This is the application of professional tattoo techniques in the reconstruction of a breast after a mastectomy.

Normally, when the mastectomy has affected the nipple and areola as a whole, various techniques are applied to restore their presence. The nipple is usually recreated using small skin flaps folded on themselves; and for the areola we have from skin autotransplantation to dermabrasion. However, sometimes these techniques do not offer the best solution. For example, nipple projection may be difficult to maintain in patients whose tissue is very thin or has become very soft after radiation therapy. It may be the case that the patient dislikes the idea of her breasts showing constantly projecting nipples. And some women simply do not want to undergo surgery again after their previous experience. Sometimes the areola is pigmented, but if this pigmentation is performed by unqualified personnel specialized in this type of procedure, the results leave something to be desired.

The highest expectations are achieved by means of the hyper-realistic tattoo method, a procedure that is also the safest solution (it does not require a new intervention with its possible complications). And it is a solution with a high degree of satisfaction, according to some studies (more than 90% of patients are satisfied or very satisfied with the result).

In the early days of this technique, it was the surgeons themselves who used a light tattoo ink for the areola and a darker one for the nipple. The tattooing technique used used to be quite basic and limited, and there was not much communication between the medical community and the professional tattooists, whose knowledge is very applicable in this aspect of breast reconstruction. Some tattoo artists have been pioneers in applying their talent in this field.

From a purely technical approach, a skilled professional tattooist plays with factors such as the type of needle, the speed of the tattoo machine, and the types of pigments, as well as artistic skills, use of colors and “hyper-realistic” representations. When tattooing the nipple and areola, other non-specialized professionals use injection speeds that are twice as fast as those of a tattoo artist. When done on very thin skin or skin in a delicate state, recovery takes longer, scarring may occur, the pigment is not retained as well as it should be, and often requires more than one tattoo session. In addition, they often use pigments based on vegetable oils or metallic salts, with a limited color palette and durability problems, with color degeneration to metallic tones; while traditional tattooist pigments have a much wider range of colors. A tattoo artist can use a color wheel to compare with the color of the skin to accurately choose the colors to be used, this is called the “colorimetry” measurement process.

But the most interesting aspect is the artistic aspect: tattoos made by non-specialists are usually quite simple: basically, areas of flat colors, without contrast, without defining structures such as nipple, Montgomery’s tubercles, etc.

This is when the technique is perfected by professional tattoo artists, pioneers in applying their art in the reconstructive area, who go further and achieve a “3D finish” in their tattoos, simulating the areas of light and shadow that the nipple and areola would produce if they were present. Instead of making a circle of dark ink to “paint” the nipple, which actually spoils the illusion of projection, what they do in a very simplified way is to create a circle of lighter ink but with a dark border. This border is slightly thicker at the bottom, creating a shadow effect. This could be done by a doctor with his normal tattooing equipment, but a skilled tattooist can go further and, for example, reproduce Montgomery’s glands, which are those little bumps on the areola, surrounding the nipple, as well as create shadows on the underside of the nipple. The goal is to make the entire nipple-areola complex look as realistic as possible.

These “3D” tattoos can be used either to simulate a complete nipple-areola assembly or to enhance or retouch the result of a breast reconstruction. For example, if after reconstruction the nipples are not even, some additional shadow can be tattooed on the one with less projection. Similarly, a new nipple-areola complex can be created by copying that of the other breast (in cases of single-breast surgery), or both can be reconstructed in cases of bilateral involvement.

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