What happens once a nipple graft has failed (FTM transgender)? (Photo)

The most important thing right now is to keep strong communication with your surgeon and follow their instructions closely. In situations like this, time is really our best tool — nipple grafts go through different stages of healing and sometimes take several weeks to fully integrate.Graft integration is the process where the graft (the nipple-areola tissue) reconnects with the new blood supply from the chest wall. Early on, the graft survives mostly by absorbing nutrients from the wound bed (this is called plasmatic imbibition), then tiny new blood vessels begin to grow into it (neovascularization).This process can be slow, especially if the graft had areas of poor circulation or pressure. It’s normal for scabs to form, and sometimes the appearance can look worse before it looks better.Even in cases where part of the graft doesn’t survive, the body is very good at healing these areas over time — and there are always options later for tattooing or revision if needed.Stay patient, stay connected to your surgeon, and give your body time to do its work.

If a nipple graft fails after top surgery, the healing process will depend on the extent of the failure. In the early stages (first few days to weeks), it’s often too soon to make a definitive judgment. Grafts may appear problematic initially, but they could still heal over time. In cases of failure, you may experience scarring, "bloody craters," or partial nipple loss. However, pain is typically not severe, and some residual pigmentation may remain.
If the graft fails completely, the area should be left to heal for a few months, during which time the remaining tissue can be assessed. Secondary procedures, such as creating a new nipple with local skin or using nipple tattoos for coloring, can be performed once healing is complete. It’s important to follow your surgeon’s care instructions and attend follow-up consultations to monitor progress. While nipple graft failure can be frustrating, there are various options for reconstruction to achieve the desired result.
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

Hi,Thanks for the post and photo. At eleven days, it is too early to determine if the graft is failing or not. I would continue using lubricated dressings like xereform and avoid shearing to the area. Also, areolar grafts tend to look worse before they look better. After a month you will have a clearer picture of how you are healing. Sincerely,Dr. Dadvand

HI. First of all, hang in there and it will definitely heal eventually and likely look just fine.  But here is my controversial opinion.  In my opinion, free nipple grafts never really take.  The areola takes just fine, but the thicker bigger nipple really never takes fully.  The surgeon did not do anything wrong this is merely the nature of skin grafts.  Skin grafts take and heal by a process called imbibition, whereby they develop a blood supply and their life source from the blood vessels on the chest.  The thinner the graft the more readily it takes, and very thick grafts NEVER TAKE. Most people use this method for top surgery.  I used to use this method, but no longer do because I was frustrated that my patients had to go through what you are going through.  SO I developed a technique to make a new tiny nipple using the skin on your chest, and then I just graft the areola around it like a donut. And it works every time.

Thank you for your question. If the grafts continue to have difficulties healing you will likely be left with partial nipple loss and some residual pigment. In this case I recommend that you wait a total of 2 to 3 months for all of the healing to be done. At that point you may desire nipple tattooing where a tattoo artist can place more pigment to the skin and give it the appearance of a nipple. I do not think you will have any pain or unmanageable scarring from this. Make sure you are following up with you surgeon to determine the best management. Best of luck! 

It's rare for the entire nipple graft to fail unless there is some catastrophic event like the bolster or dressings accidentally shearing the entire graft off. It's more common for parts of the nipple not to take or parts to have a deep slough. The best thing is to allow this to heal, and see what parts can be salvaged. In the case of complete failure, it's still best to allow the area to heal (although excision of the wound can be considered as well for faster healing), and later do a nipple reconstruction with the local skin and tattoo over this for coloring. 

Dear alexjm,
I hope that you are healing well.  11 days is far too early to tell whether a free nipple graft has failed.  I recommend continuing your dressings as specified by your surgeon (I typically would have you apply triple antibiotic ointment and Xeroform/Vaseline gauze) and be certain to treat your nipples gently and avoid any rubbing or shearing.  Please check out my video below.
Sincerely,
Dr. Kpodzo

It is too early to tell if you nipple grafts have actually failed. Continue to treat them as outlined by your physician. If they have indeed failed, the day will arrive when the skin has healed, and it would be possible to determine what additional method is appropriate for reconstruction.