Nipple Graft Guide

Written by Dr. Bryan Chung

Many of my patients are worried about nipple/areola graft loss. Let’s talk a bit about how grafts work.

In its most basic terms, a skin graft is when skin is taken from one part of the body and put onto another part of the body. You can take almost ANY skin and put it (properly) somewhere else. Skin grafts are used for SO MANY THINGS: burns are probably the most commonly known uses for skin grafts, but plastic surgeons use them for all kinds of reconstruction.

When a skin graft is harvested, it is removed from its blood supply. This means that until it gets a NEW blood supply, the skin cells in the graft are going to slowly starve. A skin graft applied properly to its new location initially gets its nutrition from the fluid that is produced in the wound that is created in the new location.

For a nipple/areola graft, that’s on your chest. Over the course of about a week, your body grows new blood vessels into that grafted skin. That’s why you’re not allowed to get your grafts wet for the first week after surgery: If a little bit of water gets behind your graft, those little new blood vessels trying to grow into your graft won’t be able to get past the water film.

However, even if your grafts succeed (or “take”), there’s something you need to know about how your skin works. I came across this little comic and I think it explains things perfectly:

The living part of your skin is at the bottom/deep part of your skin. The deepest cells in your skin replicate, and push their clones upwards towards the surface of your skin. The stratum granulosum is the second highest “zone” in your skin. The skin cells that are pushed to the very top, as you can see in the comic, are dead.

This means that every skin graft has a living and a dead component. The deeper layers are still alive and need the blood that’s going to come from those new blood vessels. The top layer is already dead and isn’t coming back from the dead.

Nipple/areola grafts turn dark even if they’re doing fine because that top dead layer is getting pushed off by the bottom, living layers pushing newly dead skin cells to the top. In plastic surgery, we call it “slough” (pronounced “sluff”). Most skin grafts, after succeeding, will slough, where the very top dead layer falls/peels off, leaving a layer of shiny skin underneath.

Your surgeon can usually tell if the skin graft didn’t make it, or whether you just have slough. Either way, the solution is still the same: Don’t let your grafts crust over. Just put some Vaseline or petroleum jelly (a super thin layer) on them and keep them covered so they don’t dry out. If you’re just sloughing, the slough will come off in the shower on its own (don’t scrub your nipple off!). Eventually, new dead skin cells will take over on the very top, giving you a nice matte (not-shiny) look again.

Sometimes, the pigment cells die or stop working and these also live very close to the top layer of your skin (and therefore your graft). Most of the time they’re start producing pigment again, but it can be many months before they don’t look a little weird.