One in eight women will develop breast cancer in their lifetime,1 with over one-third of patients treated with mastectomy.2 Most often, the procedure results in removal of the nipple-areola complex, which has been found to significantly impact the psychosocial and sexual well-being of patients.3 The nipple-areola complex is what transforms the reconstructed mound into a breast and completes the anatomical restoration process. It is commonly reconstructed using local flap techniques, grafts, dermabrasion, and tattooing.4
When surgical reconstruction is chosen, nipple projection is difficult to maintain,5,6 and once achieved, it is constantly protuberant, which may disturb patients. Surgical reconstruction following adjuvant radiation treatment is often complicated because of thin and friable skin. Tattooing-only in such cases is safer7 and preferable to avoid operating in an irradiated field. Furthermore, the majority of patients are satisfied with their tattoos and would choose tattooing again.8,9
Recently, skilled tattoo artists have perfected three-dimensional nipple-areola complex tattooing, a technique that uses artistic principles to create more realistic aesthetic results.10 Tattooing over an existing flap is also possible and is termed a four-dimensional reconstruction. Micropigmentation increases patient satisfaction by achieving excellent results without surgical intervention. However, the technique is only performed by those skilled in tattooing, whose professional credentials may be difficult to assess by both patients and surgeons.
The nipple-by-number device is a three-dimensionally–printed stencil developed to achieve accurate, reliable, and personalized aesthetically superior results by any provider without the need for previous experience in tattooing. To learn more about current nipple-areola complex tattooing practices and assess the need, a survey was implemented to plastic and reconstructive offices throughout the United States.
This study was deemed exempt from institutional review board approval in accordance with the Declaration of Helsinki, as the survey did not involve patient subjects. A questionnaire to 15 major U.S. metropolitan areas was implemented by phone to 775 plastic and reconstructive surgery offices to assess the services provided, referral patterns, demographics of tattoo providers, location where tattooing is performed, and costs of the service. Results were recorded by phone from 753 offices, for a response rate of 97 percent. Of offices that provide breast reconstruction services, 23 percent (n = 173) neither perform nor refer for tattooing. Approximately 60 percent (n = 452) of plastic and reconstructive offices do not perform breast reconstruction and do not refer for tattooing. When these offices do refer the patient to another plastic and reconstructive office, 3 percent lead to dead-end referrals (i.e., the office cannot perform or refer for tattooing). Approximately 32 percent of all tattooing is performed in the provider’s office. Only 11 percent of tattooing performed by tattoo artists or aestheticians is supervised within a physician’s office. Only 21 percent of tattooing is performed by physicians and 9 percent is performed by allied health professionals (Fig. 1). The national average for out-of-pocket costs to the patient are $640 and $956 U.S. dollars for unilateral and bilateral tattooing, respectively (Fig. 2).
To achieve a more realistic, three-dimensional–appearing nipple-areola complex tattoo, there must be careful attention to light and shadow principles when shading the nipple and Montgomery tubercles.10 Using these principles, the nipple-by-number device was developed. The device is composed of multiple, removable stencil layers of three-dimensionally–printed plastic with customizable holes to allow for well-controlled and precise tattooing during coloring, shading, and highlighting (Fig. 3). [See Video 1 (online), which shows the exploded views of the stencil.] The device allows a more facile and efficient approach by allowing those not skilled in the freehand artistic techniques of light and shadow to create a three-dimensional recreation of the nipple-areola complex (Fig. 4). In addition, it allows the user to create uniform shape color and tone in a paint-by-number approach by tattooing within prefabricated windows.
The process begins with the patient choosing whether to have the premorbid nipple-areola complex anatomy customized from photographs or choosing a standard nipple-areola complex anatomy. A Tegaderm11 (3M Science, St. Paul, Minn.) dressing is used to keep the nipple-by-number device in place. The layers of the stencil are applied progressively as the various structures are tattooed. The Montgomery tubercle stencil layer can be manipulated to create highlights and shadows as needed. The stencil is then removed en bloc and standard post-tattoo care is followed. [See Video 2 (online), which shows the stencil example and guide.]
The device has etchings on the vertical axis to guide the depth to push the needle. In addition, the device can be altered regarding thickness, customized to facilitate the user pushing the tattoo needle with the appropriate pressure. In this fashion, the stencil can also serve as a guard to prevent pushing too firmly when tattooing. This permits medical professionals and nonmicropigmentation specialists to shorten the learning curve with regard to needle and artistic light and shadow technique, thus performing effective three-dimensional (Fig. 5) and four-dimensional (Fig. 6) tattooing with the stencil.
Because of lack of information available on current tattooing practices, a survey was implemented to plastic and reconstructive offices throughout the United States. The survey showed that the majority of nipple-areola complex tattooing is outsourced and performed by unsupervised aestheticians or tattoo artists. Average out-of-pocket costs are not inexpensive and range from $340 to $1331 and $591 to $2183 U.S. dollars for unilateral and bilateral nipple-areola complex tattooing, respectively. Over half of the plastic and reconstructive offices around the United States neither perform nipple-areola complex reconstruction nor offer a referral.
The importance of using realistic artistic principles to create an aesthetically superior and three-dimensional–appearing nipple-areola complex is well known but may not be easily achievable for plastic surgery practices that do not regularly perform permanent makeup or tattooing. Using a darker color for the areola, a lighter color for the nipple, and a dark border around the nipple with thickened inferior portion leads to more realistic results than traditional tattooing techniques.10 Enhanced results are achieved by including Montgomery tubercles.
To make three-dimensional nipple-areola complex tattooing accessible to the plastic surgery practice and prevent the challenges that come with outsourcing, while consistently achieving optimal results, the nipple-by-number device was developed. This device is a low-cost, multilayered, plastic stencil that allows the process of three-dimensional nipple-areola complex tattooing to be easy, fast, and customizable according to patient preferences. The patient has the option of reliably restoring premorbid nipple-areola complex anatomy based on a custom version from preoperative photographs or may choose standardized nipple-areola complex anatomy from a catalogue of designs. The device is versatile in that it can create both three-dimensional (Fig. 5) and four-dimensional (Fig. 6) reconstructions.
The nipple-by-number device will decrease the number of patients who are left to independently find a safe and skilled tattoo artist to complete their breast reconstruction and aid more plastic and reconstructive practices in providing this important service. Finding a tattoo parlor is anxiety-provoking to many patients, who would prefer tattooing in a medical facility, preferably where the reconstruction was performed. For the provider, the nipple-by-number device makes it more feasible to offer three-dimensional and four-dimensional nipple-areola complex tattooing within their office in a quick, effective, and reproducible way.
By making three-dimensional and four-dimensional nipple-areola complex tattooing easy, quick, affordable, and accessible to providers and patients alike, the nipple-by-number device eliminates the need to outsource the service and ensures consistently superior, realistic, and customizable results.
1. NIH National Cancer Institute. 2012 breast cancer statistics. Available at: https://www.cancer.gov/types/breast/risk-fact-sheet
. Accessed February 10, 2018.
2. Kummerow KL, Du L, Penson DF, Shyr Y, Hooks MA. Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg. 2015;150:9–16.
3. Bykowski MR, Emelife PI, Emelife NN, Chen W, Panetta NJ, de la Cruz C. Nipple-areola complex reconstruction improves psychosocial and sexual well-being in women treated for breast cancer. J Plast Reconstr Aesthet Surg. 2017;70:209–214.
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. 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.
6. 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.
7. 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 464–465.
8. Spear SL, Arias J. Long-term experience with nipple-areola tattooing. Ann Plast Surg. 1995;35:232–236.
9. Goh SC, Martin NA, Pandya AN, Cutress RI. Patient satisfaction following nipple-areolar complex reconstruction and tattooing. J Plast Reconstr Aesthet Surg. 2011;64:360–363.
10. Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing: A new technique with superior results. Plast Reconstr Surg. 2014;133:1073–1075.
11. 3M Science. Applied to Life. 3M United States. 3M Global Gateway. Available at: https://www.3m.com/3M/en_US/company-us/
. Accessed February 15, 2018.