Repigmentation of the nipple-areola complex following gender-affirming mastectomy with free nipple grafting

Free nipple grafting (FNG) is commonly performed during gender-affirming mastectomy (GAM) to reposition and resize the nipple-areola complex (NAC). Although postoperative NAC hypopigmentation is well-recognized, its longitudinal trajectory in transgender patients remains poorly characterized.

A retrospective cohort study was performed by including patients who underwent GAM with FNG at a single academic center. Inclusion required standardized preoperative, early postoperative (0-6 months), and mid postoperative (6-12 months) photographs, with a subset having late photographs (>12 months). NAC hypopigmentation was quantified using the ImageJ software by blinded reviewers. Longitudinal changes were assessed using paired t-tests, and subgroup analyses were performed using the ANOVA and unpaired t-tests.

A total of 104 patients met the inclusion criteria. At the early postoperative follow-up, 68 patients (65%) demonstrated measurable NAC hypopigmentation. Mean hypopigmentation decreased from 13.4% at early follow-up to 7.4% at mid follow-up (p < 0.0001) and remained stable at late follow-up (7.2%, p = 0.216 for mid vs. late follow-up). Patients demonstrated heterogeneous pigmentation trajectories, including repigmentation, no change, and depigmentation. Early postoperative hypopigmentation differed by race (p < 0.0001), with more hypopigmentation observed in Black patients compared to White and Asian patients. Longitudinal improvement between early and mid-follow-up was observed among Black and Asian patients but not among White patients.

NAC hypopigmentation after FNG in GAM is common in the early postoperative period, and frequently improves within the first postoperative year and stabilizes thereafter. These findings provide objective data to inform patient counseling regarding the expected time course of pigmentation changes and potential secondary interventions.