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Nipple Reconstruction After Mastectomy

Yes, it’s a thing!

Laura Frese PA-C: Laura Frese PA-C is a Physician Assistant at Cedars-Sinai Medical Center in the department of Plastic and Reconstructive Surgery. She received her Masters in the Physician Assistant program at St. Louis University followed by a surgical residency at Johns Hopkins. For the past 15 years, her practice as a PA has had a strong focus in breast reconstruction.

Holly is a writer, performer, and health advocate, sharing her personal experience as a breast cancer survivor and carrier of the BRCA1 gene mutation to raise awareness, and support women as they navigate their own cancer journey - practically, spiritually, and emotionally. With training and background in Reiki, spirituality, and holistic health/wellness, her writing runs the gamut from being a regular contributor at The Huffington Post, to produced playwright, to Senior Writer for a global non-profit.

If one or both of your nipples were removed during your mastectomy, the magic of modern offerings such as surgeries and tattooing can actually recreate or reconstruct them. While reconstructed nipples won’t look or feel like your original nipple, and they will never change in size due to temperature or external influences, the following methods provide generally positive aesthetic results.  

Surgeries

Several surgical approaches can be used for nipple reconstruction, depending on tissue health and other issues to be discussed with your surgeon. Depending on the technique, the following surgeries are outpatient, can take from 15 minutes to over an hour, and will be performed at least four months after saline or silicone implant reconstruction. This gives the new breast time to heal and settle into its permanent position. If reconstruction was performed using the DIEP flap method (using the body’s own tissue), the nipple is typically reconstructed at least three months after surgery - and anytime thereafter -  to allow for swelling to resolve and the breasts to settle into position; this allows for proper nipple placement.

If you had radiation, it is suggested to wait longer for nipple reconstruction, up to six months or more, to allow the skin time to heal and reduce the risk of post-surgical and wound healing complications. Also, because radiation can change the shape of the breast mound, waiting offers a better chance for correct nipple placement and symmetry. It’s also important to note that reconstructed nipples on radiated breasts may have less projection than on those that are non-radiated.

While serious complications from nipple reconstruction surgeries are rare, one risk includes tissue breakdown, or necrosis, when the tissue used to make the nipple doesn’t get enough blood, and the nipple “dies.” Nipple flattening or retraction can also occur, as can poor positioning of the new nipple, which happens more often when the nipple reconstruction is done at the same time as the breast reconstruction; however, surgery is usually available to fix either of these issues.

For the following nipple reconstruction surgery methods, the areola can later be created through tattooing. As with all procedures, your doctor or care team will tell you how to prepare and give follow-up instructions for recovery and healing, including how to care for your new nipples. And, just a heads up: reconstructed nipples can shrink up to 50 percent of their original size during healing, so the nipple is often reconstructed with greater projection and size to accommodate such shrinkage.

And if you’re considering the cost and concerned this might not be covered by insurance because it’s technically cosmetic, you’re in for a happy surprise: In America, thanks to the Women’s Health and Cancer Rights Act of 1998, if your health insurance covers breast reconstruction, it also must cover nipple reconstruction surgery.

Skin flap reconstruction

Surgeons often refer to this type of reconstruction as “origami of the skin,” as small flaps of skin from your reconstructed breast are raised around the nipple location. They are then folded and sutured together, and the skin manipulated,  to create an elevated mound that will become the new nipple. Sometimes additional skin, fat, or synthetic fillers are used to make the nipple more erect, like a natural one would be.

The two main benefits of this type of surgery are that the reconstructed nipple will project out from the breast, creating a more natural look, and that this method keeps the tissue connected to its blood supply, reducing the risk of its not healing properly.

Skin graft

If there isn’t enough skin tissue to create the nipple, your cosmetic surgeon may suggest a skin graft, in which a small piece of skin from a different part of the body (donor site) will be grafted to construct it. A benefit to this method, studies have shown, is that it offers the best match to a natural nipple’s color and texture. Grafts are usually taken from the abdomen, inner thigh,  buttocks, or labia. The labia is considered a good option because the pigmentation matches that of the areola. But  — in case your surgeon doesn’t offer this info outright — an unintended consequence of using the labia as a donor site is that pubic hair could grow out of the reconstructed nipple (!!). This still might be the right choice for many women, but be armed with this info so you can ask your surgeon about it if you’re discussing going this grafting route.

Nipple Sharing (also called Autologous Graft)

If you have a mastectomy on one breast only, and the nipple on the other breast is large enough, the cosmetic surgeon can graft a portion of it onto your reconstructed breast and build a new nipple. Doing this allows the surgeon to match the two nipples in color, size, and position — a major plus.

Medical Tattooing

Tattooing can be used to create both a 3D nipple and areola, and to enhance a reconstructed nipple by making its color similar to a nipple’s natural shade.

Nipple tattooing should ideally be the last stage of your breast reconstruction process, occurring at least four months after your last procedure; the timing and individual circumstance should be discussed with your surgeon and/or tattoo artist. These tattoos can be done by staff members at a plastic surgeon’s office, or by a specialized nipple tattoo artist. Generally, nipple tattoo artists yield the best results, due to their specialization, training, and experience. Ask your cosmetic surgeon’s office if they can recommend a nipple tattoo artist who works with women who have had breast reconstruction after a mastectomy, and ask to see photos of their work.

Before beginning the tattoo, which can take 30 minutes or more per nipple, the artist will discuss your preferences for nipple and areola size, shape, placement, and color. If you still have one of your natural nipples, the tattoo artist will try to best match the new nipple’s color and size to it, or if you have a picture of your pre-mastectomy nipples, showing that will be helpful. This will help the artist pick the right pigment colors and location for the nipple and/or areola tattoo(s). In fact, the cosmetic surgeon team generally finds photos of your natural breasts to be helpful throughout the whole reconstruction process. 

While we’re on the topic of photos, I found taking photos of my breasts before my mastectomy to be a celebratory way to honor them and say goodbye. As a gift, my mom got me a “boudoir” photo shoot, and I’m grateful both for the experience and that I have those photos.

If your skin was damaged by radiation treatments or got too thin when tissue was removed during the mastectomy, or if you have lymphedema and/or a history of infections in that area, then you might not be a candidate for tattooing. As always, discuss with your doctor.

3D Nipple Tattoo

More women have been choosing to go the tattoo route, with the advancement of permanent 3D tattooing, as it avoids needing more surgeries. With this method, a nipple and/or areola are tattooed directly onto the breast mound via 3D tattooing (no surgeries needed!), using shading and shadow to create the appearance of a raised nipple. It’s important to remember that while this gives the appearance the nipple is protruding, it is not actually elevated.

Enhancing reconstructed nipple and areola

After you’re healed from nipple reconstruction surgery, tattooing can be used to add color to the nipple, create the appearance of an areola, and make both look more realistic; so realistic in fact, that with shading, coloring, and adding fine details, a tattoo can even create the illusion of the little bumps called Montgomery glands that appear on the areola!

The color of the tattoos may fade slightly over time, but touchup sessions can easily fix that. While there may be mild discomfort or the feeling of pressure, because feeling is lost in the breast due to the mastectomy, tattooing usually isn’t painful. There may be some flakiness or crusting in the area for a few days, but healing generally takes seven to 10 days; you will be given instructions on how to take care of them while they heal. 

 Insurance doesn’t always pay for medical tattooing, especially if it’s not performed by a medical professional, but tattooing also comes with advantages — the main one for many being that it avoids yet another surgery. This route also has an easier healing and recovery process, and many feel the cosmetic results are better due to the fact that the artist can add coloring and fine details that can’t be done with a surgery. Plus, while some consider it a disadvantage that a tattoo offers no physical dimension, others are glad their nipples don’t show through their clothes. To me, this would be a huge benefit — my nipples (which are still my own) were frozen during the mastectomy in a such a position that they are forever “standing at attention,” and are very hard to cover up!

Temporary options

Prosthetic Nipples

If you’re still undecided about the route you’d like to go, unable for medical reasons to do nipple reconstruction, are in between procedures, or decide to go “un-reconstructed,” then temporary prosthetic nipples may offer a great alternative.

Made from soft silicone, they are either self-sticking or held in place for several days or longer with a special skin adhesive, and can be put on/taken off at will. Available in different sizes, colors, and projections, with many companies offering custom-made options, prosthetic nipples look and feel like the real thing. Some insurance companies will even cover it; submit a receipt for the prosthetic nipples and a prescription or letter from your doctor stating the prosthetic nipples are medically necessary.

Temporary Tattoos

Another temporary and inexpensive option is rub-on nipple “tattoos.” Applied with a wet cloth, they can last one to two weeks, and are easily removed with rubbing alcohol. While they don’t offer any projection, they do provide the 3D look of a nipple.

If you are considering nipple reconstruction or recreation, discuss your preferences and priorities with your surgeon and/or tattoo artist.  Don’t be afraid to ask all the questions necessary to understand what each procedure entails. The good news is there is no rush; you can take your time to decide!

And if you’re considering the cost and concerned this might not be covered by insurance because it’s technically cosmetic, you’re in for a happy surprise: In America, thanks to the Women’s Health and Cancer Rights Act of 1998, if your health insurance covers breast reconstruction, it also must cover nipple reconstruction surgery.

- Holly Sidell


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