation of the healing process provided here can help reassure the patient and their primary care providers.

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1. Hage JJ, van Kesteren PJ. Chest-wall contouring in female-to-male transsexuals: basic considerations and review of the literature. Plast Reconstr Surg. 1995;96(2):386-391.
2. Monstrey S, Selvaggi G, Ceulemans P, et al. Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm. Plast Reconstr Surg. 2008;121(3):849-859.
3. Wolter A, Diedrichson J, Scholz T, Arens-Landwehr A, Liebau J. Sexual reassignment surgery in female-male transsexuals: an algorithm for subcutaneous mastectomy. J Plast Reconstr Aesthet Surg. 2015;68:184-191.
4. Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr Surg. 1966;38:414-419.
5. Davidson BA. Concentric circle operation for massive gynecomastia to excise redundant skin. Plast Reconstr Surg. 1979;63:350-354.
6. Ramella V, Papa G, Arnez ZM. Surgical therapy: chest wall contouring for female-to-male transsexuals. In: Trombetta C, Liguori G, Bertolotto M (eds) Management of Gender Dysphoria: A Multidisciplinary Approach. Springer, Milano;2015:281-287.
7. Rudolph R, Klein L. Healing processes in skin grafts. Surg Gynecol Obstet. 1973;136(4):641-654.
8. Converse JM, Smahel J, Ballantyne DL Jr, Harper AD. Inosculation of vessels of skin graft and host bed: a fortuitous encounter. Br J Plast Surg. 1975;28:274-282.
9. Thornton JF. Skin grafts and skin substitutes. Selected Readings in Plastic Surgery. 2004;10:1-23.
10. Birch J, Branemark PI. The vascularization of a free full-thickness skin graft: I.A vital microscopic study. Scand J Plast Reconstr Surg. 1969;3(1):1-10.
11. Birch J, Branemark PI, Lundskog J. The vascularization of a free full-thickness skin graft: II.A microangiographic study. Scand J Plast Reconstr Surg. 1969;3(1):11-17.
12. Birch J, Branemark PI, Nilsson K. The vascularization of a free full-thickness skin graft: III.An infrared thermographic study. Scand J Plast Reconstr Surg. 1969;3:18-22.
13. Converse JM, Rapaport FT. The vascularization of skin autografts and homografts; an experimental study in man. Ann Surg. 1956;143(3):306-315.
14. Zarem HA, Zweifach BW, McGehee JM. Development of microcirculation in full thickness autogenous skin grafts in mice. Am J Physiol. 1967;212:1081-1085.
15. Wolff K, Schellander FG. Enzyme-histochemical studies on the healing process of split skin grafts. J Invest Dermatol. 1965;45:38-45.
16. Tsukada S. Transfer of free skin grafts with a preserved subcutaneous vascular network. Ann Plast Surg. 1980;4(6):500-506.
17. Medawar PB. The experimental study of skin grafts. Br Med Bull. 1945;3:79-81.
18. Conway H, Sedar J. Report of the loss of pigment in full thickness autoplastic skin grafts in the mouse. Plast Reconstr Surg (1946). 1956;18(1):30-36.
19. Waris T, Astrand K, Hamalainen H, Piironen J, Valtimo J, Jarvilehto T. Regeneration of cold, warmth and heat-pain sensibility in human skin grafts. Br J Plast Surg. 1989;42(5):576-580.


Alvina Won, MD, is currently offering cosmetic surgery services at Eviva Surgery Center in Shoreline, WA. She completed an AACS general cosmetic surgery fellowship in 2019 under the mentorship of Tony Mangubat, MD, at La Belle Vie Cosmetic Surgery Center. She completed her General Surgery training in 2004 at the Unviersity of Iowa Hospitals & Clinics. She is now Board Certified in Cosmetic Surgery as well as General Surgery.
E. Antonio Mangubat, MD, is the founder and medical director of La Belle Vie Cosmetic Surgery since 1987. He is an internationally recognized cosmetic surgeon with over 20 years of clinical experience as well as teaching and research expertise.

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Published In

Article first published online: April 26, 2020
Issue published: December 2020


  1. free nipple grafts
  2. skin grafts
  3. transgender surgery
  4. subcutaneous mastectomy

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© The Author(s) 2020.
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Published online: April 26, 2020
Issue published: December 2020



Alvina Won, MD
E. Antonio Mangubat, MD
La Belle Vie Cosmetic Surgery Center, Tukwila, WA, USA


Alvina Won, La Belle Vie Cosmetic Surgery Center, 16400 Southcenter Pkwy, Suite 101, Tukwila, WA 98188, USA. Email: [email protected]

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