The Final Stage: Nipples and Tattoos

I was very pleased to be invited by Dr. Lin to occasionally contribute to this blog. I have been an oncology social worker at BIDMC for more than thirty years and work primarily with women who have breast cancer. In addition to my professional interest, I have a strong personal one as I have been diagnosed and treated for two primary (unrelated) breast cancers, once in 1993 and once in 2005. I write a daily blog for BIDMC called Living with Breast Cancer; there is a link to it on the right side of this blog. To tempt you to read more of my musings, I am sharing here a recent entry about Nipples and Tattoos (that title ususally is an attention-grabber):

Breast reconstruction is always a hot topic, and women sometimes wonder about the value of the final phase: nipple reconstruction and tattooing.
A woman in one of my hospital-based groups recently asked others on our Listserv about their experiences. It occurs to me that others may find these comments helpful. I am, therefore, attaching some of the letters that she received in response to her questions.
If you have anything to add about your own reconstruction and decisions, I would love to hear from you. Just click on “comments” and share your thoughts.
My experience with tattoo/nipple recon was mixed. the nipple reconstruction does indeed protrude slightly, but this is not a problem since the saline pouch is a little smaller than the original and thus a small falsie covers the deficiency. As for the tattoo, Erickson did a fair job after I advised him on how to mix the colours. It is, by the way, not entirely painless even with novocaine. The ink fades slowly so the tattoo has to be darker than you might expect at first. In short, my view now is that had I had a double mastectomy and recons, the whole nipple and tattoo process would have been worthwhile; if I had it to do again, I wouldn’t bother.
I had nipple reconstruction and a tattoo. The nipple was initially a little “pronounced” but it flattened. I requested a pale tattoo which faded to the point where it is almost not visible now. Dr.X trained with the doctor who did my reconstruction so I think you need not worry about the nipple if he does it even though he did not do any of my surgery. Dr. X did my tattoo. I would follow his advice about color. I did not and as I said, it has faded a lot.
My name is XXXX I had the nipple reconstruction. I was hoping for the most realistic version possible. So I wanted them to stick out like my previous ones did. My reconstructed nipples stick out but not very much nothing like the real ones. They look fine it’s just for me when I look at them I think OK reconstructed. Also my tattoos faded very quickly. I had been told they would but I thought it would take a long time. Not so very much lightened to the point of needing to be redone even before the first year was up. I just had my 1 year follow up with the plastic surgeon and she thought they needed to be redone as well. I hope this helps,
I’m not really qualified to answer, as have only had lumpectomy. But I did some reading when I accompanied a friend to her nipple tattooing, though I’m hardly an expert.
If using a non-medical tattoo artist, please make sure that he/she follows the Mass. Dept. of Public Health model regulations for “body art” (attached), and uses sterile inks/needles. There is always a risk of infection/lymphedema in the affected breast. If the breast has been radiated, tattooing would be an increased risk due to the nature of radiated skin. My friend’s tattoo was done by her surgeon’s nurse. The only problem was that the choice of colors for the nipple tattoo was somewhat limited (sort of like choosing grout colors for tile) — there are only a few shades for each skin tone. Although the nurse did make “dots” with the tattoo needle, instead of a solid line, which would have been more unnatural, we couldn’t get a close enough color match to her other nipple. We were told that tattoo inks do fade over time, though.
She did have her nipple reconstructed, and it does stick out a little bit, but it looks quite natural- perhaps your surgeon has photos of his work? One more thing — I did have a “Nipple Party” for my friend, to commemorate the completion of her reconstruction. We thought it was a nice idea.
I can’t be a LOT of help, but I did have nipple reconstruction. The nipples stuck out for a few months + or -, but soon became basically flat and almost completely unnoticeable. There is perhaps the slightest outline of a nipple in the very thinnest nighty. For the most part I wear stretch camisoles (with an inside elastic ‘bra’) now that I don’t really need a bra – and the nipples can’t be seen through these at all. I believe, however, there are several ways to reconstruct the nipple, so suggest you find out which version your surgeon suggests/does.
I have to say that getting nipples (which originally I wasn’t going to do as I was out of energy & wanting the nighmare to be over) turned out to be a huge emotional boost to me. Having the ‘details’ gave my new ‘breasts’ personality. A glance in the bathroom mirror reflected an image that looked very natural. With a bilateral mastectomy, ‘matching’ a ‘real’ breast wasn’t an issue.
My tattoos (almost 3 years now) have faded (the pink/brown colors don’t have the lasting power of red/blue & my doc doesn’t like to make them too dark), so I am considering having a touch up. Be really, really clear with your surgeon how big you want the aeroli to be…its not possible to make them smaller once tattooed.
I have had a nipple reconstruction and then a couple years later I had it tattooed by the PA that assists the surgeon that did my TRAM flap. My reconstructed nipple does stick out some but it is softer and is not nearly as noticeable in clothes as my natural one is. So, I have often gotten more padded bras to conceal my natural nipple whereas it is not an issue for my reconstructed one..
I also eventually did get my tattoo, just last September, a little more than two years after my surgery, and think that for me, because I had the nipple reconstructed, it looks more natural than it would than if I hadn’t done it because the tattoo is more uniform in color than my natural one. For my natural one the nipple is darker than the areola. I’ve been tempted to go back for a little “touch up” to get a more natural effect. If the color scheme were closer to my natural nipple it might make having a reconstructed nipple less important as I think this is what makes it look more natural, out of clothes anyway. I guess I mean I think that having the coloring right might be more natural looking than having the reconstruction but don’t know if going to a tattoo artist will increase the likelihood of a better tattoo outcome or not.
From what I understand there are several nipple reconstructions that may be offered; grafting from either behind the ear or the labia, the star origami -style which is done w/very little discomfort but needs the tattoo to define the color & shape, or just a tattoo, w/o depth or dimension. I had my reconstruction in ’98 using a wedge of my back muscle & skin, i had the first of the origami type but didn’t go back for the finish so the skin feels smooth rather than protruding and had the tattoo done last year by a tattoo artist not a plastic surgeon, she used several colors and her shading gives the illusion of depth. I like it – it is very subtle (I think). The result probably depends on the surgeon, yes?
My experience with tattoo/nipple recon was mixed. the nipple reconstruction does indeed protrude slightly, but this is not a problem since the saline pouch is a little smaller than the original and thus a small falsie covers the deficiency. As for the tattoo, Dr X did a fair job after I advised him on how to mix the colours. It is, by the way, not entirely painless even with novocaine. The ink fades slowly so the tattoo has to be darker than you might expect at first. In short, my view now is that had I had a double mastectomy and recons, the whole nipple and tattoo process would have been worthwhile; if I had it to do again, I wouldn’t bother.

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Samuel Lin, MD, FACS
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