This story is part of Survivor's Guide, a series on navigating the impact of breast cancer through beauty and self-care.
Over the last 10 years, nipple and areola reconstruction for people who've been through breast cancer treatment has advanced greatly. In addition to surgical reconstruction, cosmetic tattooing has become a more popular choice for those who have undergone a mastectomy (removal of the entire breast). Nipple-areola tattooing is a type of reconstruction that involves tattooing a nipple on the skin and adding color and shading in such a way that it looks three dimensional and hyperrealistic.
A nipple tattoo is similar to a regular tattoo because it's permanent, but it’s also different because "you are working on compromised skin," artist Vinnie Myers — who, to date, has tattooed nipples onto nearly 12,000 women — previously told Allure. It's imperative to find a trusted artist with a portfolio and to have a discussion about color, size, and the overall look advised Myers. "Ultimately, these should be your decisions because they are staying with you forever."
While medical records of successful mastectomies date back to the late 1800s, nipple and areola reconstruction only started to become common in the 1980s. It wasn't until the late '80s and early '90s that medical nipple and areola tattooing gained popularity. More recently, non-medical tattoo artists have started incorporating it into their practice — and some medical facilities have started hiring or working with more tattoo artists specifically for these types of reconstructions.
Cosmetic and medical tattoo artist Mandy Sauler has been practicing nipple-areola tattooing for the past nine years, and currently works with Penn Medicine’s Ruth & Raymond Perelman Center for Advanced Medicine in Philadelphia. She also founded Sauler Institute of Tattooing, where she trains tattoo artists and medical providers. She focuses on the entire reconstruction process and offers patients the post-mastectomy option of nipple-areola tattooing.
To understand how these procedures work, it's useful to know how nipples are naturally structured. Although many people think of the nipple and areola as one entity, they're actually two separate ones. "It's the nipple in the center and the areola on the outside," Sauler explains.
Nipple reconstruction involves only the nipple. In the past, options after a mastectomy were limited: "It was always: You had nipple reconstruction, then you had the tattooing," says Sauler. Now, patients can have a nipple made, where skin is taken from the surface of the breast and then "crocheted" up to create a bump. However, Sauler says that some women decide not to have a nipple made for a variety of reasons: they might not be a good candidate, or they might not be interested in the additional surgery, which takes an average of six to eight weeks to heal. With advancements in tattooing technique, some patients are skipping reconstruction, opting instead for a tattoo that creates the illusion of a 3D nipple.
"Our philosophy: I probably wouldn’t allow a tattoo artist to do surgery on me, so I probably shouldn't allow a surgeon to do a tattoo on me."
Frank Dellacroce, plastic surgeon and founding partner at the Center for Restorative Breast Surgery at St. Charles Surgical Hospital in New Orleans, which is dedicated to breast reconstruction, notes that some surgeons are taking a possible or planned nipple-areola tattoo into consideration when doing a mastectomy or reconstruction surgery. The surgeon will make an incision that will purposely not interfere with the recreation of the nipple or the ink application. "We don't create a lot of new scarring so that the color and the application of the ink by our artist can last," he says, "and [the ink] can do well in that tissue that has been handled very carefully and very intentionally from the beginning."
Dellacroce says that having an artist's eye to help with the nipple-areola tattooing is important. He understands that the marriage of his own medical background with an artist's expertise and an artist’s background is what can create a successful result: "Our philosophy is this: I would probably never allow a tattoo artist to do surgery on me, so I probably shouldn't allow a surgeon to do a tattoo on me." He says that breast reconstruction is a collaborative effort, "a painter and a [sculptor], working in the same studio."
Piret Aava, also known on Instagram as the "Areola Doctor" and the "Eyebrow Doctor," has been practicing cosmetic tattooing for about seven years, but focusing specifically on areolas for the past three. After studying with the women from Poland-based AmazINK Areola at a workshop in the States, Aava added areola tattooing to her résumé, a service, she notes that usually takes longer than, say, eyebrow tattooing, in which she usually knows what to expect. In contrast, because every patient's mastectomy results are different, areola tattooing is highly individualized.
"It’s really unpredictable what [a client will] come in with," Aava says. "Sometimes they have a lot of scars in the area so we have to start with treating [those] first and softening the scar tissue so the pigment will stay. And sometimes it takes multiple treatments."
Every areola tattoo is different, depending on what the client may (or may not) already have. Like regular tattoos, they take a bit of planning and preparation, including being sketched out before the tattoo starts. If the client has one nipple, the artist will typically work to match it in color, hue, and size. Aava says, "If it's just one [nipple], we try to match it to the other side. We draw [the tattoo] first and make sure that there's symmetry. It's all about shading and making it look realistic and three dimensional."
A major difference between nipple-areola tattoos and tattoos on other parts of the body is the general absence of pain during the procedure. "The area is normally numb," Aava says because most of the nerves in that area are usually cut during the mastectomy. However, if there is any remaining sensation, Aava will apply a numbing cream before doing the tattoo.
The healing process for nipple-areola tattoos is very similar to all other types of tattoos — and a lot shorter than the weeks-long healing period for surgical nipple reconstruction. Aava says that she typically puts a clear bandage on the tattoo and tells the patient to leave it on for a week.
While everyone is different, these types of tattoos typically take about five to seven days to heal, according to Sauler. "[The tattoo] is really not invasive," she says. "It's just scratching into the dermal layer of the skin, so it's not very deep," and the care is similar to taking care of a scratch. Dellacroce recommends using sunscreen on the tattooed area — even if it's covered by clothing — for about a month after the procedure to ensure proper healing. "We recommend that sunscreen be used even under garments because incisions and scar lines can [heal] better when they are protected from sunlight as well," Dellacroce says.
There is always a minor risk with any tattoo, even ones that are done professionally. "[The risks] include infection, as would be with any abrasion injury to the skin," Dellacroce says. "[I personally] haven't seen it happen in the patients we treat, but [an infection] would be treatable with antibiotics." Other possible risks, he says, are scar formation — especially if a patient is prone to scarring — or a rare allergic reaction to the pigment in the tattoo.
"You can't do anything like cosmetic tattoos while going through chemo. Make sure you’re fully healed and get an okay from your doctor."
Sauler started her training institute, in large part, because she was seeing botched nipple-areola tattoos that were done by members of the medical community. Patients often came to her to have the work corrected or touched up. So, Sauler says, "I started training medical providers, I started training tattoo artists, I started training permanent makeup people to provide the service…fine-tuning [their techniques] and giving them the proper equipment." And teaching the proper way to do nipple-areola tattooing, she says, has increased the quality of service at the medical centers she works with.
Of course, you should always check with your doctor before having any reconstructive work. "You can't do anything [like] cosmetic tattoos when you’re going through chemo," Aava says. "You want to make sure you're fully healed and get an okay from your doctor."
Dellacroce feels that the most important part of his work is spreading awareness about all the reconstruction options available for breast cancer survivors. Delivering this information can help overcome some mental barriers that could prevent a patient from seeking treatment. "I think a lot of [those barriers are] fear," he says. "We're afraid sometimes to find out what might be going on and maybe we're afraid of what that might entail in terms of treatment."
It's important for patients to feel empowered and speak up and seek medical advice if something doesn’t feel right with their bodies. "Take advantage of the resources available to you and study as much as you can before you have a procedure," Dellacroce advises. "Once you have your arms around what can be done, you're empowered, you’re a more well-informed consumer of your health care, and that should parlay into better outcomes and a higher result in the quality of life afterward."
Breast cancer can be a scary subject to tackle. For many, simply having an understanding of one's options — and it’s important to emphasize that nipple reconstruction and breast implants are options, not requirements — can quell that fear.
Since nipple-areola surgery is typically one of the final phases of treatment, Dellacroce says that it can be rather transformative and a finish line for those who have gone through not only the mastectomy but breast cancer as a whole. "It's bigger than the sum of the parts," he says. "Because it really does represent healing, not only of your physical body but of your emotional self and your psyche, and everything else."
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