Paramedical Tattooing: Unique Application in Nipple-Areola Reconstruction

Sir,

Although tattooing has existed for millennia for the purposes of cultural identification and personal adornment, current advancements in technology have allowed for realistic, three-dimensional tattooing. Paramedical tattooing, which refers to the use of tattoos for the purposes of concealing scars, discolorations, and constructing realistic anatomic images, has become a new application of inked art. Nipple-areolar tattooing is a multi-purpose tool for medical and post-operative conditions.

Paramedical tattooing is a relatively new concept—artists use tattoos to conceal scars, stretch marks, discolorations, or to ink realistic anatomic impressions. Tattoo artists can ink fingernails, recolor vitiligo depigmentation, and even mask scars from a canine attack.¹ Given these artistic qualities, collaboration with a tattoo artist in a plastic surgery setting is valuable.

An example would be in the treatment of post-mastectomy patients. Areola tattooing is widely accepted as part of the breast reconstruction process. Tattoos are safer than nipple reconstruction with grafts, which have a reported 46.9% complication rate.² The areola and nipple complete the aesthetics of the breast. Missing an areola or nipple can result in significant emotional challenges, especially when considering that the breasts represent so much of a woman’s identity. A study conducted in Georgetown Medical Center on patients who received paramedical tattoos following their reconstructive procedures reported high patient satisfaction rates—86% among 151 patients studied at the plastic surgery center.³ We offer two examples of techniques in the field.

CASE 1: NIPPLE-AREOLA TATTOO AFTER MASTECTOMY AND BREAST RECONSTRUCTION

A 52-year-old woman presented to the clinic after receiving an initial lumpectomy followed by bilateral mastectomy due to breast cancer two years before. The patient had reconstruction completed following tissue expander and implant placement. Ultimately, due to safety concerns and the improved healing process related to tattoos, the patient elected for a tattooed impression of the nipple and areola. The skin, which had become fibrotic due to scar tissue from radiation, required careful pigmentation using multiple colors for the appropriate realistic effect.

CASE 2: AREOLA HYPOPIGMENTATION SECONDARY TO ISCHEMIA

A 33-year-old patient seen in clinic suffered from bilateral hypopigmentation of her areolas secondary to ischemia following a mastopexy with breast implant placement (Fig. 1). Cosmetic procedures, which are ultimately completed for the purposes of enhancement, can be devastating when they do not result in the desired look. The tattoo artist was able to create a realistic areola to the patient’s liking by layering several pigments (Fig. 2).

Fig. 1.

Stile Aesthetics Collection: Frank Stile pre tattoo bilateral areola hypopigmentation secondary to ischemia. Used with permission.

Fig. 2.

Stile Aesthetics Collection: Frank Stile status post tattoo-areolar darkening. Used with permission.

CONCLUSIONS

The medical tattooing process follows similar sterile techniques as operative procedures conducted at our surgery center. This form of tattooing can improve the aesthetic and symmetry of the breast, with high patient satisfaction outcomes and improved patient self-esteem. This proves useful not only in post-mastectomy patients, but also in women whose areolas change in shape or color following pregnancy, nursing, or surgical complications as in the aforementioned patient. Others may elect for cosmetic purposes, such as dislike for their natural color. Tattoos can create a sense of normalcy despite medical conditions that alter one’s appearance. Thus, we encourage plastic and reconstruction surgeons to work with a tattoo artist to assist in the healing process.