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Looking Beyond the Knife: Establishing a Framework for Micropigmentation following Breast Reconstruction

Carney, Martin J. B.S.; Weissler, Jason M. M.D.; Sauler, Mandy; Serletti, Joseph M. M.D.

Author Information
Plastic and Reconstructive Surgery: July 2017 - Volume 140 - Issue 1 - p 243e-244e
doi: 10.1097/PRS.0000000000003466
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As the final stage of breast reconstruction, nipple-areola complex reconstruction and tattooing help achieve a natural aesthetic and symmetric result.1,2 Taking care to achieve pigmented color match, and maintaining nipple projection, can profoundly enhance patient satisfaction and aesthetic appearance of the breast as a whole.3 Although plagued by nipple projection and contour loss, in addition to color fade over time, tattooing or micropigmentation as an adjunct to reconstruction remains an ideal modality for achieving optimal cosmesis.4 Recent descriptions of three-dimensional tattooing substantiate the inherent value of integrating appropriately trained tattoo artists and micropigmentation experts into the reconstructive paradigm.5 Given certain identifiable barriers to adoption of practice, such as geographic accessibility, three-dimensional tattooing is certainly an underused reconstructive option. This problem is two-fold and attributable to (1) a general paucity of micropigmentation experts trained in three-dimensional nipple-areola tattooing, and (2) a historical divide between tattoo expertise and plastic surgery. We discuss the clinical utility of having a fully integrated cosmetic micropigmentation specialist (M.S.) within our high-volume breast reconstruction center, and touch on the pearls for successful reproducibility at other institutions.

With the increasing number of breast reconstructions performed annually, we must recognize the shortcomings of an evolving reconstructive landscape and identify further opportunities for advancing the field of plastic surgery. In hopes of building on our institutional reconstructive foundation, we have identified micropigmentation following breast reconstruction to be a critical yet underappreciated component of a comprehensive reconstructive archetype. Currently at our institution, three-dimensional micropigmentation is performed in the clinic setting three times per week. With implementation of on-site tattooing, we establish a necessary foundation for continuity of care within one health system, thus facilitating postoperative follow-up through simplified interaction and enhanced patient experiences.

In addition, in patients who refrain from additional surgery for nipple-areola reconstruction, three-dimensional micropigmentation offers a refined aesthetic result.5 The reconstructive paradigm can be challenging for patients to navigate; thus, offering three-dimensional micropigmentation streamlines postoperative care and offers optimal cosmetic reconstructions in an eloquent and precise manner (Fig. 1). Unfortunately, there is an identifiable gap in accessibility to these services, highlighting the need for more trained specialists to serve the rising demand of patients undergoing reconstruction. To address this recognized concern, the lead micropigmentation expert at our institution has developed opportunities for artists to learn this valuable skill set through designated courses using cutting-edge technology. Ultimately, through best-practice techniques and hands-on mentorship, an efficacious and reproducible rubric emerges to successfully create tattoo “realism” for breast reconstruction patients.

Fig. 1.
Fig. 1.:
Before and after three-dimensional micropigmentation following autologous breast reconstruction. (Photographs courtesy of Mandy Sauler.)

Patients must be afforded every opportunity to achieve a reliable new normal in breast reconstruction. Integration of a micropigmentation specialist within a breast reconstruction center in conjunction with the increased training opportunities in three-dimensional nipple-areola micropigmentation provides an avenue for aesthetic improvement, fosters widespread provider availability, and establishes a reliable and reproducible platform for enhanced breast reconstruction outcomes.


The authors have no financial interest in any of the products or devices mentioned in this article.

Martin J. Carney, B.S.
Jason M. Weissler, M.D.
Division of Plastic Surgery
Department of Surgery
University of Pennsylvania

Mandy Sauler
Division of Plastic Surgery
Department of Surgery
University of Pennsylvania, and Sauler Institute of Tattooing

Joseph M. Serletti, M.D.
Division of Plastic Surgery
Department of Surgery
University of Pennsylvania
Philadelphia, Pa.


1. Costa MP, Ferreira MC. Aesthetic quality of the nipple-areola complex in breast reconstruction with a new local graft technique. Aesthetic Plast Surg. 2009;33:774779.
2. Hamori CA, LaRossa D. The top hat flap: For one stage reconstruction of a prominent nipple. Aesthetic Plast Surg. 1998;22:142144.
3. Spear SL, Convit R, Little JW III. Intradermal tattoo as an adjunct to nipple-areola reconstruction. Plast Reconstr Surg. 1989;83:907911.
4. Spear SL, Arias J. Long-term experience with nipple-areola tattooing. Ann Plast Surg. 1995;35:232236.
5. Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing: A new technique with superior results. Plast Reconstr Surg. 2014;133:10731075.


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