1. Free Nipple Grafting
An Alternative for Patients Ineligible for Nipple-Sparing Mastectomy?
Erin Louise Doren, MD,* Lauren Van Eldik Kuykendall, MD,* Jonathan Jeremiah Lopez, MD,*
Christine Laronga, MD, FACS,Þ and Paul David Smith, MD*Þ
Abstract: Nipple-sparing mastectomy is an option for patients fitting onco-
logic criteria and may improve cosmetic outcomes of breast reconstruction.
When anatomical limitations exist, we propose the use of free nipple grafting,
akin to reduction mammaplasty. This study is a retrospective review of pa-
tients having a nipple-sparing mastectomy and immediate reconstruction using
free nipple grafting (N = 36 breasts). Average graft take was 93.6% with no
nipples having complete graft loss. Four nipples (11%) lost all projection
and 4 nipples experienced significant hypopigmentation requiring tattooing
(11%). For those ineligible for nipple-sparing mastectomy due to anatomical
limitations, free nipple grafting is an option with acceptable complication rates
similar to free nipple grafting in reduction mammaplasties and, more impor-
tantly, saves women a subsequent operation for nipple reconstruction.
Key Words: breast reconstruction, nipple-sparing mastectomy, free nipple
grafting, nipple reconstruction, breast reduction
(Ann Plast Surg 2014;72: S112YS115)
Over the past several decades, the surgical management of breast
cancer has significantly evolved with guidance by principles of
patient safety, oncologic safety, and more recently cosmetic out-
come.1,2
The optimal cosmetic outcome following mastectomy and
reconstruction involves preservation of the nipple-areolar complex.2
The nipple-areolar complex defines a breast as a breast and similarly
defines a reconstructed breast mound.2
Nipple-sparing mastectomy is
emerging as a safe alternative to skin-sparing mastectomy for both
therapeutic and prophylactic indications in properly selected pa-
tients.3
Additionally, nipple-sparing mastectomy has been demon-
strated repeatedly to have a positive impact on body image and
patient statisfaction.3
Spear et al, among many others, have developed widely accepted
patient selection criteria for nipple-sparing mastectomy based on on-
cologic and surgical factors.2,3
The oncologic criteria include a tumor
size less than 3 cm, tumor greater than 2 cm from the nipple-areolar
complex, clinically negative axillary nodes, and no skin involvement
or inflammatory cancer/Paget disease.2,3
Operative criteria include
negative intraoperative frozen section and negative permanent nipple
pathology.2,3
Certain anatomic criteria also exist that can preclude
patients from undergoing nipple-sparing mastectomy, which include
large breast size (greater than 500 g), breast ptosis (grade II-III), radi-
ation, and prior periareolar incisions.2Y4
Additional patient factors,
although not absolute contraindications, can cause an increased risk
for postoperative complications. Factors including BMI greater than
25 kg/m2
, breast mass greater than 750 g, and sternal notch to nipple
distance greater than 26 cm are associated with increased risk of
flap necrosis, partial flap loss, and wound dehiscence.3,4
When these anatomical limitations exist, alternative strategies
for preserving the nipple include reducing the skin envelope before
mastectomy, grafting the nipple-areolar complex, or performing a
mastopexy at the same time as the mastectomy.1,2,5
In 1987, Woods
described his approach to nipple-sparing mastectomy with simulta-
neous mastopexy and suggested that the nipple could be spared and
the skin envelope reduced at the time of mastectomy to create better
cosmetic outcomes.5,6
However, that option has become less favor-
able because of the need to retain larger quantities of breast tissue to
ensure nipple and flap viability.5
More recently, Spear et al proposed
a staged approach with a pre-mastectomy mastopexy or reduction in
carefully selected patient with ptosis or macromastia.5
Although this
staged approach has comparable complication rates to published
ranges of nipple-sparing mastectomy and skin-sparing mastectomy
with immediate reconstruction, the patients are subjected to multiple
operations.5
We propose an alternative, single-stage reconstruction
with the use of free nipple grafting, akin to reduction mammoplasty,
with anticipated similar complication rates.
METHODS
This study is a retrospective review of 21 prospectively gath-
ered patients having a nipple-sparing mastectomy with immediate
breast reconstruction using free nipple grafting. Moffitt Cancer Center
has established our institutional eligibility and exclusion criteria for
nipple-sparing mastectomy which encompasses oncologic and technical/
cosmetic considerations. Patients, thus, were excluded from standard
nipple-sparing mastectomy at our facility based on the following in-
stitutional ineligibility criteria: prior periareolar incisions (n = 2),
breast size greater than 700 g (n = 3), grade II-III ptosis (n = 1), pre-
vious radiation treatment (n = 5), and desire for autologous recon-
struction (n = 10).
Skin-sparing mastectomies were performed by a single breast
surgeon in a standard fashion via a circumareolar incision. The
nipple-areola complex was then harvested from the mastectomy
specimen as a full-thickness graft with a 10-blade scalpel (Fig. 1).
Frozen sections from the base of the nipple were sent to assure there
was no malignancy or atypia in the specimen. The nipples were
defatted in a standard fashion with minimal thinning of the dermis.
Breast reconstruction, prosthetic or autologous, was then performed,
on occasion requiring a vertical reduction pattern or change of nipple
position. Free nipple grafts were then re-implanted to the de-
epithelialized recipient sites and secured with a Xeroform bolster.
Bolsters were removed in the clinic on postoperative days 7Y10.
Complications and outcome were recorded in the patient’s medical
record and subsequently logged in the breast reconstruction database.
Photos of all patients were reviewed at the last documented postop-
erative visit to assess overall graft take, nipple projection, and areola
CLINICAL PAPERS
S112 www.annalsplasticsurgery.com Annals of Plastic Surgery & Volume 72, Supplement 2, June 2014
Received October 21, 2013, and accepted for publication, after revision, October 29, 2013.
From the *Division of Plastic Surgery, Department of Surgery, University of South
Florida, Tampa, FL; and †Comprehensive Breast Program, H. Lee Moffitt
Cancer Center, Department of Women’s Oncology, Tampa, FL.
Conflicts of interest and source of funding: none declared.
The contents of this paper were reported in poster format at the American As-
sociation of Plastic Surgeons (AAPS), New Orleans, Louisiana, April 2013
and at the Southeastern Society of Plastic and Reconstructive Surgeons
(SESPRS), Bonita Springs, Florida, June 2013.
Reprints: Erin Louise Doren, MD, Division of Plastic Surgery, Department of
Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor,
Tampa, FL 33606. E-mail: edoren@gmail.com.
Copyright * 2013 by Lippincott Williams & Wilkins
ISSN: 0148-7043/14/7202-S112
DOI: 10.1097/SAP.0000000000000077
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

2. pigmentation. A chi-square test using exact method with Monte
Carlo estimation was used to determine if the type of breast recon-
struction affected complication rates. Complications included any-
thing that required surgical or procedural intervention.
RESULTS
Of 21 patients, 8 women had bilateral prophylactic mastectomy,
6 women had unilateral mastectomies, and 7 women had bilateral
mastectomies for unilateral cancer, totaling 36 nipple-areola grafts
harvested. The mean patient age at the time of surgery was 48 years
(range 21Y66 years) and none of the women had a current or recent
(6 months) history of tobacco use. The mean BMI was 24.98 (range
20Y33.1). Most of the women had grade 2 ptosis and the mean
breast weight at mastectomy was 481.76 g (range 110.4Y835.8 g).
The mean follow-up was 17.28 months (range 0.7Y69 months).
Reconstruction was performed as follows: implant sparing with
latissimus dorsi muscle flap (2/36), transverse rectus abdominus
myocutaneous flap (TRAM) (18/36), and latissimus dorsi flap
with tissue expanders (16/36). All nipple base pathology was found
to be benign on frozen and permanent specimens. Upon removal
of nipple Xeroform bolsters, many patients had a small amount of
epidermolysis. The average graft take, with full-thickness necrosis be-
ing a value of zero and no necrosis 100, was 93.6% (range 60%Y100%).
No patients had complete nipple necrosis (0%). Average nipple pro-
jection was 59% of original size (n = 34, as 1 patient did not have long-
term follow-up photo) (range 0%Y100%). Four (of 36) nipples (11%),
in 3 patients, lost all projection and required subsequent nipple recon-
struction. Pigmentation of the nipple-areola was rated by the surgical
team on a scale of 0%Y100%, zero with no pigmentation remaining,
100% normal pigmentation, the average was 86.5% (n = 34, as 1 patient
did not have long-term follow-up photo) (range 20%Y100%). In addi-
tion, four (of 36) nipples (11%), in 2 patients, experienced significant
hypopigmentation requiring subsequent nipple-areola tattooing. The
type of reconstruction did not impact the rate of complications requiring
intervention or return to the operating room (Table 1). No patient had
recurrence of cancer on final follow-up visit. Examples of preoperative
and postoperative patients can be found in Figures 2 and 3.
DISCUSSION
Nipple-sparing mastectomy is increasingly being performed in
appropriately selected patients for both therapeutic and prophylactic
indications.1,3,5,7
The benefits of preserving the nipple-areolar com-
plex go beyond mere cosmetic results of the breast reconstruction
but also include functional outcomes and patient satisfaction as it
can be difficult to match projection, size, color, shape, texture, po-
sition, and sensation with nipple reconstruction.7
Ensuring optimal
outcomes requires appropriate patient selection from an oncologic,
surgical, and anatomic perspective. In patients who meet inclusion
criteria from an oncologic standpoint but are limited secondary to
anatomic factors such as breast size and degree of breast ptosis, the
reconstructive options for preserving the nipple-areolar complex
become limited and quite challenging. Newer strategies are being
developed to prevent postoperative complications, such as skin flap
and nipple necrosis, which are even more important in this patient
population which requires preserving all the native breast skin.5
For
women desiring nipple-sparing mastectomy and immediate recon-
struction but technically limited by larger breast size or degree of
ptosis, we investigated the feasibility of free nipple grafting as a
single-stage approach. Akin to a reduction mammaplasty, we ex-
perienced good aesthetic results and a low rate of postoperative
complications.
In contrast, Spear et al has proposed a pre-mastectomy,
mastopexy/reduction, staged approach as an alternative to permit
nipple-sparing mastectomy in the large- or ptotic-breasted patient.5
This approach entails that the mastopexy or reduction be performed
as a pre-mastectomy procedure with repositioning of the nipple and
reducing the skin envelope. After a minimum of 4 weeks, a nipple-
sparing mastectomy through the mastopexy incisions is performed
with subsequent final reconstruction.5
Using this staged approach,
they report that 17% of the breasts had a complication that required
return to the operating room, and 13% had partial nipple-areolar
complex necrosis with no total nipple-areolar complex necrosis.5
Patient satisfaction or surgeon satisfaction with final nipple position
were not discussed. Although the pre-mastectomy staged approach is
an acceptable alternative with comparable complication rates, the
major disadvantage is that the patients are subjected to multiple op-
erations, which may increase morbidity and cost, and contribute to
patient dissatisfaction. Our single-stage approach using immediate
reconstruction with free nipple grafting in patients with anatomic
limitations deserves consideration as a viable alternative.
Free nipple-areolar grafting has been described for many de-
cades in patients undergoing reduction mammaplasty.8,9
Indications
for reduction mammaplasty with free nipple-areolar grafting include
patients with massive breast hypertrophy or gigantomastia, previous
breast surgery that may risk viability of the nipple, overweight ptotic
FIGURE 1. Free nipple grafts harvested.
TABLE 1. Type of Reconstruction Versus Complication Requiring Intervention
Reconstruction Total No Complication Yes Complication P
LD with implant sparing 2 (5.6%) 1 (50%) 1 (50%) 0.3207
LD with TE 16 (44.4%) 14 (87.5%) 2 (12.5%)
TRAM 18 (50%) 13 (72.2%) 5 (27.8%)
Total 36 28 (77.8%) 8 (22.2%)
LD indicates latissimus dorsi; TE, tissue expander.
Annals of Plastic Surgery & Volume 72, Supplement 2, June 2014 Free Nipple Grafting for Nipple-Sparing Mastectomy
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3. breast, and poor-risk elderly patients or those with severe systemic
disease where shorter anesthetic time would be an advantage.8Y10
Disadvantages of free nipple grafting include loss of nipple sensation,
loss of projection, hypopigmentation, and graft loss requiring further
reconstruction.8Y10
However, a properly prepared full-thickness nipple-
areolar graft can preserve both projection and nipple contour which
leads to improved patient satisfaction and cosmetic outcomes.10
Ad-
ditionally, there is some evidence that nipple sensation and erotic
function can be partially recovered postoperatively with free nipple
grafting.9
Our rates of graft loss, loss of projection, and hypopigmen-
tation are comparable to the reported rates in the literature for re-
duction mammaplasties with free nipple grafts.8Y11
A review of
free nipple grafting and patient satisfaction in breast reduction by
McGregor et al showed complete loss of the nipple-areolar complex
in 1 patient and partial loss in 18% of patients requiring minor
interventions.8
Additionally, nipple projection was satisfactory in
14 women (55% of nipples) and nipple sensation was present in 30%
of nipples.8
Guven et al retrospectively reviewed 24 patients under-
going reduction mammaplasty with free nipple grafting over a 4-year
period. He reported partial nipple-areolar complex loss in 8% of
patients, all of which were treated conservatively, and hypopigmen-
tation in 20.8% of patients.11
The major advantage of our method is that the reconstruction
can be done in 1 stage, saving the women subsequent operations. The
rate of re-operation was low, with no patients requiring nipple re-
construction for graft loss and 3 requiring reconstruction for
complete loss of projection. Adequate cosmetic results were obtained
despite having some loss of nipple projection and hypopigmentation
as the presence of a native nipple on a reconstructed breast positively
influences patient satisfaction.12
Previous studies have shown that
patients express dissatisfaction with various aspects of their recon-
structed nipple including poor shape, size, texture, position, color, and
projection.12
Although surgical reconstruction of an absent nipple can
provide acceptable aesthetic results, these results are not ideal.12
In this study, criteria for free nipple grafting with nipple-
sparing mastectomy were a prior periareolar incision, breast size
greater than 700 g, grade II-III ptosis, previous radiation treatment,
and desire for autologous reconstruction. When the reason for using a
free nipple approach was significant breast ptosis, it raises the issue
of how did we change the nipple position. On occasion, we recom-
mend performing a small crescent or vertical mastopexy at the time
of mastectomy and reconstruction to change the position for place-
ment of the nipple graft. However, we found that this is rarely nec-
essary as the act of removing the breast tissue and shaping with
immediate autologous reconstruction allows the nipple position to be
adjusted and subsequently the mastectomy skin shrinks to the desired
position. As a direct result of this study, we have changed our view on
the use of free nipple grafts for the reason of autologous recon-
struction alone. Studies have now demonstrated that it is safe to bury
flaps, including free flaps, for single-stage breast reconstruction with
nipple-sparing mastectomy in the appropriately selected patients.13
Therefore, currently we perform nipple-sparing mastectomy, with-
out free nipple grafts, on patients having autologous and free flap
FIGURE 2. A, Preoperative, patient with right breast cancer and prior periareolar incision. B, Postoperative, right breast latissimus
implant reconstruction and free nipple graft, left breast augmentation for symmetry.
FIGURE 3. A, Preoperative, right breast cancer, desire for autologous reconstruction. B, Postoperative, right mastectomy with
TRAM reconstruction and free nipple grafting.
Doren et al Annals of Plastic Surgery & Volume 72, Supplement 2, June 2014
S114 www.annalsplasticsurgery.com * 2013 Lippincott Williams & Wilkins
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4. reconstruction, as long as they do not have significant breast ptosis or
breast size, and we are confident that the nipple will end up in the
correct position.
CONCLUSIONS
Increasingly popular nipple-sparing mastectomy is an option for
women meeting oncologic and anatomic criteria. For those women in-
eligible for technical reasons, free nipple grafting is an option with
complication rates similar to free nipple grafting in reduction mam-
maplasties. More importantly, free nipple grafting at mastectomy with
immediate reconstruction saves these women a subsequent operation
for nipple reconstruction.
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