How is a free nipple graft created?

The first step involved in Double Incision Top Surgery involves marking a small oval around the existing nipple within the colored skin of the areola, and this oval usually measures about 26-30mm horizontally by 20-22mm vertically. A small blade is used to incise this marked oval and the blade is then used to raise the new nipple areola off of the underlying tissue. This process is called "harvesting the graft". All the skin around the location where the graft is taken from is planned to be discarded with the elliptical skin excision that is part of the double incision approach. The nipple graft is usually bulkier than we would like it to be, so small instruments called mosquitos are used to provide tension on the graft, and a small scissor called a curved iris scissor is used to remove some tissue from the underside of the graft until it is thinned out just the right amount. We want the graft to have some structure but also to be thin enough to "take" to the surrounding tissue where it will be placed. A very thick graft would be unlikely to survive because for the first few days the graft relies on oxygen and nutrients that get absorbed from the surrounding blood supply where the graft is placed. A very thin graft will develop an almost inverted nipple, so the balance lies somewhere in between. Once the graft is adequately thinned out, it is placed in a moist sponge and allowed to sit while the rest of the surgery is performed.

Once the double incision surgery is complete, the new nipple position is marked out after carefully measuring for symmetry. Usually the graft is placed about 20 cm from the sternal notch, and along the lateral edge of the pectoralis major muscle. A similar oval is marked out as when harvesting the graft, and the skin overlying the marked oval is shaved off, a process called "de-epithelialization" which means removing the very top layer of skin, leaving the thicker layer of skin underneath, called the "dermis". The dermis is the part of your skin that is red and bleeds, and this layer provides a healthy wound bed for the nipple graft to take.

Then the nipple graft is sutured in place using fine sutures followed by thicker sutures around the graft that will be used to tie a dressing over the graft. This dressing is called a "bolster" and is made of an outer layer of xeroform which gives it the yellow appearance because it has iodine in it. Before the bolster is attached, fine punctures are made in the graft which do not affect the future aesthetic of the graft, but allow for fluid egress to prevent bleeding underneath the graft.

How Does the Graft Heal?