For many women the final stage of their reconstruction involves the tattooing of new nipples. Two small coloured circles may seem insignificant, but for many women they represent the end-point in a long and often arduous journey to recover from the trauma of breast cancer.
Reclaim Your Curves recently spoke to Para-Medical and Cosmetic Micro-Pigmentation practitioner Letitia Henderson, founder of In My Skin in Bendigo, Victoria, to find out more about the process of nipple tattooing and their restorative impact.
RYC: Letitia, can you tell us a bit about your background and your qualifications as a cosmetic nipple/areola tattooist?
LH: Firstly, I think my work is much more complex than being a "tattooist". I'm a Div 1 Registered Nurse with 20yrs experience in acute and chronic healthcare. Most of my career has been spent working in Mental Health and providing individual and group therapy, with a special interest in grief and loss.
In 2010 I was running a support group for women who had been through breast cancer and were at varying stages of recovery. During one of the sessions, an attendee who had undergone breast reconstruction surgery couldn't wait to show us her "new boobs". We all got to see the "new boobs" and her amazing transformation. She described having new nipples as being "the icing on the cake” and that she finally “felt whole again."
I was immediately interested in knowing more. I had always considered myself to be "quite arty" and so I saved my pennies and undertook a Diploma of Paramedical and Cosmetic Tattoo in Melbourne. This Diploma, alongside my Bachelor Degree in Health Science (which gives me a good understanding of anatomy and physiology) and my mental health background put me in the perfect position to offer the service.
RYC: Do you provide a 3D tattooing service for those women who have not had a nipple reconstruction but want to give the impression of a nipple?
LH: Most women I work with have not undergone reconstructive surgery with nipple formation, so I enjoy the challenge of creating an areola that has a 3D look for my clients. Sometimes it can be quite difficult and time consuming to get the shading correct for a true 3D look but we always get there!
RYC: Are most clients referred to you by their surgeons? Can women contact you directly or do they need a medical referral?
LH: Many of my clients are referred to me by their General Practitioner to discuss areola re-pigmentation. I have met with a few local plastic surgeons and breast care nurses, however, I find that most of my clients are well past the "treatment phase" of their journey.
As I don’t advertise on TV or radio many women come to me via word of mouth. When clients finally discover that my business exists here in Bendigo they are very excited to be able to access the procedure locally.
RYC: How long after breast reconstruction is complete should you wait before having the areola tattooed? Is it a longer wait for women who have had radiation to the breast?
LH: I would suggest waiting at least 6 months post reconstructive surgery before having areola tattooing done. The body needs time to heal, scars to soften and fade and for the new form of the breast to settle. I also recommend that people wait 6 months following radiation therapy before recreating the nipple and areola with a medical tattoo.
RYC: Are there any factors which may preclude some women from having nipple/areola tattoos?
LH: If you are, or think you could be pregnant or if you are currently breastfeeding, you should wait until after you have given birth and have finished breastfeeding before undergoing areola re-pigmentation.
If you are prone to keloid scarring, or any condition that predisposes you to the overgrowth of scar tissue, you should not undergo any form of cosmetic tattooing because the tattooing may trigger an overgrowth in scar tissue.
If you have taken medication containing isotretinoin e.g. (roaccutane) in the past 12mths you should not undergo medical or cosmetic tattooing because you may develop an overgrowth of scar tissue. You need to wait for 12 months after ceasing this type of medication before having a tattoo procedure.
RYC: What colour range is available? How do women decide on which colour is best for them?
LH: The colour range is almost endless! If only one areola has been removed, the re-pigmentation practitioner needs to skillfully mix and create the pigment which matches the person’s existing areola. This can be time consuming and tricky! I keep a complete assortment of hypo-allergenic areola pigment colours and work with my clients to select the most natural looking colour for them.
A clients’ skin tone and body chemistry will affect the healed colour of their tattooed areas. You should also keep in mind that a simulated or scarred areola will probably need more than one tattooing session to achieve the best looking result.
RYC: Do you use medical grade tattooing pigment? How does this differ from normal body art pigment?
LH: The areola pigments I use are designed specifically for medical areola tattooing and are of world class quality. They are made from iron oxides, which have been used on the skin for hundreds of years - making them the safest pigments available. Iron oxide pigments are also MRI safe. Normal body art pigment is not suitable for areola re-pigmentation as it often contains chemicals which are more likely to cause allergic reactions and skin conditions. Also, as they are sold in larger bottles than areola pigments, there are cross contamination and hygiene risks.
RYC: Is there any pain involved and if so, what pain management strategies do you use?
LH: Most clients are surprised to find tattooing quite tolerable. It is a superficial process, but afterwards it may be a bit sore, like minor sunburn, for 2-3 days. Many of my clients have very little feeling in the area because the reconstructed breast doesn't have the same sensation, so no topical anesthetic is needed, and these clients describe a feeling of slight pressure only.
For clients who are able to feel pain and sensation in the area I apply a topical anesthetic which takes 15-20mins to absorb prior to commencing the tattoo procedure and then an additional (LET) lidocaine-epinephrine-tetracaine gel type anesthetic is applied once the skin is broken. I repeatedly apply LET gel throughout the procedure to ensure the client is completely comfortable.
RYC: How do you prevent infection?
LH: I undertake my procedures in a medical consulting room as this environment is less likely to allow cross contamination to occur. Proper storage of pigments and equipment is crucial to infection prevention. My equipment has single-use disposable parts which are incapable of allowing blood and body fluid to flow back into the device. Prior to tattooing, the skin around the site is cleaned with a skin antiseptic.
Every needle I use is individually wrapped and hygienically sealed and single use only. Following each procedure, I immediately dispose of my needles into a medical waste sharps container. A sterile dressing kit is opened at the start of each procedure and all instruments, pigments and antiseptic wipes are placed on the dressing barrier. Medical gloves are worn throughout.
I use pre-dispensed cleaning solution and single-use gauze wipes to remove excess pigment and blood from the tattoo site and dispose of wipes into the clinical waste container.
The needle assembly and transmission of my tattoo device is changed after each procedure to ensure maximum prevention against infection. Being a Div 1 RN with 20yrs experience working within medical and hospital settings provides my clients with extra reassurance that I take every measure possible in infection control.
RYC: Can you tell us about the process on the day of having the tattoos i.e.: how long does it normally take, what preparation (if any) needs to be done and what needs to be done to protect the area afterwards?
LH: On arrival the client fills in a written health assessment, answering questions relating to their age, general health, allergies and medical conditions. I then read through the In My Skin consent form which the client must sign prior to undertaking the procedure. This ensures the client is fully informed about the procedure they are undergoing. I take "before" photos which are kept confidentially, unless the client provides me with signed consent to use the photos for educational or advertising purposes.
The client is prepped and an anesthetic cream is applied. The client’s dignity is maintained with respect at all times. Privacy is of the utmost importance to me and staff know they are not to enter my consulting room during a procedure.
I mix pigments so that the tattoo closely matches the client’s existing nipple areola colour. I may be able to accomplish this in one sitting, but a second sitting is generally needed for a better colour match. If my client has undergone bilateral breast reconstruction, I can re-create her natural colour based on the pre-mastectomy photos, or I can mix pigments to create a colour that nicely complements her skin tone. The colour can be darkened or lightened depending on the individual’s preference.
The pigment is applied using a hand-held pen-like device, which basically works like a miniature sewing machine: the needles move up and down really fast, depositing the colour just below the surface. I hold the machine while guiding it along the skin. The pigments are built up using dots, lines and/or a circular motion.
At the end of the procedure (which can take up to 2 hours if topical anesthetic needs to be applied) I clean the area with a gentle antiseptic gauze swab, take an "after" photo and then coat the area with a thick layer of antiseptic barrier cream. I place a nursing pad over the areola and the client puts on their bra to hold it in place. The pad acts as a barrier to prevent the newly tattooed areola from rubbing against a bra or clothing and the cream helps keep the area moist, which assists with healing. The client is asked to apply the cream multiple times each day, especially prior to bathing (to prevent soap and shampoo soaking into the newly tattooed areola, which can fade the colour if it has not completely healed, and reduce exposure of the skin to infection).
Finally, I provide the client with the antiseptic barrier cream, nursing pads and aftercare instructions to follow for 2 weeks after the procedure. I encourage clients to contact me if they have any questions or concerns during the healing period.
RYC: Are there follow-up visits required?
LH: I ask the client to return 4-6 weeks after the initial procedure for a perfecting session. This allows me to perfect any inconsistencies in pigmentation and make any corrections or adjustments necessary. Sometimes the tattoo will fade quite a bit and I find the perfecting session is often necessary to complete the depth of pigmentation colour. Sometimes 2 perfecting sessions may be required.
RYC: What are the costs involved? Are there any health rebates available?
LH: The cost is $600 per areola, which includes 1-2 perfecting sessions. While the cost of breast reconstruction is covered by most private health insurance providers, medical tattooing of the areola is not, although some Medicare rebates may be claimable if your doctor or surgeon includes the procedure as part of your treatment plan.
I donate 20% of each areola tattoo to the McGrath Foundation.
RYC: Finally, do you find it's an emotional experience for women having a nipple tattoo?
LH: Most clients look in the mirror at their new areolas and cry tears of joy (more often than not I'm crying tears of joy with them!) A beautiful woman in her early 40s recently had both areolas re-pigmented with 3D nipple tattoos, she was so happy she didn't want to put her top back on! For the past 14 years she wasn’t aware that areola/nipple tattoo even existed! Thankfully, her GP suggested she come and see me and she hasn't stopped smiling since.
Most of my career has been spent working with individuals and families who are in the throes of grief and trauma. I have spent years supporting clients who are undergoing cancer treatment and who are struggling with their own mortality. My work with clients at this “opposite end of the spectrum" is not only refreshing, it has allowed me to see the full and complete circle of diagnosis, treatment, recovery and beyond!
I believe it is an absolute honour for a woman to share this part of her journey with me and the conversation and rapport that we establish during the procedure is often as cathartic as the actual procedure. I am continually overwhelmed by each individual's story; no two clients are ever the same. The resilience of women in the face of adversity is miraculous.
Interview by Jane Goodwin-Moore
Publicity and Consumer Information, Reclaim Your Curves
Jane Goodwin-Moore is a writer and consumer. She interviews Australian health professionals about their role and thoughts on breast reconstruction in Australia