A Single Arm, Single Center Pilot Study Evaluating the Safety and Healing Time of a Decellularized, Whole Donor Nipple-Areola Complex Reconstruction Graft
Phase: NA
Conditions: Breast Cancer
Sponsor: Stanford University

 
 
 
 
A Single Arm, Single Center Pilot Study Evaluating the 
Safety and Healing Time of a Decellularized, Whole Donor 
Nipple-Areola Complex Reconstruction Graft   
 
Study Protocol and Statistical Analysis Plan 
NCT04534010 
November 15, 2023 

Protocol for Interventional Studies at Stanford Cancer Institute 
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Protocol Version #4 
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Stanford Cancer Institute 
Protocol Document for  
Investigator Initiated  
Interventional Studies 
 
 
 
 
 
 
 
 
Document History 
Notes 
Version 1       Date: 19 June 2020 
Initial Submission 
Version 2       Date: 6 August 2020 
Revised Copy Submission 
Version 3       Date: 09 June 2023 
Revised Copy Submission 
Version 4       Date: 15 November 2023 
Revised Copy Submission 

Protocol for Interventional Studies at Stanford Cancer Institute 
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A Single Arm, Single Center Pilot Study Evaluating the Safety and Healing Time of the 
NACgraft™ for Nipple-Areolar Complex Reconstruction 
 
Coordinating Center 
Stanford Cancer Institute 
875 Blake Wilbur Drive 
Stanford, CA 94305 
 
Protocol Director 
Arash Momeni, MD 
770 Welch Road, Suite 400 
Palo Alto, CA 94304 
Phone: 650-723-6189 
Fax: 650-725-6605 
Email: amomeni@stanford.edu 
 
Co-Investigators 
Dung Nguyen, MD  
770 Welch Road, Suite 400 
Palo Alto, CA 94304 
 Phone: 
 
Email: nguyendh@stanford.edu 
 
Biostatistician 
Michael Januszyk, MD, PhD 
257 Campus Dr. West, 
 
Stanford, CA 94305 
Phone: 
 
Email: 
 
 
Study Coordinator 
 
257 Campus Dr. West, 
 
Stanford, CA 94305 
Phone: 
 
Fax: 650-721-3406 
Email: 
 
 
Version #4 / Version Date: (11-15-2023) 

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TABLE OF CONTENTS 
TABLE OF CONTENTS ............................................................................................................. 3 
PROTOCOL SYNOPSIS ............................................................................................................. 5 
SCHEMA ....................................................................................................................................... 7 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS .............................................. 8 
1. 
OBJECTIVES ....................................................................................................................... 9 
1.1. 
PRIMARY OBJECTIVE ....................................................................................................... 9 
1.2. 
SECONDARY OBJECTIVES ................................................................................................. 9 
2. 
BACKGROUND ................................................................................................................... 9 
2.1. 
STUDY DISEASE ............................................................................................................... 9 
2.2. 
STUDY DEVICE ................................................................................................................ 9 
2.3. 
RATIONALE .................................................................................................................... 10 
2.4. 
STUDY DESIGN .............................................................................................................. 11 
2.5. 
CORRELATIVE STUDIES BACKGROUND .......................................................................... 11 
3. 
PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES ...................... 13 
3.1. 
INCLUSION CRITERIA ..................................................................................................... 13 
3.2. 
EXCLUSION CRITERIA .................................................................................................... 13 
3.3. 
INFORMED CONSENT PROCESS ....................................................................................... 14 
3.4. 
RANDOMIZATION PROCEDURES ..................................................................................... 14 
3.5. 
STUDY TIMELINE ........................................................................................................... 14 
4. 
TREATMENT PLAN ......................................................................................................... 14 
4.1. 
GENERAL CONCOMITANT MEDICATION AND SUPPORTIVE CARE GUIDELINES ............... 14 
4.2. 
CRITERIA FOR REMOVAL FROM STUDY .......................................................................... 15 
4.3. 
ALTERNATIVES .............................................................................................................. 15 
5. 
INVESTIGATIONAL DEVICE INFORMATION ......................................................... 17 
5.1. 
INVESTIGATIONAL DEVICE ............................................................................................. 17 
5.2. 
INTERVENTION DESCRIPTION ......................................................................................... 17 
5.3. 
AVAILABILITY ............................................................................................................... 17 
5.4. 
AGENT ORDERING ......................................................................................................... 17 
5.4. 
AGENT ACCOUNTABILITY .............................................................................................. 17 
6. 
DOSE MODIFICATIONS ................................................................................................. 17 
7. 
ADVERSE EVENTS AND REPORTING PROCEDURES ........................................... 17 
7.1. 
POTENTIAL ADVERSE EVENTS ....................................................................................... 17 
7.2. 
ADVERSE EVENT REPORTING......................................................................................... 18 
8. 
CORRELATIVE/SPECIAL STUDIES ............................................................................ 19 

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9. 
STUDY CALENDAR ......................................................................................................... 20 
10. 
MEASUREMENTS ........................................................................................................ 21 
10.1. 
PRIMARY OUTCOME MEASURE: TIME TO COMPLETE HEALING .................................... 21 
10.2. 
PRIMARY OUTCOME MEASURE: DEVICE SAFETY ......................................................... 21 
10.3. 
SECONDARY OUTCOME MEASURE: TIME TO 50% AND 75% GRAFT HEALING ............. 22 
10.4. 
SECONDARY OUTCOME MEASURE: OPERATIVE TIME .................................................. 22 
10.5. 
SECONDARY OUTCOME MEASURE: NAC SENSITIVITY ................................................ 23 
10.6. 
SECONDARY OUTCOME MEASURE: NIPPLE PROJECTION ............................................. 23 
10.7. 
SECONDARY OUTCOME MEASURE: NIPPLE DIAMETER ................................................ 23 
10.8. 
SECONDARY OUTCOME MEASURE: PATIENT SATISFACTION ........................................ 24 
10.9. 
SECONDARY OUTCOME MEASURE: NAC VASCULARIZATION ..................................... 24 
11. 
REGULATORY CONSIDERATIONS ........................................................................ 25 
11.1. 
INSTITUTIONAL REVIEW OF PROTOCOL ...................................................................... 25 
11.2. 
DATA AND SAFETY MONITORING PLAN ..................................................................... 25 
11.3. 
DATA MANAGEMENT PLAN ....................................................................................... 25 
12. 
STATISTICAL CONSIDERATIONS .......................................................................... 26 
12.1 
STATISTICAL DESIGN ..................................................................................................... 26 
12.2. 
INTERIM ANALYSES .................................................................................................... 27 
12.3. 
DESCRIPTIVE STATISTICS AND EXPLORATORY DATA ANALYSIS ............................... 27 
12.4. 
PRIMARY ANALYSIS ................................................................................................... 27 
12.5. 
SECONDARY ANALYSIS .............................................................................................. 27 
12.6. 
SAMPLE SIZE .............................................................................................................. 28 
12.7. 
CRITERIA FOR FUTURE STUDIES ................................................................................. 28 
13. 
REFERENCES ................................................................................................................ 29 
APPENDIX A: PARTICIPANT ELIGIBILITY CHECKLIST............................................. 31 
APPENDIX B: NIPPLE RECONSTRUCTION SATISFACTION SURVEYS ................... 33 
 
 

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PROTOCOL SYNOPSIS 
TITLE 
A Single Arm, Single Center Pilot Study Evaluating the 
Safety and Healing Time of the NACgraft™ for Nipple-
Areolar Complex Reconstruction 
STUDY PHASE 
Feasibility  
INDICATION 
Nipple-Areola Complex (NAC) Reconstruction 
INVESTIGATIONAL 
PRODUCT OR PROCEDURE 
NACgraft™ - a decellularized skin allograft of the 
human nipple-areolar complex 
PRIMARY OBJECTIVE(S) 
To evaluate safety and healing time after NAC 
reconstruction with the BioAesthetics’ NACgraft™.  
SECONDARY 
OBJECTIVE(S) 
To evaluate operative time, NAC vascularization, 
dimensions, sensation, and patient satisfaction up to 12 
months after reconstruction surgery with the 
BioAesthetics’ NACgraft™. 
TREATMENT SUMMARY 
This single arm pilot study is designed to obtain 
preliminary safety, healing, patient satisfaction and other 
data in adult female subjects undergoing uni- or bilateral 
nipple-areola 
complex 
reconstruction 
with 
the 
BioAesthetics’ NACgraft™.  
 
The study consists of a screening period (up to 3 weeks 
before engraftment) to determine study eligibility and 
prepare the NACgraft(s)™, a treatment period during 
which time uni- or bilateral engraftment surgery is 
performed, and a follow-up period during which time 
safety, healing time, vascularization, nipple dimensions 
and sensitivity, and patient satisfaction are assessed.   
 
The total duration of the study is approximately 13 
months for each subject.  
 
Up to 20 female subjects will be screened in order to 
perform NAC engraftment on 15 subjects.  Primary, 
secondary and exploratory endpoints will be assessed up 
to 12 months after engraftment.  
 
On the day of surgery, NACgrafts™ will be engrafted 
according to standard reconstructive technique. Using 
sterile technique, the recipient site on the breast mound 
will be de-epithelialized sharply and meticulous 
hemostasis 
obtained 
with 
electrocautery. 
The 
NACgraft™ will then be sutured into place. In women 
undergoing bilateral NAC reconstruction, this process 
will be repeated for the contralateral breast. A sterile 
dressing will be applied and patients will be discharged 
home according to institutional guidelines; written 

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instructions will be provided for the care of the 
NACgraft(s)™ and dressings. The dressing will include 
antimicrobial ointment, followed by a non-adherent, 
occlusive dressing (e.g. Adaptic, Xeroform) secured in 
place using a foam dressing cut into a donut (e.g., 
Allevyn) to prevent compression of the graft. 
 
Patients will be return to the outpatient clinic regularly 
until the graft(s) are fully healed: on or about 
postoperative Days 7, 14, 28, and 42. They will return on 
days 90, 180, and 360 for measurement of long-term 
endpoints including nipple dimensions, sensitivity, and 
for satisfaction survey completion. 
SAMPLE SIZE  
N=15 patients 
STATISTICAL 
CONSIDERATIONS 
Time to complete healing for each NAC will be defined 
as the first weekly visit at which the graft has been 
deemed to be >99% epithelialized. Max, Mean, Median, 
and 95% Confidence Interval of these data will be 
presented, as will percent (%) healed over time for each 
graft. No formal statistical testing will be performed for 
any other endpoint; summary statistics will be presented 
at each time point. 
 
 
 

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SCHEMA 
 
 
 
 
Inclusion Criteria: 
• 
Patient age 18-65 
• 
Patient desires NAC grafting ≥3 months after autologous breast reconstruction 
• 
Patient agrees to sleep on back until grafts healed (6 weeks) 
• 
Patient agrees to abstain from aspirin, smoking, alcohol (>2 drinks per day), or excessive caffeine 
(>300mg per day) until grafts healed (6 weeks) 
• 
Patient agrees to not undergo NAC tattooing until completing study (12 months) 
• 
Patient is able to understand and willing to sign informed consent. 
Informed Consent 
NO:  
Standard of care 
YES: Enroll in study 
 
Baseline questionnaire 
SURGERY 
NAC engraftment 
 
Secondary Outcome: 
Operative time 
Clinical follow up period (12 months) 
 
Primary Outcome: 
• Time to complete healing of graft 
 
Secondary Outcome: 
• Time to 50% and 75% healed 
• Surgical time 
 
Exploratory Outcomes: 
• NAC dimensions 
• NAC sensitivity 
• Patient assessment of degree of self-esteem, body 
image, psychological well-being 
• Overall patient satisfaction with regard to: 
color/pigmentation, size, projection, texture, 
symmetry 
Monitor for 
adverse events 
Criteria for withdrawal 
• Patient withdraws consent. 
• Patient has disease progression 
(e.g., breast cancer recurrence) 
or requires further radiation or 
surgery 
• Serious Adverse Event (e.g., 
infection, allergic reaction) 
requiring removal of graft. 
• Patient fails to comply with 
study instructions (such as non-
adherence with tobacco) 
• Any condition which would 
place patient at unnecessary risk 
if they continued with study. 

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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
AE 
Adverse Event 
BD-NRC 
Biodesign® Nipple Reconstruction Cylinder 
BMSC 
Bone Marrow-Derived Mesenchymal Stem Cell 
BMI 
Body mass index 
CGTP 
Current Good Tissue Practices 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
Dcl-NHP-NAC 
Decellularized Non-Human Primate Nipple-
Areolar Complex 
DSMC 
Data Safety Monitoring Committee 
ECOG 
Eastern Cooperative Oncology Group 
ECM 
Extracellular Matrix 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HCT/P 
Human Cells, Tissues, and Cellular and Tissue-
Based Products 
HIPAA 
Health Insurance Portability and Accountability 
Act 
HIV 
Human Immunodeficiency Virus 
IDE 
Investigational Device Exemption 
IRB 
Institutional Review Board 
NAC 
Nipple-areolar complex 
NACgraft™ 
Decellularized human nipple-areolar complex graft 
NHP 
Non-Human Primate 
N-NAC 
Native Nipple-Areolar Complex 
PD 
Protocol Director 
SAE 
Serious Adverse Events 
SRC 
Scientific Review Committee 
SWM 
Semmes Weinstein Monofilament 
VAS 
Visual Analog Scale 
 

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1. 
OBJECTIVES 
1.1. 
Primary Objective 
To evaluate safety and healing time after nipple-areola complex reconstruction with the 
BioAesthetics’ NACgraft™.  
1.2. 
Secondary Objectives 
 
To evaluate operative time, NAC vascularity, dimensions (projection, sensitivity), 
sensitivity, and patient satisfaction up to 12 months after nipple-areola complex reconstruction 
surgery with the BioAesthetics’ NACgraft™.   
2. 
BACKGROUND 
2.1. 
Study Disease 
There are over 3.5 million breast cancer survivors in the US, many of whom have 
undergone reconstructive surgery.1 Close to one-third of early stage and two-thirds of late-stage 
breast cancer patients opt for mastectomies.1,2  Patients without a NAC continue to experience 
psychological distress even after the breast mound has been reconstructed.3 NAC reconstruction 
is of key psychological importance for these patients, decreasing feelings of distress and increasing 
body image and self-esteem.4,5 Women with NAC reconstruction have significantly higher sexual 
well-being, aesthetic and general satisfaction, and quality of life scores, as compared to women 
without NAC reconstruction.6,7  However, there is no standard, viable method to reliably 
reconstruct a permanent and natural NAC. Current NAC reconstruction options are limited to 
rubber prostheses, 3D tattoos, and surgical techniques to create NAC-like structures from a 
patient’s own skin tissue or acellular dermal allografts.8–10 These approaches produce NACs that 
either lack physical depth or fail to maintain a protrusion for more than a few months.11,12 
According to breast reconstructive surgeons, current methods of nipple reconstruction are the 
limiting factor for a complete breast reconstruction. 
2.2. 
Study Device 
The BioAesthetics NACgraft™ is a decellularized NAC derived from deceased human 
donors.  Proprietary washing/rinsing steps provide a removal of immunologic elements (including 
cells and nucleic acids). The NACgraft™ is then packaged in a tube containing sterile PBS for 
individual attachment to a de-epithelialized portion of the human breast after breast reconstruction 
and is protected with dressings until re-vascularization, re-epithelialization and dermal/neural 
elements repopulate the device, leaving a living human NAC substitute. By preserving the ECM 
of the native human NAC, including its non-immunogenic signaling molecules and structural 
format, the BioAesthetics NACgraft™ serves as a scaffold that allows vascular, neural, dermal 
and epithelial infiltration until the time of complete healing. The BioAesthetics NACgraft™ has 
been studied extensively in in vitro and in preclinical models including mice and non-human 
primates to demonstrate their safety and therapeutic potential, as detailed in Section 2.5.21,22 
BioAesthetics’ NACgraft™ fits within the Food and Drug Administration (FDA)’s HCT/P 
(Human Cells, Tissues, and Cellular and Tissue-Based Products (21 CFR Part 1271)) regulatory 
pathway (see Appendix A1 of Investigator’s Brochure). To advance to clinical use, the product is 
manufactured in accordance with Current Good Tissue Practices (CGTP) and must submit a 
registration with the FDA 90 days prior to marketing. The NACgraft™ will be registered with the 
FDA prior to study initiation. Therefore, no Investigational Device Exemption (IDE) is required 
for this feasibility study. 

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2.3. 
Rationale 
Over 200,000 mastectomies are performed annually in the US for the prevention or 
treatment of breast cancer.1 These surgeries involve the partial or complete removal of the breast 
tissue, including the NAC. Additionally, more than 3.5 million breast cancer survivors are living 
in the US, many of whom have had mastectomies.1 Close to one-third of early stage and two-thirds 
of late stage breast cancer patients opt for mastectomy as a treatment.1,2 Following mastectomy, 
over 70% of women elect to undergo reconstruction.13 NAC reconstruction can have a significant 
impact on a woman’s psychological well-being.14–16 Women are more comfortable undergoing a 
mastectomy if the nipple can be spared during the procedure, or if nipple reconstruction is possible 
when nipple-sparing is not an option.17 Research has shown that the NAC may play a more 
significant role in determining psychological well-being than the reconstructed breast mound. 
NAC reconstruction has been shown to correlate with self-esteem and improved body image. 
Furthermore, NAC reconstruction provides a sense of closure to their cancer experience.4,5 Close 
to 80% of women who underwent NAC reconstruction would describe NAC reconstruction as 
being important and would encourage other women to undergo NAC reconstruction.6 Women with 
NAC reconstruction are described feeling more confident in social settings, more emotionally 
capable, emotionally healthy, self-confident, feminine, attractive, and “normal”.6 Women with 
NAC reconstruction have higher sexual well- being, general and aesthetic satisfaction, and quality 
of life scores compared to women without NAC reconstruction.6,7 
Despite the widespread popularity and health benefits of post-mastectomy NAC 
reconstruction, current options for reconstruction are often inadequate. Options for NAC 
reconstruction include three-dimensional (3D) tattooing, adhesive prosthetics, acellular collagen 
matrix derived from porcine intestinal submucosa, or surgical techniques to create NAC-like 
structures from skin tissue such as local flaps or nipple-sharing grafts, or acellular dermal matrix 
sheets.8–10 Unfortunately, these approaches either lack physical depth or fail to maintain a 3D 
structure for more than a few months.11,12 Patient outcomes for surgical NAC reconstruction are 
dependent on surgical skill and time, and patients often end up requiring additional costly revisions 
when their reconstruction NAC(s) lose projection. Furthermore, nipple-sharing grafts are not 
feasible for all patients and only available for women who have had a unilateral mastectomy and 
have a nipple of adequate size.18 Use of decellularized porcine small intestinal submucosa, such as 
Cook Medical’s Biodesign® Nipple Reconstruction Cylinder (BD-NRC) has had mixed results, 
retaining only an average of 40% nipple projection at 12 months post reconstruction.12 Thus, there 
remains a great need for an easy-to-apply, permanent, and aesthetically pleasing method for NAC 
reconstruction. 
These clinical challenges inspired the BioAesthetics group to develop the NACgraft™, 
which serves as a scaffold for NAC regeneration that can be engrafted onto the exterior of the body 
on a de-epithelialized wound bed (onlay engraftment) in the anatomical location of the NAC. The 
NACgraft™ onlay graft differs from previous acellular allografts, which are intended for 
subcutaneous placement. This graft undergoes a patent-pending decellularization process which 
has been rigorously developed, characterized, and published in peer-reviewed journals.19,20 
 
 

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2.4. 
Study Design 
This single arm pilot study is designed to obtain preliminary safety and performance data 
in adult female subjects following treatment with the BioAesthetics’ NACgraft™. NACgrafts 
will be surgically engrafted onto 15 patients, via uni- or bilateral onlay engraftment. Given the 
nature of the treatment, this is an open (no masking) trial. No randomization will occur. The 
primary outcome being evaluated is safety/efficacy of the treatment approach. The overall study 
design is as follows:  
• 
Potential patients will be screened to determine study eligibility up to 3 weeks before 
the engraftment.  
• 
On the day of surgery, NACgrafts will be engrafted according to standard 
reconstructive technique. Using sterile technique, the recipient site on the breast mound 
will be de-epithelialized sharply and meticulous hemostasis obtained with 
electrocautery. The NACgraft™ will then be sutured into the wound bed with 
dissolving suture. In women undergoing bilateral NAC reconstruction, this process will 
be repeated for the contralateral breast. A sterile dressing will be applied and patients 
will be discharged home according to institutional guidelines; written instructions will 
be provided for the care of the NACgraft(s) and dressings. The dressing will include 
antimicrobial ointment, followed by a non-adherent, occlusive dressing (e.g. Adaptic, 
Xeroform) secured in place using a foam dressing cut into a donut (e.g., Allevyn) to 
prevent compression of the graft. 
• 
Safety, healing time, sensation, vascularization, patient satisfaction, and nipple 
characteristics will be assessed over a 12-month period. Patients will return to the 
outpatient clinic on postoperative Days 7, 14, 28, and 42. Visits thereafter will take 
place on days 90, 180, and 360 post-engraftment. 
2.5. 
Correlative Studies Background 
The BioAesthetics NACgraft™ has been studied extensively in in vitro and in preclinical 
models to demonstrate their safety and therapeutic potential, as detailed below.21,22 
 
In a recent study,21 NAC tissue was harvested from rhesus macaques according to 
institutional guidelines and decellularized through a modified protocol.23,24 Briefly, NAC grafts 
are incubated with a series of agents alternating with water including Triton X-100, sodium 
deoxycholate, sodium chloride, antibiotic/antimycotic agents, and DNase I, then stored in 
antibiotic/antimycotic solution until use. This process removes cellular components while 
preserving the extracellular matrix (ECM) structure. Decellularized NACs were subjected to 
histological and quantitative analyses, including culture with bone marrow-derived mesenchymal 
stem cells (BMSCs) in vitro. They were found to be completely devoid of cells while retaining 
ECM integrity and a high degree of bioactivity. Specifically, collagen and glycosaminoglycan 
content were not significantly altered by decellularization, whereas elastin content was 
significantly decreased. The graft promoted BMSC proliferation and viability in vitro.  
 
In a follow up study, nonhuman primate (NHP)-derived NAC tissue was decellularized and 
their ECM components analyzed by both proteomic and histological analyses.22 Decellularized 
NHP NAC grafts again showed the removal of intact cells and a greatly diminished intracellular 
protein profile, as compared with intact NHP NAC tissue. Decellularized NAC grafts were then 
tested in a murine model. N=15 mice received subcutaneous implantation of a decellularized-NHP-

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NAC (dcl-NHP-NAC group 1 and 2). Additional groups included native NAC (N-NAC), 
commercial control (Strattice, catalog No. 1016002; LifeCell Corporation, Branchburg, NJ), or 
surgery only (sham). Two dcl-NHP-NAC groups were included to reflect different 
decellularization batches. Tissue was harvested at days 2, 14, 21. Histology revealed greater 
neovascularization in dcl-NHP-NAC grafts as compared to the commercial control, with no 
observed biocompatibility issues. The grafts were then tested in an NHP model. Briefly, 18 dcl-
NHP-NACs and two native host nipples were onlay grafted onto partial thickness wounds along 
the dorsal midline of resus macaques. Grafts were harvested at weeks 1, 3, and 6 for histological 
analysis. Results demonstrated successful neovascularization of the grafts that reached a steady 
state by 3 weeks post-engraftment. Furthermore, grafts showed complete re-epithelialization by 3 
weeks, which remained unchanged through the end of the study.  
 
This approach has now been replicated using human-derived NAC grafts implanted in an 
NHP model (manuscript in preparation). Results showed graft re-epithelialization, vascularization, 
and the presence of nerves within graft tissue by the 6-week timepoint, with preserved nipple 
projection. In summary, the above preclinical trials confirm the safety and clinical potential for 
this device to improve patient care.  
 
 
2.6 Nipple Morphology and Pigmentation Considerations  
 
When a NAC is recovered from a deceased donor, the areola diameter, nipple diameter, 
and nipple projection/height are measured. These characteristics and pertinent demographic 
information (age, race, BMI, etc.) will be tracked with each NAC as part of inventory. For 
consistency in the manufacturing process, the diameters of the areolas are uniformly sized to 
2 cm, but the diameters (usually < 2 cm) and projections of the nipples themselves are not 
altered. We will categorize the NACgrafts as small, medium, and large on the basis of both 
nipple diameter and projection. In speaking with patients, it is clear that each has a unique 
preference for nipple size. When the physician places an order, the size 
preference will be matched from the inventory. 
 
With respect to pigmentation, the process of decellularization generally removes all 
pigment (melanin) from the graft such that it appears as a pale white color just like Alloderm® or 
other acellular dermis products. In individuals with very darkly pigmented NACs, we sometimes 
see that a layer of melanin remains on the surface of the NACgraft after decellularization. In our 
studies of NACgraft engraftments on non-human primates whose skin lacks melanin, we saw 
that after healing occurred (6 weeks) the color of regenerated NAC was the same as 
the surrounding skin tissue, but with a pink hue due to blood vessel infiltration. On a microscopic 
level, what we saw is that cells infiltrated the graft and lined up along the basement membrane 
between the epidermis and dermis of the NACgraft and regenerated a new epidermis underneath 
the existing decellularized epidermis, sloughing off the decellularized epidermis. So, from these 
observations, we expect that regardless if melanin (only contained in the epidermis) remains on 
the surface of the graft or not after decellularization, it will be sloughed off during the healing 
process and the graft will take on the color of the patient’s surrounding skin. Therefore, we 
expect that NACgrafts do not need to matched for race. Since non-human primates do not have 
melanin, we could not ascertain from those studies whether the NACgrafts promote higher 
concentrations of melanocytes/melanin than normal skin and, therefore, result in a darker 

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pigmented NAC as compared to surrounding skin. If a patient is not satisfied with the color of 
their new NAC, tattooing can be performed after healing is complete. 
 
 
3. 
PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES 
Refer to the Participant Eligibility Checklist in Appendix A.  
3.1. 
Inclusion Criteria 
 
3.1.1. Women between 18 and 65 years old. No race-ethnic restrictions. 
3.1.2. Patient has undergone uni- or bi-lateral autologous breast reconstruction a 
minimum of 3 months prior to enrolling in the study. 
3.1.3. Patient agrees to sleep on her back until the graft(s) have healed 
(approximately 6 weeks). 
3.1.4. Patient agrees to abstain from taking aspirin, drinking alcohol (>2 drinks 
per day), or consuming excessive amounts of caffeine (>300mg per day) 
until the graft(s) have healed (approximately 6 weeks). 
3.1.5. Patient agrees to not undergo NAC tattooing until completing the study 
(approximately 12 months after engraftment). 
3.1.6. Patient is able to understand and willing to sign an informed consent form. 
3.1.7. Eastern Cooperative Oncology Group (ECOG) or Karnofsky Performance 
Status restrictions: N/A  
3.1.8. Life expectancy restrictions: N/A  
3.1.9. Requirements for organ and marrow function: N/A  
3.2. 
Exclusion Criteria 
3.2.1. Patient is currently smoking or using tobacco or nicotine products (i.e. 
patch, gum, or nasal spray) or has used such products in the past 12 months. 
3.2.2. Patient has a history of delayed wound healing, Vitamin C deficiency, 
diabetes (Type I or Type II), BMI<18.5 or >40 kg/m, or any other 
uncontrolled comorbidity. 
3.2.3. Patient is currently receiving radiation or chemotherapy or received 
radiation to the breast wall. 
3.2.4. Patient has a history of prior NAC reconstruction  
3.2.5. Patient has had NAC tattooing. 
3.2.6. Therapy restrictions: none 
3.2.7. Investigational Agent restrictions: none 
3.2.8. Patient has a history of allergic reaction to any decellularized biologic 
matrix product. 
3.2.9. No patient will be excluded from the study due to history of HIV or cancer. 

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3.3. 
Informed Consent Process 
All participants must be provided a consent form describing the study with sufficient 
information for participants to make an informed decision regarding their participation.  
Participants must sign the IRB approved informed consent prior to participation in any study 
specific procedure. The participant must receive a copy of the signed and dated consent document.  
The original signed copy of the consent document must be retained in the medical record or 
research file.  
3.4. 
Randomization Procedures 
No randomization will occur. 
3.5. 
Study Timeline 
Primary Completion: 
The study will reach primary completion 24 months from the time the study opens to 
accrual. 
Study Completion: 
The study will reach study completion 24 months from the time the study opens to accrual. 
4. 
TREATMENT PLAN 
On the day of surgery, NACgrafts™ will be engrafted according to standard reconstructive 
technique. Using sterile technique, the recipient site on the breast mound will be de-epithelialized 
sharply and meticulous hemostasis obtained with electrocautery. The NACgraft™ will then be 
sutured into the wound bed with dissolving suture (e.g., chromic gut). In women undergoing 
bilateral NAC reconstruction, this process will be repeated for the contralateral breast. A sterile 
dressing will be applied, and patients will be discharged home according to institutional guidelines; 
written instructions will be provided for the care of the NACgraft(s)™ and dressings. The dressing 
will include antimicrobial ointment, followed by a non-adherent, occlusive dressing (e.g. Adaptic, 
Xeroform) secured in place using a foam dressing cut into a donut (e.g., Allevyn) to prevent 
compression of the graft. 
Patients will be return to the outpatient clinic regularly until the graft(s) are fully healed: 
on or about postoperative Days 7, 14, 28, and 42. They will return on days 90, 180, and 360 for 
measurement of long-term endpoints including nipple dimensions, sensitivity, and for satisfaction 
survey completion.  
In the event that the NAC Graft fails, the surgeon will determine if re-grafting is 
appropriate. The patient will be offered to undergo a second NAC Graft procedure. 
4.1. 
General Concomitant Medication and Supportive Care Guidelines 
Patients will continue their regular medications and receive routine postoperative following 
NAC reconstruction. No additional supportive medications are needed. No use of radioisotopes or 
radiation machines are required for the study. The procedures performed are similar to normal 
postoperative care following NAC reconstruction. The risks associated with the intervention are 
the same risks as with other surgical NAC reconstruction techniques, and include allergic reaction, 
asymmetry, swelling, graft failure requiring revision/debridement, hematoma, infection requiring 
debridement and/or antibiotics, scarring, delayed healing, and unsatisfactory aesthetic results.  

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4.2. 
Criteria for Removal from Study 
Reasons for patient withdrawal from the study include the following: 
• Patient withdraws consent. 
• Patient has disease progression (e.g., breast cancer recurrence on the side(s) of 
NAC reconstruction), requiring additional treatment such as surgery or 
chemotherapy. 
• Unacceptable adverse events, such as infection, hematoma, or allergic reaction 
requiring removal of the NACgraft. 
• The patient fails to comply with the study guidelines or postoperative care 
instructions (such as non-adherence with tobacco) 
• Any other medical condition which would place the patient at unnecessary risk 
if they were to continue in the study, determined on a case-by-case basis. 
4.3. 
Alternatives 
There will be several tiers of risk protection implemented in the proposed clinical study.  
• Risk Protection by Graft Manufacturing: The first tier of risk protection for the 
proposed study is in the manufacturing of BioAesthetics’ NACgrafts™. Grafts 
will be decellularized and manufactured according to current Good Tissue 
Practices (CGTP) guidelines. See Investigator’s Brochure and Instructions for 
Use. 
• Risk Protection by Subject Selection Criteria: The first clinical risk mitigation 
strategy is to conduct a thorough subject eligibility screening according to our 
explicitly defined, carefully reviewed study inclusion/exclusion criteria. In 
addition to representing the patient characteristics defining our anticipated 
indications for use, these eligibility criteria ensure the selection of subjects who 
have an acceptably low-risk profile, and for whom participating in our study 
does not present a significant elevation of risk. These criteria will be identified 
during the recruitment process and through a review of the user’s medical 
history. In addition, patients with characteristics that may elevate their risk of 
infection or injury as part of the current study will be excluded:  
• 
Tobacco usage  
• 
Delayed wound healing  
• 
Vitamin C deficiency  
• 
Diabetes  
• 
Uncontrolled comorbidity  
• 
Body mass index outside of 18.5-29.9 kg/m2 range  
• 
Currently receiving radiation or chemotherapy, or have received radiation 
to breast wall  

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Note - these individuals will be allowed to enroll if their conditions can be resolved prior 
to study enrollment. We will also carefully confirm that all enrolled subjects exhibit sufficient 
cognitive capacities, maximizing their ability to respond appropriately in the event of any 
complications – e.g., by contacting study personnel.  
• Risk Protection by HIPAA Compliance: Potential loss of patient privacy and 
confidential information is possible but is expected to be a low risk as 
institutional and federal HIPAA regulations will be followed to protect patient 
data. The clinical site will operate according to standard HIPAA-compliant 
procedures for handling of routine clinical data, and all research data will be 
entered/uploaded directly to the secure clinical study validation software on a 
daily basis. Hard copies of any research-specific data collection forms will be 
kept in a secure, locked file cabinet, to which only the clinical site’s lead 
investigator and study coordinator will have access as designated in the final 
study protocol. All members of the clinical staff participating in the study will 
maintain strict HIPAA compliance, and the results gathered will be treated as 
confidential, thus requiring all staff to maintain confidentiality to minimize risk 
to privacy. By using standard, validated procedures and best practices for 
handling clinical research data wherever possible and tailoring these processes 
to the standard procedures and workflow of Stanford Hospital & Clinics to the 
extent possible, the likelihood of success will be maximized and the possibility 
of data breach will be minimized.  
• Specific clinical study measures to manage risk will focus on routine subject 
monitoring in the form of weekly and monthly clinical visits. These will be 
conducted by a study nurse or coordinator, and include visual inspection, 
performed by at least one surgeon, for complications and extent of healing. 
During the clinical visits, patients will be prompted to answer a brief verbal 
survey to screen for any adverse events. Patient satisfaction will also be 
assessed at 6 and 12 months. If subjects exhibit symptoms indicative of adverse 
events requiring medical attention, which are defined by a detailed clinical 
decision tree, she will receive medical attention as necessary and appropriate.  
• Incidental findings arising from study data will be discussed between the 
clinical site lead investigator and BioAesthetics’ team, at regularly scheduled 
data review meetings. 
There are no applicable alternate procedures or treatments. Any patients who exit before 
engraftment will not receive a NACgraft for nipple replacement. However, these patients may opt 
to undergo nipple reconstruction – with BioAesthetics’ NACgraft™ or a commercial alternative – 
at a later time point. Any patients who exit after engraftment will have had nipple reconstruction 
and the benefits and risks associated with the NACgraft™. Current commercial alternatives 
include:  
• Surgical techniques that create a NAC-like structure from existing local or 
secondary tissues or acellular dermal matrix sheets, such as Alloderm or 
Glyaderm  
• 3D tattooing  

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• Cook Medical’s Biodesign Nipple Reconstruction Cylinder® (BD-NRC), an 
acellular collagen matrix derived from porcine intestinal submucosa. BD-NRC 
plugs still requires the same local or secondary site nipple reconstruction.  
5. 
INVESTIGATIONAL DEVICE INFORMATION 
5.1. 
Investigational Device 
See NACgraft™ Investigator’s Brochure for complete investigational device information. 
5.2. 
Intervention Description 
This is a single-arm interventional study. The study group will undergo NAC 
reconstruction in the office or operating room depending on any concurrent procedures. Following 
antiseptics and injection of local anesthesia, an area of skin on the reconstructed breast mound is 
de-epithelialized with a scalpel. After obtaining hemostasis with bovie electrocautery, the graft is 
sewn in place using an absorbable suture. A soft dressing is then placed over the graft (antibiotic 
ointment, non-adherent occlusive dressing, foam/sponge dressing cut into a donut). The dressing 
is taken down on postoperative day 7 at the patient’s first follow up appointment. Dressings are 
continued until epithelialization is complete over the entire graft (this is anticipated to occur over 
4-6 weeks). The Foam dressings will be used for 6 weeks to prevent graft compression.  
5.3. 
Availability 
BioAesthetics Corporation will provide the NACgrafts™.  
5.4. 
Agent Ordering 
BioAesthetics will be notified upon patient enrollment and NACgrafts™ will be prepared 
and shipped to study site up to 3 weeks prior to engraftment.  
Grafts will be sent to the Hagey Laboratory for Pediatric Regenerative Medicine at Stanford:  
257 Campus Dr. West, GK 200 
Stanford, CA 94305 
Phone: 650.736.2776 
The NACgrafts™ will be stored according to BioAesthetics’ defined protocol prior to surgery. 
5.4. 
Agent Accountability 
The NACgrafts™ will be kept in a secure storage location, accessible only to study 
personnel, to avoid access to unauthorized persons.  
6. 
DOSE MODIFICATIONS 
Due to the nature of the device, does modifications are not relevant to this study.  
7. 
ADVERSE EVENTS AND REPORTING PROCEDURES 
7.1. 
Potential Adverse Events 
The potential risks have been identified below. The existing standard of care would be 
applied to any adverse event. More detailed risk mitigation strategies are described in section 4.3 
– Alternatives. 
Loss of Privacy and Confidentiality: Potential loss of patient privacy and confidential 
information is possible.  

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Medical Risks: The potential risks will be summarized in the consent form and will be 
reviewed with the patient by the surgeon or study coordinator (as designated in the final protocol). 
Patients will additionally be able to access a member of the study team with any questions 
pertaining to risks for this study.  
Since a surgical procedure is required for the placement of the BioAesthetics NACgraft™, 
there are several expected adverse events that are related to the surgery itself.  These are similar to 
the risks with any nipple reconstruction procedure and they include: 
• Swelling/edema 
• Infection 
• Wound contracture 
• Pain 
• Bleeding 
• Lack of or abnormal sensation 
• Unanticipated cosmetic result 
• Asymmetry 
• Scarring 
• Need for revisionary procedures 
Adverse events that may result from the use of NACgraft™ itself include, but are not 
limited to the following: 
• Lack of device integration 
• Lack of device epithelialization 
• Device slough 
• Abnormal coloration with healing 
• Allergic reaction to remaining trace amounts of processing reagents listed in the 
Cautions section. 
• Graft rejection 
• Transmission of known pathogens including Hepatitis B or C, HIV I/II, syphilis 
or other bacteria. 
• Transmission or causation of diseases of unknown etiology and characteristics. 
7.2. 
Adverse Event Reporting 
Adverse events will be graded according to CTCAE v4.03.  Both Serious and Non-
Serious Adverse Events will be clearly noted in source documentation and listed on study 
specific Case Report Forms (CRFs).  The Protocol Director (PD) or designee will assess each 
Adverse Event (AE) to determine whether it is unexpected according to the Informed Consent, 
Protocol Document, or Investigator’s Brochure, and related to the investigation. All Serious 
Adverse Events (SAEs) will be tracked until resolution, or until 30 days after the study 

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treatment.  
 
 
SAEs CTCAE Grade 3 and above, and all subsequent follow-up reports will be reported 
to the Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) using the study 
specific CRF regardless of the event’s relatedness to the investigation. Following review by the 
DSMC, events meeting the IRB definition of ‘Unanticipated Problem’ will be reported to the 
IRB using eProtocol within 10 working days of DSMC review, or within 5 working days for 
deaths or life-threatening experiences. 
8. 
CORRELATIVE/SPECIAL STUDIES  
No further correlative laboratory or animal studies are planned. 
 
 

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9. 
STUDY CALENDAR 
 
Screening 
Day 0 
Day 
7a 
Day 
14a 
Day 
28a 
Day 
42a 
Day 
90a 
Day 
180a 
Day 
360a 
Personnel 
Description 
Informed Consent 
X 
 
 
 
 
 
 
 
 
Study Site 
Staff 
 
Height and 
Weight (for BMI) 
X 
 
 
 
 
 
 
 
 
Study Site 
Staff 
 
Medical History 
X 
 
 
 
 
 
 
 
 
Study Site 
Staff 
 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Site 
Staff 
Patient vital signs (heart rate, blood pressure, temperature) will be taken with the patient in a 
seated position and medications will be recorded. 
Current 
Medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Site 
Staff 
NACgraft 
Engraftment 
 
X 
 
 
 
 
 
 
 
Surgeon 
 
Surgical Time 
 
X 
 
 
 
 
 
 
 
Study Site 
Staff 
Duration will be the time difference between initial incision of the wound bed (i.e. de-
epithelialization) and placement of the final suture. 
Discontinue 
Nipple Protector 
 
 
 
 
 
X 
 
 
 
Surgeon 
The use of nipple protector bandage will be discontinued after 6 weeksb. 
Photographsa 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Site 
Staff 
Digital photographs of each NACgraft will be taken for documentation and transmission to 
surgeon for specified endpoints.  
Wound Healing 
 
 
X 
X 
X 
X 
X 
X 
X 
Surgeon  
Visual inspection of the graft(s) will be conducted to assess the extent of NACgraft healing 
and identify any complications (e.g. necrosis, infection). Assessments will be performed by 
the study site Surgeon and, using the photographs. Wound healing will be assessed via the 
following metrics: epithelialization (0-100%), granulation (0-100%), ischemia/necrosis (0-
100%), dehiscence (0-100%), and overall healing (0-100%). 
Infection 
 
 
X 
X 
X 
X 
X 
X 
X 
Surgeon  
Grafts will be assessed for infection via the following metrics: A) no infection; B) hyperemia 
(no infection); C) cellulitis (superficial infection); D) abscess or purulent infection. 
Vascularity 
 
 
 
 
X 
X 
X 
X 
X 
Surgeon + 
An assessment of blood flow to the NAC will be determined visually both by the surgeon 
and, using the digital photographs, by surgeon.. The NAC color will be graded as white, 
pink, light brown, blue, purple or black.  In addition, each NACgraft will be pricked with a 
lancet/lancing device (the type used for obtaining fingerstick glucose measurement) in each 
quadrant of the areola, plus the nipple, for a total of 5 regions to determine vascularization. 
Lancing will be discontinued after the first post-operative visit demonstrating vascularity. 
Graft Dimensions 
 
 
 
 
 
X 
X 
X 
X 
Study Site 
Staff 
Nipple projection/height and diameter will be measured with a Depth Gauge and Drill 
Gauge, respectively. 
NAC Sensitivity 
X 
 
 
 
 
 
X 
X 
X 
Surgeon 
Sensitivity testing will be performed with the patient laying down and eyes closed. The 
areola will be divided into 4 quadrants, plus the nipple, for a total of 5 regions to be tested 
using the Semmes Weinstein monofilament technique. 
Patient Surveys 
X 
 
 
 
 
 
X 
X 
X 
Study Site 
Staff 
Patients will complete the Nipple Reconstruction Satisfaction Survey – Pre at Screening and 
Nipple Reconstruction Satisfaction Survey – Post at Days 90, 180, and 360. 
a: window +/- 4 days| b: subject discretion and/or PI discretion to continue beyond 6 weeks  

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10. 
MEASUREMENTS 
10.1. Primary outcome measure: time to complete healing 
10.1.1. Relevant Subset 
All patients (n=15).  
10.1.2. Measurement Definition 
Time to healing for each NACgraft will be as the first weekly visit at which the 
surgeon deems the graft >99% overall healed. This measurement will be reported as the 
number of weeks to healing. 
10.1.3. Measurement Methods 
Degree of healing will be based on visual assessment by the surgeon with the 
following metrics on a visual analog scale (VAS): vascularization, overall healing (0-
100%). Photographs will be taken, stored and transmitted securely to BOX. Time to 
complete healing will be defined as the first visit at which the surgeon determine that there 
is >99% overall healing of the graft. 
10.1.4. Measurement Time Points 
Healing assessment will take place at each postoperative visit until healed including 
day 7, 14, 28, and 42. Further early postop follow up visits may be considered as 
determined by the surgeon.  
10.1.5. Response Review 
N/A 
10.2. Primary outcome measure: device safety 
10.2.1. Relevant Subset 
All patients (n=15).  
10.2.2. Measurement Definition 
Safety of the device will be measured by any observed complications that occur 
following treatment. Primary safety endpoints will include presence/absence of infection, 
necrosis, allergic reaction, or any complication that can be attributed to the graft procedure. 
The degree and frequency of these adverse events will be recorded and reported. These 
endpoints will be reported in the study case report form (CRF) and will be continuously 
tabulated and reviewed by the study staff. 
10.2.3. Measurement Methods 
Photographs will be taken using standardized digital photography, stored and 
transmitted securely to surgeon for independent review. Grafts will be evaluated by the 
surgeon with the following metrics on a visual analog scale (VAS): ischemia/necrosis (0-
100%); dehiscence (0-100%). In evaluating for complications, the surgeon will classify 
grafts as having A) no infection; B) hyperemia (no infection); C) cellulitis (superficial 
infection); D) abscess or purulent infection. Additional adverse events or complications (as 
defined in CTCAE v4.03, see Section 7.2) will also be recorded and reported in categorical 
format. 

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10.2.4. Measurement Time Points 
Healing assessment will take place at each postoperative visit until healed including 
day 7, 14, 28, and 42. Further early postop follow up visits may be considered as 
determined by the surgeon.  
10.2.5. Response Review 
N/A 
10.3. Secondary outcome measure: Time to 50% and 75% graft healing 
10.3.1. Relevant Subset 
All patients (n=15).  
10.3.2. Measurement Definition 
Time to 50% and 75% healing for each NACgraft™ will be as the first weekly visit 
at which the surgeon deems the graft >50% healed and >75% healed, respectively. This 
measurement will be reported as the number of weeks to healing. 
10.3.3. Measurement Methods 
See Section 10.1.3. 
10.3.4. Measurement Time Points 
See Section 10.1.4. 
10.3.5. Response Review 
See Section 10.1.5. 
10.4. Secondary outcome measure: operative time 
10.4.1. Relevant Subset 
All patients (n=15).  
10.4.2. Measurement Definition 
Operative time will be defined as the amount of time passing between incision of 
the skin and final suture placement during graft surgery. 
10.4.3. Measurement Methods 
Operative time will be measured in the procedure room with a standard stopwatch 
and reported in minutes/seconds. If in the operating room this is reported by operating staff. 
If done in the clinic, the procedural nurse will assist with timekeeping. Operative time will 
be recorded separately for each NACgraft™ during bilateral procedures.  
10.4.4. Measurement Time Points 
Measurements will take place on day 0 (day of surgery) 
10.4.5. Response Review 
N/A 

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10.5. Secondary outcome measure: NAC sensitivity 
10.5.1. Relevant Subset 
All patients (n=15).  
10.5.2. Measurement Definition 
NAC sensitivity is defined as the sensation felt by the patient on the NACgraft™ 
according to the scale in Section 10.5.3.  
10.5.3. Measurement Methods 
Measurement is performed using Semmes Weinstein Monofilament (SWM) testing 
with the patient lying down with her eyes closed. The areola will be divided into quadrants, 
so a total of 5 regions (nipple + each areolar quadrant) will be assessed. Each monofilament 
represents a log of the force needed to bend the microfilament, with the larger 
monofilaments requiring more force to bend. Filament sizes will be converted to 
categorical variables (0 = no sensation, i.e. unable to feel 6.65 filament; 1 = can feel 6.65 
filament, 2 = can feel 4.56 filament, 3 = can feel 4.31 filament, 4 = can feel 3.61 filament, 
and 5 = can feel 2.83 filament). 
10.5.4. Measurement Time Points 
Measurements will take at 3 months, 6 months, and 12 months. 
10.5.5. Response Review 
N/A 
10.6. Secondary outcome measure: Nipple projection 
10.6.1. Relevant Subset 
All patients (n=15).  
10.6.2. Measurement Definition 
Nipple projection is defined as the distance from the breast mound to the most 
projecting tip of the NACgraft, reported in millimeters. 
10.6.3. Measurement Methods 
Nipple projection is measured with the patient laying down on her back using a 
depth gauge 
10.6.4. Measurement Time Points 
Measurements will take place on day 0 (day of surgery), day 42, 3 months, 6 
months, and 12 months. 
10.6.5. Response Review 
N/A 
10.7. Secondary outcome measure: Nipple diameter 
10.7.1. Relevant Subset 
All patients (n=15).  

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10.7.2. Measurement Definition 
Nipple diameter is defined as the diameter of the nipple at its base (i.e. where it sits 
on the breast mound), reported in centimeters. 
10.7.3. Measurement Methods 
Nipple diameter is measured using a drill gauge. 
10.7.4. Measurement Time Points 
Measurements will take place on day 0 (day of surgery), day 42, 3 months, 6 
months, and 12 months. 
10.7.5. Response Review 
N/A 
10.8. Secondary outcome measure: patient satisfaction 
10.8.1. Relevant Subset 
All patients (n=15).  
10.8.2. Measurement Definition 
Patient satisfaction will be measured using a standardized postoperative survey 
utilizing a LIKERT (numerical) scale to collect feedback from the patient on a variety of 
indicators including NAC position, overall appearance, symmetry, color, softness, 
sensation, appearance while nude, appearance when clothed, size, projection, and effect on 
overall breast appearance. Feedback will additionally be obtained in regard to contribution 
of reconstructed NAC on sex life, well-being, self-esteem, and whether the patient would 
undergo the procedure again or recommend the procedure to others. Scores will be reported 
on a scale of 1 (strongly disagree) to 5 (strongly agree).  
A pre-operative survey will collect feedback from the patient on their perceived 
satisfaction with their reconstructed breast prior to NAC reconstruction. Survey items 
include satisfaction with breast shape, sensation, sense of well-being, self-esteem, and sex 
life. 
10.8.3. Measurement Methods 
Patient satisfaction pre- and post-NAC reconstruction will be measured using 
standardized Pre-Operative and Post-Operative Nipple Reconstruction Satisfaction 
Surveys (see Appendix B).  
10.8.4. Measurement Time Points 
The time point will take place at study enrollment (pre-operative survey) and 
postoperatively at 3 months, 6 months, and 12 months. 
10.8.5. Response Review 
N/A 
10.9. Secondary outcome measure: NAC vascularization 
10.9.1. Relevant Subset 

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All patients (n=15).  
10.9.2. Measurement Definition 
NAC vascularization is defined by the presence of vascular tissue within the graft. 
Presence of bleeding from the graft following needle puncture using a lancet device will 
serve as the objective confirmation of vascularization.  
Visual assessment using categories on a color chart (white, pink, light brown, blue, 
purple or black) will also be performed.  
10.9.3. Measurement Methods 
Presence of bleeding will be determined using a lancet device after cleaning the 
area with an alcohol swab. Results are reported for 5 quadrants (four corners plus central 
nipple). Once a quadrant shows bleeding, lancing is deferred for all future visits. 
Visual assessment using categories on a color chart (white, pink, light brown, blue, 
purple or black) will be performed at all follow up visits specified in Section 10.9.4. 
10.9.4. Measurement Time Points 
Measurements will take place on day 28, 42, 3 months, 6 months, and 12 months. 
10.9.5. Response Review 
N/A 
11. 
REGULATORY CONSIDERATIONS 
11.1. Institutional Review of Protocol 
The protocol, the proposed informed consent and all forms of participant information 
related to the study (e.g. advertisements used to recruit participants) will be reviewed and approved 
by the Stanford IRB and Stanford Cancer Institute Scientific Review Committee (SRC).  Any 
changes made to the protocol will be submitted as a modification and will be approved by the IRB 
prior to implementation.  The Protocol Director will disseminate the protocol amendment 
information to all participating investigators. 
11.2. Data and Safety Monitoring Plan 
           The Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) will be the 
monitoring entity for this study. The DSMC will audit study-related activities to determine 
whether the study has been conducted in accordance with the protocol, local standard operating 
procedures, FDA regulations, and Good Clinical Practice (GCP).  This may include review of the 
following types of documents participating in the study: regulatory binders, case report forms, 
eligibility checklists, and source documents.  In addition, the DSMC will regularly review 
serious adverse events and protocol deviations associated with the research to ensure the 
protection of human subjects.  Results of the DSMC audit will be communicated to the IRB and 
the appropriate regulatory authorities at the time of continuing review, or in an expedited 
fashion, as needed. 
11.3. Data Management Plan 
The Protocol Director, or his designee, will prepare and maintain adequate and accurate 
participant case histories with observations and data pertinent to the study.  Study specific Case 
Report Forms (CRFs) will document treatment outcomes for data analysis.   Case report forms will 

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be developed using the REDCap database system and will be maintained by the Study Coordinator. 
CRFs will be kept in a locked office, only accessible to the research team. 
12. 
STATISTICAL CONSIDERATIONS 
12.1 
Statistical Design 
The purpose of this clinical study is to determine the initial safety and utility of 
BioAesthetics’ NACgraft™. The proposed sample size of 15 subjects is not intended to support 
definitive conclusions around our primary outcome measures, but rather to:  
• 
Provide support that the NAC graft is safe for marketing purposes 
• 
Confirm ability to gather necessary data for an adequately powered larger clinical study 
in the future  
• 
Provide preliminary estimates of these measures and their associated variability, in part 
to better define sample size requirements for a future larger study.  
Outcome measures for this study address:  
• 
Safety: For safety, we are collecting data on the degree of healing and the incidence 
of engraftment- related adverse events (e.g. infection, necrosis).  
• 
Performance: For graft performance, we are collecting data on the following:  
• 
Degree and timing of healing 
• 
Duration of surgical engraftment procedure 
• 
Nipple characteristics 
• 
Projection 
• 
Sensitivity 
• 
Vascularization 
• 
Patient Satisfaction: Finally, we will access user experience from satisfaction 
surveys addressing the following areas:  
• 
Body image 
• 
Overall satisfaction 
• 
Satisfaction with nipple 
• 
Self-esteem 
• 
Psychological well-being 
Additionally, we will assess the completeness of feasibility study data in terms of missing 
or incomplete measurements for each outcome and will determine any associated operational 
modifications needed to enhance data collection in a future study. Preliminary estimates will be 
developed for each type of measure. Each estimate will be assessed with descriptive statistics (t 
distribution for continuous variables, Poisson distribution for incidence rates, etc.) and 95% 
confidence intervals will be applied.  
12.1.1. Randomization 

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No randomization will take place. 
12.2. Interim analyses 
No statistical stopping rule will be employed. 
12.3. Descriptive Statistics and Exploratory Data Analysis 
Descriptive statistics will be employed including t distribution for continuous variables, 
Poisson distribution for incidence rates, etc. and 95% confidence intervals will be applied for the 
measured primary and secondary outcomes. 
12.4. Primary Analysis  
Primary outcome measure: To evaluate safety and healing rates following NAC 
reconstruction using the BioAesthetics NACgraft™. 
12.4.1. Analysis Population 
All study participants will be included in the analysis population. Intention-to-treat 
analysis will be performed and statistics for sub-groups containing no missing data or non-
adherence will be included.  
12.4.2. Analysis Plan 
Time to complete healing for each NAC will be defined (as described in Section 
10.1) as the first weekly visit at which the surgeon deems the graft >99% overall healed. 
This outcome will be characterized in terms of distributional characteristics such as the 
maximum, mean, median, and variation (as 95% confidence interval) of these data.  
Safety outcome data as described in Section 10.2 that are reported as percentages 
(ischemia/necrosis, erythema, dehiscence) will be characterized in terms of distributional 
characteristics such as the maximum, mean, median, and variation (as 95% confidence 
interval). Measurements reported as categorical variables (infection) will be characterized 
as a percent.  
12.5. Secondary Analysis 
Secondary outcome measures include time to 50% and 75% healing, operative time, nipple 
projection, nipple diameter, NAC sensitivity, NAC vascularization, and patient satisfaction survey 
scores. 
12.5.1. Analysis Population 
All study participants will be included in the analysis population. Intention-to-treat 
analysis will be performed and statistics for sub-groups containing no missing data or non-
adherence will be included.  
 
 
12.5.2. Analysis Plan 
Secondary outcome data as described in Section 10.3 – 10.9 will be characterized 
in terms of distributional characteristics such as the maximum, mean, median, and variation 
(as 95% confidence interval). Numerical scores (weeks to 50% and 75% graft healing, 
operative time, nipple projection, nipple diameter, NAC sensitivity, weeks to NAC 
vascularization, and LIKERT survey scores) will be characterized in terms of distributional 
characteristics such as the maximum, mean, median, and variation (as 95% confidence 
interval). Measurements reported as categorical variables (infection) will be characterized 

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as a percent. 
12.6. Sample Size 
12.6.1. Accrual estimates 
According to the Stanford STRIDE database, Between January 1 2019 and January 
1 2020, 25 patients with a history of autologous reconstruction for breast cancer underwent 
nipple-areolar reconstruction. Thus, we expect patient accrual to be achievable within the 
desired study timeframe. If accrual falls short of expectations, the study duration will be 
extended. 
12.6.2. Sample size justification 
The proposed sample size of 15 patients is not intended to support definitive 
conclusions around our primary outcome measures, but rather will (a) provide support that 
the NAC graft is safe for marketing purposes, (b) will confirm our ability to gather the 
necessary data in an adequately powered larger clinical study in the future, and (c) provide 
preliminary estimates of the study measures and their associated variability, in part to better 
define sample size requirements for the larger study. 
12.6.3. Effect size justification 
This is a single arm (non-randomized study) thus effect size is not applicable. 
Previous literature indicates that NAC reconstruction can be a significant determinant of 
psychological well-being in breast cancer survivors.4,5 In a recent study, 80.3% of women 
who underwent NAC reconstruction would encourage other women to undergo NAC 
reconstruction (n=107, no confidence interval given).6 Women who have undergone NAC 
reconstruction have been shown to have significantly higher general (72.2% vs 52.8%, P < 
0.0001) and aesthetic (70.5% vs 46.5%, P < 0.0001) satisfaction scores compared to 
patients without nipple reconstruction (n=490 NAC reconstruction, n=206 without 
reconstruction).7 Furthermore, patients who underwent NAC reconstruction using the 
Cook Medical BD-NRC (n=82 reconstructions in n=50 patients) only retained 40% nipple 
projection at 12 months post-reconstruction (3.8 ± 1.5 mm, compared with 10.5 ± 2.2 mm 
1 week after surgery).12 Data from this trial will be compared to these historical figures to 
look for trends and inform future studies. 
12.7. Criteria for future studies 
Completion of the study without any serious adverse events, with a >95% healing rate, and 
with patient survey scores at or above previously published data on patients who have undergone 
NAC reconstruction, will indicate a positive study result and convince us to continue with a fully 
powered study. Retention of NAC projection at the level or superior to previously published results 
will be additional reason to proceed with a larger clinical study. 
  
 
 

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13. 
REFERENCES 
1. Breast Cancer Facts & Figures 2017-2018. (2017). 
2. Siegel, R., Naishadham, D. & Jemal, A. Cancer statistics for Hispanics/Latinos, 2012. CA 
Cancer J Clin 62, 283–298 (2012). 
3. Plastic Surgery Statistics Report. (2015). 
4. Delay, E., Mojallal, A., Vasseur, C. & Delaporte, T. Immediate nipple reconstruction during 
immediate autologous latissimus breast reconstruction. Plast. Reconstr. Surg. 118, 1303–1312 
(2006). 
5. Wellisch, D. K., Schain, W. S., Noone, R. B. & Little, J. W. The psychological contribution 
of nipple addition in breast reconstruction. Plast. Reconstr. Surg. 80, 699–704 (1987). 
6. Bykowski, M. R. et al. Nipple-areola complex reconstruction improves psychosocial and 
sexual well-being in women treated for breast cancer. J Plast Reconstr Aesthet Surg 70, 209–
214 (2017). 
7. Momoh, A. O. et al. The impact of nipple reconstruction on patient satisfaction in breast 
reconstruction. Ann Plast Surg 69, 389–393 (2012). 
8. Craft, R. O. & May, J. W. Staged nipple reconstruction with vascularized SurgiMend acellular 
dermal matrix. Plast. Reconstr. Surg. 127, 148e–9e (2011). 
9. Rao, S. S., Seaman, B. J. & Davison, S. P. The acellular dermal matrix onlay graft for areolar 
reconstruction. Ann Plast Surg 72, 508–512 (2014). 
10. Seaman, B. J., Akbari, S. R. & Davison, S. P. A novel technique for nipple-areola complex 
reconstruction:  the acellular dermal matrix onlay graft. Plast. Reconstr. Surg. 129, 580e–581e 
(2012). 
11. Evaluation 
of 
the 
Cook 
Biodesign® 
Nipple 
Reconstruction 
Cylinder. 
.https://clinicaltrials.gov/ct2/show/results/NCT01216319?sect=X70156&view=results#outco
me1 (2016). 
12. Collins, B. et al. Nipple Reconstruction with the Biodesign Nipple Reconstruction Cylinder: 
A Prospective Clinical Study. Plast Reconstr Surg Glob Open 4, e832 (2016). 
13. MedCore. US Market Report for Breast Reconstruction. (2017). 
14. Al-Ghazal, S. K., Fallowfield, L. & Blamey, R. W. Comparison of psychological aspects and 
patient satisfaction following breast conserving surgery, simple mastectomy and breast 
reconstruction. Eur. J. Cancer 36, 1938–1943 (2000). 
15. Lohsiriwat, V. & Petit, J. Nipple Sparing Mastectomy: from prophylactic to therapeutic 
standard. Gland Surg 1, 75–79 (2012). 
16. Nano, M. T. et al. Psychological impact and cosmetic outcome of surgical breast cancer 
strategies. ANZ J Surg 75, 940–947 (2005). 
17. Didier, F. et al. Why do women accept to undergo a nipple sparing mastectomy or to 
reconstruct the nipple areola complex when nipple sparing mastectomy is not possible? Breast 
Cancer Res. Treat. 132, 1177–1184 (2012). 
18. Storrs, C. Double mastectomies for breast cancer tripled in 10 years. CNN (2016). 

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19. Chen, W. F., Barounis, D. & Kalimuthu, R. A novel cost-saving approach to the use of 
acellular dermal matrix (AlloDerm) in postmastectomy breast and nipple reconstructions. 
Plast. Reconstr. Surg. 125, 479–481 (2010). 
20. Cypel, T. K. & Brown, M. Twelve-year delay of a nipple-sharing graft: A case report. Can J 
Plast Surg 21, 190–191 (2013). 
21. Pashos, N. C. et al. Characterization of an Acellular Scaffold for a Tissue Engineering 
Approach to the Nipple-Areolar Complex Reconstruction. Cells Tissues Organs (Print) 203, 
183–193 (2017). 
22. Pashos, N. C. et al. Acellular Biologic Nipple-Areolar Complex Graft: In Vivo Murine and 
Nonhuman 
Primate 
Host 
Response 
Evaluation. 
Tissue 
Eng 
Part 
A 
(2020) 
doi:10.1089/ten.TEA.2019.0222. 
23. Bonvillain, R. W. et al. A nonhuman primate model of lung regeneration: detergent-mediated 
decellularization and initial in vitro recellularization with mesenchymal stem cells. Tissue Eng 
Part A 18, 2437–2452 (2012). 
24. Scarritt, M. E. et al. Hypertensive rat lungs retain hallmarks of vascular disease upon 
decellularization but support the growth of mesenchymal stem cells. Tissue Eng Part A 20, 
1426–1443 (2014). 
25. Temple-Oberle, C. F. et al. The breast reconstruction satisfaction questionnaire (BRECON-
31): an affirmative analysis. J Surg Oncol 107, 451–455 (2013). 
26. Platt, J. & Zhong, T. Patient-Centered Breast Reconstruction Based on Health-Related 
Quality-of-Life Evidence. Clin Plast Surg 45, 137–143 (2018). 
 
 

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APPENDIX A: Participant Eligibility Checklist  
 
Protocol Title: 
A Single Arm, Single Center Pilot Study Evaluating the Safety and 
Healing Time of the NACgraft™ for Nipple-Areolar Complex 
Reconstruction 
Protocol Number: 
 
Principal Investigator: 
Geoffrey Gurtner, MD 
 
II. Subject Information: 
 
Subject Name/ID: 
 
Gender:    
 Male     
 Female 
 
III. Study Information: 
 
SRC Approved 
 IRB Approved 
 Contract signed 
 
 
IV. Inclusion/Exclusion Criteria 
 
Inclusion Criteria 
(From IRB approved protocol) 
Yes No 
Supporting 
Documentation* 
1. Patient is between 18 and 65 years of age, inclusive. 
 
       
2. Patient has undergone uni- or bi-lateral autologous 
breast reconstruction a minimum of 3 months prior to 
enrolling in the study. 
 
       
3. Patient agrees to not undergo NAC tattooing until 
completing the study (approximately 12 months after 
engraftment). 
 
  
Provider initials/Date 
4. Patient agrees to sleep on her back until the graft(s) 
have healed (approximately 6 weeks). 
 
 
 
Provider initials/Date 
5. Patient agrees to abstain from aspirin, smoking, alcohol 
(>2 drinks per day), or excessive caffeine (>300mg per 
day) until grafts healed (6 weeks). 
 
 
 
Provider initials/Date 
6. Patient is able to understand and willing to sign an 
informed consent form. 
 
  
Provider initials/Date 
Exclusion Criteria 
(From IRB approved protocol) 
 
1. Patient is currently smoking or using tobacco or 
nicotine products (i.e. patch, gum, or nasal spray) or 
has used such products in the past 12 months. 
 
       
2. Patient has a history of delayed wound healing. 
 
       

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3. Patient has a Vitamin C deficiency. 
 
       
4. Patient has diabetes (Type I or Type II). 
 
       
5. Patient has any uncontrolled comorbidity. 
 
       
6. Patient has a body mass index <18.5 or >40 kg/m2. 
 
       
7. Patient is currently receiving radiation or chemotherapy 
or received radiation to the breast wall. 
 
       
8. Patient has a history of prior NAC reconstruction. 
 
       
9. Patient has had NAC tattooing. 
 
       
 
*All subject files must include supporting documentation to confirm subject eligibility.  The 
method of confirmation can include, but is not limited to, laboratory test results, radiology test 
results, subject self-report, and medical record review.   
 
IV.  Statement of Eligibility 
 
By signing this form of this study, I verify that this subject is [
 eligible / 
 ineligible] for 
participation in the study. This study is approved by the Stanford Cancer Institute Scientific 
Review Committee, the Stanford IRB, and has finalized financial and contractual agreements as 
required by Stanford School of Medicine’s Research Management Group.   
 
 
Treating Physician Signature: 
Date: 
Printed Name: 
 
 
Secondary Reviewer Signature: 
Date: 
Printed Name: 
 
 
Study Coordinator Signature: 
Date: 
Printed Name: 
 
 
 

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APPENDIX B: Nipple Reconstruction Satisfaction Surveys 
  
 

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