Risks of free nipple graft compared to no free nipple graft?

If your priority is going as small as possible and you're okay with the trade-offs (loss of breastfeeding ability, decreased sensation, possible pigment/texture changes), a free nipple graft is a very reasonable and safe option when performed by an experienced surgeon. Just be sure to follow all post-op care instructions closely, especially in the first 2–3 weeks when graft take is most critical.

If your rationale is to have the smallest possible breast size, even at the expense of nipple sensation or appearance, then a free nipple graft is likely a good consideration.

However, you must be aware that, on the one hand, you won't have sensation, and on the other, the nipple's appearance will not be the same as it would be if it were based on a pedicle, as is done in all other methods. The nipple might have a different color and be flatter. Furthermore, you must consider that there is a significant chance of partial necrosis.

Another option would be to perform the reduction in two stages, using a different method initially and then further reducing the breast volume in a second step. This would have the disadvantage of two separate operations but the advantage of better sensation and a better appearance of the nipple-areola complex.

Practically flat is a very unusual request, and if that is really what you want, probably a free nipple graft is what you would need. But that depends on where you are starting from. You did not mention your current breast size, nor are there any pictures.
Reasons not to get a free nipple graft: complete loss of sensation (you can't depend on any sensation coming back; loss of erotic sensation to the nipple; partial, patchy, or complete depigmentation of the graft skin.
If it has been recommended that you need an inverted T incision. Because you have too much skin for an alternate incision, you will likely have thin flaps if you are aiming for a nearly flat look. That increases your risk of skin or flap necrosis. This is more related to how much tissue you want removed, rather than the free nipple graft.
With a septum-based breast reduction, you can maintain blood supply, venous drainage and nipple sensation, whichever pedicle your surgeon uses, and still remove a lot of tissue.
So, the question is whether your surgeon, assuming they use a septum-based technique, feels comfortable really removing the amount of breast tissue that will please you.

The risks of free nipple technique includes the loss of ability to breast-feed, loss of nipple sensation, and possible hypopigmentation in the nipple-areola. These as you stated do not cause any concern for you. Therefore, it should be a very straightforward procedure for you. Other than these risks I mentioned above, we do not expect any serious side effects. Best of luck to you.

Dear Hannahp656

This is a great question. It is of course correct that breast feeding is impossible after FNG.

The normal result of FNG for sensation is complete loss of sensation. Perhaps 5-10% of patients, according to the literature, regain some sensation, but it typically does not include any erogenous sensation.

It seems that you may need to choose between nipple sensation and a very small size.

Best of luck,
Dr. Romanelli

Hello and thank you for your question. The disadvantages of performing a free nipple graft include loss of the ability to breast-feed in the future and loss of nipple sensation. You may also experience delayed wound healing, flattening of the nipple and nipple areolar discoloration. However, in cases of very large breast reductions, it is often the preferred technique to avoid more serious complications of partial or complete nipple areolar loss and significant fat necrosis. Good luck. I hope this helps.

Plastic surgeons generally avoid free nipple grafting because of nipple numbness and the loss of the ability to breast feed.

Best Wishes,

Gary Horndeski, M.D.

Thank you for your query. A free Nipple grafting technique for breast reduction can certainly give you the “practically flat” chest that you are looking for. There is a small chance of nipple-areola complex necrosis and also a chance of losing nipple projection. Please discuss your concerns with your surgeon and his/her experience with this technique. All the best!

To keep the nipple area alive, enough breast tissue must be kept. This limits how small one can go with a reduction. If you want to be a B or A cup, the free nipple graft is the safest option. However, you will sacrifice function and sensation with a graft. Most women do not regain sensation. There is still a low risk of partial or complete necrosis with the graft. Please make sure of your decision, because it cannot be undone.

Free nipple grafts are not analogous to maintaining the nipple on native breast tissue. This is the case in multiple regards- firstly, you are unlikely to have any sensation to FNGs if this is done. If you do have any resulting sensation it will be extremely muted compared to your normal baseline sensation. You have already mentioned that you are not interested in breast feeding, however following FNG they would also lose any dynamic change (with temperature, stimulation etc). This may or may not be a bother to patients, everyone is different. FNGs also have a tendency to flatten out when compared to a breast reduction where the nipple is preserved on native breast tissue. Finally, any skin graft runs the risk of not adhering fully with partial nipple loss following FNG. This can be true with either FNG or in aggressive breast reductions where we are trying to take off as much breast tissue as possible while preserving some tissue to supply the nipple.
In most instances, free nipple grafting is reserved as a "last resort"- if there is considerable concern about blood flow either due to the degree of nipple elevation needed or due to breast tissue being removed. Make sure that you have a fully informed discussion with your surgeon about the differences between these options as you consider surgery.
Sean Fisher, MD Aesthetic Plastic Surgeon Seattle, WA