Plastic & Reconstructive Surgery:
Breast: Ideas and Innovations
Halvorson, Eric G. M.D.; Cormican, Michael M.D.; West, Misti E. R.N.; Myers, Vinnie
Boston, Mass.; Atlanta, Ga.; The Woodlands, Texas; and Finksburg, Md.
From the Division of Plastic Surgery, Brigham & Women’s Hospital; the Department of Surgery, Emory University; The University of Texas M. D. Anderson Cancer Center; and Little Vinnie’s Tattoos.
Received for publication December 4, 2012; accepted November 13, 2013.
Presented at the 55th Annual Scientific Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, in Amelia Island, Florida, June 2 through 6, 2012.
Disclosure: The authors have no financial relationships to disclose. No funds were received in the preparation of this article.
Eric G. Halvorson, M.D., Division of Plastic Surgery, Brigham & Women’s Hospital, Boston, Mass. 02115, email@example.com
Summary: Traditional coloring techniques for nipple-areola tattooing ignore the artistic principles of light and shadow to create depth on a two-dimensional surface. The method presented in this article is essentially the inverse of traditional technique and results in a more realistic and three-dimensional reconstruction that can appear better than surgical methods. The application of three-dimensional techniques or “realism” in tattoo artistry has significant potential to improve the aesthetic outcomes of reconstructive surgery.
For many women, nipple-areola complex reconstruction is an essential element of breast reconstruction and completes an emotional and complex process of feeling whole again. There are several different strategies for nipple-areola complex reconstruction and varied techniques. Nipple reconstruction is performed with various local flaps. Areola reconstruction has been achieved with grafting, dermabrasion, and tattooing. Some patients choose tattoo-only nipple-areola complex reconstruction, yet nothing has been published on this technique, and improvements are needed.
Our literature is filled with variations of local flap designs for nipple reconstruction. Unfortunately, projection can be difficult to maintain, especially in patients with thin or irradiated soft tissue.1–4 Some patients may not like the fact that reconstructed nipples maintain projection at all times. Others forego surgical approaches because they do not want another surgical procedure. Lastly, in irradiated patients, tattooing may be the safest option, considering the increased complication rate in these patients. Tattoo-only nipple-areola complex reconstruction is therefore a good option for certain patients. Spear and Arias reported that 84 percent were satisfied with their tattoo and 86 percent would opt for tattooing again.5 We present a new three-dimensional technique for tattoo-only nipple-areola complex reconstruction that offers an aesthetically superior result.
Most nipple-areola complex tattoos are performed using lighter ink for the areola and a central circle of darker ink for the nipple (Fig. 1). Although this traditional method produces a satisfactory result, we have recently used a new technique, inspired by the work of tattoo artist Vinnie Myers (www.vinniemyers.com), with improved results. The three-dimensional technique is essentially the inverse of traditional nipple-areola complex tattoo. It is usually performed more than 3 months following breast reconstruction.
The areola is created according to the patient’s preferred diameter and color. Instead of using a darker inner circle to create the appearance of a nipple, a lighter inner circle is created with a dark border. This border is thickened inferiorly to create a shadow effect. A satisfactory result can be achieved with standard medical tattooing equipment (Fig. 2); however, a professional tattoo artist with specialized equipment and ink can produce an outstanding result, including tattooing of Montgomery glands (Figs. 3 and 4).
The plastic surgery community takes pride in its artistic sensibility. With respect to nipple-areola complex tattoo, however, our simple assumptions have resulted in an artistic blunder. Artists have long recognized that light and shadow create depth. Objects in light stand out, whereas those in shadow are recessed. Burget and Menick noted this in their classic article on nasal subunits.6 Any prominence such as the nose, ear, or nipple will achieve three-dimensionality when light and shadow are used appropriately in two dimensions. This is the rationale for the new three-dimensional nipple-areola complex tattoo technique presented.
Basic fundamentals of tattooing have also been ignored in traditional nipple-areola complex tattoo (e.g., machine speed, needle type, and color mixing). Medical practitioners often use preset speeds in excess of 180 cycles per second. This is twice the frequency of traditional tattooing and typically involves thin or compromised skin. The result is increased healing time, scarring, and poor pigment retention. It is not uncommon for patients to require two sessions for adequate pigmentation. Pigments used in medical facilities are typically vegetable oil–based dyes or metal salt pigments mixed very thin and available in a small range of colors, limiting the choices available (especially when matching a native nipple-areola complex). It is widely known that medical tattoos fade with time, sometimes becoming invisible after several years. By using traditional tattoo pigments and a color wheel, excellent color match can be achieved with significantly improved pigment retention. Unfortunately, there is a significant disconnect between the cosmetic and traditional tattoo industries, a discussion of which is beyond the scope of this article. It is our belief that improved results for our patients will be realized when these two industries share best practices and establish education programs.
Although referring patients to tattoo artists for three-dimensional nipple-areola complex reconstruction may take some business away from a surgeon’s practice, it is our obligation to offer patients the best results possible. Still, some patients are wary of tattoo parlors and prefer to have their nipple-areola complex tattoo performed in a medical facility. It is our hope that tattoo artists and health care providers will collaborate to bring the technology and skills required into the medical arena. Some tattoo artists work in a medical facility on a periodic basis. Searching the Internet for local tattoo shops and speaking with them by phone is a good way to establish contact with interested tattoo artists. In addition, www.pinkinkproject.com has a list of tattoo artists.
The cost of three-dimensional nipple-areola complex tattoo varies by location and tattoo artist, and whether or not the facility or patient seeks insurance reimbursement. One of the authors (V.M.) currently charges $400 for a unilateral tattoo (45 minutes) and $600 for a bilateral tattoo (60 minutes). Most insurance companies reimburse patients $300 to $400. It is unusual for a patient to require more than one session for a durable result.
The three-dimensional technique can also address asymmetries following surgical nipple-areola complex reconstruction. By adjusting the darker ring of color around the nipple, the tattoo artist can account for asymmetries in nipple projection without surgery. Furthermore, when projection is almost or completely lost, this technique can give the illusion of projection without surgical revision. The three-dimensional nipple-areola complex tattoo technique has also changed how we perform surgical nipple reconstruction with areola tattooing. Whereas we used to tattoo the nipple construct darker than the areola (effectively decreasing the illusion of projection), we now forego tattooing of the nipple construct.
The technique of three-dimensional nipple-areola complex tattooing presented is, in our opinion, a significant advance in obtaining improved aesthetic results for women undergoing breast reconstruction. We have only begun to explore the possible applications of medical tattoos in plastic surgery. The application of three-dimensional techniques or “realism” in tattoo artistry has the potential to expand the role of medical tattooing, and may allow us to enhance the aesthetic results of head and neck reconstruction (e.g., eyebrow, lip vermillion tattoo), extremity reconstruction (e.g., nailbed tattoo), and so on.
1. Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions. Ann Plast Surg. 2009;62:591–595
2. Richter DF, Reichenberger MA, Faymonville C. Comparison of the nipple projection after reconstruction with three different methods (in German). Handchir Mikrochir Plast Chir. 2004;36:374–378
3. Jabor MA, Shayani P, Collins DR Jr, Karas T, Cohen BE. Nipple-areola reconstruction: Satisfaction and clinical determinants. Plast Reconstr Surg. 2002;110:457–463; discussion 464
4. Boccola MA, Savage J, Rozen WM, et al. Surgical correction and reconstruction of the nipple-areola complex: Current review of techniques. J Reconstr Microsurg. 2010;26:589–600
5. Spear SL, Arias J. Long-term experience with nipple-areola tattooing. Ann Plast Surg. 1995;35:232–236
6. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239–247