Who Will Buy a Poorly Iced Cake?

by Michael S. Beckenstein MD
Who Would Buy a Poorly Iced Cake?

Plastic surgeon and breast reconstruction specialist, Michael S. Beckenstein, M.D. describes how important nipple areolar reconstruction is to the overall results of breast reconstruction.

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Who Will Buy a Poorly Iced Cake?


When one is shopping, at a bakery, for a cake to bring to a friend’s house will they will choose a poorly iced cake when it is compared to the nicer looking one next to it? Of course not! It is human nature to seek out the pleasant, aesthetically pleasing items. It is also ingrained in our minds to seek out neatness and symmetry as well. So a baker or pastry chef will not only strive to bake delicious deserts, but they will also painstakingly make them appear as delectable as possible. The same premise holds true for breast reconstruction. The reconstructive surgeon must not only create pretty, symmetric breast mounds, he/she must also “ice the cake” with aesthetically pleasing, appropriately located nipples and areolae. If this seemingly small portion of the breast reconstruction is insufficient, the whole result is unsatisfactory!

Reconstructing breasts is a complex process that requires the forces and principles of art, science, technology, and human physiology to meet at the hands of a skillful surgeon. Experience, judgment and flawless execution are required of the surgeon to create aesthetically pleasing breast mounds for women stricken with breast cancer. When this fete is finally accomplished the final portion of the breast reconstruction, nipple areolar reconstruction, is relatively minor compared to the complex surgical procedures just completed. Seemingly minor, the nipple areolar reconstruction is often offered less efforts and sometimes simply relegated to cosmetic or medical tattooists. This is the “icing on the cake” and those involved in this process must realize the magnitude of this responsibility as the ultimate aesthetics, of breast reconstruction, depends on this final portion! As for the surgeon recreating breast mounds, those engaging in nipple areolar reconstruction/tattooing must be proficient in anatomy, aesthetics as well as highly skilled and experienced in the techniques of micropigmentation. Several important guidelines to assist in creating aesthetically pleasing nipple areolar complexes will be presented here.

Nipple location is the most important factor in completing breast reconstruction. If the nipple position is not appropriate, the entire result is compromised. There are several anatomic landmarks for locating the nipple. The nipple should be positioned along the meridian of the breast. This is a vertical line that divides the breast in equal halves. The nipple should be approximately 20-23 cm from the sternal notch on the meridian. Another anatomic landmark is at the level of the mid humerus. These landmarks can greatly assist in nipple location.


When one breast is reconstructed it is relatively easy to transpose the new nipple location by measuring the natural side and making aesthetic adjustments for any asymmetries. For bilateral reconstruction the best way to locate the nipples is covering one side and locating the nipple using measurements and aesthetic adjustments. Then cover this side and perform the same on the other side. Once this is complete, uncover both sides and carefully observe and make any aesthetic changes deemed appropriate. It is also advisable to place round bandaids over these locations and have the patient “live with them” for awhile and see if she is pleased with what was chosen. The patient is the one who lives with what we chose for them. Obtaining their input is invaluable to creating a content patient population!

Once the nipple position is chosen, the areolar diameter is the next anatomic issue. Again, for unilateral reconstructions, simply transpose the measurements of the natural areoala onto the reconstructed breast. Always make any aesthetic adjustments necessary. The aesthetic areolar diameter ranges from 38-42 mm with a 45 mm extension for larger breasts. Several templates and devices are available with these dimensions to assist in marking the areolae, but nothing is better and more natural looking than free handed drawings.

The final aspect of creating natural nipple areolar complexes is employing micropigmentation. This requires not only skill and experience in these techniques, but the technical ability to create three dimensional shading and highlighting. An artistic eye for colours and shading is requisite as well as the true anatomy of the nipple areolar complex, with the ridges, Montgomery glands, and subcutaneous blood vessels. The cosmetic or medical tattooist must become very familiar with these anatomic features and the various colour schemes of nipple areolae. Each race and various nationalities have inherent skin tones and knowledge of this will sharpen the abilities to create aesthetically pleasing nipples and areolae.

Advanced training in micropigmentation is essential and there are courses in 3D areolar tattooing to provide skills in these required techniques. Art courses are advised to develop an aesthetic “eye” and artistic ability to perform the shading and highlighting needed to create natural nipple areolae. Finally, intense anatomic study of nipples and areolae is advised. Through simple search engine resources, one can review thousands of photos of nipple-areolar complexes that when reviewed with a critical “eye” will enable one to develop a knowledge base to create aesthetically pleasing breast reconstructions.

It is ironic that the simplest portion of breast reconstruction is arguably the most important. The nipple areolar complex is the “icing on the cake” and if it is not performed correctly will yield a poor result. The medical or cosmetic tattooist must go to “pastry school” to learn how to create the appropriate nipples and areolae to complete a nice breast reconstruction. Intense training in micropigmentation, artistic appreciation, and anatomic study are requisite to attain the level of ability.  This is so women, who were stricken with breast cancer, can resume their lives with natural, aesthetically pleasing breasts that will allow them to move on from the adversity they just faced.



Associated Articles: 3D Nipple Tattooing a New Service?

Comment: Dr. Beckenstein is one of the leading Plastic Surgeons both in the USA and Internationally our immense gratitude to Dr. Beckenstein for his contribution to our educational articles.


Date of most recent revision: 15/12/2014 (mutatis mutandis)
Original publication date: 15/12/2014

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