Topical Nitropaste Reduces Partial Free Nipple Graft Loss in Gender-Affirming Mastectomy: A Randomized Controlled Trial

BACKGROUND: Topical nitroglycerin has been shown to enhance wound healing and reduce flap necrosis after oncologic mastectomy. However, its impact on gender-affirming mastectomy outcomes, particularly in free nipple grafts, has not been well studied. This study was performed to evaluate the effectiveness of topical nitroglycerin in patients undergoing double-incision mastectomy with free nipple grafts (DIFNG), focusing on graft and wound-related outcomes. METHODS: Adult patients undergoing DIFNG between August of 2022 and June of 2024 at a tertiary hospital were randomized into control (bacitracin) and treatment (topical nitroglycerin, 15 mg per side) groups. All procedures followed a standardized surgical technique and perioperative regimen. Outcomes, including partial and total graft loss and wound complications, were assessed during routine bolster removal and postoperative visits. Ordinal logistic regression was performed to control for smoking status. RESULTS: Among 111 patients (56 control, 55 treatment), there were no significant differences in demographic characteristics or preoperative factors. The partial graft loss rate was significantly lower in the treatment group (18.2% versus 36.6%; P = 0.004). Postoperative complication rates, including seroma, hematoma, and wound complications, were not significantly different between the 2 groups. Rates of nipple graft hypopigmentation were significantly higher for Black patients compared with White patients, but not significantly different between the control and treatment groups. CONCLUSION: Topical nitroglycerin application in DIFNG significantly reduces partial nipple graft loss without affecting wound complications.