3D Nipple Tattooing a New Service?

by Andrea Darby - Master Medical Tattooist & Industry Educator
3D-SAT Nipple Tattooing

Cosmetic & Medical Tattooists have been providing Nipple Areola Complex (NAC) Tattooing services to their clients for decades, in fact some have been offering and perfecting their techniques for NAC tattooing services for the past 30 years including various methods for creating a 3D appearance. Regardless of the geographical location most qualified medical tattooists that we have spoken to regard areola tattooing as part of their contribution to society and they generally only charge modest fees for the service to recoup the cost of their medical consumables.

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The medical community have been aware of the areola tattooing services that are available from cosmetic and medical tattooist for at least 20 years1-4. However it has only been in the last 5-10 years or so that the medical community have truly begun embracing areola tattooing as a viable option for their patients post mastectomy, either as an alternative to nipple reconstruction or as an adjunct to surgical nipple reconstruction5.

As a medical tattooist I myself have been intensively developing and improving my own techniques for 3D Simulative Areola Tattooing (3D-SAT™) for the past 5-6 years, last year I even attended training in the UK provided at the Royal College of Surgeons which demonstrates the zeal with which the breast surgeons have now embraced areola tattooing for their patients.

SBS television station in Australia produced an interesting short documentary about a breast cancer survivor who underwent areola tattooing provided by a Registered Nurse as the final stage of her reconstruction. The subject of the documentary named Cass Boyle is to be applauded for sharing her story and her innermost feelings, both before, during, and after the completion of her areola tattooing.

If you have had reconstructive surgery and you have had a nipple reconstruction that lacks pigmentation or if you have a blank canvas reconstruction (no nipple) then Areola tattooing may be an option to consider and discuss with your surgeon and significant others for the purposes of adding colour to the reconstructed nipple or to create a simulated 3D nipple.

However I stress that it is important that you seek this service from an appropriately qualified cosmetic & medical tattooist, we are concerned that there is a trend towards this service being provided in traditional body art studios, without the use of clinical procedural standards, and some tattooists appear to be 'cashing in' with aggressive commercial promotion of the service. We have even seen some examples of body art tattooists implying that they have recently developed the brand new service of 3 dimensional nipple tattooing, apparently they are unaware that many medical tattooists have been offering exactly that service for 2-3 decades.

Due to the lack of regulation in most countries in relation to who can provide medical tattoo services; there is a significant risk of patients being mislead about the nature and quality of the service being provided by the different types of service providers if the patients are not fully informed about the standards that they should expect for medical tattooing and the availability of the service near their location.

Patients who have gone through a struggle with breast cancer and the trauma of reconstruction deserve to have all aspects of the reconstructive process provided at the highest possible standard and they are also entitled to 'Informed Consent' in relation to the nature, quality, options and alternatives prior to committing to any aspect of reconstruction.

There are some important factors to look for prior to undergoing this type of service;

Quality of Outcome - Obviously you will want to ensure that the technician can provide you examples of the kind of outcome that can be expected from the treatment that you are considering. Before and after photographs of previous clients/patients should be available to you to view during the initial consultation and you should be given time to consider the treatment plan without obligation to proceed.

Medical Disclosure - A short medical questionnaire should be completed to identify any contraindications or preclusions to undergoing the treatment or if medical advice should be sought.

Click here to see an example of a pre-treatment screening questionnaire.

Privacy - Medical disclosure documentation and photographs should be treated as medical records and use of those records restricted to the provision of the service unless you have provided your express written consent. For example you will want to be sure that your photographs are not shown to others or displayed in advertising unless you have given your written consent. Of course you should also expect complete privacy during the actual treatment.

Qualifications - Has the technician been specifically trained in the provision of Para/Medical Tattoo techniques and you should enquire who provided the training in that service.

Procedural Techniques - Obviously you will want to ensure that the technician is complying with local health regulations and the World Health Organisation Standard Precautions in Healthcare. Typically a medical tattooist will provide the service at a similar procedural standard as you might expect for a minor clinical procedure, e.g. using sterile medical grade supplies and consumables, sterile dressing packs, clinical grade gloves (preferably sterile), face mask, clean protective apron for every client/patient etc. This is vitally important to ensure that micro-organisms do not end up infecting a newly reconstructed breast and also because some patients may be immunocompromised following treatment for their breast cancer.

Pigments - The technician should be willing to show you the MSDS (materials safety data sheets), full identifiable ingredients list (including cas numbers), evidence of product allergy testing, and confirmation that the pigments have been specifically manufactured for Cosmetic/Medical Tattooing. If this information is not available then you have no guarantees of any particular manufacturing standard that would be suitable for medical tattooing.

Random testing of a standard range of body art pigments by New Zealand health regulators6 showed variable levels of compliance with recommended limits on levels of heavy metals such as Lead, Cadmium, Cobalt, Mercury, Arsenic and other substances which may be harmful to human health. A study conducted by scientists in Denmark7 found that 10% of unopened bottles of body art pigments that they tested were contaminated with micro-organisms and 17% of previously opened bottles were contaminated.

In May/June 2014 European and Australian health regulators issued a recall on 9 tattoo pigments listing the health threat as 'serious', seven of the tattoo pigment products were found to contain a cancer-causing chemical (carcinogen) 4-methyl-m-phenylendiamine and four also contained other contaminants (including lead and copper or arsenic, lead and nickel).

Australian regulators noted that "the products recalled originated mainly from the USA (five products), China (three products), and Japan (one product) indicating that inks sourced from North America are not safer than those from other countries". This is a significant conclusion because service providers sometimes claim they are using safer pigments because they sourced them from the USA.

Also body art pigments often contain azo dyes some of which have a higher incidence of allergy and skin reactions in comparison to other colourants and may also liberate potentially cancer causing aromatic amines 8. For these reasons well trained Para/Medical Tattooists will preferentially use pigments that have been specifically manufactured for cometic and medical tattooing so that they know the manufacturer is restricting their use of colourant ingredients to a much narrower range of safer ingredients and are also providing a product that has guaranteed sterility.

No matter how careful a technician is with their hygiene each time that a bottle of pigment is reopened there is a small chance of contaminating the pigment and or its container, the larger the bottle of pigment is the more often it will be reused and the greater the risk is of cross infection. For these reasons the technician should also provide the service to you with the smallest container of pigment possible to provide the most hygienic option to the client.

Example of a Single Use
Medical Tattoo Pigment

Vial of Single Use Medical Tattoo Pigment

Large bottles of pigment greater in size than 15ml, as are typically used in the body art industry, have the greatest risk of being contaminated with micro-organisms due to the frequency of re-use.

Our Position:
standard body art pigments should not be used for medical tattooing services.

Infection Prevention - In most countries the regulatory standards in place relating to tattooing were created to contend with standard body art and cosmetic tattooing, we are yet to see regulations that make adequate specific provisions for medical tattooing from any country. There is a potential for the development of a Salon Acquired Infection 9 following any tattoo service and due to the additional health considerations of patients who may seek medical tattoo services it is reasonable to expect a higher standard of procedural hygiene than would normally be provided at a tattoo studio

Equipment - There is a wide range of equipment available for the purpose of tattooing from the traditional coil devices used by the body art industry right up to high precision microprocessor controlled devices as is often used by Cosmetic & Para/Medical Tattooists.

It is important to be aware that coil tattoo machines as used by the body art industry are not manufactured for the purpose of, or in accordance with medical equipment standards.

Also of particular importance is the quality of needles that are being used, the body art industry commonly use needles sourced from Asia which offers cheaper manufacturing and often lower quality needles as compared to clinical grade needle modules frequently used by Cosmetic & Para/Medical Tattooists sourced from countries with higher manufacturing standards such as Germany. Cosmetic/Medical Tattoo needle modules are far more hygienic due to having an internally sealed chamber which helps prevent flow back of bodily fluids into the hand piece during use.

Amiea Hygenic Needle Cartridges

The technician should also be able to provide independent certification of sterilization for the needles that they intend using for the procedure which can easily be provided by the manufacturer if in fact the needles are genuinely sterile, simply having the word 'sterile' or 'sterilised by gamma radiation' stamped on the needle packaging does not necessarily guarantee sterility.

Waiting Period - Understandably patients are often very keen to have their areola tattooing performed as soon as possible, completing the final finishing touches to the reconstruction is recognised as an important step towards a patients emotional healing. However during the 6-12 months after breast reconstruction the reconstructed breast may continue to change in shape, size, and orientation, as swelling subsides healing completes and final settling of the new structure occurs.

For this reason the longer that you feel you are able wait after reconstruction before having areola tattooing performed will ensure that the areola tattoo can be positioned optimally on the reconstructed breast after these changes have taken place. If surgical Nipple/Areola reconstruction has also been performed then it is best to wait 3-6 months after the surgery to permit the new areola complex to heal fully before tattooing.

Sometimes a surgeon may suggest tattooing in stages both before and after surgical nipple reconstruction, the benefit being that colour can be added to the donor skin for the formation of the nipple prior to the surgery and then again after healing. The benefit of this technique is that the pigment colour may hold better and the final result can be more aesthetically pleasing.

Patients who have had radiotherapy are normally advised by their treating doctors to wait 6 months after their last treatment before undergoing tattooing.

Health Practitioner Supervision
- A medical tattooing service that has a state or federally registered health practitioner providing direct supervision of the service should provide some additional reassurance about the service.

Topical Anaesthetics - Often women who have had reconstructions will find that they have some very sensitive areas of skin particularly surrounding scar tissue, most Cosmetic and Medical Tattooists should have some knowledge/training in the safe and legal use of topical anaesthetics

Inappropriate use of alkaline topical anaesthetics such as Emla cream (pH 9.0+) does have the potential to affect the colour and final healed results
11 of a cosmetic tattoo, however I have not seen any plausible evidence that would indicate that purpose specific topical anaesthetics with a close to neutral pH (>6.5 - <8.0) would affect the colour or pigment retention outcome of cosmetic tattooing.

We have seen some spurious claims that any form of topical anaesthesia will adversely affect the outcome of areola tattooing, we have not seen any plausible evidence that would support those claims which were most likely made by those without adequate training in medical tattooing. There are a variety of pain management techniques that do not involve the use of topical anaesthetics which well trained technicians should be aware of, it would be inappropriate to needlessly subject a woman to discomfort during areola tattooing simply due to the lack of competency of the technician.

Complementary Services - In addition to areola tattooing most medical tattooists have also been trained to offer complementary services such as scar meso/needling techniques either to promote the return of natural skin colour or to improve the surface topography of reconstruction scars.

Cosmetic Tattooists are also able to offer services such as eyebrow tattooing for those who have experienced permanent loss of hair following radiotherapy or chemotherapy. These types of specialised services can be provided at the same time as the areola tattooing and they are not usually available at a body art studio.

Referral - A personal referral to a technician by a medical practitioner or via a patient advocate group/body may be helpful but unless the party making the referral is a recognised provider of training and certification for medical tattooing then the referral should not be considered as a replacement for ensuring that your technician meets the service standard detailed in points above.

Health professionals and organisations who might consider referring a patient post mastectomy and reconstruction to a standard body art tattoo parlour for the purpose of areola tattooing would do well to consider their potential liability in the unfortunate event of an adverse outcome for the patient.

Surgical Reconstruction Experts Providing 3D Tattooing - The ideal situation for a patient undergoing surgical reconstruction is if the surgeon is working in close association with a medical tattooist who is trained in 3D Areola Tattooing therefore I encourage the reconstructive surgeons to have a member of their own team trained in contemporary medical tattooing as the best means of ensuring that services are provided at the highest possible standards for their patients.

Education - I have produced a 3D-SAT Workbook which has become the go-to reference for many Medical Tattooists for Areola Tattooing.

In september of 2014 I had the immense pleasure of providing medical tattoo training services to Dr. Michael S. Beckenstein and his clinical/surgical team, Dr. Beckenstein is one of the USA's leading plastic and reconstructive surgeons and I consider him to be a foremost expert, Click here to read Dr. Beckenstein's comments about my Medical Tattoo training services.

After seeing first hand the outcomes of reconstructive procedures in several countries I can say without hesitation that the standard of patient outcomes being achieved by Dr. Beckenstein and his team are extraordinary and in some cases ground breaking. I recommend Dr. Beckenstein to any woman wanting the very best breast reconstruction available provided by a compassionate health professional.
To read more about Dr. Beckenstein click here.


Date of most recent revision: 20/10/2014
Original publication date: 24/10/2013

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The content of this article should be regarded as general information & is provided solely for the purpose of discussion & is not intended to replace cosmetic tattoo training or medical advice in any instance, always check with a cosmetic tattoo master trainer and or a qualified medical practitioner before acting on any information regarding cosmetic tattooing or in relation to any medical condition or medical circumstance.

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