After breast reconstruction, some women opt to forego nipple reconstruction, although many others consider it to be the final step in the process. It’s an optional procedure that can be performed once the new breast has settled in place, or anytime—weeks or months—thereafter.
An older way of creating the nipple and areola involved transferring a small skin graft from the labia or upper thigh, since tissue from these areas is naturally darker than breast skin and doesn’t require tattooing. But the process can be uncomfortable (particularly involving a labial graft), it creates another incision that must heal, and it leaves a scar at the donor site. Labial tissue also tends to grow hair, so new nipples created in this way do as well.
Considering the disadvantages of nipples made with skin grafts, you can see why most surgeons think this procedure is outdated, preferring instead to make the new nipple with a small flap of breast skin. There are many different ways to do this (see illustration), and surgeons typically use the technique they most prefer. Tattooing then darkens the new nipple and simulates the areola around it. Some surgeons like to create the nipple, use a graft of darkened skin for the areola, and then tattoo the nipple to match the natural pigment.
One advantage of nipples/areolas created with skin grafts is that the pigment is permanent, while nipple/areola tattoos tend to fade considerably after a few years.
Done well, tattooed nipples and areolas look quite natural. The trick is to get someone who really knows what they're doing and takes the time to choose a pigment that matches your skin tone and that you’re happy with. Nipple tattooing takes just a few minutes. Tattoos are often applied in-office by the plastic surgeon or a member of the office staff (usually an RN). More surgeons now have tattoo artists provide the service or refer patients to them. This is actually better, because professionals tend to tattoo deeper into the skin, so that fading is less likely.
Many tattoo artists now specialize in reconstructive nipple tattoos, and some offer their services to breast cancer survivors at no charge. (Federal law requires health insurance companies that cover the cost of mastectomy also pay for breast reconstruction, including nipples and tattoos. If your plastic surgeon refers you to a professional tattooist, however, be sure to check with your insurance company to ensure preauthorization and subsequent payment.)
If you want to forego having nipples reconstructed, you might want to consider having just a tattoo—many professional tattoo artists can create beautifully simulated nipples with a 3-D look. Several companies also make adhesive nipples in varying pigments and sizes, which can be worn temporarily.