Areola Tattooing - An Overview

Following breast cancer diagnosis, the landscape of treatment can be very overwhelming. Your team of doctors will most likely recommend a particular sequence of treatment. Most commonly this begins with surgery to remove the breast cancer or the whole breast. If the complete breast is removed, breast reconstruction may be performed. Breast reconstruction may occur in one surgery or as separate procedures. If chemotherapy and/or radiation are part of your care, it will normally follow surgery. There are a number of different breast reconstruction procedures, depending on the extent and location of the cancer. You may or may not have the option for nipple sparing or nipple reconstruction. Areola tattooing is generally not required with nipple sparing unless there is hypopigmentation (loss of color) during the healing process. If nipple reconstruction is performed, the tattoo process focuses on restoring color.

 

 

If nipple reconstruction is not performed, the areola tattoo is performed using light and dark shadows to create the illusion of a protruding nipple.

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and 3D areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals. If nipple reconstruction is not performed, the areola tattoo is performed usinglight and dark shadows to create the illusion of a protruding nipple pr 3 dimension (3d).

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Choosing Your Artist

List of questions to ask:

How much training have you had?
Do you use topical anesthetics for pain?
Which brand of tattoo pigment do you use?
Do you use single-use disposable needles?
Do you carry professional liability insurance?
Does the cost of service include a touch-up visit?
Do you provide paperwork for insurance submission?
Do have training in Blood Borne Pathogens, OSHA or CDC guidelines?

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

Areola tattoos, like decorative tattoos, consist of embedding pigment below the first layer of the skin into the dermis. This creates a permanent coloring of the tissue. There are a variety of terms used to describe this service, including: micropigmentation, paramedical tattooing and areola re-pigmentation. This service does not fall under any healthcare licensing umbrella. Consequently the training and execution of this skill will vary greatly depending on the provider. Individuals performing this service may be tattoo artists, doctors, aestheticians, nurses or other healthcare professionals

General Information

Per Red Cross guidelines, blood cannot be donated for one year following your tattoo procedure.

Tattoo procedures done over scar tissue or healed incision(s) are more difficult to treat and can result in loss of pigment being retained in the skin. (i.e; Abdominal Tram Flap or a Latissimus Dorsi Back Flap surgical procedure for breast tissue reconstruction). An Abdominal Tram Flap procedure uses the muscle and tissue from the abdomen and a Latissimus Dorsi Back Flap procedure uses the muscle and tissue from the back area. Radiation treatments and use of Tamoxifen may affect pigment retention.

Rendering a nipple is as much art as it is science. Below is a literal rendering I did in watercolor, side by side with the photo I used. . Many nipples in human anatomy are quite irregular.

Most areola tattoos are circular or oval. There is a fine balance between making them so perfectly round they look cartoon-like and finding a lifelike flattering resemblance.  Regardless the effect of 3 dimension is achieved by the illusion of light creating a cast shadow.

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Design Considerations Unilateral Tattoo

Considerations during the design stage include positioning, shape and color matching. The pictures on the right shows a tattoo (not performed by me) and some of the problems with design. Firstly it is in the wrong position. Secondly the shape does not match the natural areola. The third picture shows a rendering of the same areola after correction for location, shape and color.

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SHAPE & COOOUR CORRECY

The Consultation and Procedure

PAINTING-AN-AREOLA

This picture shows an example of the temporary design created during the consultation to show the client an approximation of color, shape and general design.

Preparing for the day of the procedure. Try to avoid Vitamin E supplements, caffeine, alcohol and highly salted foods 24 hours before your procedure, as they dilute the blood and can increase bleeding and lymph rising to the surface during the procedure. Over the counter anti-inflammatories also have a blood thinning effect, so please avoid Advil, aspirin and ibuprofen.

Day of the procedure.  Please allow for 2 hours for your first appointment. The area will be cleaned and a template for the nipple drawn out. Topical numbing of the area is performed depending on skin sensation. Most individuals experience little to no discomfort. After the tattoo is completed dressing is applied and aftercare instructions are reviewed.

Pricing

  • Areola tattoo consultation $50*
  • Billateral 3D areola tattoo $500 (Includes 2-3 visits)
  • Unilateral 3D areola tattoo $350 (Includes 2-3 visits)
  • Bilateral areola correction $250-$400
  • Unilateral areola correction $200-$300
  • Areola Touch Up $250-$400

*This fee is will be deducted from the cost of the procedure. During the consultation we will assess if you are a candidate for areola tattooing and discuss shape, color and sizing.

 

For individuals without any medical coverage my fee for 3d areola tattooing is reduced to $50-80. This is to cover my equipment expenses. Each individual is assessed on a case by case basis to determine if they qualify. This offer is available to the post masectomy and transgender communities.

FDA Regulation of Tattoo Pigment

Currently the FDA does not test or screen the content of either traditional tattoo pigment or the pigment used in permanent make-up and restorative/areola tattooing. Many of these colorants identified in tattoo pigment are known carcinogens or skin irritants. Many of these are banned for use in cosmetics because of health concerns. It is reasonable to assume if it’s not safe to apply a substance to the surface of the skin, it is not safe to embed in the skin.

In a European report (RAPEX) 2/3’s of the 126 cases of adverse reactions from tattoo or permanent make-up pigment were associated with 3 of the largest US ink manufacturers: Intenze (35%), Eternal ink (21%) Starbrite (8%). Studies have shown that these companies contain known carcinogens, many of which are banned by the FDA and the European Union.
As tattoo pigment is not regulated, it is important to do your due diligence. Ask your tattoo artist about their practices to protect you through the use of non-carcinogenic ink. Unfortunately, many tattoo artists are not aware of the health risks associated with the major US manufacturers of tattoo pigments. Wendy Evans uses Atomic Ink, imported from Italy, which is regularly screened for banned carcinogens, heavy metals and microbial contents.

Ink Research

Currently the FDA does not test or screen the content of either traditional tattoo pigment or the pigment used in permanent makeup and restorative/areola tattooing. In contrast the Council of Europe (CoE), the governing body for the European Union, is more diligent about monitoring and regulating tattoo pigment. In 2003 a comprehensive list was compiled by the CoE of cosmetic colorants that have been identified as potential carcinogenic, mutagenic or reprotoxic substances. Many of these colorants are banned for use in cosmetics due to these associated risks (ResAP, 2008). Considering this list in terms of colorants used in tattoo ink it is “ad oculos” or self-evident, that if it’s not safe to be applied to the surface of the skin, it is not safe to embed the substance in the skin.

Most of the tattoo ink used in Europe is imported from the US. Since 2004 a rapid alert system or non-food dangerous products, called RAPEX, has been set up. During the last decade 126 alerts related to tattoo and PMU inks have been reported. Out of the 126 notifications, 109 referring to tattoo and 11 to PMU inks, were related to chemical risks. Two thirds of the notified inks were produced in the United States, Consistently, the majority (64%) of products not in line with CoE ResAP (2008)1 recommendations or with national legislations belonged to three American brands, Intenze (35%), Eternal ink (21%) Starbrite 2 (8%). Many tattoo artist have not reviewed the clinical research regarding ink and are not aware that most traditional US tattoo ink contains levels of carcinogens that exceed regulatory standards. Banned substances found to be present in these inks included heavy metals, preservative, and a class of carcinogenic coloring agents, (PAA’s) and PAH (darkening pigment). In a study of over 800 inks tested, one third of the inks contained PAH, The International agency for Cancer Research classifies compounds in the PAH group of chemicals as Type 1.This category is used when there is sufficient evidence of carcinogenicity in humans. Other studies (Journal of Applied Microbiology, S.W. Nho S.‐et al .February 2018 https://doi.org/10.1111/jam.13713 ) investigating 13 US makers of Tattoo and PMU ink found that 42% of the inks tested contained bacterial or fungal contaminants. As a result of the lack of FDA regulation, some artists have switch to importing tattoo Ink from Europe. Atomic Ink, is made in Italy and all of their ink batches are tested and screened. Atomic inks complies with the European legislations ResAP (2008) in regards to the release of aromatic cancerous amines, PAH and in relation to the content of heavy metals. The only available US permanent make-up pigment to have undergone any safety efficacy studies is Kolorsource. This company produces an areola color range. I have no financial or vested interest in atomic ink or Kolorsource.

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All inks are sterilized to guarantee the optimum microbiological security. Unfortunately, many tattoo artist are not aware of the health risks associated with the major US manufacturers of Tattoo pigments.

Insurance

If a Doctor doesn't perform the tattoo is it still covered by my insurance?

Coverage of areola tattooing is a federally mandated (Women’s Health and Cancer Rights Act of 1998) part of breast reconstruction. However, insurance carriers do not currently have “in-network accreditation” for this service. This complicates the reimbursement process because essentially all areola tattoo artists are “out of network”. As such, coverage for this service must be submitted out of network unless performed by an MD. HMOs and PPOs will frequently deny the initial claim based on this fact. Generally a follow up letter of medical necessity, referencing the Women’s Health and Cancer Rights Act will result in coverage being approved. A general rule is that most insurance companies require submitting the claim twice before you can expect payment. Unfortunately, payment is not guaranteed.

The following is a checklist of items that should be submitted to the insurance company:

1) Use of the correct CPT Codes (current procedural terminology).
2) A prescription from your doctor.
3) Appropriate medical documentation, including diagnosis code.
4) Pictures with a scale measuring the surface area of the tattoo.
5) National provider identification (NPI) number and/or Council for Affordable Quality Healthcare (CAQH) completion and attestation.

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The Artist

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I am a licensed Aesthetician and Physical Therapist (PT) practicing in Littleton, Colorado. My training in Wound care in PT school, provided a sound background in dermatological considerations with regard to tattooing. I have extensive training in decorative, restorative and cosmetic tattooing.

-Training in microblading (250 hours).
-Training in traditional coil tattooing (250 hours).
-Training in medical aesthetics and laser modalities. (750 hours).
-Training in permanent make-up and camouflage with Susan Church, co-founder and first president of the (SPCP) Society of Permanent Cosmetic Professionals (135 hours).
-Training in permanent make-up with Erla Trujillo, a 15 year veteran in permanent make-up (135 hours).
-Training in Advanced Areola Tattooing at the Sauler Institute, University of Pennsylvania, Perelman School of Medicine (60 hours).

Gallery

Areola Alternatives

Not everyone wants nipple simulation. Some people opt for an alternative that provides scar camouflage and also expresses their personality through decorative art. This example shows an individual who opted for butterflys.

FAQ

When should areola tattooing be performed?
Will the tattoo needles puncture my implants?
Is it painful?
If I don’t have a picture of my breast before surgery how do you determine color and shape?
How long will it last?
How long does it take?
Are there particular aftercare instructions?
How soon can I exercise after the procedure?

Areola tattooing is normally the last stage of the reconstruction process. Generally you should wait a minimum of 3 months after your last surgery, before undergoing areola tattooing. If you had radiation you need to allow time for the tissue to recover, which may be 3-6 months depending on skin damage. If you are unsure, ask your doctor.

Theoretically, if the implant lies over the pectoral muscle and the skin around the implant is stretched extremely tight, there may be a risk of rupturing the implant. It is very rare as a tattoo needle only penetrates the top 2 mm of the skin. If you have implants, be sure to tell your artist whether your implants are over or under the muscle. Your artist will assess the skin thickness and tightness to determine if this is a potential problem. Ask your plastic surgeon if you have any concerns.

Most post-mastectomy patients have diminished sensation in this area. If discomfort is felt, a topical anesthetic may be applied during the procedure. Some traditional tattoo artists feel the use of a topical anesthetic interferes with the longevity of the tattoo. There is no published research to support this viewpoint.

During the consultation with your artist, they will, under your guidance, determine color and size by first painting on the area. This pigment is temporary and easily removed. Once the color, size and design is approved, you are ready for your 3D areola tattoo. The artist will create dimension using color and shading to create a realistic nipple and areola. Most clients are surprised how realistic it looks.

Just like a regular tattoo, the color will fade by about 30% after the first week. After that time your tattoo is relatively permanent. You will have some long term fading over decades. Tattoos can be touched up any time if you are not satisfied with the retention of pigment in your tattoo. 

The procedure normally takes 90-120 minutes for the first session. Often, we schedule a 2nd appointment to touch-up the tattoo and add finishing touches and skin camouflage if necessary.

After the procedure a dressing will be applied. I prefer a Tagaderm dressing, which you will leave on for 3 days. After that time you can wash the area as normal with a gentle cleanser and moisturize with Aquaphor; Bacitracin or comparable antibiotic ointments may be used. If you have not used this before you should do a patch test first. Studies show 2-7% of the population has an allergy to Bacitracin.

Avoid vigorous exercise, bouncing movements or any movements that may rub against the breast area (chest exercises) for 3 days.. Do not rub or traumatize the procedure area while it is healing, as pigment may be removed along with crusting tissue. No hot tubs, swimming or baths for 7 days.

Aftercare

Over the next 14 to 21 days your tattooed area will go through three stages of healing:

1. Heal: The body's natural defenses will create fine scabs to protect the area whilst healing.
2. Peel: After a approximately 10 days, when the tattooed area is healed, the scabs will fall off.
Do Not Pick off the scabs from the treated area as this will result in pigment loss.
3. Fade: Once the scabs have finely healed and fallen off the tattooed area, you will see a lighter shade of the implanted color. After 4/6 weeks the pigment in the tattoo will have settled and this will be the color of your nipple and areola.

What should you expect after the procedure?
The dressing, which is applied immediately after tattooing, should remain in place for 2-3 day as the areola area may continue bleeding. The dressing is waterproof so you may shower with it on.

 

Skin care instructions Days 3-10

(For maximum results, please adhere to the post-care instructions)
After 2-3 days you may remove the dressing. As it is an adhesive dressing you may wish to do this in the shower.

Gently use a warm cloth to pat away the excess blood, lymph (clear, watery fluid) and stained pigment on the skin from the procedure area every morning and night. To prevent infection, try not to touch the pigmented area with your fingers until it is completely healed. Keep the pigmented area clean and dry.
You may apply a thin layer of Aquaphor 2-3 times daily and before bathing (always using a clean cotton swab/Q-tip, until the area has healed). Dab off excess product with a tissue. Overuse of Aquaphor will not let the area heal properly. Continue to apply Aquaphor until the scab falls off to avoid loss of pigment.

  • Avoid sleeping on your stomach.
  • Any clothing coming into contact with the area should be freshly laundered and changed daily.
  • Steam and hot water can potentially cause the color to fade prematurely. Avoid getting shower gel/cleanser and water on the area as much as possible. Do not use soap, saunas, steam rooms, Jacuzzis/hot tubs, or engage in hot yoga, swimming in chlorinated pools, oceans or lake water for 7-10 days or until the area has completely healed.
  • Avoid vigorous exercise, bouncing movements or any movements that may rub against the breast area (chest exercises) for 3 days.. Do not rub or traumatize the procedure area while it is healing, as pigment may be removed along with crusting tissue.
  • Ice and hot packs may be used to relieve swelling.
  • Mild tenderness and discomfort is normal as the tissue heals. Please contact your aesthetician and/or physician immediately if you experience symptoms such as intense itching, swelling, blistering, severe redness, excessive heat/warmth, a migrating red ring or any other complications.
  • Remember all procedures must heal, peel and fade. The tattoo will be much darker for the first 7-10 days or until the tissue has healed due to a mixture of blood, lymph (clear, watery fluid) and stained pigment on the skin surface. After the area peels, the color will be softer. Most tattoos fade up to 30% within the first 6-8 weeks
  • Breast Areola Tattoo Procedures are generally one to three visits.
  • Use sun block after the tattoo has healed to prevent future fading of pigment color (if exposed to sun or tanning bed).

Mission Statement

As a lifelong artist, my mission is to combine art and science to raise the bar in areola tattooing. The tattoos shown here are all samples of my work. I spent extensive time training in 3D areola tattooing to enhance a woman’s confidence and beauty and avoid the “bulls-eye” look of some nipple tattoos. This final phase of breast reconstruction should restore self-confidence and be a moment of celebration.